Not All of Us Are Saints A Doctor's Journey With the Poor
, by Hilfiker, David, M.D.
- ISBN: 9780809074013 | 080907401X
- Cover: Paperback
- Copyright: 8/1/2004
In 1983, Dr. David Hilfiker left his practice in rural Minnesota and began to practice poverty medicine in a ravaged community not far from the White House. Fascinating and deeply affecting, this is his elegantly written true story of that time. Previously published by Hill and Wang. "From the Paperback edition.
David Hilfiker, M.D., is the author of Not All of Us Are Saints.
Not All of Us Are Saints
Chapter 1A DOCTOR'S JOURNEYThis is absurd! What am I doing, near midnight, chasing John Turnell down the middle of Sixteenth Street? He's raving, swearing, pushing me away. What am I, a white man in white doctor clothes, doing entreating this drunken black homeless man to come home with me out of the night?It was in October 1983 that John Turnell was first brought in from the streets. He could hardly walk. Buried in a dark, matted coat, pants reeking of urine, eyes cast on the floor, he sat passively in the corner of the examining room at Community of Hope Health Services."I hurt all over," he mumbled, barely audible. "My neck, my arm, my back, my leg. They're all achin'. My foot won't do nothin'."He glanced up and our eyes met briefly. "I'm alcoholic," he said. "But I ain't had nothin' to drink in four days." He looked away. "Gotta stop these shakes. I know I gotta stop drinkin' this time. It's killin' me." He paused and I searched for something to say. But he began again, almost in a whisper. "And I'm pissin' all over myself,too. I can't stop it ..." He hung his head. There was no expectation of help. He was simply reporting.Thirty-eight then, he had jumped from a burning building six years earlier, breaking his back. "Pained ever since," he said. He'd been hospitalized for surgery but got no relief from his suffering.I examined him. The pain, weakness, paralysis, and sensory loss from his broken back and the concomitant nerve damage were widespread. His left foot dragged, and the large thigh muscles of his left leg had atrophied. The nerves to his bladder were injured, so urine leaked all over his clothing. He had lost sensation in his buttocks and could not feel the large ulcers developing there that now drained constantly.He didn't have medical coverage, but the private hospital at which I had privileges allowed me to admit an occasional indigent patient for further examination. In the end, though, there was not much to be done. Further surgery was not recommended; long-term physical therapy would probably have been of some help, but there was no way to pay for it; the neurological damage--loss of sensation, constant pain, foot drop, weakness, incontinence, impotence--was permanent.For the next several months, I saw John every week in the clinic as I tended his ulcers. He stayed at a small shelter in the neighborhood. His pain never really went away, but--if he slept on a real bed and took pain medication regularly--he could keep it under control. He got used to wearing a leg bag for his urine. We found a foot brace so he could walk without a limp. "It don't bother me so much anymore," he said to me one day when I asked how he was getting along. "You get used to it. I walk okay with the brace, and at least I ain't pissin' all over. As long as I stay sober, anyway," and he grinned.I would see that grin again. It was big and bright, inviting, without a trace of resentment. And there was a certain sparkle in the eyes that looked directly into mine. He seemed to accept his woundswithout anger or resignation. I sometimes wondered how that was possible. Why didn't he just give up the fight?No, I exaggerate: He did not accept all his wounds ... not his impotence. "You know what it's like?" he would say. "You know how she looks at you? She never says nothin', never gets mad. She says it don't make no difference to her, but when she's ready, no woman's gonna stay around for a man who can't perform." We once had a urologist ready to evaluate John's impotence, to look for something that could be done, but there was no insurance for the in-hospital tests, and the evaluation was put on hold ... indefinitely, it turned out.As John got better, the shamefaced, bedraggled derelict who came into my office every Thursday evening was gradually replaced by a handsome man with an engaging style. He looked me in the eye, smiled, made little jokes. He thanked me "for all you've done." I began to hope for his future. Abandoned as a child, alcoholic since adolescence, homeless for years, even he started to talk about a future. He got a custodial job nights, running a waxing machine. But then, a few weeks later, he told me his back had started acting up and he had quit the job. At my urging and with the help of our social worker, he applied for disability coverage under the Supplemental Security Program (SSI) of the federal Social Security Act, but he was not enthusiastic. He wanted to work, he said, not live off welfare.Then, suddenly, John disappeared. I heard he was on the streets again. Several months later, his SSI disability claim was denied; the form letter said John was not sufficiently incapacitated. A volunteer lawyer associated with our clinic began an appeal, but John needed to appear in person, and no one knew where he was. The deadline passed.When, after eight months, John finally showed up again at the clinic, I hardly recognized him. He was unshaven, gaunt; his lusterless eyes sagged in a hollow face. He moved slowly, agonizingly.Light reflected off the spittle in his beard. Sitting in the chair opposite me, he looked much smaller than his six feet. His dark, oversized clothes stank of urine, and his eyes remained fixed on the ground in visible shame. Although sober that evening, he had, he told me, started drinking again shortly after leaving his job waxing floors. Sleeping in alleys, stairwells, and crowded shelters, he had aggravated his back pain, broken open the ulcers on his buttocks, and lost both leg bag and foot brace. Like a perverse safety alarm, however, the increasing pain had put an end to the drinking and goaded him into the clinic, embarrassed and repentant. I did not guess then how often this pattern was to repeat itself.We saw each other irregularly. He was always sober by the time he showed up at the clinic. The pattern became unmistakable: He would begin to feel good about himself, find a job, only to leave it after a few weeks (often because it aggravated his back), and then disappear into the streets and the alcohol. Invariably, as he got closer to independence, some inner compulsion would shatter his dream.As I watched him try to work while in severe pain, as I noticed the