By Duaa Eldeib, ProPublica
Teresa Ruvalcaba lay on a bed in the emergency room of Chicago’s Mount Sinai Hospital, her right breast swollen to nearly twice the size of her left, the skin so thick and dimpled that the doctor examining her would note that it resembled an orange peel.
Ojalá que sólo sea una infección, she thought, as she struggled to catch her breath, not knowing she had a partially collapsed lung. I hope it’s just an infection.
For more than six months, the 48-year-old factory worker had tried to ignore the pain and inflammation in her chest. She was afraid of visiting a doctor during the pandemic, afraid of missing work, afraid of losing her job, her home, her ability to take care of her three children. She kept working until she couldn’t, until the pain forced her to ask her son to drive her to the hospital on this cold, cloudy night in January.
Seven miles away, 24-year-old Sergio waited in his cramped childhood bedroom, clothes scattered on the floor and his medical school entrance-exam books untouched on a shelf, his eyes locked on his phone. Sergio usually accompanied his mother anywhere she might need help with her limited English, but because of the pandemic, he hadn’t been allowed past hospital security. After two and a half hours of silence, he texted her in Spanish, “How’s it going?”
“My son they are doing all the checkups they are going to put me in a machine right now for the checkup,” she typed back, also in Spanish.
The page from the hospital caught oncologist Dr. Paramjeet “Pam” Khosla in her kitchen in the southwest suburbs, where she, her husband and their two adult daughters had lingered to talk after dinner. Although she had been in practice for more than 20 years, Khosla’s heart still jumped a little whenever the phone buzzed on the nights she was on call.
A chest X-ray showed a large mass in the chest of a woman complaining of pain in her breast, the emergency room doctor told her. Concerned, Khosla told him to order an immediate biopsy. They agreed she would see the patient as soon as she could.
Here we go again, she thought.
In the shadows of COVID-19, another crisis has emerged. With the pandemic in its second year and hope intermittently arriving along with vaccine vials, it’s as if a violent flood has begun to recede, exposing the wreckage left in its wake. Amid the damage is an untold number of cancers that went undiagnosed or untreated as patients postponed annual screenings, and as cancer clinics and hospitals suspended biopsies and chemotherapy and radiation treatments. Across the country, preventive cancer screenings plummeted by as much as 94% during the first four months of last year. At Mount Sinai, the number of mammograms dropped by 96% during that same period. By July, screenings had started to rebound, both nationally and at Mount Sinai, but still trailed pre-COVID-19 numbers. Fewer screenings led to a decline in new diagnoses, which one study found fell by more than 50% for some cancers last year. But people didn’t stop getting cancer; they stopped getting diagnosed.
As patients return to their doctors, the toll of those dark months is becoming visible. The National Cancer Institute has predicted almost 10,000 excess deaths over the next decade from breast and colorectal cancer alone because of pandemic-related delays in diagnosing and treating these two cancers, which often can be detected early through screening and account for about 1 in 6 cancer deaths. Like the pandemic itself, the impact is expected to hit communities of color particularly hard. Black Americans already die of all cancers combined at a higher rate than any other racial group. And cancer is the leading cause of death among Latinos, with breast cancer outranking other cancers for women.
After almost five hours at the hospital, Teresa left that night without a diagnosis but with instructions to call Khosla. Sergio picked her up outside the emergency room door. On the way home, they talked about all the tests she had undergone. Neither of them mentioned the word cancer.
Last summer, as her right breast began to swell, Teresa stuffed the left side of her bra with paper towels, embarrassed that someone at work might notice.
A solidly built woman with deep brown eyes and tattoos weaving up her neck and down her arms, Teresa had worked nearly half her life at the same candy manufacturing factory on Chicago’s West Side. She immigrated to the United States from Mexico almost on a whim at the age of 21, settled in Chicago, became a permanent resident, and got hired at “los dulces,” as she calls it. Over time, the factory’s owners changed — Kraft, Kellogg, Ferrara Candy — but Teresa remained. She eventually became a machine operator, earning $21 an hour.
The factory was more than a job to her. It was where she made friends, told jokes to pass the long hours, and blasted music, especially the upbeat cumbia songs of her teenage years, in the locker room. Her colleagues had a hard time keeping up with her energy, but they knew she would pick up the slack if someone on the line slowed down or cover for them if they were out, because Teresa never said no to work. The income allowed her to support her children on her own and, in 2008, accomplish something she had not thought possible: put $5,000 toward buying a century-old, Cape-Cod style home in a largely Latino Chicago neighborhood where the roar of airplanes from nearby Midway Airport regularly interrupted the quiet.
The tentative grasp on stability came at a price. She usually worked the overnight shift, often arriving early and staying late, then rushed home to get Aurora, Sergio and Roberto off to school. When they were young, the children enjoyed the lollipops and gummies she brought from work; it wasn’t until they were older that they noticed her bruised knees and bloodied fingers.
As the pandemic struck, Teresa didn’t slow down, even as it hit essential workers particularly hard. She had come close to losing her house in 2018 after falling behind on her mortgage payments. She couldn’t risk it happening again.
