Empty or full, crazy or sane, patient or caregiver. These might appear to be opposites, but as Emily Maloney illustrates so well in her debut essay collection, Cost of Living, one blends into the other. Maloney learned this firsthand when she checked into the ER after a suicide attempt and ended up in thousands of dollars of medical debt. A few years later, fate found her working in the billing department at a hospital, charging patients according to her own discretion. From stories of studying to become an EMT with an unhinged teacher to entering the land of the chronically ill, Maloney reveals America’s broken health care system from both sides of the hospital bed. In her essays, we see how the medical system can be as lethal as diseases themselves.
Emily holds an MFA from the University of Pittsburgh, and she’s been awarded a MacDowell Fellowship not once, but twice. Her work has been published in Glamour, The Atlantic, and VQR. The title essay of her book, “Cost of Living,” first appeared in VQR and Best American Essays 2017. A master of the craft of personal essays, she says that her writing comes to her not as her words but as a woman’s voice in her head.
I had the pleasure of speaking with Maloney over the phone about her writing process, female physicians, and the so-called problem of the hysterical woman.
The Rumpus: An earlier draft of the title essay, “ Cost of Living,” first appeared in VQR. How did you approach building that piece into a collection of essays?
Emily Maloney: I actually didn’t do that. Some of the pieces from the book date to 2008. It was my thesis at the University of Pittsburgh. With VQR, I was supposed to be writing a different story. I was on assignment, and my source fell through. There was no story. So I sent “Cost of Living”—it had a different title then—to my editor at VQR. I was like, “I’m really sorry about what happened with this other piece. I would love to still do something for VQR. Here’s a consolation prize.” He was like, “Maybe we can work with this.” And then the other pieces, some of them were in my MFA thesis. Some of them were pieces I wrote or revised or expanded later.
Rumpus: I love that you sent a piece from your MFA thesis to your editor instead of the assignment. Let’s talk about your thesis! Why did you choose individual essays rather than a continuous narrative?
Maloney: I’m still an essayist, despite my best intentions. Something that essayists sometimes talk about is the 30,000-foot view. What drew me to the format was that I wanted to have wide-reaching implications. I didn’t want it to just be a story of what happened. I also wanted to be able to have other people understand how the story ended up where it was.
Memoir—even good memoir—relies on this narrative engine to propel us through the experiences of the author. But a memoir is not just a series of experiences you had. That’s where the complication of doing this in an essay format came for me. I wanted to be able to include information that wouldn’t necessarily be part of a straight narrative memoir.
Rumpus: In many of the essays, you draw comparisons between yourself and other women who have been sick or in chronic pain: a girl in your EMT class with diabetes, a friend with chronic pain and an opioid addiction, a woman in the ER with fibromyalgia (which you have also been diagnosed with). In many places they seem to stand for symbols of the narrator. How did you go about choosing these subjects, and how did you decide how much of your story to include in those scenes?
Maloney: I didn’t want to take away from their story, but I also wanted to tell my own story. This is not Gonzo journalism; this is not “Frank Sinatra Has a Cold.” These were people I knew. These were my co-workers or patients we saw. There was a bridge between my story and their story. And I could have colored that in with what I thought their story was, but I didn’t feel comfortable doing that, even if I had interviewed somebody. I can’t tell them how to think or how to feel.
Rumpus: You wrote that for many women, their “illness tended not to be a medical failure but a failure of personality.” Why do you think this is an issue for women in particular?
Maloney: Oh, we don’t take women seriously at all. We also don’t take people of color, LGBTQ, anyone who’s not a cisgendered white dude, we really don’t take those people seriously. A lot of it is about systematic oppression. We did not include women or people of color in clinical trials. A lot of drugs are only tested on white dudes. So we know how they work on white dudes, and we don’t know how they work on anyone else.
There’s a lot of work being done now to enroll more diverse groups in clinical trials, but it’s such a challenge. If you’ve been the victim of systemic racism or oppression, you might be less likely to sign up, understandably. It’s an ongoing struggle. The face of medicine is changing, and that’s exciting. There’s a lot more women and people of color who are becoming physicians. And the idea that people can see someone who looks like them reflected back in the caregiver, that’s another way to provide better care.