cycle that always ended in the streets, I began to encourage him not to work, to accept his disability. He, however, was impatient. I tried again to help him get SSI (which would at least allow him access to Medicaid and decent medical care), but the examiners turned him down once more.One autumn, three years after our initial meeting, John returned, and I convinced him to move into Christ House, the medical recovery shelter for homeless men that a group of us had recently established with the help of our church community. Better equipped and more intensively staffed than the other shelters, dedicated exclusively to the care of those who were too sick to be on the streets, Christ House was also my home, where our family lived with a small community of physicians, other staff people, and their families. Over many months with us, John maintained his sobriety, went through a twenty-eight-day, inpatient alcohol treatment program, attended Alcoholics Anonymous meetings daily, healed his buttock ulcers,strengthened his foot, began managing his incontinence with special medications, and was able to keep even the constant pain to a tolerable level. He began attending classes at my wife Marja's small adult education school, looking to get his high-school-equivalency diploma. I allowed myself to hope again."I know it now: I just can't drink anymore, David ... ever. It's killin' me. I'm alcoholic. I didn't like it when you sent me to that treatment program, but I understand now. I got to stay away from my friends on the street who drink. Got to get new friends. Y'all have helped me so much here, and I'm gonna make it this time. God has been good. You'll see. I'll get my GED, get a job, maybe get married. I'm gonna make it."John "graduated" to a group home, continued attending GED classes with Marja, and was looking for work. Marja gave him one of our old family bicycles, so he could get around town. I felt proud of him. Then, once again, he disappeared. Two weeks later I was at the clinic when Sister Lenora Benda, the nurse in charge at Christ House, called. "John's back, David. He's been drinking, and he seems pretty depressed. He says he tried to swerve his bicycle into the path of a bus this morning, but the bus stopped. He keeps saying he wants to kill himself."I sigh and am silent. Some small part of me is dying. I knew enough to expect it, to prepare for it, but I'm still not ready. Drunk again, and now suicidal! Is this real or some bizarre gesture? Where in this city will I find a psychiatrist to evaluate a homeless drunk? Even if we can get him help, will he get something more than the superficial consultation to which the homeless are so often limited?"Can you get him over to St. Elizabeth's for a psychiatric evaluation, Lenora?""I think so. I think he still trusts me enough to let me take him."Lenora manages to thread John through the system--an accomplishment in itself--and, that same afternoon, a psychiatrist at St. Elizabeth's, Washington's only public psychiatric hospital, evaluates John. The psychiatrist declines to hospitalize him, however, becausethe suicide attempt seems to her most likely to have been just a gesture brought on by his intoxication. John is released with instructions to make an appointment with me at the office.The next evening, as I am lecturing to family physicians at their local professional association about the health care needs of the homeless in our city, the shrill signal of my pager interrupts. It seems that John has returned to Christ House and is uncontrollable. He's been marching back and forth, in and out of Christ House, lying down in front of traffic in Columbia Road or yelling and creating havoc inside. Could I come back and deal with John?I return and try to slip upstairs to drop off my lecture notes and take a few moments to collect myself. Entering our apartment, I discover John in our living room talking with Marja. He's still drunk. "Dr. Hilfiker," he says, slurring his words, "don't send me over to St. Elizabeth's again. I'll be good, I promise. I don't need no hospital. I just need to stop drinking.""But, John, what's this about running into the traffic, about committing suicide? I'm afraid you're going to hurt yourself. What's going to happen if a truck hits you?""Who told you I ran out into the street? Who said anything about suicide?" His usually quiet, reserved speech is loud and brassy. He eyes me belligerently, purses his lips, and pouts. "They're a goddamn liar. Why would I want to commit suicide? I didn't run out in no goddamn street." Oddly, in my three years of working with John, I've not actually seen him drunk before. He has always been gentle, even embarrassingly obsequious; so his belligerence tonight catches me off guard. I have also not known him to lie. Has he forgotten his suicidal gestures? Suddenly he's whining again. "Please don't send me over to St. E.'s, Dr. Hilfiker."I feel overwhelmed, boxed in. I wanted to be John's "friend," to lower the barriers between black and white, rich and poor. But now, in his extremity, he seems more like an alien, a drunk who has invaded my home. Will he turn violent? Will he try to stay? One part of me regrets my invitation to friendship and wants just to push himout to fend for himself. But another knows that without intervention John will disappear into the wilderness of the streets for another six months.And that is not the only conflict I find within my splintered thoughts and feelings. A wiser self knows that I am not in charge of John's recovery, that he must be the one to fight for sobriety; but I cannot let go. Frantically, I try to formulate even a short-term plan to return John to his path of recovery. But now he's up and pacing. I turn my back briefly, and he lurches from the apartment. For a moment I consider just letting him go. But I follow and finally catch up to him on the busy Columbia Road sidewalk outside our building."Where are you going?" I take his arm softly. I'm self-conscious out here on the street, a white man pulling this unwilling black man through a sea of mostly colored humanity."I ain't goin' to no St. E.'s, I can tell you that. I ain't goin' to no place like that. They just fuck you over." Despite his protestations, John allows me to lead him back into Christ House. He sprawls in a chair just across from the nurses' station, his long legs purposely obstructing even the wide main hallway.I don't know what to do. We are not a detox center, and it's not fair to ask the lone night nurse and his aide to devote their entire energies to one patient withdrawing from alcohol; but I can think of no alternative. "John, do you want to spend the night here at Christ House?" I ask, bending our rules almost backward, partly