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Our Malady - Timothy Snyder

Last updated Feb 26, 2024


# Metadata

# Highlights

# PROLOGUE Solitude and Solidarity

Malaise is what we feel when we have a malady. Malaise and malady are good old words, from French and Latin, used in English for hundreds of years; in American Revolutionary times they meant both illness and tyranny. (Location 50)

Our malady is physical illness and the political evil that surrounds it. We are ill in a way that costs us freedom, and unfree in a way that costs us health. (Location 55)

In five hospitals over three months, between December 2019 and March 2020, I took notes and made sketches. (Location 65)

The rage was beautifully pure, undefiled by an object. (Location 76)

I raged therefore I was. (Location 81)

Death would extinguish my sense of how things could and should be, of the possible and beautiful. (Location 90)

A visit helps us to be alone. Being together in solidarity permits a return to solitude in tranquility. (Location 99)

the ways my children’s lives were bound to my own. What mattered was not that I was distinct, but that I was theirs: their father. Every bit of their existence involved the expectation of my presence. They had never not touched me. Their planks had always been bound to mine. (Location 112)

The empathy placed me among others. In this mood, it was not so important that I was special. It was important that I was inside other people, in their memories and expectations, a support in the shape of their lives, a buoy during difficult passages. Since my life was not just my own, then my death was not just my own. (Location 121)

I needed the torch and the raft, the fire and the water, the solitude and the solidarity, to get well, to be free. (Location 126)


The mortality rate of babies borne by African American women is higher than in Albania, Kazakhstan, China, and about seventy other countries. (Location 134)

Our system of commercial medicine, dominated by private insurance, regional groups of private hospitals, and other powerful interests, looks more and more like a numbers racket. (Location 140)

If birth is not safe, and is less safe for some than for others, then something is wrong. (Location 142)

The purpose of medicine is not to squeeze maximum profits from sick bodies during short lives, but to enable health and freedom during long ones. (Location 144)

By 2020, when I was fifty, the difference in life expectancy had grown to four years. It is not that other countries have more knowledge or better doctors. It is that they have better systems. (Location 150)

their governments treated them better, and because they had better access to information and care. (Location 153)

Our botching of a pandemic is the latest symptom of our malady, of a politics that deals out pain and death rather than security and health, profit for a few rather than prosperity for the many. (Location 155)

A virus is not human, but it is a measure of humanity. (Location 160)

Our malady makes pollution deaths, opioid deaths, prison deaths, suicides, newborn deaths, and now mass graves for the elderly all too familiar. (Location 161)

To be free is to become ourselves, to move through the world following our values and desires. Each of us has a right to pursue happiness and to leave a trace. Freedom is impossible when we are too ill to conceive (Location 165)

Freedom is sometimes a scream in the dark, a will to go on, a solitary rage. (Location 172)

a person wanting to be free over the course of a life also needs calm voices, friendly visits, confidence that illness will bring attention and not abandonment. (Location 172)

Freedom is about each of us, and yet none of us is free without help. Individual rights require common effort. (Location 175)

A right is something that we are convinced we deserve, but it only becomes real in the world when forced upon the powers that be. (Location 177)

# LESSON 1. Health care is a human right.

I was in a condition known as sepsis; death was close. The nurses guarding the entrance to the emergency room did not seem to take me seriously, (Location 197)

Like most American emergency departments, this one was overflowing, with beds lining the hallways. (Location 202)

Getting attention in emergency rooms is a matter of figuring out who staff are and catching someone’s eye. (Location 205)

racism hurt my life chances that night; it hurts others’ life chances every moment of their lives. (Location 212)

emergency departments in the evening are full of older alcoholics and younger people who have been stabbed or shot. (Location 213)

The doctors and nurses seemed unable to complete a sentence, let alone think about my case as something with a history. (Location 231)

When I concentrate on what I read, I have a very good memory. Much of my thirties and forties I spent reading first-person accounts of the Holocaust and other German crimes, Stalinist mass shootings and famine, ethnic cleansings, and other atrocities. (Location 265)

Something in me paused over a Jewish orphan taken in by childless Ukrainian peasants: “You will be like a daughter to us,” they said, she remembered, I remembered. (Location 269)

