Review: Cost of Living: Essays by Emily Maloney

Reviewed by Ann Przyzycki

It is five in the morning and I am in the ER with my school-aged daughter who has been vomiting for four days—most recently, a worrisome dark green bile. She again touches the numbing “sticker” they have put on the back of her hand. “Don’t make me get an IV,” she pleads. A new doctor, the fourth we’ve seen since arriving last night—because they work in teams—is putting on gloves and a gown outside our door. She enters wearing a domed, powered air-purifying respirator that is commonplace in our COVID-era sci-fi reality. She sits at the foot of the bed. “The ultrasound is inconclusive for appendicitis.” She frowns. “We could do a CT, but that is a lot of radiation.” It is as if she is telling me that she could add more lemon if I want, but the drink is going to be pretty sour. This doctor is empathetic in what must be her routine task of delivering inconclusive information, yet she looks to me to decide what comes next. I am scared and want to know why what seemed to be only a “twenty-four-hour bug” is getting progressively worse. I am disoriented because earlier the nurse said, “all signs are pointing to appendicitis.” My husband and I decide to not ask for a CT in the ER and follow the surgical team’s recommendation to admit my daughter as an inpatient for an abdominal series and observation.

As patients and caregivers, we enter the ER or the doctor’s office and say so what’s the problem? I am ready to pay the cost in order to fix it. This consumer approach works at the Apple Store Genius Bar. Now, compound the scenario with being scared and in pain, and we urgently expect answers to issues that are infinitely more complicated. In the end, my daughter was hospitalized for four days and submitted to a barrage of tests, scans, and pokes. Everything was “normal,” and she eventually recovered. We don’t know what it was exactly, only what it was not. So much of this healthcare experience of my family was echoed in Emily Maloney’s new collection, Cost of Living. Our stressful two weeks of illness and wondering what is wrong, is what Maloney has experienced to varying degrees for most of her life. She bravely recounts her personal medical history because she knows there are countless others in both short- and long-term quests for better health. What are the obstacles to better health? Is our first obstacle the patient’s perspective of misplaced hope that Maloney evokes? She writes: “I had believed that doctors knew everything. That I could fix myself, my life, with the right doctor or the right medication or more money. That the medical world, that science itself, was black and white. Yes or no. Hypothesis proven or disproven. I had always put my trust in science; I believed that the dollar answered to the doctor. I thought: If I could just do this work, maybe I could pay my debt.”

Maloney’s five-figure debt is from her hospitalization after a suicide attempt when she was nineteen. “[A] cost I believed I would shoulder well into my thirties, a figure that felt more like a student loan than an appropriate cost for medical care. . . . Suicide should be cheaper, I remembered thinking.” Maloney has been a patient since age three when she began to bang her head against the floor and her mother took her to her first therapist. She will be treated by twelve more therapists (all before Julie, who is treating her at the time of her suicide attempt), as detailed in the essay “Some Therapy.” These therapists will prescribe the twenty-two different drugs that are itemized in “A Brief Inventory of My Drugs and Their Retail Price.” The catalog of side effects is dizzying. Maloney seems to feel resigned when she writes, “This was something I’d come to believe, with time, ran in our family, a darkness that couldn’t be eased or eliminated.” She writes with a sense of urgency that comes from absorbing the magnitude of it all—after so much therapy and medication, she still was not healthy. It will be years until her medical debt is deemed to be beyond the statute of limitations and she will be free from paying it. And it will be even more time until she sheds inaccurate mental illness diagnoses and progresses toward more accurate ones—fibromyalgia, Hashimoto’s, adult-onset asthma, endometriosis—that account for physical ailments.

She takes this personal experience, coupled with her professional experience as an ER tech, a student of bioethics, a rep for a pharmaceutical company, and a journalist, and turns her gaze toward a detailed documentation of the ins and outs of seeking care and its jaw-dropping costs in a system tied up in protocols and bottom lines. To what extent is the system an obstacle to better health? The first hospital she works at is $54 million in debt and the nursing supervisor tacks up a sign on the wall: “Use only what is necessary.” Patients return again and again in a kind of “catch-and-release program.” “The government thought that these people should have been cured, explained in hundreds of pages on the Centers for Medicare & Medicaid Services website.” Maloney gives us not only the raw data but also beautifully rendered personal stories behind the numbers.

In “For Pain,” her friend and coworker, Kathleen, deals with prescription drug addiction after being in a car accident. Maybe “if she had seen another doctor, one who found a way to give her the MRI necessary to see the problem and the surgery required to fix it—maybe she would have been a totally different person, living a totally different life. I want to believe this. I do.” And therein lies the poignancy of this collection: can’t we do better for the next Kathleen or the next Emily who is wheeled in through the automatic doors?

The collection was written pre-COVID and ends just as COVID cases are beginning to rise. All the fissures in the dam that Maloney has so eloquently cast light on have now been obliterated by the tidal wave of the pandemic. All the chronic pain that patients, including providers as patients, were dealing with before COVID didn’t go anywhere and, in fact, is exacerbated in any number of ways. As Maloney writes, there is a “pandemic layered over pandemic like sediment. I want to know what’s happening a few layers down. In one group, they have put the suicide hotline in the header, so people can have someone to call.”

I look online at today’s New York Times and again Maloney’s insights reverberate: “We Know the Real Cause of the Crisis in Our Hospitals. It’s Greed. Nurses would like to set the record straight on the hospital staffing crisis. . . . chronic understaffing by profit-driven hospitals that predates the pandemic.” Maloney, too, would like to set the record straight in this compassionate and precise portrait of the American healthcare situation that we are all in collectively. Individually, she is still working through her own story because “the truth is, I don’t know the truth.” These essays are the important testimony we all need to heed collectively and hear individually—we all face the cost of living.

Ann Przyzycki is an editor and writer who lives in Seattle.