because John has become in some sense a friend, mostly because I cannot admit that we have lost him this time around.John agrees to take a tranquilizer to smooth the process of detoxification and lessen the likelihood of seizures, and I retreat to the nurses' station to write orders for his admission. Three times within the next fifteen minutes, however, John bolts from Christ House, and I run to retrieve him. Each time he's more belligerent; each time I am, perhaps, a little more hesitant to chase him.I begin to fill out commitment papers, more out of despair than hope. As I finish, John once more runs outside, and I, once again,follow. As usual, Columbia Road is busy in the late evening: Latin music blares from small knots of Salvadoran men; the sidewalk café of the Ethiopian restaurant next door is full of black people laughing and talking in foreign tongues; well-dressed couples walk past beggars; children from a nearby housing development twist their way through the crowded streets even near midnight. Wading into this human sea, I catch up with John, but this time he is not about to be turned around."No way I'm goin' to St. E.'s. I thought you was my friend, Dr. Hilfiker. You ain't my friend." He stares straight forward and marches on, shouting epithets at me as I trail behind. "You just like all those other white motherfuckers. You don't care for no niggers. You get paid all that money to take care of us. We don't get nothin'."I follow along in silence for almost a mile. What am I doing here, well past any reasonable bedtime, chasing a drunk down this street? Finally I stop and call to him. "John, I'm going back. I want you to come with me."He continues walking, but fifty feet later turns. We stare at each other for a full minute. Finally his tall body wilts like a limp doll's, and he drags himself back toward me, defeated.I have no idea why he's changed his mind. Perhaps it is the residue of the trust I thought had bonded us over these years. Perhaps he simply feels powerless and enraged. Trying to start a conversation, any conversation, to keep John's mind off St. E.'s, I ask him whether he ever thinks about going back home, to the South. "I never knew my mother," he says, apparently answering some question of his own. "She was crazy, spent most of her days in the state hospital. 'Paranoid schizophrenic,' they called it. My father, he drank a lot. I never saw him till I was six, and he came back home just to beat me. He kept telling me I was bad, just like her. He said I was crazy, too, and belonged in a hospital just like her. He hated me. Never said nothin' good about me. I lived at different places, but mostly I just raised myself. I started drinkin' when I was twelve. Iknew I had found something there. It made me feel good. When I drink, I ain't afraid to say nothin'. When I'm sober I can't say what's on my mind. I couldn't tell you any of this if I wasn't drinkin'." I have learned more about John's past in these two minutes on the street than in two years of interviews. He looks at me and grins ... that wide smile with those white teeth almost luminous against the dark night ... but fear lies behind the eyes.Back at Christ House sometime around midnight, I put John into a room and continue the process of committing him for psychiatric help. First, I call the public Crisis Resolution Unit, which is specifically mandated to intervene in situations like this. The receptionist says they are currently "short-staffed" and won't be able to help. She suggests calling the police. The police dispatcher says a unit will be "right over." When--after half an hour--nothing happens and I can hear John getting restless, I call again. "Well, you didn't say it was an emergency," the dispatcher says testily. Ten minutes later, John runs from his room. I catch up with him for what feels like the tenth time just as he lurches into the street and sprawls in front of an automobile, which jerks to a halt.A moment later a squad car pulls up. I explain the situation to the officer and show him the commitment papers I have completed. The officer looks troubled. He tells me the police are not allowed to transport psychiatric patients from a "private facility" unless the police officer himself witnesses the patient being a danger to self or others. He says he didn't see John lying in the street. We will have to find our own transportation.How could he not have seen John lying in the street? I can't believe it!Asking the officer to wait, I call Crisis again. The head of the unit confirms my understanding that once I have filled out appropriate forms the police are obliged to transport. He asks me to wait a few minutes while he calls the precinct captain to straighten matters out. The officer and I wait. John goes into his room and passes out. Icall Crisis back. They are still "working on it." Well after one o'clock in the morning, the officer leaves, John lies passed out in a room, and I go upstairs to bed. No one ever calls back from Crisis.I'm not surprised to be awakened the next morning by the night nurse reporting that John has left.Later that morning, Lenora calls me at the clinic. John has returned to Christ House, she has called Crisis, and this time a team has come and taken him to St. Elizabeth's. She asks me to call a certain psychiatrist at St. E.'s."Dr. Hilfiker, I have just examined Mr. Turnell," reports the doctor. "I feel that his suicide gestures are really the result of his drinking. I don't think that he requires mental hospitalization but rather alcohol detoxification."I notice my hands shaking as I grip the telephone. "Doctor, John's suicide attempts are obviously caused by his drinking, but he's nevertheless a danger to himself at this time. As you know, they won't be able to force John to stay at the detox unit. He'll just walk out of there."Despite my protests, the psychiatrist refuses to hospitalize John, referring him instead to the detox unit. John promptly walks out.Over the next year John returns to my office several times. He no longer needs to wait until he is sober to visit. At one point he steals $250 from Angela, our receptionist. He marries a Haitian refugee with a two-year-old child. At the time of their wedding, he has known her just a month and has been drunk--as far as I can tell--the entire time. Just before the wedding, John comes, drunk, to my office with his prospective wife and child. While in our waiting room John starts hitting the boy, threatening to kill him. We eventually have to call Child Protective Services just to protect the boy. Since then I have seen John and his family several times on the street, he always walking fifteen feet ahead, she dragging the child behind, like a scene from an old foreign film.