Life is not just inside people; it passes through people. (Location 278)

The permanent distraction of doctors and nurses is a symptom of our malady. (Location 284)

People are much poorer at almost every task when they are close to a cell phone; both physicians had kept theirs turned on and close by. (Location 296)

Like everything that happened, this wasn’t my bad luck. It is the nature of the system that doctors are harried and make mistakes. (Location 306)

After my postoperative care was mishandled, I underwent another procedure on my liver, to add two more drains. (Location 314)

nerve damage caused by my immune system when it reacted to an overwhelming threat. (Location 317)

If some Americans have access to health care thanks to wealth or connections, they will feel pleased because they are included and others are not. Such a feeling turns our human concern about health into a silent yet profound inequality that undermines democracy. (Location 322)

When everyone has access to decent care at minimal cost, as is true for almost all of the developed world, it is easier to see fellow citizens as equal. (Location 324)

If everyone can assume that treatment will be available when necessary, they can turn their minds and their resources to other matters, make freer choices, pursue greater happiness. (Location 330)

When health care is competitive the winners do wrong to others, but they also get worse care themselves. (Location 336)

As I stepped back from death, I was looking for easy ways to bridge the gap between what I wanted to do and what I could do, (Location 344)

The Nazis treated health care as a way to divide the humans from the subhumans and nonhumans. If we see others as bearers of ailments and ourselves as healthy victims, we are little better than they. (Location 359)

If we truly oppose the Nazi evil, we will try to think our way to its opposite, to the good. (Location 360)

Stalin’s Gulag was run according to this logic of reverse health care. Because Soviet administrators regarded prisoners as economic units, health care was distributed according to calculations about productivity. (Location 364)

The constitution of the World Health Organization, founded in 1946, states: “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” (Location 374)

The Universal Declaration of Human Rights of 1948 states: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.” (Location 376)

Perhaps my grandfathers complained about pain during their working lives. But I can’t imagine their doing so. No one ever told me directly not to talk about pain, but I took this in very young. (Location 392)

Before there were medicines that worked to halt migraines (triptans), I found myself in the emergency room every few weeks, (Location 403)

When I got sick in December 2019, my diffidence about pain was unhelpful. (Location 405)

When my appendix burst I did not realize what had happened and ignored the pain: after all, I had been told that I had an infection and that it would hurt for a while. (Location 409)

My tolerance of pain comes from the same place as the rage that saved my life. It has helped me to do work that I value. Yet enduring pain in silence also creates a vulnerability, (Location 414)

We can slip from silence about pain to silence about addiction, as millions of Americans have done. (Location 417)

My brother, a physicist who has had to undergo several surgeries, says that opioids are harder on his brain than the procedures and the anesthesia. (Location 423)

The neurologist, who examined me carefully and ran tests, suggested that my worsening condition had to do with separation from people I loved. As a young man, I thought that he was either being very French or making fun of me. It took time for me to realize that he was onto something. (Location 432)

The difference is not that we have fancy chemicals and the Europeans do not. The difference is that doctors in Europe have time to do something beyond write out prescriptions. (Location 444)

Medication is important, but it has its limits. (Location 450)

In our country, where pharmaceutical advertisements are the main source of health information, we keep learning the lesson that suffering is our personal responsibility and that pills are the cure. (Location 457)

Suffering and self-medicating are both lonely activities; they can feel like free choices, but they create an imbalance that leaves us in bondage. (Location 459)

the four decades after the war were an era of upward social mobility. The last four decades have been tough. The number of manufacturing jobs peaked in 1979. (Location 466)

Small farming is becoming untenable as a way of life. Farmers, the men who seemed invulnerable to me as a kid, now kill themselves in higher numbers than people in just about any other line of work. (Location 469)

The welfare state, meant to complement the solitude of ambition with the solidarity of support, has been taken apart. (Location 472)

Until the 1980s, American fathers who worked hard could expect better life chances for their children. That is no longer true. (Location 474)

It used to be that American politicians competed with visions of a brighter future. Now a good deal of our politics is the solicitation and manipulation of pain. (Location 477)

Pill mills are doctors’ offices where physicians do nothing but prescribe opioids, usually in exchange for cash. (Location 480)