She worked overtime and filled in for co-workers who were sick with COVID-19. Between shifts, she picked up groceries for that night’s dinner, then collapsed on the living room couch for a few hours, only to wake up and do it all over again. She had created a plan to protect herself from the virus, wearing two masks and latex gloves on her hourlong commute on the train and bus. Even though her chest felt as if it was on fire, she kept working. She didn’t want to get COVID-19 at a doctor’s office or the emergency room, and she was so busy she didn’t have much time to think about her symptoms.
“I didn’t pay a lot of attention to it because I have to be both a mother and a father to my children,” she said.
Her tattoos mapped her life, its struggles and devotions. A lion for León, the city in Mexico where she grew up; a Chicago flag for her home since; her mother’s face to mark her death, a loss that still makes Teresa’s breath catch eight years later. When she faced losing her home, she pledged to memorialize Santa Muerte — Saint Death, a Mexican folk saint — in a tattoo if she could save it. Her prayers were answered when she was able to refinance her mortgage, and Teresa, resolute, had the saint inked on her neck. At an ornate altar in her dining room, she made offerings of flowers and apples and lit candles to Santa Muerte. As she felt herself getting sick, she prayed for her health, and for joy and protection for her family.
Finally, when her chest, raw and warm to the touch, hurt too much for her to work, she asked for time off and scheduled a virtual appointment at a nearby clinic in early January. The doctor, viewing her breast through a computer screen, thought Teresa had an infection and prescribed antibiotics.
The pills didn’t help. Still, less than a week later, Teresa sat on the worn living room couch, making plans to return to work the next day. Then, unable to tolerate the burning any longer, she wept. Her daughter, Aurora, hearing the sobs, came to check on her. Teresa agreed to let Sergio take her to the ER.
Sergio was in college before he learned there was a term for what he had been doing for as long as he could remember: language brokering.
When his family went to the neighborhood clinic, 6-year-old Sergio explained to the doctor that he and his siblings needed their school physicals. He negotiated a payment plan with the utility company when he was 9. And throughout his childhood, at parent-teacher conferences, he proudly translated his teachers’ comments: exemplary student, near-perfect attendance, excels at exams.
Those achievements eventually won him a full-tuition scholarship to Pomona College in California, making him the first in his family to leave home for college. Even there, his responsibilities followed him. He monitored his mother’s bank account on his phone, watching anxiously when the balance dipped near zero. When, during his junior year, the mortgage company filed for foreclosure on their home, his family emailed him the documents to translate, which he did, late at night, alone in his dorm room.
Sergio’s freshman year at college had nearly broken him. The classes were rigorous, the pace accelerated, and the lower his grades sank, the more he felt like an imposter. Worse, if he flunked out, he wouldn’t be able to get a good job, and he knew his family was counting on his support. His sister, Aurora, 26, has developmental delays and has not worked consistently although she has an associate’s degree in graphic arts. His 21-year-old brother, Roberto, dropped out of high school a few months shy of graduation with what the family believes is undiagnosed depression. His 2017 honor roll certificate still hangs on the refrigerator.
Sergio didn’t resent the pressure, but he felt engulfed by it. “Everything was relying on me to succeed, and I wasn’t succeeding,” he said. “It got to the point where I didn’t want to be the one solely responsible for improving the lives of my family. I wanted out of that responsibility.”
At points, he even contemplated suicide. But with the help of a therapist, he regained his footing and sense of purpose. He found work at a research lab focused on improving mental health in Latino and other marginalized communities, and he volunteered as a translator for Spanish-speaking patients at a local hospital. He began dating another pre-med student, Ayleen Hernandez, after he offered to help her study for biology and she accepted even though she already knew the material. And he discovered a way to understand his own experience. One day in class, when a professor discussed language brokering, Sergio was captivated. He ended up writing his undergraduate thesis on the topic, citing research showing that Latino communities often place the needs of the family above those of the individual.
In the acknowledgements, he addressed his mother: “The resilience and strength you’ve exhibited during our family’s most difficult and trying moments have not gone unnoticed,” he wrote. “I hope to one day ameliorate these stressors, so that you don’t have to anymore.”
After graduating in 2019 with a degree in cognitive science and a minor in Chicana/o-Latina/o studies, Sergio moved back home to work for a year and help with the bills before applying to medical school. Even though he had hoped to find a job in health care, he felt he needed to accept the first offer he got, confirming prices with suppliers for a company that sells industrial products online. He told himself it was only temporary and, in the interim, he would study for the MCAT and volunteer as a Spanish interpreter at a free clinic in Chicago.
Then came the pandemic, and after that, he noticed his mother getting tired and weak. He urged her to go to the doctor, and she kept promising she would as soon as she had a day off. He decided to stay home a little longer.
Pam Khosla knew the answer to the question before she asked it. Turning to the patient on the exam table, a 53-year-old Black woman in jeans and metallic blue boots, she said, “You missed your mammogram. What happened?”
“COVID,” the woman answered.
Khosla, a white lab coat enveloping her slight frame, rolled closer in her chair. She pointed to an image of the patient’s right breast on the desktop computer screen.
“See that starlike structure?” she asked, her voice gentle but assured. “It’s cancer.”