I am a family physician who practices in Washington, D.C., a city replete with the most advanced medical technology in the world. But the reader who hopes to encounter clever medical sleuthing, rare cures, dramatic surgical interventions, or even a glimpse of the medical wizards who perform such heroics might as well close the book here. For I practice "poverty medicine," a profession more like the medicine practiced in the Third World than what is ordinarily considered "modern medicine."Since 1983 I have worked at Community of Hope Health Services, a small, church-sponsored clinic in the inner city, and since 1985 also at Christ House, a thirty-four-bed medical recovery shelter for homeless men too sick to be on the streets yet not sick enough to be in the hospital. The medicine I now practice looks very different from what I did during the first seven years of my career, when I was a country doctor in a small town in northeastern Minnesota. There in Minnesota, the reassuring model of traditional medicine I had learned in my medical training still obtained: While other aspects of the patient's life were certainly important, illness was a distinct phenomenon that could basically be treated in and of itself. As "the Doctor" I assumed a role of real importance. My scientific medical expertise was useful, valued.As soon as I entered the world of the inner-city poor, however, my "power" as a physician succumbed to the same forces that dominate the lives of my patients, and I had to learn what is really a new specialty--poverty medicine. I did not understand at first, but poverty medicine is in a sense about everything but medicine, about everything but doctoring as it is normally experienced in the middle-and upper-class world in which I was reared, trained, and first practiced. Disease as usually defined by medicine is prevalent and, by and large, worse among the poor of the inner city than among the more affluent. But health, in the world of my patients, is not simply a matter of disease and treatment; indeed the "strictly medical" is not the crucial factor in most healing.By the very nature of my patients' circumstances, much of mywork does not even feel like the proper use of my training and abilities. I spend my time listening to stories about shelter conditions, dangerous neighborhoods, economic hardship, family tragedies that I can do nothing about ... except listen and care. I spend other large blocks of time finagling treatments for which another doctor would simply write a prescription: finding free medications, urging a specialist to volunteer care, traipsing by telephone through the maze of the public hospital to secure the results of a single test. Even in my day-to-day work, I am a "clinic doctor," dispensing routine medical care that--as far as the science of it is concerned--someone with far less education and experience could easily do.Poverty medicine, of course, isn't recognized as a field within the profession of medicine. It's a medical specialty without schools, standards, accreditation, journals, or associations. Its few practitioners frequently do their own fund-raising and band together for support in loosely knit alternative organizations without funding or power. It's a specialty with an enormous population of patients in America, yet virtually no practitioners.Like my specialty, this book is, in a sense, about everything but medicine, for in working with people of poverty the simplest medical act reveals the deepest social contradiction.This book is less about medicine than about class. My wife Marja and I are solidly middle-class. As a physician I could easily command a salary in excess of $100,000; as even a beginning teacher Marja could earn more than $27,000. Everything about our lives--our upbringing, our education, our level of consumption, the vacations we take, the church we attend, our prejudices about who deserves what and why--is deeply rooted in the middle class. This book explores what it is like for a middle-class doctor to work with the poor; what it is like for a middle-class family to "live with" the poor in what must be one of the very few experiments of its kind in the United States today to put doctors and homeless patients under the same roof; what it is like to walk between the worlds of the rich and the poor.This book is less about medicine than about race. My patients are overwhelmingly black because poverty in our nation's capital is primarily a black--although increasingly a Hispanic--phenomenon.1 Everything a white doctor does--from choosing to practice in a black community in the first place to admitting patients to the large, mostly black community hospital rather than the small, wealthy, mostly white hospital across town to writing about his experiences for publication--brings the questions, confusions, and problems of race in America rushing to the fore.This book is less about medicine than about culture. Great is the distance between a Yale-educated, third-generation white American and a poor, probably undereducated black person born in the rural South. From the entertainments we choose to the religious traditions we uphold, from our child-rearing practices to our beliefs about healing, from our family structures to our celebrations, my patients and I live in very different worlds. We struggle to share even a language.This book is less about the medical treatment of esoteric diseases than about medical helplessness before the drugs of choice lodged so deeply in our society. When we think of inner-city addictions, most of us think of crack cocaine or heroin. In fact, the drug the reader will encounter most frequently in this book, the drug of most concern to me as a physician, the drug that--even in our neighborhood--does more damage than all the others combined, is alcohol.This book is less about bold prescriptions for political or societal change than about what it's like to find oneself suddenly enmeshed in the crumbling relationship between government and the poor. It's about the grim consequences of two decades of governmental withdrawal and the deliberate underfunding of social agencies, about the helplessness of helpers running into the closed doors and cul-de-sacs of social policy. It is about the wholesale abandonment of the poor.At its heart, then, this book is about the nature of poverty and its awful power to break the spirit. There are many poor people in thecity of Washington who, with great courage, resist that power, get by more or less like middle-class people ... only without money. Some of them are in this book. But because of the particular places at which I work and because of my focus on the homeless, this book is more about brokenness and failure, frustration and hopelessness than about successes and the hope they allow us.I don't claim to have sorted out the complex linkages among race, poverty, and class in America any better than the many scholars and thinkers who have generated such a profusion of books on these subjects. In fact, although I've written many articles and stories about my work, although I've lectured widely to medical students and physicians about poverty medicine, I've found it difficult indeed to write this book. Because my form of medical practice tends to bring up virtually every large and confusing social issue and because life next to the poor revealed one contradiction after another in my own life, it was sometimes impossible to work out the nature of this "medical" book "about" a doctor. At several points I was simply unable to proceed for months on end, once for an entire year. My difficulties in writing only mirrored my problems as a poverty doctor. No matter how "simple" the medical problems I faced, I often found myself hopelessly lost in a forest of uncertainties.What I can offer is primarily that I, a middle-class, white professional, have been there in that "other land"--a land that most of us see only when we stare into the face of a beggar insistently accosting us on the street or in brief, sanitized television reports that can be zapped off the screen--and that, with whatever hesitations, I want to be where I am.