Then there’s the problem of the hysterical woman. We used to leech women, because we thought that women had too much blood. We had Galenist [an ancient Greek physician and proponent of the theory of the four humors] ideas about medicine that persisted into the early twentieth century. We’ve got a long way to go. We’re not leeching women to hasten their deaths anymore. They [leeches] are FDA-approved, I will say that.
A lot of the care pathways in medicine—when we go to evaluate, diagnose, and treat a patient—may have been created by pharmaceutical companies. Like, “Here’s how you can treat patients with X drug.” And then there are a lot of things we don’t know about. For a long time we thought fibromyalgia was a late-twentieth-century women’s hysteria problem.
Rumpus: Many other memoirs focus on male doctors and medicine’s masculine culture. But in your book, the main psychiatrist is a woman named Julie. Did writing about a female doctor change the way you approached the story?
Maloney: That’s really interesting. Female physicians have considerably less support in their careers. The rate of suicide among female psychiatrists is very high. Veterinarians are also like this, and they tend to be women. It’s the problem of being a doctor in today’s late capitalist society. Did Julie prescribe me 26 medications over five years? Yes. Do I think she was doing the best she could with the resources she had? Yes.
If you have children or if you’re going through a divorce or if you’re dealing with your parents who are aging, any life event, [and you’re a woman] you don’t have paid leave. Child care is exorbitantly expensive. A lot of women are stuck in a lot of different ways, even if they get a lot of great opportunities along the way. A lot of women doctors go on to practice part-time or not at all. We don’t provide female physicians with the support they need. It means a lot of women are leaving the profession.
Rumpus: You do a great job of balancing empathy with awareness of structural problems. One of the big issues is that female doctors might not even realize some of the patriarchal views in medicine that they’re perpetuating.
Maloney: It’s a lot in the way that they were educated, right? Patriarchy has such a lasting grasp on all of us. It’s hard to get free of that. That’s a huge component for a lot of physicians in particular, men or women or whatever their gender. There’s still this oppressive patriarchal view of medicine and how it “should” be practiced.
Rumpus: I’m curious how working at a hospital in different capacities affected your own medical journey and the way you write about it.
Maloney: Unfortunately, we live in a country where we’re operating from an emergency model. There’s no wellness-based model where people can see their primary care physician on a regular basis, because no one can really afford it. So instead, patients are coming into the ER with serious medical problems. That kind of situation is not something that is going to go away anytime soon. The problem needs to be solved through massive infrastructure changes and an increase in health literacy. Instead of operating from an illness-based model, we need to be operating from a wellness-and-prevention-based model.
Rumpus: You wrote many of these essays while working in the health care industry. How do you balance these day jobs with your writing life?
Maloney: I did write some of those initial scenes while I was working in the ER. My first job out of graduate school was a long-term temporary assignment. I was paid hourly. That was great. I advise that. Get a nice long-term temp hourly job, because then your weekends, your evenings, your lunches, that’s all your time. I would often go into the office but not clock in until I had at least written something for thirty minutes sitting at my desk.
This book was sold on proposal. I drafted an initial proposal over several days while my husband and I were in New York on vacation. Then I sent it to my agent, and we worked on it over a while. Then I was able to get a residency to MacDowell, where I finished the proposal and the sample pages. From there it got sent out. I was also lucky to have some amazing magazine editors. Two of the pieces in the book were in VQR, so I got the incredible guidance of Paul Reyes and Allison Wright. They are sharp and phenomenal people. To have that level of attention to detail on the magazine side is phenomenal. And then to get that also with this book is pretty great too. My book editor James Melia was exceptionally helpful in getting me to see the big picture especially, the big arc of the book.
Rumpus: How long did it take you to write the book?
Maloney: I write really slow. I have a nonverbal learning disability. So I talk fast, but I think slow. It gets me into trouble.
When I’m writing, there’s a woman in my head. She’s kind of mean. She’s not me. She starts talking, and then I write down whatever she says. For a long time, I thought I had mental illness, but it turns out I’m just a writer.
