Emily Maloney's Cost of Living: Essays (Henry Holt and Co., 2022) offers up a rich collection of observations on the ironies, paradoxes, and economic unfairness endemic to American health care. Maloney made a suicide attempt as a young adult and incurred a large medical debt as a result of her treatment. She spent the next decade striving to pay off that debt, for a time working for low wages as an ED technician. After detailing the many costs incurred-"Suicide should be cheaper," she comments wryly-Maloney goes on to describe years of medication-dependent psychiatric care (which likely wasn't helping her), mistakes that sometimes pepper hospital care, and the quandary of how to avoid opioid addiction while also alleviating chronic pain. This book exposes key incongruities at the heart of American health care.
Maloney grew up in a decidedly dysfunctional family and saw 12 different therapists for anxiety and behavioral issues during her childhood and adolescence. Her father suffered from depression and was only intermittently employed. Her mother suggested that smoking "a little bit of pot every day" would help Maloney better manage her emotional struggles. In high school, the money she earned as a dog groomer at PetSmart often went toward buying the family groceries because her parents' combined annual income was under $20,000. For years after she left home, she returned weekly to wash their dishes.
Maloney's 13th therapist, a psychiatrist, loaded her up with one psychotropic medication after another-26 drugs in all, including lithium, which was prescribed for her ostensible bipolar disorder. Maloney explains her suicide attempt, an overdose of lithium, by stating, "It wasn't that I had wanted to die, exactly. It was more that I just couldn't keep living." Maloney was just 19 years old.
Working with yet another therapist, Maloney learned that she did not have bipolar disorder or any other psychiatric illness. Rather, she was diagnosed with hypothyroidism, a nonverbal learning disability, and vitamin D deficiency. At the start of Cost of Living, Maloney writes, "I had believed . . . that I could fix myself, my life, with the right doctor or the right medication or more money." But her experiences with misdiagnoses and unnecessary medications taught her otherwise.
The book attests to how such experiences aren't unusual. When Maloney was working as an ED tech, another tech intentionally switched the leads on the electrocardiograph, which resulted in several patients being admitted with implausibly identical "abnormal" heart rhythms. Maloney also flat-out admits that patients often aren't told when they are dying, a claim I can validate from my own work in hospice.
While studying for a degree in bioethics, Maloney accompanied hospital medical teams on rounds. She observed that the medical students did not show the nurses respect, even though the nurses knew more about the patients, and possibly the appropriate treatment choices, than the medical students did. Reflecting on conflict within the team, she asserts that medical students can actually endanger patients: "The ethical implications of the relationship between med students and nurses seem potentially problematic at best; at worst, we are harming patients, one medical student at a time."
The end of the book explores the pain-addiction crisis currently plaguing American medicine and certain swaths of American society. In 1999, the Veterans Health Administration declared pain the fifth vital sign, and that sign is still being used despite the reality that, as Maloney says, "pain as a vital sign is not working." Then, as opioid abuse reached epidemic proportions, in 2018 the Centers for Disease Control and Prevention (CDC) issued prescribing guidelines for narcotics that set an upper limit on dosages. But some patients require much higher amounts to control their chronic pain and improve their ability to function. When such patients become desperate, they may turn to illegal sources. Maloney describes "the spike in heroin use" that followed the release of the CDC guidelines.
Our health care system has been described as "broken" so often that the statement is almost a cliche. Maloney revives the truth in it, showing real people who continue to be hurt by the system's many flaws. This empathic book repeatedly draws back the curtain on American health care, quietly insisting that thoughtfulness and genuine concern are key to lowering the costs of living in the United States.