I came to the inner city in part because I believed that poverty in our country was more a matter of injustice than of personal characteristics or bad luck, and because I believed in the possibility of justice. I came because I was aware, to some degree, of my privileged background, of the inherent power of a white male in oursociety. I came with the conviction that we who had grown up with education and opportunities had not so much deserved our affluence as inherited it and that the poor were--by virtue of their oppression--"deserving." I came, in other words, with hope: If poverty were the result of oppression, then even a small group of affluent people could make a difference by providing--through well-run service projects (subsidized housing, health centers, day-care and education institutions, job training, and other services)--the beginning of a way out. If injustice were the cause of the poverty, then my presence as a health care provider would in some small way help my patients climb the "ladder" I knew was there.I also came with a desire to help the poor, but (if I am honest) there was an element of obligation as well. For better or (usually) for worse I have operated much of my life out of a sense of "oughtness," and within my religious and cultural tradition there was certainly an ethical imperative to help the poor. Any relationship works both ways, however. What happens to a person when he--as an affluent, comfortable, well-intentioned physician--walks next to some of the barriers that ordinarily separate rich and poor? What happens when one who is wealthya lives next to and works with people whose poverty is the result of the very structures that have brought him his wealth?This, then, is a book about a journey, a journey that began both as a struggle against injustice on behalf of those abandoned by the rest of us and as a search for my own spiritual center. Though I knew the journey would be difficult, I thought that its goals and direction at least would be clear. I could not guess how deeply the struggle with the misery of the inner city would be mirrored in thechaos of my internal quest. My desire to understand the nature of that misery led me by turns to blame the rich, the poor, and myself for what I saw, and it led me also to a painful encounter with the limits of what I was capable of, and who I was.My journey, of course, began long before I ever arrived in Washington, D.C. From 1975 until 1982, my family and I lived in the middle of a vast wilderness area in northeastern Minnesota, where I practiced family medicine. Marja, our three children (Laurel, Karin, and Kai), and I delighted in the stark beauty of the natural environment and in the intimacy of our small town. A rural community offers profound blessings to the doctor: I shared the joy of childbirth and the grief of illness or sudden death. I cherished the opportunity for trust between doctor and patient, and basked in the gratitude bestowed on the country doctor.But the stress of rural medicine also took its toll. Living and working over one hundred miles from the nearest specialist, I needed to practice constantly at the limits of my competence--and frequently beyond: placing an emergency intracardiac pacemaker in a patient with a severe heart attack, although I hadn't done the procedure in years; performing a cesarean section on a friend, despite my inadequate surgical training; treating complex medical problems while repeatedly second-guessing myself about not referring the patient to a specialist's care in Duluth.I found it difficult to be "the Doctor" in a small town where one could never be quite off-duty. When I was on call, I was not only the family doctor taking the late-afternoon telephone plea from the distraught mother, but also the emergency room physician evaluating the child's acute asthma attack later that evening. If necessary, I then became the pediatrician who admitted the child to the hospital a little before midnight and, sometimes, the house officer called down in the middle of the night to treat the worsening shortness of breath. If my pregnant patient came to afternoon office hours in labor, I could be sure to be up most of the night as I took turns being office doctor, telephone consultant, admitting physician, labor room nurse,delivering obstetrician, neonatal pediatrician, and finally honorary godfather. A few hours later I would be a pediatrician again, doing morning rounds on the newborn, and then general physician back in our clinic. It was wonderfully exhilarating ... and unbearably exhausting.It took me seven years to realize that the constant stress of my work no longer allowed me to receive the blessings of rural practice. I found myself frequently depressed, almost always anxious, sometimes terrified of going to work. I had chosen medicine in order to be of service to others, but I was unable to find the fulfillment I wanted from my life of service. I needed to leave.2Our family moved for a year to Marja's home in Finland. There --amid natural beauty so similar to Minnesota's yet so far from the stress--I managed to recover my balance. Before leaving Minnesota, however, Marja and I had been introduced to Church of the Saviour, a small, ecumenical religious community in Washington, D.C., dedicated to working with poor people of the inner city. We thought of it often while we were away, and particularly of the efforts of one member.In 1976 Janelle Goetcheus, a physician, and her husband, Allen, a Methodist clergyman, while waiting for visas (which were ultimately not forthcoming) for traditional Christian missionary work in Southeast Asia, had visited Washington, where they witnessed the desperation of inner-city life and the absence of available medical care. The Goetcheuses were permanently detoured. Initially, Janelle worked in an emergency room and volunteered at various clinics, but soon she called together a group from Church of the Saviour to found Columbia Road Health Services, a small neighborhood clinic that burgeoned from a second-floor walk-up into the complete family-practice clinic that now sees over fifteen thousand patient visits a year, predominantly from the refugee Hispanic community. She also helped to establish Community of Hope Health Services, another family-practice clinic on nearby Belmont Street, and a third small clinic at SOME (So Others May Eat), a soup kitchen sponsoredby the Catholic Church. Although sponsored by separate organizations, the three clinics functioned as a loosely knit group practice providing health services to the poor. In early 1983 I accepted the invitation to join her in her work.Even after a year's rest and contemplation, my motivation in coming to Washington was not clear to me. I experienced a vague sense that my own fulfillment was to be found in a life among the poor, but I was not sure whether I felt that way or merely wanted to feel that way, whether my motivation was simply an internalization of certain biblical texts and childhood messages or whether it was really my own belief. I certainly couldn't talk about what I was doing without becoming quickly confused, all the more so since a move from an idyllic wilderness area to inner-city Washington hardly made sense: If I had not been able to tolerate practice in a small, supportive town, how was I to survive the inner city?In some ways, however, practice in the city actually proved easier. My partners and I soon realized that what the city's poor really needed was access to the health care system, frontline doctors offering primary care who could help them connect with the wider system. With an abundance of specialists around, I no longer delivered babies, set fractures, or took care of complicated medical problems. When patients called in the middle of the night, I remained a family doctor and referred them to an emergency room for evaluation. I soon stopped hospital practice and the acute care of seriously ill people altogether.Not only did the changes in my role give me some hope of surviving the stress, but I also entered into a community of persons all engaged in similar work, and we were remarkably supportive of one another. For all its drawbacks, it seemed that poverty medicine might suit me better than any "normal" practice.Despite my eagerness, however, there was no way to prepare myself to face the unraveling of the social fabric, the larger loss of community that was the truth of inner-city Washington. I was initially shocked and angry at a system that had abandoned those leastable to help themselves. There was no housing; medical care was inaccessible; public education was a disaster; jobs with living wages were unavailable. Most of my new patients had the same kinds of medical illnesses I had tended in Minnesota, but they also suffered from a kind of neglect I had not imagined possible.That shock, though, I could at least see coming. What caught me completely off guard was my patients' internalization of their abandonment. Children who had not been adequately loved now saw themselves as unlovable; young people who had been inadequately trusted could now trust no one; adults who had been pushed down too many times now saw failure as inevitable; addicts for whom no treatment was offered had now--for practical purposes--given up on the possibility of a meaningful life. I was not prepared for the hostility, the seeming ingratitude, the noncompliance, the irrationality that is so much a part of the inner-city reality.This was a journey into a strange and threatening world.
