Ansell presents the urgent medical situation of Windora Bradley, his long-term patient. Windora, an African American woman living in a disadvantaged neighborhood in Chicago, suffered a stroke during a consultation at the hospital where Ansell was working. He rushed to the consultation room where she was, trying to save her and minimize the impact of the stroke. The scene underscores the theme of the book: The lethal impact of inequality on health.

Ansell reflects on Windora’s health history, noting that her deteriorating health is a direct result of her socioeconomic status, race, and residential location. Ansell argues these factors have set Windora on a path of “American roulette.” This is an allusion to Russian roulette, a game of chance played with a revolver containing one bullet, where the player spins the cylinder and places the muzzle against their head before shooting. Ansell describes the American roulette as a rigged game where the poor and marginalized are predisposed to early death by an unfair system. The metaphor of the American roulette stands for the American healthcare system, which is both potentially deadly and rigged to the disadvantage of poor and racialized citizens.