Doctor shines light on the good and bad of a troubled health care system
In ‘The People’s Hospital,’ Dr. Ricardo Nuila draws from his time at Ben Taub Hospital
As his book “The People’s Hospital” winds toward its conclusion, Dr. Ricardo Nuila tells the story of a patient named Geronimo. Geronimo, 36, arrived at Ben Taub Hospital with an ailing liver about to initiate a chain reaction of organ failures. His disability check just exceeded the threshold for Medicaid, so Geronimo’s medical team at Ben Taub reached out to local officials for help getting him to qualify for a transplant.
Nuila brilliantly sets up a high-stakes narrative of life and death in a dysfunctional national health care system. He presents a scene involving health care workers, a patient and his family, a low-income health insurance program and, adding a touch of absurdity, a congressman.
Obscured by all the action of diagnosis and negotiation is a medical procedure that has existed for 60 years: a human to human liver transplant.
Here, the storyteller gently pumps the brakes to remind readers of the miraculous nature of an occurrence we’ve come to take for granted. “Each time a liver is transplanted into a new host,” Nuila writes, “it’s the medical equivalent of a rocket breaking through the atmosphere.”
An internal medicine physician, Nuila has written a first book with symphonic breadth and organization: Themes appear and reappear; he counters drama and grandness with quiet, contemplative and intricate moments. Parts of the book slip into the realm of memoir, as Nuila, a Houston native, is a child and grandchild of doctors and also the child of Salvadoran immigrants, which allows him to detail the ways practicing medicine has changed across generations and across borders. At times, his book is pointed and damning about a health care system, maddening for its complexities, inconsistencies and costs.
In February 2020, Nuila read from “The People’s Hospital” at Inprint Houston’s Poets and Writers Ball. Then, his book seemed imminent. Three years and one global pandemic later, “The People’s Hospital” has finally found its way to bookstore shelves.
“I felt so naïve,” Nuila says. “I’d tell people I was writing a book about health care and Ben Taub. They’d ask when it would be done, and I’d answer ‘in six months.’ That was six years ago. But every moment, it felt like I was going to turn a corner there would be something else to do, something new to write about.”
Part of the complicated process was determining the voice he wished to present in the book. Nuila originally envisioned a collection of narratives about a few particular patients he’d treated in his time at Ben Taub. He gradually grew more comfortable inserting himself into the narrative. He ended up with a story that is reflective, descriptive and prescriptive.
“There was this mental block where I didn’t want it to be about me,” he says. “I feared it being labeled a medical memoir. I saw those books when I was coming up through medical school. That kind of narrative has been done before. I wanted to focus on the patients’ narratives. But thinking about my career and my dad’s, I could get into things like how the system has changed as well.”
Is health care earned?
Nuila received a D on his first proper English essay as a freshman in high school.
“It had no thesis,” he says. “But I don’t think I knew what a thesis was at the time.”
The summer before his sophomore year, Nuila’s reading assignment was Cormac McCarthy’s “Blood Meridian.” He blitzed through it with the simple goal of completing the assignment.
“I realized I didn’t understand any of the book,” Nuila says. “So I tried again. I slowed down and went through each sentence.”
That experience subtly permeates the pages of “The People’s Hospital,” whose author — despite working in a field of frenetic activity — wields a degree of control over time. The patients presented in the book represent a small percentage of those Nuila has seen since he arrived at Ben Taub as an intern more than a decade ago. But the author creates a comfortable pace that courses through the processes at Houston’s Level I public hospital, where patients have arrived, he writes, “with hand-drawn maps, our hospital marked like treasure.”
The book finds a fulcrum in Roxana, a patient without private insurance who entered Ben Taub with signs of gangrene on her arms. Because her condition wasn’t immediately life-threatening, she would have been viewed in many hospitals as stable and not admitted. Throughout his book, Nuila highlights a philosophical disparity: Is health care a right? Or is health care earned?
Nuila makes reference to “The Hospital,” which becomes something of a shadow text to “The People’s Hospital.” “The Hospital” concerned Fourth Ward’s Jefferson Davis Hospital, whose conditions were so bad they prompted Dutch writer Jan de Hartog to write his 1964 book about the “monument to misery.”
“The People’s Hospital” presents an institution that suggests progress over 60 years. But in a city renowned for its medical institutions, Ben Taub is an outsider.
A fork in the road
Given the density of his workdays, Nuila could easily have drawn his narrative strictly from the confines of his hospital. But part of his training as a physician served him well as a writer.
“There’s this fundamental desire to get to know the people I see as a doctor and better understand their lives,” he says.
He applied the same approach to the reporting and writing process. Nuila found several patients willing to meet and discuss their experiences in interviews conducted after their discharge.
“I think going to their homes and speaking with them, it was crucial for their stories to be complete,” he says. “If they’re going to be in the book, you don’t want them to be static. So it felt important to understand their lives.
“Of course, that was a tough part of the process. It took a lot of time.”
Nuila found a way to balance his two passions, but years ago he wondered if they were incompatible. While studying at Baylor College of Medicine, Nuila thought about abandoning his path in medicine. “I loved my literature and English classes,” he says. “But I had a writing instructor who told me I’d be crazy to leave medicine. He said I should learn all I could about creative writing, but medicine is where I’d find the stories. And that stuck with me.”
While working at Ben Taub, Nuila took writing workshops offered through Inprint.
“I was attentive to these stories at the hospital,” he says. “But I was struggling trying to figure out how to be a writer. And I really wanted to write. I had an appreciation for what a good sentence required. But I was struggling with how to string them together and call them a form. So those workshops are where I learned the basic rules of writing. How to build a scene.”
In talking about writing, Nuila could also be talking about medicine: “I love the puzzles, figuring things out.”
Part of the process
Nuila hasn’t committed to a next project yet, but he’s intrigued at pursuing some ideas in the realm of fiction. “I feel myself drawn to fiction and beauty a bit right now,” he says. “We’ll see where it leads.”
But it’s hard to imagine “The People’s Hospital” won’t prompt demand for further commentary on the health care system in the United States.
The book publishes this week, and it already has drawn strong notices in the New York Times and on NPR.
The author’s ability to braid such wide-ranging elements — reportage, critique, memoir — into a single narrative generates a strong pull.
At one point in “The People’s Hospital,” Nuila plays the part of patient. Like many of us, he receives in the weeks following his discharge a confounding spate of medical bills, despite the fact that he was insured. Nuila knew the system well enough to competently protest certain charges. And he knows not every patient can navigate the system the same way.
“I’m lucky in that I’ve not had much necessity for health care,” he says. “But we all need the system in some way at some time. And when we do, it often feels Kafkaesque.”
He knows some of the issues raised in “The People’s Hospital” will prompt strong reactions but says, “my goal wasn’t simply to preach to the choir. I try to avoid left/right characterizations.”
He sees in Ben Taub a path for health care outside the exclusivity that emerged when health care became a businessfirst industry, where “safety-net hospitals” are prevalent rather than outliers. And because of his work, Nuila is able to do so without undercutting the value of the medicine itself — as when he informs readers in the book that surgeons call a liver transplant “a Lazarus procedure for a reason.”
After years of practicing medicine and years of writing, Nuila says, “I almost see medicine and writing as one thing. Both train you to appreciate nuances. My mind has become less dogmatic because of writing. And it’s helped me as a doctor. They’re both about searching. And early on with both, I’d be task oriented. Now I don’t see myself as being as task oriented. It’s all part of a process.”
“There’s this fundamental desire to get to know the people I see as a doctor and better understand their lives.”
Dr. Ricardo Nuila