There are a variety of obstacles any middle-class reader is likely to face in accompanying me on this journey. Not the least, for some readers, will be its religious aspect. I am the son of a clergyman, reared in a mainline Protestant church. Although as a young adult I left the church for over fifteen years, I always felt a vocation to serve others. The decision to enter the inner city was born of a conscious desire to move into closer relationship with God. When Marja and I joined Janelle Goetcheus, we did so as much for the opportunity to live and work within a Christian spiritual community as for the chance to practice a certain kind of medicine.Some readers, coming across names like "Christ House" or "Samaritan Inn," may feel imposed upon, even though ours is an ecumenical church community that emphasizes spiritual growth and acts of mercy and advocacy rather than doctrine or theological correctness. Isn't it enough, some readers may nonetheless feel, to bring oneself to a book on homelessness and poverty--a book that hasevery possibility of being amply guilt-inducing--without having to deal with the self-righteousness of the church? I often discover such wariness when I talk to medical audiences about poverty medicine. For some, the very existence of a religious mission at the core of my practice is grounds for dismissal: of me, of poverty medicine, of the homeless, of any connection between the middle class and the poor. For others, the spiritual dimension to our doctoring can evoke images of paternalistic missionary work, of the white man and his culture ultimately disempowering poor people of color by "serving" them. If this were the "religion" hawked in this book, I would have none of it either.A reader who does not personally experience religion as a source of strength may be tempted to dismiss the "religiously motivated" as saints or lunatics (the distinction is not always obvious to the uninitiated) whose purposes and life experiences have little to do with one's own. Medical students with whom I talk sometimes say, "I can see how you might survive in the inner city, with your Christian community and your faith in God and God's healing, but what about me? I have no religious faith and no community. How is your experience in any way relevant to mine?"I usually answer that each of us is on a spiritual journey, articulated or not, and our deepest beliefs invariably shape who we are. My religious beliefs do inform my decisions to live and practice in Washington's inner city, but that makes me little different from any other person trying consciously and reflectively to live according to his or her convictions. God, according to all religious traditions, lives within each of us. Any person trying to live by attending to that "deep stillness within"--whether expressed in Christian, Jewish, Islamic, Buddhist, Native American, or absolutely secular language--should find him- or herself at home with the spirituality (and, I hope, with the language) in this book.More practically, if one dismisses spiritual (or even explicitly religious) motivation for medical work with the inner-city poor--in Washington, at least--there's not much left to talk about in the1990s except the leaching of all care from the ever-growing worlds of poverty and homelessness. In the 1980s, as government money was withdrawn from the ghettos, as private investment never entered, as community organizing petered out, as a few private practitioners struggled (too often unsuccessfully) to make ends meet while caring for the indigent, often all that was left were church groups and other parareligious organizations trying against overwhelming odds to address even the barest, most basic needs of the poor.My own hope is that even those who find religious labels and beliefs embarrassing or irrelevant will find something for themselves here. "Religious" or not, conscious of it or not, safely ensconced in the suburbs or not, each of us is inextricably bound to--indeed, tangled up with--the pain of the poor. My hope is to reveal some of those bonds, to acknowledge our common community.One last concern: It is dangerous, and ultimately misleading, to speak--as I frequently do in the pages to follow--of "the poor," for this implies a homogeneity that does not exist. Poor people are not an indistinguishable mass, and the causes of poverty are multiple.I have, in fact, only a single fear in offering this book, but that fear almost keeps me from publishing. It would be easy for the reader to infer from many of the specific poor or homeless people I write about that virtually all inner-city people are addicted, mentally ill, incompetent, or otherwise severely damaged. It is possible that a superficial acquaintance with the people I introduce here will only reinforce stereotypes and prejudices about the poor as lazy, hostile, ungrateful, inadequate. If this book results in such an extension of our already sizable hatred for the poor, I will have contributed to the problem rather than to its solution.Like any other group of people, my patients vary enormously in talent and ability, health and intelligence. But the nature of my work as an inner-city physician is to attend to those particular urban poor people who are doing the least well. The reader will not meet too many inspiring people in this book, not because there are no suchindividuals in my practice but because it is the others who have had such a profound impact on my life. There are obviously many poor people--and many in my practice--who need little else but justice: a temporary place to stay, a decent education, a chance to work, access to health care, affordable housing. But there are also multitudes so broken that such improvements will have little overall effect on their lives. The "liberal" inclination to see in economic and political oppression the causes of poverty must not blind us to the fact that an unjust society produces a kind of brokenness that cannot always be redressed simply by removing the injustice.All of the stories in this book are stories of real people. Because the writing often occurred years after the events, certain details and dialogues may not be exact, although I have done my best to make them so. With the exception of colleagues and some public officials, however, the names of those who appear here have been changed and details of their stories have frequently been intentionally altered, sometimes enough to make individuals unrecognizable even to themselves. Where this was not possible, I have shared the stories with those involved and they have not only given me permission to tell their stories but have actively encouraged me to do so. To them I am grateful.Copyright © 1994 by David Hilfiker
