Victor LaValle doesn’t shy away from Big Issues. In his previous novel, “Big Machine,” he confronted racism, religious fundamentalism and terrorism on the U.S. homefront, and had the chutzpah to toss in a few Lovecraftian demons, just in case anyone in the front row was nodding off. “The Devil in Silver,” LaValle’s newest offering, is another fearless exploration of America’s heart of darkness, set within the most terrifying landscape of our time: the American health-care system.

Pepper works for a moving company in Queens. He’s 42, single, with an occasional anger management problem, the kind of guy once termed a big galoot. “A big man but not a hard man. He’d probably do more damage falling on you than punching you.” In a spectacularly wrongheaded effort to impress an attractive neighbor, he beats up the woman’s ex. When the police are called in, he beats them up, too.

Before you can say, “Paging Nurse Ratched,” the cops haul Pepper off to Northwest, the psychiatric unit of New Hyde Hospital.

Is Pepper crazy? No more than most of us. But it’s nearly time for the cops’ shift change. Taking him in to the station house and doing paperwork would take too long, and New Hyde is closer than the station. . . . So Pepper becomes an involuntary admit.

Note to self: Do not do anything, ever ever ever, that will lead to an involuntary admit.

‘The Devil in Silver’ by Victor LaValle (Spiegel & Grau)

“You’ll be with us for three days,” a doctor tells Pepper. “That’s the law. . . . And in that time we’ll evaluate your mental state.”

In his room, Pepper thinks back to the only thing he remembers about psychiatric hospitals: the film version of “One Flew Over the Cuckoo’s Nest.” He briefly considers escape, then prayer and finally falls asleep. He gets one phone call, right? Worst-case scenario, he’s only there for 72 hours. Right?

Pepper’s attempt to make a call is scuttled by a nurse whose “actions screamed ‘Staff Member’ but her wardrobe cooed ‘Casual Grandma.’ ” Before she’ll give him access to a phone, he has to take two pills: One is lithium; the other is Haldol. You know what happens next.

Or, rather, what doesn’t happen. At the woefully understaffed New Hyde, you’re checked in but never checked out. Staff members don’t have time to interact with patients, beyond feeding everyone a sedative cocktail several times a day. Instead, doctors, nurses and orderlies crouch over antiquated computers, entering endless streams of data as they try to master an accounting system that appears to be designed for another bureaucratic nightmare entirely. (Perhaps my health insurer?)

Pepper and the other patients he eventually befriends pass their hours in a pharmaceutically induced haze. In one of the novel’s most frightening scenes, Pepper shuffles to the nurse’s station to see if he can sign himself out. There he sees a copy of the New York Post and realizes that his three-day window for escape is long passed. He’s been in Northwest for four weeks. And he’ll remain there much longer.

With “The Devil in Silver,” LaValle performs a dizzying high-wire act: He balances social satire, horror and mordant humor, but never jettisons genuine affection and empathy for even the most damaged of his characters. This includes New Hyde’s beleaguered staff, which counts among its members a dedicated psychiatrist who starts a book group for the patients; their first selection is “Jaws.”

The novel could have lost a subplot that involves sightings of a creature that may be demonic — recent headlines about the fate of uninsured or underinsured hospital patients trump any imaginary horrors. And Pepper’s growing fascination with the life of Vincent van Gogh seems unnecessary in a story that does such a masterful job on its own of evoking the fragile bonds of trust and love and desire that link the residents of Northwest. “Kafkaesque” is a term applied to so many novels that its currency is almost bankrupt, but “The Devil in Silver” earns it.

In his author’s note, LaValle relates how the “offices” where he wrote this novel — two donut shops near the George Washington Bridge branch of New York’s Port Authority — provided inspiration in the form of a rotating, Dickensian cast of real-life characters. This century could use its own Dickens to put a human face on the overwhelming social crises that threaten us all. LaValle might be the guy for the job. I hope he has good health insurance.

Hand’s most recent novels are “Radiant Days” and “Available Dark.”


By Victor LaValle

Spiegel & Grau. 412 pp, $27