Does the U.S. Healthcare System Favor the White and Wealthy?

MICHAEL HOLMES: Now, the U.S. is being warned to prepare for a summer surge in COVID-19 cases across Southern States. Our next guest has witnessed the pressures of the pandemic firsthand as an emergency physician. Dr. Thomas Fisher is sharing his experiences in his new book, “The Emergency: A Year of Healing and Heartbreak in a Chicago ER.” Here he is speaking to Michel Martin about the book and the state of American health care.

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MICHEL MARTIN, CONTRIBUTOR: Dr. Thomas Fisher, thank you so much for talking with us.

DR. THOMAS FISHER, AUTHOR, “THE EMERGENCY”: It is a pleasure being here. Thank you for having me on.

MARTIN: The title of your book is, “A Year of Healing and Heartbreak in the Chicago ER.” This book chronicles kind of the before, during, and sort of after of the COVID crisis.

DR. FISHER: Uh-huh.

MARTIN: Is it the COVID crisis that kind of motivated your thinking. Because it’s obvious that you’ve been thinking about these things very deeply for a very long time. I might argue for the entirety of your career because you kind of had a front-row seat to these issues.

DR. FISHER: Yes.

MARTIN: So, why this book? Why now?

DR. FISHER: I actually started writing the book before COVID. And there’s a chapter where I described what the emergency department was like when we were overburdened with the chronically ill and the acutely injured, the old and the young, and how we were constrained in our capacity to manage them effectively by time and resources. But then COVID happened. And it condensed the time it took for society to protect some and harm others and have that manifest in their health. Normally, it takes 30 or 40 years for food deserts and violent communities, and jobs that injure them to lead people to the emergency department. That burden of illness that society creates takes time. But COVID condensed that into a matter of weeks. Where, depending on your job, you either were able to shelter at home and continue to work from a screen. Many people got much wealthier during the pandemic. While others were stocking shelves and driving Ubers, and working in warehouses or slaughterhouses where they were exposed to COVID not because of anything intrinsically biological about them, but because of the way society protects or exposes them to illness and disease. And they fell ill in droves and came to my emergency department. And so, it was a perfect opportunity to describe the societal variables that shaped our bodies. And the inequities that now distribute our health in a very concise timeframe. And it was unlucky for society but a perfect opportunity to continue to write this arc. And so, in many ways, what I was writing was reshaped by the pandemic.

MARTIN: For people who still don’t get the degree to which race and income — a race or access to wealth, maybe we should put it that way, were determinants of how people fare during COVID. I mean, Chicago in journal, your emergency room in particular, are a perfect case study of that. The death rate for African-Americans was far greater than that for white people living just a few miles away.

DR. FISHER: Yes.

MARTIN: And that manifested very early on. I mean, a news organization did a deep study of the first 100 people to die of COVID in Chicago. And I think 70 percent of them were black, even though black folks are only 30 percent of the population of Chicago now.

DR. FISHER: Uh-huh.

MARTIN: And obviously, you know, why is that?

DR. FISHER: Look, Chicago is densely segregated by race and has been for a very long time. This segregation in Chicago leads the Southside which is largely black to not only fall ill from chronic diseases but also from acute illnesses. I’m just looking at a couple of statistics so that I — so that I don’t get it wrong.

MARTIN: Uh-huh.

DR. FISHER: In Chicago, in our predominantly black communities, the highest lead levels are amongst black folks. In Washington Park, a neighborhood not far from the hospital that I practice in and the neighborhood I grew up in on the Southside, 15 percent of adults are disabled compared to four percent in the predominantly white loop. Black women in that neighborhood deliver dangerously low birth weight babies, 3.5 percent of the time compared to only one percent of the time in Lincoln Park. The evidence is clear and consistent. You know, Black folks live shorter and more painful lives not because of any biological or genetic difference, but because of the way we’ve distributed our healthy food resources. Our good jobs. The clean air that we breathe. The sorts of protections that allow for us to be free of violence in the community. The wealth that protects us from these swings in job attainment or loss. All of these things become part of our bodies. And then when we fall ill, these same societal distributions lead us to have better or worse access to the health care resources that help us get well. And so, for example, black folks are much less likely than white folks to have the desirable private health insurance that hospitals and doctors prefer. And in fact, they’re 50 percent more likely than white folks to be uninsured entirely. And so, if you look at a map of Chicago’s racial segregation, you will see that black folks are crowded into these communities where they are uninsured and on Medicaid. And if you are to overlay where our health care resources, these health care resources that prefer private pay insurance, you’ll see those are similarly distributed towards those on the wider Northside where more people are insured. And so, we have redistributed our health resources and our health care resources along the lines of racial cast. And ultimately based on who can pay and who cannot. Creating winners and losers. The challenge then is that when you lose, you paying not only with your wallet, you’re paying with your life.

