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Just Another Business

The Knick sharply captures American health care's historic inequities.

Clive Owen (center left) stars in The Knick, a TV drama about an early-twentieth-century Manhattan hospital Mary Cybulski / Cinemax

The abdomen, chest, and brain,” a British surgeon said in 1874, “will forever be closed to operations by a wise and humane surgeon.” In The Knick, a Cinemax drama whose subject is an early-twentieth-century Manhattan hospital, we can see he was soon proven wrong.

The series — whose second season began airing last week — depicts the gloveless hands of surgeons aggressively exploring all three of these daunting body cavities. It’s this bloody medical realism, set to a minimalist score under Steven Soderbergh’s direction, that has deservedly attracted much attention.

Yet the show’s exploration of some of the American health care system’s troubling underpinnings has been at least as compelling. In particular, The Knick intelligently portrays the terrible practice — and legacy — of “medical apartheid,” as well as the rise and commercialization of the American hospital.

The series centers on the Knickerbocker, a fictional “charity” hospital located in the Lower East Side at the turn of the century. Waves of immigrants are arriving from Eastern Europe and Ireland, and surgery is undergoing a revolution — in The Knick, thanks to the likes of the fictional John Thackery (Clive Owen), the hospital’s dazzling, drug-addicted head surgeon (cocaine injection by day, opium inhalation by night).

The Knickerbocker’s robber-baron patron, meanwhile, evinces a liberal streak, hiring as Thackery’s deputy surgeon Algernon Edwards (André Holland), a black physician who trained in Paris. The beginning of the second season finds Thackery consigned to an institution for treatment of his addiction (in truth, the drugs flow freely), while Edwards has risen to interim chief in his place.

Throughout the show, the conflict between Edwards and his surgical colleagues gives some sense of the racism that black health care workers encountered in this era. Though many have heard of the infamous Tuskegee syphilis experiment, the degree to which racism suffused the entire structure of American health care is less known.

The barriers for black physicians were enormous: the show’s conceit that Edwards attended medical school at Harvard, for instance, is unbelievable — according to one history of American medical education, the school didn’t admit a single black medical student until after World War II. Today, the persistent socioeconomic gulf created by slavery and racism contributes to persisting racial disparities in the proportions of physicians of color.

Of course, racism wasn’t merely a problem for practitioners, but for patients. In The Knick, Edwards witnesses a black patient flatly refused admission into the hospital’s clinic, which pushes him to open a makeshift operating room in the hospital basement. While some aspects of this plot arc prove a bit strained — while running the underground clinic, Edwards manages to rapidly pioneer new surgical techniques and technologies — it realistically depicts the systematic relegation of people of color to inferior hospital facilities.

Down South, Jim Crow meant apartheid-like hospital segregation. But even where hospitals weren’t separated by race, Charles E. Rosenberg writes in The Care of Strangers: The Rise of America’s Hospital System, blacks would nonetheless “occupy the least desirable locations ” — in some cases being “shunted into basements or attics.”

Nor was this short-lived. Several decades later, there were still extraordinary incidents of racism — including at the actual Knickerbocker Hospital. “In one much-publicized incident,” the book Harlem at War details (as quoted in an article exploring the show’s potential namesake), “the wife of [musician] W. C. Handy . . . lay critically ill in an ambulance for more than an hour while officials of Knickerbocker Hospital discussed whether to admit her.”

The cardiologist Bernard Lown — renowned for developing the direct-current defibrillator and for his long career of progressive activism — found similarly “blatant racism” at Johns Hopkins medical school shortly after World War II. “There were no black doctors, medical students, or nurses,” he writes, while “white” and “colored” blood were segregated for the purposes of transfusion (a convention Lown subverted by mislabeling bottles of blood).

In Edwards’ underground clinic, we see the dismal reality of segregated medicine. At one point, for instance, Edwards runs out of stitches while operating and is forced to dash upstairs for supplies while the patient bleeds to death.

There have been improvements in the study and alleviation of these fatal disparities. But truly addressing such inequalities would mean going beyond the mainstream “disparities” discourse and disrupting two of their most pernicious sources: economic inequality and our non-universal health care system.

