The incessant wail of ambulances speeding down Cottage Grove Avenue on their way to University of Chicago Medical Center (UCM) gave me a second-hand sense of the enormous impact of COVID-19 on the South Side. And so, I was eager to read an account straight from the floor of the trauma center when I heard about The Emergency: A Year of Healing and Heartbreak in a Chicago ER by Thomas Fisher, MD, MPH.
Fisher is an emergency room physician at UCM who also served as a White House Fellow in the first term of the Obama administration and an insurance executive in Chicago. Growing up on the South Side, he attended Kenwood High School before going on to study at Dartmouth College and coming home for his medical training at University of Chicago’s Pritzker School of Medicine. His book chronicles his experience serving on the frontline of the COVID-19 pandemic, while also treating the spate of gun violence victims rushed to his ER at the same time.
Practicing emergency medicine during the pandemic feels, for Fisher, akin to Sisyphus’ ordeal: “Every day I push the boulder; every day it rolls back.” In quick succession, Fisher faces a litany of illnesses and injuries in the ER—diabetes, chronic pain, burn trauma, gun-shot wounds, and head gashes—and very little time to address each, not to mention getting the time to uncover the stories of the patients. “But I want to know the twists in the path that led them here, sitting in front of me in an ER bay for three minutes. Without these details, by the end of a four-hour block, patients start to blend together in my mind,” Fisher writes.
To recapture the sense of each patient as an individual human being with a rich and complex life history, Fisher writes letters to them, included in alternating chapters of the book. What, asks his correspondent, were the confluence of events that led you to my ER unit that fateful day?
The answer he partly supplies himself in detailed accounts of the systemic inequalities in the American healthcare system and the particular social circumstances of the South Side. In one such passage, Fisher writes about the stark racial disparities in Chicago: “Opportunities and safeguards are concentrated on the North Side. As a result, Black people, who densely populate the South Side, are forced to endure a gauntlet of health risks: jobs that maim, food that sickens, air that chokes, and guns that kill. This would be a simple story of winners and losers, except there is no competition—not a fair one at least.” Fisher explains that while this result is “consistent with the values of market capitalism…the losers pay with their lives.”
One of the health myths Fisher seeks to expose in his letters is the idea that health is solely a matter of personal responsibility and individual choice. Instead, our health is mostly determined by our genes or social and economic factors like level of education, wealth, and neighborhood.
But, by detailing this in a letter to a twenty-five-year-old patient with kidney trouble and a recent gunshot injury, I couldn’t help asking if reading it would be any salve for his wounds both apparent and latent? Reading Fisher’s epistles, I found myself fretting over this and similar questions.
Is the form of letter writing, so ably used by James Baldwin and Ta-Nehisi Coates to name just two prominent examples, more than a sleight of hand for Fisher by which to convey the wealth of knowledge he’s absorbed over a long career? Did he even go to the post office to mail these voluminous letters? I’m skeptical. So while the intention of the letters appears to be a noble attempt to connect with his patients, it comes off as little more than a narrative device for what is an exhaustive and damning account of Chicago’s healthcare system.
And data confirms that Chicago is a dispiriting outlier in terms of racial health disparities. According to an analysis by New York University’s Langone Medical Center, Chicago had the largest gap in terms of life expectancy across neighborhoods at thirty years among the 500 largest U.S. American cities. Whereas in Englewood, where ninety-five percent of the population is Black, the average life expectancy is only sixty years old, in predominantly white Streeterville, residents live, on average, until they are a venerable ninety years old. Just for reference, the average life expectancy for residents of Englewood is lower than that of residents in war-torn countries like Afghanistan and the Democratic Republic of the Congo.
Although Fisher makes ample note of these facts, the biggest revelations contained in the letters are twofold. First is the story of how UCM’s management after the Financial Crisis proposed to close a significant number of Intensive Care Unit (ICU) beds reserved for trauma patients, many uninsured, poor, and Black South Siders, and reserve them for so-called ‘Patient of Distinction,’ meaning white well-to-dos with private insurance, some from the North Side but even catering to those from as far afield as Wisconsin and Indiana.