If all we have is lonely rage, we fail, become addicted, listen to the wrong people, harm those we care about, and die. (Location 487)

The one piece of information that best predicts whether Mr. Trump won or lost a county in November 2016 was the degree of opioid abuse. (Location 490)

Desperate voters close off care to themselves, their families, and everyone else by voting for politicians who traffic in pain. (Location 495)

Once pride becomes resentment, we forget that we need help and claim that only others do. (Location 498)

They want people staggered by suffering, and so they oppose health care. Pain is their politics; their propaganda is a death trap. (Location 501)

But hypocrisy is the least of their sins. Flattering while denying care adds sadism to manslaughter. (Location 507)

Between the choice to live in pain and the choice to take pills, there should be a world of alternatives: health care that we can find, or that can find us. (Location 512)

If we are concerned about American health, and American freedom, then everyone should be insured, and everyone’s insurance should cover what helps to relieve pain. (Location 515)

It is tempting to find meaning in suffering and death. (Location 520)

Brutal amputations were common, pus and swelling were misunderstood as signs of healing rather than infection, and burns were treated by bleeding the patient. (Location 535)

Jefferson thought that health was the most important element of a good life, after morality. (Location 544)

its authors had the wisdom to specify that “the enumeration in the Constitution, of certain rights, shall not be construed to deny or disparage others retained by the people.” This leaves room for a right to health care. (Location 546)

We are not free when we are sick. And when we are in pain, or when we are anxious about illness to come, rulers seize upon our suffering, lie to us, and strip away our other freedoms. (Location 550)

# LESSON 2. Renewal begins with children.

One night I woke from a nightmare to the realization that my photographs of their first few years of life were not backed up. (Location 564)

That pregnancy and birth, the first for Marci and me, created a sense of what good health care felt like from the inside: intimate and inexpensive. (Location 574)

Throughout the pregnancy (and after the birth) my wife carried a handy “mother-child passport,” recognized throughout the country, where doctor visits, test results, and inoculations were recorded. (Location 577)

Austrians usually speak a neutral version of German to foreigners, but in intimate settings switch to dialect, which is harder to understand. (Location 581)

In the United States, one often has the feeling that there is a hidden logic dictating events, because there is: a logic of profit. In Austria, it was clear that the goal was the welfare of the unborn child. Prenatal visits were mandatory, in exchange for access to the welfare state. (Location 587)

After the birth, mother and baby were required to remain in the hospital for ninety-six hours. The idea was to ensure that newborns got a good start and that mothers learned how to breastfeed. (Location 597)

The nurses were not interested in how the mothers felt about breastfeeding; they had a program to make sure that breastfeeding began. (Location 602)

About ninety percent of mothers in Austria learn how to breastfeed. (Location 604)

My relative satisfaction with health care that was less terrible than others’ kept me from seeing how disastrous the entire system was, and how much better it could be. (Location 616)

it is important to acknowledge how policy changes practices, and how practices change norms. (Location 622)

The horrors of the twentieth century had made German a language of death. As old ladies on the sidewalk complimented me on my beautiful child, German became a language of life. (Location 626)

In large matters and small, machine protocols get between patients and their caretakers. The computer programs are about billing, and (Location 633)

In the United States one has to have good insurance or spare cash to see a lactation consultant, and most people do not. In this way, inequality affects the biology of babies from their first hours. (Location 654)

we were stunned at the quality of the public preschool in our working-class neighborhood. It had the amenities and good cheer of the private day cares and preschools we had visited at home. (Location 662)

We felt bad about that. There was a twinkle in his teacher’s eye when we raised the subject: “But what a great feeling it is,” she said kindly, “to knock something down.” (Location 668)

I had trouble understanding why American parents were so feverishly engaged with their own children, yet so hesitant about making contact with other children. (Location 673)

The institutions that helped us, from the public hospital to the public kindergarten to the public transport (with an elevator at every subway stop), were not one-way gifts to families with children. They were an infrastructure of solidarity that held people together, making them feel that at the end of the day they were not alone. (Location 691)