Which brings us to the show’s second, albeit related, political theme: its depiction of the financial prerogatives and charitable bona fides of the early American hospital. In the series, hospital higher-ups frequently tout the care they provide to, as one board member calls them, the “poor and unwashed” immigrant masses of lower Manhattan.

The truth, however, is far more complicated. Hospitals do have their origins, in the Byzantine Empire, as fundamentally charitable institutions for the poor. By the early twentieth century, however, they were already transforming into profit-oriented institutions.

“From the late nineteenth century on,” Rosemary Stevens writes in her history of the American hospital, In Sickness and in Wealth, “US voluntary hospitals have relied, to a great extent, on fees from paying patients.”  Though they continued to draw on the largesse of rich benefactors, “in terms of day-to-day operations . . . the early-twentieth-century hospital was more like a business,” incentivized “to behave as successful, competitive enterprises in which the goal was expansion of units sold, including surgical operations and filled private beds.”

The pecuniary side of care is sharply portrayed in The Knick (even if the show at times succumbs to cable-TV excess). In the pilot episode, the hospital’s ambulance driver is paid for bringing in a wealthy uptown patient, who he basically steals from a rival hospital’s ambulance at the point of a club. “Hooked a fine one. Banker from up Fifth Avenue,” the driver tells the hospital administrator. “I’m sure this one will be in a private [room] with us for a few weeks and be paying his bill in full.”

Members of the hospital board have similar motivations. In response to various financial pressures, they push throughout the first season to close the Knick and head uptown, where richer patients can be found.  “[W]e’ve held our charitable hand out much too long,” says one board member. “Medical advice is as much a commodity as bread,” argues another. “And to give either one or the other to the unworthy is wrong. It encourages irresponsibility and reckless use of valuable resources.” Such arguments eventually win out, and in last week’s episode, construction for a new uptown hospital begins.

These boardroom conflicts reflect the Janus-faced essence of the early American charitable hospital.

Consider this description in a 1914 directory of the real-life Knickerbocker Hospital (cited in the aforementioned article on the institution): “Gives free medical and surgical treatment to the worthy sick poor of New York City. Incurable and contagious diseases and alcoholic, maternity and insane patients not admitted.”

Also striking are the figures from the hospital’s 1903 annual report, before it was named the Knickerbocker (the intended relationship of the show’s hospital with the institution of the same name is unclear, but unimportant for this point).

Of 15,191 total days of hospital treatment for the year, for instance, only 955 were “wholly free.” The report also shows the hospital’s dependence on additional funding from the city — also portrayed in The Knick when the hospital administrator gives kickbacks to the city health inspector for subsidized tuberculosis patients sent his way.

The charitable core of the hospital, in other words, was on the wane. “Free care,” according to Stevens, “seemed, increasingly, an annoying and unnecessary loss to the hospital; certainly not the central purpose of the enterprise.”

The balance between the hospital as a business and the hospital as a charity, however, shifted over time. The commercialization of the American medical enterprise — which now includes the mammoth pharmaceutical and insurance industry — increasingly consigned the voluntary charity hospital to the dustbin of history. But this was not the only path: hospital care could’ve been transformed from charity to social right, instead of charity to commodity.

Thackery, when he is in his right mind, scoffs at this emergent commercializing tendency. He’s uninterested in the board’s financial scheming. He rejects a lucrative offer from a patent medicine company, whose representative he tosses from his office: “Away you moldy rogue, away.”

For though he is an intolerant, self-destructive egomaniac, he is — at heart — a true believer in the crusade of medical progress. Viewers can’t help but root for him when he employs a new technique for caesarian sections that allows him to save — at long last — the life of a woman dying from an obstetrical hemorrhage.

That triumphant spirit must be part of the Left’s health care vision — one that harnesses the zealous pursuit of medical progress, but in service not of ego or money, but of society. And our aim shouldn’t be to recover the charity hospital of a bygone era, but a future where all can share equally in the product of that progress.