Scene 110: Epilogue (continued)
2025
New to this publication? Jump to page one of this book.
“…the past had other possibilities, and so do we today.”
—Paul Starr, The Social Transformation of American Medicine
My overwhelming sense in writing this book is that things didn’t have to turn out the way they did in health and medicine. I see the need for historical, transformational change everyday in my work as a full-time emergency physician. Many of the basic assumptions we hold about how health is created and delivered were established more than a century ago, shaped by a world vastly different from ours. Those assumptions aren’t just outdated; they were deeply flawed when they were implemented. The very foundation of our health system is weak, and true transformation will require rebuilding it from the ground up.
In the intervening years we have witnessed phenomenal advances: powerful new medications, vaccines that stop once-devastating diseases, surgical techniques unimaginable a century ago, and the promise of genomics and precision medicine. Yet despite this technical progress, there remains a pervasive sense that our health system can—and should—be much, much better. The need is immense, and everyone I talk to can sense that something is fundamentally off. For example: the United States spends far more per person on health care than any of its peers yet has one of the lowest life expectancies among wealthy nations. Black women die from pregnancy‐related causes at roughly three times the rate of white women. Many health-care professionals are exhausted and burnt out. Medical bills continue to cause bankruptcy despite insurance expansion. Chronic diseases remain rampant. For-profit interests in pharmaceuticals, food, private equity-owned hospitals and health services increasingly shape what gets treated—and how—with mounting administrative burden and cost. The historical assumptions about how health is created and delivered, the beliefs embedded more than a century ago, still structure our system today. And so, the foundation remains weak. True transformation will require rebuilding from the ground up.
Here are the lessons I’ve drawn from my researching and writing journey:
First, Scruggs and those who worked alongside him never lost sight of their ultimate goal: the health and well-being of their people. They didn’t let new discoveries, institutional traditions, financial limitations, or the urgency of treating individual illness distract them from that central purpose. For Scruggs, health was a social and moral endeavor. For Royster and many other leading physicians of his time, technical considerations played an outsized role by focusing on procedures and acute care. The same tension persists today: medications and surgery still too often take precedence over prevention, behavior change, and community empowerment.
Second, Scruggs pursued equity, egalitarianism, and empowerment. He directed his energy toward those who suffered most. Guided by data, he championed clean water and tuberculosis care for the disadvantaged. He sought to lift up those closest to suffering—Black people, women, and ministers—by giving them tools, education, and agency. Through new institutions, he directly challenged the social hierarchies that harmed his community’s health.
Royster, by contrast, took pride in the prestige that came from elite institutions and helped reinforce the hierarchies that maintained them. The elitism that hardened in his time still shapes our health system today.
Third, Scruggs’s relentless commitment to health and well-being required constant adaptation. He reimagined, revised, or abandoned outdated roles, professions, and institutions in pursuit of what worked. For him, health was not just the result of a doctor’s visit, a medicine, or a surgery—it was an emergent property of society, shaped by countless interacting forces that evolved over time. There was no fixed blueprint. Health was then, and remains today, an ongoing journey of learning and renewal.
Royster’s focus on personal advancement, by contrast, helped cement inequitable institutions. Though he was innovative in surgery, that progress came at a cost, and Black North Carolinians bore that cost most heavily.
Finally, Scruggs was moved by deep empathy and solidarity with his people, rooted in the Richmond Institute, and likely long before. He loved and cared for them; their destiny, hopes, and struggles were his own. He was, as he said, “in close sympathy” with them. Royster, too, gave generously of his time and money to his Black patients, but his philanthropy operated within a framework of inequality that preserved his social standing. For him, medicine often seemed a path to personal elevation rather than shared health and well-being.
Transforming our health system today, built on the foundations of the late 1800s, will be a long, messy process—like the founding of the United States or the ongoing struggle for racial justice. But we can learn from Scruggs, Mary Burgess, and the St. Agnes nursing students, who built trust and connection in 1890s Raleigh. True transformation will demand courage, dialogue, creativity, and sacrifice. It will be uncertain and imperfect.
But it will also be worth it.
New to this publication? Jump to page one of this book.
Need a reminder who the characters are? Take a look at this list.
Sources and Notes:
https://www.kff.org/other-health/the-u-s-has-the-lowest-life-expectancy-among-large-wealthy-countries-while-far-outspending-them-on-health-care/?utm_source=chatgpt.com
https://www.healthsystemtracker.org/chart-collection/u-s-life-expectancy-compare-countries/?utm_source=chatgpt.com
https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/?utm_source=chatgpt.com
https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2022/maternal-mortality-rates-2022.htm?utm_source=chatgpt.com
https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2023/maternal-mortality-rates-2023.htm?utm_source=chatgpt.com
https://pmc.ncbi.nlm.nih.gov/articles/PMC7384760/?utm_source=chatgpt.com