I am not a physician. I have never cultured a specimen, read a chest film, or signed a death certificate. I trained as a dramatist at Columbia, in the Oscar Hammerstein II Center, which qualifies me to tell you how a scene builds and not much else about a hospital. So let me get the obvious objection out of the way early, because it is the first thing a serious reader should ask. What business does a playwright have writing a book about hospital-acquired infection? The answer is the whole book, and it starts in a shut room in Newark in 2002.
The Word in the Shut Room
I was teaching in the School of Public Health at what was then the University of Medicine and Dentistry of New Jersey. I had been hired by William Halperin, a physician who had spent a career at the Centers for Disease Control counting the dead, and he had hired a playwright on purpose. His students, he thought, had been trained into a precision that cost them something. He wanted somebody to loosen it. My course was called Public Health Crises Reflected in the Humanities, and it sat epidemiologists in front of a play, a film, a photograph, and made them say out loud the thing their training had taught them to swallow.
One afternoon, door closed, Bill asked whether I knew the word nosocomial.
I did not.
He answered his own question, the way a teacher does when the room has gone quiet. Nosocomial means hospital acquired. It names the illness a patient did not have on the way in and is carrying on the way out.
The following week I put the same question to my graduate students. Not one of them knew it. Some of them were already working in clinics and health departments, in the field whose entire job is to count this kind of harm, and the word for it was new to every person in the room.
That is the moment the book comes from. Bill had known the word since medical school and had filed it, the way a long career teaches you to file the unbearable, under the ordinary. His students had never heard it. And I, arriving cold in middle age, heard it once and could not put it down.
Why the Late Arrival Is the Qualification
Here is the turn, and it is the reason I think the objection answers itself.
Nosocomial is more than a century old. Somebody needed that word. Somebody coined it, taught it, and handed it down through generations of physicians who have said it ever since without a flinch. A word like that is a container built to hold something unbearable at a temperature a person can carry. Say hospital-acquired infection often enough and it becomes a line item. Say adverse event and the blood drains out of it. Call a death a mortality outcome and you have moved it into a spreadsheet where it can be totaled and compared and discussed on a Tuesday afternoon without anybody’s voice breaking.
My whole trade runs that machine backward. A dramatist takes the smoothed and swallowed thing and grinds the edge back onto it until it can cut again.
The medicine in this book is not mine and I never pretend it is. The counts, the cultures, the peer-reviewed findings, all of it comes from people who do that work and publish it. What I brought is the refusal to let a proven horror be discussed calmly. The doctor supplies the evidence. The dramatist supplies the insistence that the evidence is unbearable and ought to be treated that way.
Arriving late turns out to be a form of sight. The people who feel a horror last are sometimes the only ones left who can still see that it is one.
What the Book Actually Does
DO HARM runs in three movements.
Part One is the provable case, built on numbers a reader can check. It opens in a Vienna maternity ward in 1847, where Ignaz Semmelweis worked out from a register of the dead that he and his colleagues were carrying childbed fever from the autopsy room to the delivery bed on their own hands. He put a basin of chlorinated lime at the door and the death rate collapsed, and his colleagues destroyed him for it. He died in an asylum of the same class of infection he had spent his life trying to stop. From there the book moves to the organisms our own antibiotics bred, to the ventilator and the catheter that run infection down roads built to deliver care, and to copper, which has killed bacteria since the age of the pharaohs and still goes uninstalled.
Part Two carries the shape into rooms where nobody can take a culture. The prison built to stop crime and teaching it; the asylum called a place of safety; the classroom that promises to open a child’s mind and measures, year on year, the closing of it; the parish and the camp and the troop, where the trust that makes the good work possible is the same trust that makes the predator possible; the study that priced a child’s blood against a cheap repair; and the faith that promised to carry its people out of the world and kept the promise the only way it could.
Part Three asks why the harm survives being proven, which is the question Semmelweis’s failure poses and every institution since has answered the same way.
The Chapter Where I Lose
Now the part I would rather not advertise and am going to advertise anyway.
In Chapter Five I set down a rule for telling a floor of harm, the kind welded to a function, from an alibi dressed up as one. Five conditions, written to disqualify other people’s claims. In Chapter Eleven I ran that rule across the part of the American hospital infection rate I had spent four chapters calling a floor.
It failed on three of the five.
Read the direction of that, because it runs opposite to what you would expect. If that residue is not a floor, then more of the harm is preventable than I had credited, and the hospitals have less cover than I gave them. The error I corrected was one I had made in their favor.
The floor sits lower than I put it, and I cannot tell you where. I left the failed test standing on the page, in the order it failed, because a rule like that only earns its keep when somebody runs it and prints what comes back, including the times it comes back against the person who built it.
A book that indicts institutions for defending themselves against their own evidence does not get to be an exception.
Where It Sits
DO HARM stands beside the Institutional Autopsy trilogy, Carceral Nation, The Claimed Body, and Underwritten, and it is the volume where the method gets tested against a case that can be measured. Everything in those books argued from the record. This one argues from the record and from a colony that either grows on a plate or does not.
I have also taken the book out to the rest of the constellation this week. There is a Human Meme episode on the word itself and what euphemism is built to do, and a Prairie Voice piece that comes at the whole argument through a lost cemetery at a federal boarding school in Nebraska.
The book refuses to close on a cure and says so on its first page. What it asks for is smaller than a cure and harder than a motto. Name the floor. Remove the harm that is not floor. Tell the patient the truth about what the cure is carrying into them. And when the machinery does harm, refuse the comfort of a blame that settles on nobody at all.
Bill asked me a question across a desk twenty-four years ago and then answered it himself, because I had nothing to give him. This is the answer I have spent the time since assembling.
DO HARM: Nosocomial Disease and the Institutions That Manufacture the Harm They Promise to Cure is available now from David Boles Books in Kindle and paperback, with a free PDF edition to download at BolesBooks.com.
Facts matter.
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