MARTIN: I was talking about the emergency room. One of the revelations of your book is that you have an average of three minutes to spend with each patient. How is that possible?

DR. FISHER: So, let me give you a big overview. The emergency department that I work in is massive. There are about 70 something beds that we cover and each area has different resources available in order to care for specific sorts of interventions. I was working right at the front of the house where I’m trying to sort through the sickest people in the waiting room and launch them through their care trajectory by early diagnosis and testing. And the ability to go through a waiting room where there might be 40, 50 people waiting. Many of whom have been there five or more hours means that I don’t have a whole lot of time to spend with them. My goal is to identify exactly what is the critical issue that brought them to the emergency department. Step in, and see if I can diagnose it or relieve some suffering in the meantime. So that by the time they finally get to a room, we’ve already begun their care process. It’s frustrating sometimes because — look, I trained for a lot of years in order to have a broad skill set. I’ve got even more experience treating both simple and complex illnesses. And the ability — and not being able to deploy all of those resources in the service of somebody who so clearly needs it leads us, and me in particular, with a moral conundrum that I described in the book.

MARTIN: Well, in fact — I mean, some of the stories that really stand out in your book are the stories where you really aren’t sure you got it right. One of the ones that really stuck with me, in part, because it wasn’t so dramatic. It was the girl who had been jumped at school —

DR. FISHER: Yes.

MARTIN: — and came in with facial injuries. Tell me that story of how you treated her and why this was so frustrating?

DR. FISHER: Yes, part of why that story was important for me is because so much of what we do isn’t, like, made for TV whiz-bang like drama. It’s the mundane lives of everyday people that we become intimately exposed to. And here’s a woman who is 18, in her senior year of high school in the book. And was jumped and injured by a group of other people. And in my brief encounter with her, my job was to make sure she wasn’t seriously injured. That she maintained her eyesight and her physical functions. And that there were no injuries that we missed and everything that we found we could treat. But that doesn’t speak to whether or not she was bullied at school. And that this was an ongoing problem, or that maybe there was some misdirection and this was actually an injury that happened at home. And maybe she didn’t have a safe place to be. Maybe there was more going on with her emotional life. Was she depressed or anxious? Without the time to address all of these other variables, many of which are the variables that actually lead us here and the physical injuries were just the end result of a longer-term process. I felt frustrated that I couldn’t ensure that she wouldn’t return in just a little while.

MARTIN: Then there was the woman who had been in the emergency department for, like, hours —

DR. FISHER: Yes.

MARTIN: — with a critical illness. She wasn’t feeling well. And the lab suggested kidney failure.

DR. FISHER: That’s right.

MARTIN: And the family were like, you know what, we’ve just been here too long. Let’s go. Let’s just go.

DR. FISHER: So, in that interaction, I’m sorting through all of these patients one after the next, three minutes at a time. And here comes a family member saying, look, we’ve been waiting for five hours. Can I take my mom home? We’ll come back later but we’re about to leave. And here when I look at her chart in the computer, I realized that she actually has a critical illness. Something that needed to be — that needs to be managed immediately. That probably requires an admission and maybe a number of medications and potentially a surgical intervention to improve. And I don’t have anything to offer. I don’t have a medication that would relieve her suffering right now. I don’t have a timeframe to say that, oh, she’ll be in the next bed in a moment. And in fact, when I reviewed the list of all of the patients in the emergency department waiting, not only has she been there for five hours, others have been there longer and she might not be the sickest one out there. It’s an incredible moral conundrum where — when you are the one deciding who should come back next. How do you choose amongst all of these people who have so much need? And when you are the one making choices and there are no good answers, what kind of burden is that to give people whose job it is to do no harm? Whose job it is to cure and make people better? We all carried that weight really very heavily over time. And I think one of the ways that we’ve, over time, manage that is some doctors just look away and do their best not to confront these moral challenges or the recognition that there’s so much suffering that goes on that goes untreated. Justifies that suffering as a part of humanity and maybe it’s — in some ways reasonable for people to have to struggle. And I think that I have gone through those periods. And now I’m at a point where I’m willing to just look at it and be uncomfortable. And I think that’s part of what makes this book somewhat challenging to read is that I want the reader to look at it and know that sometimes there isn’t a solution. Sometimes there’s just suffering. And then it becomes an incumbent on all of us to figure out, is this OK? And what do we do about it?