Anne Fadiman came to our class at Pitt when I was a grad student, and she said that some of us are diamond polishers and some of us are swamp drivers. What she meant by that was that some people draft really fast because they need to drive across the swamp fast to keep their dune buggy from sinking in the mud and the sand. They have to get to the end, and then they spend a lot of time revising. Then there are people who are diamond polishers, and the word has to be right before they get to the next word. She says in her non-scientific surveys of people, seventy percent are swamp drivers and the remaining are diamond polishers. Everyone who is a diamond polisher wishes they could be a swamp driver, and all the swamp drivers want to be diamond polishers. I’m a diamond polisher. Everything takes me forever. Once I sit down to write, I can put it out. But for a long time, the book’s in my head. When I’m working on something, it’s in my head. I write in my head. I can turn the pages in my head. Then when it’s ready, I start writing. A lot of the work I do around writing is actually just loading and unloading the dishwasher or taking a walk. I ride and train other people’s horses. There’s a lot of work that happens before I even start writing, and I have to sort of expect that.
Rumpus: Yeah, I think that a lot of us can identify with going on walks and unloading the dishwasher and thinking. Does that mean that when you sit down to write, it comes out perfectly the way you want it?
Maloney: Yes. Sorry. Some people are funny about their writing processes. It’s okay if you’re someone who needs to write every day. It’s okay if you’re someone who doesn’t need to write every day. It’s okay if you’re someone who wants to outline; it’s also fine if you don’t outline anything ever. There’s a lot of rules or feelings about how writing a book should be, but very little of that actually corresponds with reality. You have to do what works for you. For me there’s a woman in my head, and she talks to me and I write down whatever she says.
Rumpus: Your own rhythm and process are going to be more helpful than listening to other people’s rules.
Maloney: There’s this idea that someone goes into their writing cave and makes magic. But it’s not like that. You need a community of people to support you, and whether that’s full readers or someone you can text and complain about the experience to or a spouse or partner. It’s cool to have people in your life who can understand, because no one else will understand.
Rumpus: It’s hard to ignore that right now you have COVID-19, and we’re talking despite the fact that you’re sick. What has that been like as a person with chronic health issues?
Maloney: It’s scary. It’s frustrating. There are benefits to the pandemic as well, especially if you weren’t someone who could attend a lot of readings. I’ve gone to a lot of readings for the last couple of years virtually, because the accessibility is there. To be able to turn on captions, because I have a very slow processing speed. I watch everything in closed captions, and I need captions for live events. I get a lot more out of those kinds of [virtual] opportunities.
Of course, it’s such a struggle to feel like you need to be careful, and I feel like we were. We haven’t gone anywhere. My husband brought it home from the doctor’s office. He has since gotten over it, so that’s good. It’s taking longer for me because of my asthma and other conditions. It’s frustrating, because you feel like you’re doing what you can to avoid getting sick. And then other people are not at all. I was really angry, because I would see people who were out living their lives, and I would think, “Shoot, what am I doing?” I hope that people can get vaccinated and take it seriously. I hope that unfortunately, as more people get sick, people start to know people who have been sick, especially people who have been really sick. At the cost of the health care system infrastructure, that could make people potentially re-evaluate their choices and say, “Maybe I should get vaccinated.”
Rumpus: What’s it like to have published a book about health care and illness at a time when that’s so top of mind for many people?
Maloney: I feel like people are both interested in and engaged around the subject, and also are sick of hearing about it. The pandemic has brought to light a lot of the issues that have been problems in the American health care system for decades. The more we continue to talk about and bring light to these topics, the more we can potentially do something about it. I worked in a hospital that in 2008 was $54 million in debt. The problems facing community hospitals are magnified and amplified by the presence of the pandemic. It’s interesting to see that people are leaving health care altogether. There are lots of people who have been made disabled by the pandemic who were on the front lines at the beginning and who got really sick and who haven’t gotten any better. The long-COVID-19 support group on Facebook is enormous and growing every day.
Rumpus: It’s terrifying. Do you have any advice for other people writing nonfiction about these themes?
Maloney: I think it’s important to operate from a point of empathy and compassion, both compassion for other characters and compassion for yourself. It can be a long experience. I recommend therapy if you’re writing about difficult topics and especially health care trauma and experiences in health care. It’s important to have a lot of good support for that process. The act of writing can come at an enormous cost. You have to be aware of that cost and see how you can help yourself be in the best position to write the book you need to write.
Author photo by Joanna Eldredge Morrissey