How children are treated when they are very young profoundly affects how they will live the rest of their lives. That is perhaps the most important thing that scientists have to teach us about health and freedom today. (Location 701)

caring about freedom means caring about children. But if we do, we can begin a renewal of a land of the free. (Location 705)

The capacities that people need in order to operate as free adults develop when we are small. The skills that we will apply to become unique human beings are created during the first five years of life, as the brain grows to nearly its full size. (Location 706)

We learn as very small children, if we ever learn, to recover from disappointment and to delay pleasure. Abundant research shows what allows these capacities to develop: relationships, play, and choices. (Location 709)

Freedom has to do with choice, but we can only choose among options we see. When we are trapped in fear we see everything in binary terms: (Location 712)

The paradox of freedom is that no one is free without help. (Location 716)

An adult who has learned to be free in solitude benefited from solidarity as a child. Freedom is thus a loan paid out and paid back over generations. Children need intense and thoughtful attention during those first five years. (Location 717)

A free country thrives over generations. (Location 720)

children need trusting relationships, unstructured play, and activities that encourage choices. (Location 722)

# LESSON 3. The truth will set us free.

friendly demeanor and gracious attitude (Location 750)

My roommate arrived on New Year’s Day, not long after returning from China, the day after authorities in that country confirmed the existence of a novel coronavirus. I soon developed a mysterious respiratory problem. I could not inhale deeply, and found it difficult to talk. (Location 752)

two ways medicine can get to truth. Sometimes treatment is a matter of thinking along with the patient, focusing on a story, and making sense of it. (Location 763)

Sometimes medicine is a matter of tests, a search for information by experimental means. (Location 765)

The president’s administration had disbanded the sections of the National Security Council and the Department of Homeland Security meant to deal with epidemics, as well as a special unit in the Agency for International Development that was meant to predict them. American health experts had been withdrawn from the rest of the world. The last officer of the Centers for Disease Control and Prevention assigned to China was called back to the United States in July 2019, (Location 771)

When Americans known to be infected were evacuated from a cruise ship in February, they were flown back to the United States on an airplane with hundreds of other people who were not yet infected. The people infected en route then scattered freely throughout the country. (Location 785)

The seven American counties with the most covid deaths would now rank among the top twenty countries. (Location 800)

Since the truth sets you free, the people who oppress you resist the truth. In any catastrophe, especially one of their own making, tyrants will find a mixture of blaming others and excusing themselves that includes an enticing element of what we want to hear. (Location 801)

Before I got sick I was reading The Lord of the Rings to my son and daughter. A noble character in Tolkien’s saga, the wizard Gandalf, is a teller of unwanted truths. (Location 806)

people choose ignorance to supply themselves with an excuse for submission: (Location 809)

Gandalf finally retorts that without knowledge freedom has no chance. (Location 810)

The truth takes work. Facts do not often line up with what we believe, want to believe, or are led to believe. Facts are what we apprehend when we place ourselves at the right distance between our emotions and the world around us. (Location 813)

This is how tyranny works: the truth tellers are banished as the sycophants huddle close. (Location 825)

No one likes bad news; an unchecked ruler never hears what he should from his yes-men; he then projects fictions, which he may actually believe, upon everyone else. This leads to suffering and death, which means more bad news, and so the cycle starts again. (Location 828)

It was tyrannical, in Plato’s sense of the word, because it revealed the tyrant’s narcissistic concern for his own image (“ the numbers”) over the reality lived by others— in this case the reality of an epidemic that would kill more Americans than any in the past hundred years. (Location 836)

It was delusive because it confused looking away with taking action, the absence of testing with the absence of infection. (Location 838)

His focus on a foreign source of “fault” meant that no one here was to blame. When no one bears responsibility, no one has to do anything. (Location 841)

Historians know that before we understood disease we blamed it on others, often people we had treated badly. (Location 842)

In the fourteenth century, Christians used the bubonic plague as an excuse to murder Jews to whom they owed money. (Location 843)

After contagion was understood, some people mischaracterized the science by associating whole groups with bacteria and viruses, or by claiming that hidden enemies delivered biological weapons. (Location 847)

