Laguna Honda sounds like a car, but it’s a hospital. It’s an almshouse in San Francisco, a place of refuge for several thousand people. It’s the last such institution in America: not an homage to high-tech mechanized medicine, like every other hospital in the country, but more of a garden in which waifs and strays who can’t go home because they have no home to go to, who can’t be cared for in the community because they have no community, can instead be regenerated. It’s a kind of New Orleans Superdome without the drama and urgency and horror but with the same slow-burning, mirror-to-the-nation pathos.
This unusual setting, an inheritor of the Hôtel-Dieu, in which the poor were cared for in medieval Europe, becomes in this absorbing book the stage for a fourfold pilgrimage. The volume is a study in patience with patients: author Victoria Sweet carefully explains the details of a series of memorable people who taught her and trained her as they opened her eyes and her soul to the nature of healing. It is a study in the hospitality of a hospital: every chapter tells of an ongoing (and often comic) battle between administrators, with their new schemes for counting, measuring, improving and evaluating, and the doctors, nurses and patients who continue to elude and evade the constraints of the bureaucrats while discovering what health is really about.
It is a study in the nature of medicine itself: unlike a book such as Ann Patchett’s State of Wonder, which appears to be a critique of American medicine but remains too much in thrall to its subject, God’s Hotel is not taken in by the sophistication of the awesome American medico-educational complex; instead it disarmingly offers imagination, practice and a complementary ethos.
It is, in the end, a personal pilgrimage: the author finds wisdom in her studies, in her visits to Europe, in walking the route to Santiago de Compostela, in remaining faithful to the hospital, its staff and its patients through sunshine and rain. All four pilgrimages are interlaced throughout the book: they are not, finally, detachable from one another.
In a crucial passage, Sweet encounters a Mrs. Muller, who, it seems, is diabetic, demented and psychotic. On close inspection Mrs. Muller turns out to have a dislocated hip: her other conditions gradually and movingly evaporate as it becomes clear that they all had arisen in response to the poor treatment of the hip. Sweet calculates that her own practice of “slow medicine”—paying close attention to patients and letting them remain in the hospital rather than resorting to interventions and medications from the outset—had in this one case alone saved the health-care system about $400,000. In exasperation she points out that in the pervading medical culture, “No expense was spared for medications, tests, and procedures, but to make up for that, staff, food, and accoutrements were cut to the bone.” All these extremely expensive interventions are usually considered necessities, while doctors and nurses are considered a luxury. She estimates that slow medicine, by discontinuing perhaps ten or 12 unnecessary medications per person, is “more efficient than efficient healthcare by at least seventy dollars per day.”
But the real focus of the book is above and beyond health-care budgets. Every scribe who has been trained for the kingdom of heaven is like the head of a household who brings out of her treasure what is new and what is old. Sweet brings out of her treasure a continual array of gifts and insights about medicine and hopeful life that infuse her account with wisdom, challenge and encouragement.
At the root of this wisdom lies the unlikely medieval figure of Hildegard of Bingen. Sweet notes there are two Hildegards in academic discourse: the theological woman of letters, and the medical infirmarian who knew a lot about the body you wouldn’t expect a medieval nun to know. Sweet’s academic project, against the grain of the field, is to synthesize the two.
The setting for this synthesis is a year in a Swiss hospital, where Sweet finds, astonishingly and symbolically, that the emergency room is comfortable, pleasant, congenial—and empty. This discovery epitomizes the revelation intended by the whole book and synthesizes the personal, medical, administrative and intellectual challenge Sweet’s cumulative argument represents. The empty Swiss emergency room is a visual, unforgettable, undeniable and compelling critique of American medicine: for the crisis of American medicine is, without doubt, crystallized in its emergency rooms.
Sweet is a born teacher, and she loves nothing more than to dwell on the etymology of key words in medicine. It’s time well spent. Thus, for example, she recalls that neither the Greeks nor the Romans had hospitals. The hospital tradition began with the medieval monastery, wherein caring for the sick poor and the ailing monks was the foremost Christian duty. Hence Western society’s commitment not to give up on people simply because they can’t contribute to its economic well-being. In Latin, hospes means both host and guest: the roles are interchangeable. For the monks (unlike the Romans), that wasn’t because they were only in the business of caring for people of the same class; it was because, by the tradition of the parable of the last judgment, any guest could be Christ. In communicating this truth, Sweet realizes she hasn’t been the host at Laguna Honda: she’s been the guest.
This is a winsome, elegant, nuanced, engaging manifesto for a partnership between contemporary and more sane medical practice, delivered in narrative form. Occasionally Sweet trespasses into the studiedly ironic self-referential quaintness of This American Life, but for the most part she practices what she preaches: close attention to the patient, careful employment of historic and alternative wisdom and combative challenges to the absurdities of bureaucratic nostrums that have little to do with either health or care. By remaining a pilgrim through Hildegard, medicine and life, Sweet avoids setting herself up as the fount of a new wisdom. Instead, she whets the appetite for a generation of physicians, nurses and—dare one hope?—administrators who will rediscover the roots of health and well-being in interdependent community, patient attention and complementary and collaborative methods of treatment.
In doing so, Sweet offers the church a model of witness. Hers is not a style of denunciation or campaign or protest or demand. Instead she combines research and practice; she sets out to learn before she proclaims; she realizes the answers may lie outside her own experience; she pays close regard to patients as the possible source of their own problems; she holds off from techniques and solutions until it’s clear what their role might be; and she knows she’s on a pilgrimage, which, like all pilgrimages, becomes a lesson not only in the destination but in the discoveries to be made on the way there.