Chapter 1A DOCTOR'S JOURNEYThis is absurd! What am I doing, near midnight, chasing John Turnell down the middle of Sixteenth Street? He's raving, swearing, pushing me away. What am I, a white man in white doctor clothes, doing entreating this drunken black homeless man to come home with me out of the night?It was in October 1983 that John Turnell was first brought in from the streets. He could hardly walk. Buried in a dark, matted coat, pants reeking of urine, eyes cast on the floor, he sat passively in the corner of the examining room at Community of Hope Health Services."I hurt all over," he mumbled, barely audible. "My neck, my arm, my back, my leg. They're all achin'. My foot won't do nothin'."He glanced up and our eyes met briefly. "I'm alcoholic," he said. "But I ain't had nothin' to drink in four days." He looked away. "Gotta stop these shakes. I know I gotta stop drinkin' this time. It's killin' me." He paused and I searched for something to say. But he began again, almost in a whisper. "And I'm pissin' all over myself,too. I can't stop it ..." He hung his head. There was no expectation of help. He was simply reporting.Thirty-eight then, he had jumped from a burning building six years earlier, breaking his back. "Pained ever since," he said. He'd been hospitalized for surgery but got no relief from his suffering.I examined him. The pain, weakness, paralysis, and sensory loss from his broken back and the concomitant nerve damage were widespread. His left foot dragged, and the large thigh muscles of his left leg had atrophied. The nerves to his bladder were injured, so urine leaked all over his clothing. He had lost sensation in his buttocks and could not feel the large ulcers developing there that now drained constantly.He didn't have medical coverage, but the private hospital at which I had privileges allowed me to admit an occasional indigent patient for further examination. In the end, though, there was not much to be done. Further surgery was not recommended; long-term physical therapy would probably have been of some help, but there was no way to pay for it; the neurological damage--loss of sensation, constant pain, foot drop, weakness, incontinence, impotence--was permanent.For the next several months, I saw John every week in the clinic as I tended his ulcers. He stayed at a small shelter in the neighborhood. His pain never really went away, but--if he slept on a real bed and took pain medication regularly--he could keep it under control. He got used to wearing a leg bag for his urine. We found a foot brace so he could walk without a limp. "It don't bother me so much anymore," he said to me one day when I asked how he was getting along. "You get used to it. I walk okay with the brace, and at least I ain't pissin' all over. As long as I stay sober, anyway," and he grinned.I would see that grin again. It was big and bright, inviting, without a trace of resentment. And there was a certain sparkle in the eyes that looked directly into mine. He seemed to accept his woundswithout anger or resignation. I sometimes wondered how that was possible. Why didn't he just give up the fight?No, I exaggerate: He did not accept all his wounds ... not his impotence. "You know what it's like?" he would say. "You know how she looks at you? She never says nothin', never gets mad. She says it don't make no difference to her, but when she's ready, no woman's gonna stay around for a man who can't perform." We once had a urologist ready to evaluate John's impotence, to look for something that could be done, but there was no insurance for the in-hospital tests, and the evaluation was put on hold ... indefinitely, it turned out.As John got better, the shamefaced, bedraggled derelict who came into my office every Thursday evening was gradually replaced by a handsome man with an engaging style. He looked me in the eye, smiled, made little jokes. He thanked me "for all you've done." I began to hope for his future. Abandoned as a child, alcoholic since adolescence, homeless for years, even he started to talk about a future. He got a custodial job nights, running a waxing machine. But then, a few weeks later, he told me his back had started acting up and he had quit the job. At my urging and with the help of our social worker, he applied for disability coverage under the Supplemental Security Program (SSI) of the federal Social Security Act, but he was not enthusiastic. He wanted to work, he said, not live off welfare.Then, suddenly, John disappeared. I heard he was on the streets again. Several months later, his SSI disability claim was denied; the form letter said John was not sufficiently incapacitated. A volunteer lawyer associated with our clinic began an appeal, but John needed to appear in person, and no one knew where he was. The deadline passed.When, after eight months, John finally showed up again at the clinic, I hardly recognized him. He was unshaven, gaunt; his lusterless eyes sagged in a hollow face. He moved slowly, agonizingly.Light reflected off the spittle in his beard. Sitting in the chair opposite me, he looked much smaller than his six feet. His dark, oversized clothes stank of urine, and his eyes remained fixed on the ground in visible shame. Although sober that evening, he had, he told me, started drinking again shortly after leaving his job waxing floors. Sleeping in alleys, stairwells, and crowded shelters, he had aggravated his back pain, broken open the ulcers on his buttocks, and lost both leg bag and foot brace. Like a perverse safety alarm, however, the increasing pain had put an end to the drinking and goaded him into the clinic, embarrassed and repentant. I did not guess then how often this pattern was to repeat itself.We saw each other irregularly. He was always sober by the time he showed up at the clinic. The pattern became unmistakable: He would begin to feel good about himself, find a job, only to leave it after a few weeks (often because it aggravated his back), and then disappear into the streets and the alcohol. Invariably, as he got closer to independence, some inner compulsion would shatter his dream.As I watched him try to work while in severe pain, as I noticed the cycle that always ended in the streets, I began to encourage him not to work, to accept his disability. He, however, was impatient. I tried again to help him get SSI (which would at least allow him access to Medicaid and decent medical care), but the examiners turned him down once more.One autumn, three years after our initial meeting, John returned, and I convinced him to move into Christ House, the medical recovery shelter for homeless men that a group of us had recently established with the help of our church community. Better equipped and more intensively staffed than the