The Republican Party, recognizing that Mr. Trump’s coronavirus policy was catastrophic, planned its fall 2020 election campaigns around blaming China for everything. (Location 851)

no matter where a contagion starts, we are all essentially the same in our vulnerabilities, and thus in our responsibilities. (Location 853)

Scapegoating another group aligns our minds with authoritarianism. First, we believe a tyrant who tells us that we are immune because we are innocent and superior; then, when we get sick, we believe that we must have been unfairly attacked by someone else, since we are innocent and superior. The tyrant who lied to us about our immunity and superiority then tries to gather power from our suffering and resentment. (Location 854)

Thomas Jefferson, Benjamin Franklin, and other men who founded this country were participants in the Enlightenment, an eighteenth-century expression of confidence that human life could be understood through the study of nature. A motto of the Enlightenment was “dare to know.” (Location 862)

public hygiene and mandatory vaccination, two developments that are largely responsible for the extension of human life in the twentieth century. (Location 865)

Once politicians embrace ignorance and death, their next move is to bluster and blame. (Location 872)

Rather than extending health care to all, a tyrant will watch people die, and try to stay in power by riding the roiling emotions of the survivors. (Location 875)

A tyrant sees malady as opportunity, presenting himself as the rightful arbiter of life and death. (Location 877)

In the worst tradition of tyrants, Mr. Trump threatened military intervention to halt the protests that followed. (Location 890)

Democracies where law is respected and the press is robust respond better to pandemics than do authoritarian regimes. (Location 893)

One of the limits on our democracy is the vast and unregulated presence of money in politics, which means that in times of crisis private equity firms and insurance companies get more of a voice in matters of life and death than patients and doctors. (Location 895)

Mr. Trump’s behaviors followed the authoritarian pattern: a denial of reality, the claim of magical immunity, the harassment of reporters, the transformation of a problem he caused into a loyalty test for others, the cultivation of fear as a political resource. (Location 899)

big data is not the same thing as the knowledge humans need to thrive. Values such as life, health, and freedom do not matter to machines. (Location 916)

Big data is generally about how your mind can be manipulated for profit, rather than how your body might better move through the world. It can reveal our particular cravings and fears, but not our common needs. (Location 924)

No social platform can promote freedom, since social platforms aim at addiction. (Location 932)

Reporters are the heroes of our time; and like all heroes at all times they are too few. (Location 937)

Reporting, like medical testing, is a way to produce facts. The reporter aims to be objective, getting close to an event while keeping emotions at a distance. (Location 941)

Most American counties no longer have a proper newspaper. First, media was centralized in larger groups. Then the financial crisis of 2007– 08 destroyed the livelihood of many reporters. Since then, the rise of social media has just about finished the job. (Location 950)

As local journalism fades, American attention shifts to national stories, ideology, and conspiracy theories designed to do harm. (Location 956)

Most of our country is now a news desert. News deserts kill us by depriving us of the information we need in our daily lives, and by leaving us confused at crucial moments when we need to act to protect our health and freedom. (Location 957)

Years before major media covered it, opioid abuse was like cancer: a subject one didn’t bring up at dinner because it probably concerned someone at the table. With too few local reporters writing about overdose, it took a decade for a national picture of the disaster to emerge. (Location 968)

By inviting a new epidemic we have extended a previous one. (Location 972)

Health is indeed like that; you appreciate it when it goes away. Truth is like health: we miss it when it fades. (Location 986)

If you lose your health completely, if you die, even the longing for health is gone. Something similar holds for truth. As we lose the people who produce facts, we are in danger of losing the very idea of truth. (Location 987)

The death of truth also brings the death of democracy, since the people can rule only when they have the facts they need to defend themselves from power. (Location 989)

We cannot generate this knowledge by ourselves as individuals: we need a general belief in the value of truth, professionals whose job is to produce facts, and robust institutions that support them. (Location 993)

paradox of liberty: we cannot be ourselves without help; we cannot thrive in solitude without the solidarity of others. (Location 994)

Local reporters warn us about dangers, help us to see challenges, and shield us from the divisive abstractions of ideology and the addictive emotions of technology. (Location 997)

We should have bailed out local newspapers in 2009; we should have bailed them out in 2020. They can be renewed now by a tax on the social media that exploited their labor and destroyed their livelihood, leaving the country poorer in spirit and weaker in health. (Location 1000)