MARTIN: In the book, you write letters to patients and colleagues that you would have liked to have sent.

DR. FISHER: Yes.

MARTIN: Will you tell us about that?

DR. FISHER: Absolutely. So, the book structure is alternating chapters. One chapter is recounting an experience, a night or a day in the emergency department where I’m taking care of sick people. And doing so in a sort of detail that brings people very, very close to the interaction that we share as teams in the emergency department. And then the chapter just after that is a letter to somebody I worked with or took care of in the emergency department. The goal of those letters is to, over the arc of the book, described the way we’ve organized our health resources in society. To explain to a patient, why are you sick before your time? Why did you wait for five hours in the emergency department, or to explain to one of my colleagues, a training, what happened with that VIP care? Why did that individual get exactly what they need while this other individual didn’t get anything that was required for their care? I took the approach of writing a letter to these individuals because I didn’t want it to be a wonky policy book. I wanted my residents and, more importantly, my patients to understand what’s going on with them? Why is it that the health care system is structured the way they — the way that it is? And do so in a way that is really accessible.

MARTIN: But you know, I have to notice — I couldn’t help but notice how many of them really were apologies.

DR. FISHER: Yes.

MARTIN: You were saying, I’m sorry, I couldn’t do better by you. It just – – it feels painful. It feels really painful to me.

DR. FISHER: It is very challenging. And I think there’s a component of this where my patients don’t know me when I walk into the room. And as soon as I have the badge that is — identifies me as a hospital employee, I’m a part of that big system that has the potential to harm them. And even though I am from the same community as they are, I grew up on the Southside, I’m taking care of people I know, either literally. And that I’ve cared for old school teachers and the parents of my friends or figuratively. And that we have the same sort of cultural touchstones, they don’t know any of that. And in some ways, I’m apologizing on behalf of the system. And in other ways, I’m apologizing on behalf of myself, when I am still human and I get frustrated and short-tempered, and I have to run off to the next room to do something because I don’t have enough time or resources to give everybody what they need. And I think that when people are sick, which we all are sick at times, what they deserve is grace and compassion, and care and mercy. And when I don’t have the capacity or didn’t deliver that, an apology is what they deserve because they didn’t get what they came for.

MARTIN: Why do we tolerate this? This is a wealthy country, why do we tolerate this?

DR. FISHER: I think there are couple reasons. One is, I think that we’ve justified a society that creates winners and losers. That creates competition and thinks that if you are on winning — if you’re winning, it is something meritorious in your character or your effort. And doesn’t earnestly recognize that the competition is rigged, and so much of that is rigged by racial cast so that so much of your opportunity to win is defined by the luck of the birth order and location. And so, when you see people who are ill earlier, we blame the victims. Well, they should’ve taken better care of themselves. They should have not smoked. They should have made better decisions without the recognition that it is context that shapes all of us for the good and bad. And it is not anything biological that creates that 30-year life difference between the Southside and the Northside. I think another reason is so much of this is pushed out of sight. I wonder if more of the world saw the wild eyes and gasping for breath of those people who came in in the early days of COVID. And it wasn’t abstracted into statistics and numbers that we might have had more empathy for, not only the people who had fallen ill but those who were trying to deliver their care. As a result of it becoming simply a million people dead, which is where the number we are nearing now, it was mothers and fathers, people who died in ways that were terrifying and suffocating. That might help to cut through this idea that there are winners and losers. That the racial caste system is somehow justified and helps us to understand that we have this shared humanity when we can see ourselves suffering in that way. That would force us to think about how do we solve these problems that create our health and these problems that create this in a poor — an unjustified and unjust health care system?

MARTIN: Dr. Thomas Fisher, thanks so much for talking with us.

DR. FISHER: Thanks for having me.