What is the most dangerous place on earth? Afghanistan? Gitmo? The San Andreas Fault? Nope, you're way off: It's the American hospital, where 100,000 people are killed each and every year, about the same number of Americans as died in the Vietnam and First World Wars combined. Yes, under the guise of health care (get the irony?), U.S. hospitals roll healthy people to their deaths with a clockmaker's precision.
Such, at least, is the prevailing view these days from quarters left and right. The Institute of Medicine, in its 2000 report, To Err is Human, kicked off the slugfest but since then, we have met all manner of flame-throwers. Take former New York Lieutenant Governor Betsy McCaughey. She has a self-congratulatory Web site dedicated to the issue. Or Boston's schoolmarm-ish Institute for Healthcare Improvement, which features the grim series, Profiles in Improvement. Or Mr. Perfect, Dr. Atul Gawande of The New Yorker, Harvard, Henry Holt publishing, and points beyond, who just has published The Checklist Manifesto. Or Peter Pronovost who also has just staked his claim for primacy with his own version of The Birth of the Checklist. Or last month, the admirable Consumer Reports, which added hospitals to items like poisonous toys and cars with iffy brakes, advising consumers to be informed or else suffer the lethal consequences of willful ignorance.
Indeed, isn't the true star of "House" not the brilliant-if-unconventional doctor H, but rather the American hospital system? I mean, bone marrow transplants and heart transplants and neonatal ICUs are kind of a big deal, no?
With all this noise it has been a strange relief to watch the city of Miami struggle to maintain its hospital system. Just yesterday, a tentative agreement was reached that would keep hospitals in this teeming metropolis open, albeit with some substantial cuts in service. The basic premise, one which required no explanation, was that hospitals are not so awful but rather are a vital part of daily life. Indeed, isn't the true star of "House" (and every medical show since Ben Casey and Dr Kildare roamed the airwaves) not the brilliant-if-unconventional doctor H, but rather the American hospital system? I mean, bone marrow transplants and heart transplants and neonatal ICUs are kind of a big deal, no?
How did all of this happen-this Orwellian inversion of the hospital as a place of refuge and rescue into nothing short of Slaughterhouse-Five? (Note to self: At the time he wrote 1984, Orwell was dying of tuberculosis. Had he become ill a decade later, he might have been cured by medications given during a hospital stay.) As someone who spends all day every day in a hospital, I am all too aware of what a zoo any hospital can be; indeed it's clear that being a patient is the hardest job in town. But this doomsday perspective long ago overshot the mark.
Before going further, however, I must disclose my considerable bias. My livelihood is that of the infection-control specialist, the person whose responsibility is to prevent the very infections said to kill thousands. If things screw up, I could be looking for work: I therefore have every reason to sweep the entire mess under the carpet (other than ethical, moral, religious, spiritual, personal, family, and humanitarian considerations). Office Barbrady at your service: Now move along, kids.
That said, it is obvious that hospitals are not as safe as the Hilton Inn or even as safe as the creepy youth hostel you stayed in 20 years ago. But neither are they killing fields. Hospitals have entered bad-guy territory for several reasons, not the least of which is their clumsiness and humiliating string of actual medical disasters. But there is more to it than that: The hospital somehow has come to be regarded with the same distrust and derision previously reserved by many for Big Government. Meet Big Health Care (not to be confused with Big Pharma), a deliberately inept, selfish, contemptuous slug of an enterprise studded with sleaze-balls lining their pockets and protecting their turf, cheerfully willing to put any patient at risk for personal short-term gain. And the star of the show is that doctor with the fresh highball making so much noise in first class-hardly a sympathetic character.
Perhaps most importantly, though, hospitals are where we die or else receive the Bad News. The American aversion to discussing even the vaguest aspect of death was in full display during the recent public hissy fit over "death panels" (a concept promulgated by our Ms. McCaughey). Of course, no one knew then or knows now what a death panel is, but it is clear that the "debate" actually involved differing views over what many consider our inalienable right to live forever. Here is the fertile nexus where fear about Big Government meets panic over one's mortality: The government is telling me I have to die some day! This is socialism! The ultimate incursion into my God-given right as a citizen! Or something. Hospitals have become a hapless scapegoat rather than the miraculous if erratic and annoying pinnacle of human achievement.
Surely most of the group piling on the American hospital realizes the complexity of the situation, just as hospital defenders recognize the value of honest self-criticism, better routinization of the seemingly routine, and the corrective ability of attention itself. Yet the debate has turned sour, with the improvement crowd tsk-tsk-tsking those of us not in the Dudley-Do-Right business full time. Furthermore, they have come to dismiss any doubt about the soundness of their advice or generosity of their motives as nothing short of a willing embrace of the deaths of thousands. And with that high moral dudgeon comes yet another risk to patients and hospitals: the corrosive effect of sanctimony.
Kent Sepkowitz is an infectious disease specialist in New York City. He has contributed to The New York Times, Slate, and, oh-so-briefly, O Magazine. He also writes academic medical articles that are at times pretty tough sledding.