We also need to remind ourselves what we know about leading a healthy life. (Location 1003)

The centralization of traditional media in our country eventually imploded into the black hole of social media, which consumes factuality without producing it. (Location 1004)

# LESSON 4. Doctors should be in charge.

In American hospitals, no one doctor ever seems to be responsible for a case, and patients strain to talk to anyone with authority. (Location 1030)

We have an imbalance between the technique of tests and the technique of conversation. Of course, it is possible to err too far in the other direction, as Germans and Austrians sometimes do, and righteously avoid tests and medication (especially antibiotics) that really are necessary. (Location 1031)

Although physicians were in short supply, what the Florida hospital did have in impressive numbers were elderly volunteers in khaki shorts and baseball caps. (Location 1043)

doctors have very little say in what happens around them, and waste their time and energy pacifying greater powers. (Location 1052)

The coronavirus was a financial bonanza for people with unrelated economic interests, such as owners of commercial real estate. (Location 1057)

Insurance companies and private equity firms had a voice in policy; physicians and patients had none. (Location 1060)

Our federal government managed to spend two trillion dollars without purchasing what we actually needed: tests, masks, gowns, and ventilators. (Location 1063)

A neighbor across the street, a physician with three small children who was treating covid patients at the local hospital, used our block email list to ask if anyone could spare masks: “the hospital is out of small N95 masks (my size).” (Location 1070)

Doctors and nurses were fired for bringing their own protective gear to work, since this revealed that hospitals’ stocks were inadequate. (Location 1079)

When Ohio started testing, a fifth of the positive results were from medical personnel. (Location 1087)

The reason why there are never excess beds, the reason why Americans who have appendectomies go home too soon, the reason why mothers are expelled prematurely from maternity wards, is that we have commercial medicine. The fundamental calculation is financial. (Location 1108)

Maintaining beds costs money. No hospital, in American commercial medicine, is going to maintain a reserve of beds when other hospitals do not do so. (Location 1115)

Then money will fly around: not to where the doctors might want, since they will not be asked, but to the sectors of the economy with the loudest voices. (Location 1119)

Health and life are human values, not financial ones; an unregulated market in the treatment of our bodies generates profitable sickness rather than human thriving. (Location 1124)

he suffered more afterwards than before, never walked properly again, and died exhausted by pain. (Location 1141)

we do not even learn from lawsuits about suffering and death caused by implants going wrong. It is likely that implants are one of the leading causes of death in the United States, perhaps even the single leading cause. (Location 1143)

The worse the problem of antibiotic resistance becomes, the less hard the market works to find the solutions. Most of the big pharmaceutical companies no longer research antibiotics at all. (Location 1151)

When you first see a nurse, she or he will likely have eyes on the screen rather than on you. This has dreadful consequences for your treatment, since you become a checklist rather than a person. (Location 1157)

When I read my own medical record, I was struck by how often doctors wrote what was convenient rather than what was true. (Location 1162)

When doctors enter their records, their hands are guided by the possible entries in the digital system, which are arranged to maximize revenue. The electronic medical record offers none of the research benefits that we might expect from its name; (Location 1164)

As one doctor explained, “Notes are used to bill, determine level of service, and document it rather than their intended purpose, which was to convey our observations, assessment, and plan. Our important work has been co-opted by billing.” (Location 1167)

Because hospitals could not perform profitable operations during the pandemic, they fired doctors just when patients needed them the most. (Location 1181)

health is mainly a matter of education and prevention, tasks more easily accomplished away from hospitals. (Location 1184)

The pressure and complication of insurance and record keeping force doctors to form groups. These groups are then purchased by private equity firms to form larger staffing companies, or purchased by hospitals, which are then purchased by other hospitals. (Location 1188)

“the Malady consists in the enormous Salaries, Emoluments, & Patronage of great Offices.” (Location 1193)

The life goal of a family friend in Ohio was to be a community doctor. And she managed to do this for a time, but only because her highly educated, math-oriented, and computer-literate husband made it his full-time job to deal with insurance and records. (Location 1195)

Specialists make more money than generalists, and young American doctors usually have debt. As a result, too few decide to become pediatricians and internists. (Location 1208)