Fisher plays a leading role in putting the kibosh on this plan through some savvy politicking with his fellow staff. He sends an email to the other physicians, organizes his younger colleagues, and promises to resign from the Center if the plan goes through. This collectively raises enough stink that, Fisher says, the higher-ups killed a plan that would have effectively segregated the hospital while also driving up wait times for Black patients due to the scarcity of available beds.
Nonetheless, today, out of 811 available beds at UCM, at least 240 are private, but only 146 are for ICU patients. And Fisher throughout the book decries the wait times his Black patients endure remain interminable and that even when they do get to see a doctor the quality of care is sometimes poor. So although he may have won the initial battle, the war is clearly far from over.
The second revelation I took from the book is that most nonprofit hospitals, despite the enormous tax breaks they get as a part of their status, typically invest less than two percent of their total revenues in providing community benefit or charity care. Digging into UCM’s 2021 financial statement reveals they provided about $31 million dollars of charity care out of total revenues exceeding $2.78 billion dollars. That’s a scant 1.1 percent.
This charity care is something UCM is legally obligated to do to keep their coveted nonprofit status. That title itself is something of a misnomer. “Revenue and gains in excess of expenses and losses” was over $500 million dollars in 2021, which translated from legalese into standard English means UCM raked in $500 million more dollars than they spent. Put differently, $500 million in profit for a nonprofit hospital. Where they pocket that money is beyond my forensic accounting skills, but I’m sure Fisher would have some good ideas for how to reinvest it into improving patient outcomes and ameliorating the stark racial health gap in Chicago.
Whereas the letters do enlighten and inspire moral indignation, chapters set in the ER bay, written in a straight-faced, clinical tone, sometimes provoke a gag reflex or a guffaw. “Despite her shoe and sock I can smell the odor of rotting meat coming from her foot. Diabetes is eating her alive. She could end up with an amputation. Evan takes furious notes. I determine what to order, file it away in my mind, and then we move on to the next.”
The next man up, “high as a kite” and dapperly dressed, charms the socks of the nurses, bringing levity to what has otherwise been a dour day of death and despair. Without venturing a guess, Fisher asks the man what he took?
“Since getting out the pen I get high on embalming fluid.”
“Do you drink it?”
“Nah, smoke.”
“How do you smoke a liquid?”
Clueless, a nurse fills Fisher in. Turns out embalming fluid is slang for PCP. Although Fisher doesn’t admit to any self-medicating of his own, many doctors turn to drugs and alcohol, just like their patients, to cope with the travails of their stressful and frenetic occupation.
The book closes, though, with a near-tragic episode that strikes close to home. Fisher’s own mother develops an acute illness that Fisher suspects is malignant cancer, and she seeks care at UCM. For hours doctors there fail to administer anything for her pain and are ultimately unable to send her home with a firm diagnosis as to her condition.
Fortunately, she turns out okay after getting treatment at her hospital, but Fisher is indignant and sends his superiors a sternly worded letter calling out the poor quality of care for even the mother of one of the hospital’s star physicians.
It is in a letter to his mother that Fisher issues this final plea for healthcare in the United States: “A humane and just system requires everyone to come together—all of us citizens—and demand moral transformation.” But while moral transformation is certainly a necessary condition for social change, the lack of significant legislation around gun reform in the aftermath of numerous mass shootings up until the one in Uvalde demonstrates that moral outrage is simply not enough. The perverse incentives of the privatized American healthcare system must be reconfigured by policy action too. And local entities like UCM can and should do more.
Max Blaisdell is an educator and basketball coach based in Hyde Park. He is originally from New York City and later served in Peace Corps Morocco. He last wrote: Chicago’s Diaspora Communities Reflect on the Tigray War.