One of the reasons specialists make more money than general practitioners is that surgery is easier to bill, and easier to charge to insurance companies, than primary care. (Location 1210)

If we value health, we can change what is profitable. (Location 1216)

Huge medical groups should be broken up by antitrust legislation. Doctors who provide primary care in underserved areas should have their debts forgiven. Gag orders of physicians should be made illegal. Doctors should be put in charge of revived federal agencies tasked with planning for and responding to epidemics. And doctors should be convened to help design a system in which all Americans are insured and have access to the care we need. (Location 1221)

# CONCLUSION Our Recovery

have knowledge about our problems, doctors entrusted with authority, time to spend with our children, and a right to health care. (Location 1229)

The idea that commercial medicine is efficient, even in simple economic terms, is grotesque. (Location 1237)

This financial chicanery makes us all sick. (Location 1246)

Solidarity means that everyone takes part, rather than some people opting out. A source of our malady is the drastic inequality of wealth that separates the experiences of a very small group from everyone else. (Location 1257)

When money becomes the only goal, values disappear, and people imitate the oligarchs. (Location 1259)

When we overlook the offshored billions of our oligarchs, we miss our chance to make Americans healthier and freer. (Location 1262)

We should regard health care as a right, take medical and local knowledge seriously, make time for young children, and put doctors in charge. (Location 1265)

Investing in childhood means less mental and physical illness down the road, less prison time, fewer broken lives. (Location 1268)

Economic logic says that the middleman should be removed when possible, and we know how it is possible in this case: with a single-payer system at the center of things, and private insurance at the margins. (Location 1271)

If we all cross the bridge to health together, the trolls cannot stop us. (Location 1273)

The most influential of the market economists, Friedrich Hayek, opposed oligopoly, or ownership by a few, which he compared to Soviet central planning. Our medical-industrial complex is a set of oligopolies. Our big data industry is also a set of oligopolies. (Location 1275)

Hayek worried about a “dispossessed middle class,” which commercial medicine is now creating. (Location 1278)

What we take for granted can change quickly and for the better. It can also change quickly and for the worse. (Location 1288)

It takes work to be free, and courage to see opportunity. This crisis is a chance to rethink the possible. (Location 1289)

Health care should be a right, doctors should have authority, truth should be pursued, children should see a better America. (Location 1290)

# EPILOGUE Rage and Empathy

For me gravel roads are about coming back, the rattle and rumble of rubber on rock announcing a return, a recovery. (Location 1304)

Even after we recover, scars and symptoms remain as a legacy of malady. Recovery is not going back to the way things were. (Location 1311)

My English vocabulary came back in bursts, like rain from some friendly cloud; I speak and write a little differently now. My other languages were not affected; (Location 1312)

when I look at my wife’s texts, I see that after surgery I asked for carrots, celery, and French mystery novels. (Location 1314)

History is never entirely behind us. We can learn from the aspirations and failures of previous selves and previous eras, and create something new. (Location 1319)

Each of us has a torch that rages against death. And each of us is a plank of a raft that floats through life with others. Health is our common vulnerability, and our shared chance to grow freer together. (Location 1324)

# Acknowledgments

Leah Mirakhor and Dr. Navid Hafez asked me to write this book. (Location 1335)

# Notes

These are themes that I discussed with Tony Judt in Thinking the Twentieth Century (New York: Penguin, 2012). I am making the case that what we take to be natural— competition for health care— is in fact artificial. For a broader argument along these lines, see Rutger Bregman, Humankind (New York: Little, Brown, 2020). (Location 1373)

My account of Hitler’s worldview can be found in Black Earth (New York: Tim Duggan Books, 2015). My other relevant book is Bloodlands (New York: Basic Books, 2010). (Location 1381)

Raul Hilberg, The Destruction of the European Jews (New Haven, Conn.: Yale University Press, 2003), 1: 271– 74. (Location 1384)

Nikolaus Wachsmann, KL: A History of the Nazi Concentration Camps (Location 1386)

Golfo Alexopoulos, Illness and Inhumanity in Stalin’s Gulag (Location 1388)

“Sleep, nutrition, relationships,” as a nurse once defined the fundaments of health care to me. (Location 1390)

Sam Quinones, Dreamland: The True Tale of America’s Opiate Epidemic (Location 1404)

The Road to Unfreedom: Russia, Europe, America (Location 1416)

Arlie Hochschild, Strangers in Their Own Land (Location 1417)

It is useful to know that the founders of Amazon and Google attended schools where screens are not allowed, and that Steve Jobs kept his children away from his company’s gadgets. Nicholas Kardaras, Glow Kids (New York: St. Martin’s Griffin, 2016), (Location 1432)

No one I know in Silicon Valley sends their children to a school where screens are allowed. Even babysitters there are required to sign agreements not to bring the addictive products into the home. (Location 1434)

American Journal of Preventive Medicine, (Location 1441)

Heather Boushey, Finding Time (Cambridge, Mass.: Harvard University Press, 2016). (Location 1444)

Frank Harrington, “The Spies Who Predicted COVID-19,” Project Syndicate, April 16, 2020. (Location 1459)

Shoshana Zuboff, The Age of Surveillance Capitalism (London: Profile Books, 2019) (Location 1562)

Safiya Umoja Noble, Algorithms of Oppression (New York, NYU Press, 2018); Virginia Eubanks, Automating Inequality (New York: St. Martin’s, 2017). (Location 1572)

Brett Frischmann and Evan Selinger, Re-engineering Humanity (Cambridge: Cambridge University Press, 2018); Jaron Lanier, Ten Arguments for Deleting Your Social Media Accounts Right Now (New York: Henry Holt, 2018); (Location 1579)

Most of our country See the continuing work of Penelope Muse Abernathy,; also Margaret Sullivan, Ghosting the News (New York: Columbia Global Reports, 2020). (Location 1590)

Peter Pomerantsev, Nothing Is True and Everything Is Possible (New York: Public Affairs, 2015); and Anne Applebaum, Twilight of Democracy (London: Penguin, 2020). Three points of reference are George Orwell’s “The Politics of the English Language” (1946), Hannah Arendt’s “Truth and Politics” (1967), and Václav Havel’s “The Power of the Powerless” (1978). (Location 1605)

ventilators. One reason why they ran short is that they are produced only in an expensive and complicated form. When the federal government tried to contract a company to build cheaper and simpler ventilators, it was purchased by another firm that made the costlier variety. (Location 1648)

Right now about 66 percent of all mammal biomass is domesticated livestock, and another 30 percent is human, meaning that all wild mammals taken together account for only about four percent. (Location 1654)

How Doctors Think (New York: Houghton Mifflin, 2007), (Location 1661)

These surprise charges are one way that private equity firms try to make a quick profit after buying hospitals and loading them down with debt; the result is that more people are shut out of health care. (Location 1688)

Friedrich Hayek, The Road to Serfdom, ed. Bruce Caldwell (Chicago: University of Chicago Press, 2017 (Location 1700)

first lecture in half a year It was recorded:; I begin at 20: 45. (Location 1702)


Nationalism, Marxism, and Modern Central Europe: A Biography of Kazimierz Kelles-Krauz, 1872– 1905 Wall Around the West: State Borders and Immigration Controls in the United States and Europe (ed. with Peter Andreas) The Reconstruction of Nations: Poland, Ukraine, Lithuania, Belarus, 1569– 1999 Sketches from a Secret War: A Polish Artist’s Mission to Liberate Soviet Ukraine The Red Prince: The Secret Lives of a Habsburg Archduke Bloodlands: Europe Between Hitler and Stalin Thinking the Twentieth Century (with Tony Judt) Stalin and Europe: Imitation and Domination, 1928– 1953 (ed. with Ray Brandon) Ukrainian History, Russian Policy, and European Futures (in Russian and Ukrainian) The Politics of Life and Death (in Czech) The Balkans as Europe, 1821– 1914 (ed. with Katherine Younger) And We Dream as Electric Sheep: Humanity, Sexuality, Digitality (in German) Black Earth: The Holocaust as History and Warning On Tyranny: Twenty Lessons from the Twentieth Century The Road to Unfreedom: Russia, Europe, America (Location 1706)