other shelters, dedicated exclusively to the care of those who were too sick to be on the streets, Christ House was also my home, where our family lived with a small community of physicians, other staff people, and their families. Over many months with us, John maintained his sobriety, went through a twenty-eight-day, inpatient alcohol treatment program, attended Alcoholics Anonymous meetings daily, healed his buttock ulcers,strengthened his foot, began managing his incontinence with special medications, and was able to keep even the constant pain to a tolerable level. He began attending classes at my wife Marja's small adult education school, looking to get his high-school-equivalency diploma. I allowed myself to hope again."I know it now: I just can't drink anymore, David ... ever. It's killin' me. I'm alcoholic. I didn't like it when you sent me to that treatment program, but I understand now. I got to stay away from my friends on the street who drink. Got to get new friends. Y'all have helped me so much here, and I'm gonna make it this time. God has been good. You'll see. I'll get my GED, get a job, maybe get married. I'm gonna make it."John "graduated" to a group home, continued attending GED classes with Marja, and was looking for work. Marja gave him one of our old family bicycles, so he could get around town. I felt proud of him. Then, once again, he disappeared. Two weeks later I was at the clinic when Sister Lenora Benda, the nurse in charge at Christ House, called. "John's back, David. He's been drinking, and he seems pretty depressed. He says he tried to swerve his bicycle into the path of a bus this morning, but the bus stopped. He keeps saying he wants to kill himself."I sigh and am silent. Some small part of me is dying. I knew enough to expect it, to prepare for it, but I'm still not ready. Drunk again, and now suicidal! Is this real or some bizarre gesture? Where in this city will I find a psychiatrist to evaluate a homeless drunk? Even if we can get him help, will he get something more than the superficial consultation to which the homeless are so often limited?"Can you get him over to St. Elizabeth's for a psychiatric evaluation, Lenora?""I think so. I think he still trusts me enough to let me take him."Lenora manages to thread John through the system--an accomplishment in itself--and, that same afternoon, a psychiatrist at St. Elizabeth's, Washington's only public psychiatric hospital, evaluates John. The psychiatrist declines to hospitalize him, however, becausethe suicide attempt seems to her most likely to have been just a gesture brought on by his intoxication. John is released with instructions to make an appointment with me at the office.The next evening, as I am lecturing to family physicians at their local professional association about the health care needs of the homeless in our city, the shrill signal of my pager interrupts. It seems that John has returned to Christ House and is uncontrollable. He's been marching back and forth, in and out of Christ House, lying down in front of traffic in Columbia Road or yelling and creating havoc inside. Could I come back and deal with John?I return and try to slip upstairs to drop off my lecture notes and take a few moments to collect myself. Entering our apartment, I discover John in our living room talking with Marja. He's still drunk. "Dr. Hilfiker," he says, slurring his words, "don't send me over to St. Elizabeth's again. I'll be good, I promise. I don't need no hospital. I just need to stop drinking.""But, John, what's this about running into the traffic, about committing suicide? I'm afraid you're going to hurt yourself. What's going to happen if a truck hits you?""Who told you I ran out into the street? Who said anything about suicide?" His usually quiet, reserved speech is loud and brassy. He eyes me belligerently, purses his lips, and pouts. "They're a goddamn liar. Why would I want to commit suicide? I didn't run out in no goddamn street." Oddly, in my three years of working with John, I've not actually seen him drunk before. He has always been gentle, even embarrassingly obsequious; so his belligerence tonight catches me off guard. I have also not known him to lie. Has he forgotten his suicidal gestures? Suddenly he's whining again. "Please don't send me over to St. E.'s, Dr. Hilfiker."I feel overwhelmed, boxed in. I wanted to be John's "friend," to lower the barriers between black and white, rich and poor. But now, in his extremity, he seems more like an alien, a drunk who has invaded my home. Will he turn violent? Will he try to stay? One part of me regrets my invitation to friendship and wants just to push himout to fend for himself. But another knows that without intervention John will disappear into the wilderness of the streets for another six months.And that is not the only conflict I find within my splintered thoughts and feelings. A wiser self knows that I am not in charge of John's recovery, that he must be the one to fight for sobriety; but I cannot let go. Frantically, I try to formulate even a short-term plan to return John to his path of recovery. But now he's up and pacing. I turn my back briefly, and he lurches from the apartment. For a moment I consider just letting him go. But I follow and finally catch up to him on the busy Columbia Road sidewalk outside our building."Where are you going?" I take his arm softly. I'm self-conscious out here on the street, a white man pulling this unwilling black man through a sea of mostly colored humanity."I ain't goin' to no St. E.'s, I can tell you that. I ain't goin' to no place like that. They just fuck you over." Despite his protestations, John allows me to lead him back into Christ House. He sprawls in a chair just across from the nurses' station, his long legs purposely obstructing even the wide main hallway.I don't know what to do. We are not a detox center, and it's not fair to ask the lone night nurse and his aide to devote their entire energies to one patient withdrawing from alcohol; but I can think of no alternative. "John, do you want to spend the night here at Christ House?" I ask, bending our rules almost backward, partly because John has become in some sense a friend, mostly because I cannot admit that we have lost him this time around.John agrees to take a tranquilizer to smooth the process of detoxification and lessen the likelihood of seizures, and I retreat to the nurses' station to write orders for his admission. Three times within the next fifteen minutes, however, John bolts from Christ House, and I run to retrieve him. Each time he's more belligerent; each time I am, perhaps, a little more hesitant to chase him.I begin to fill out commitment papers, more out of despair than hope. As I finish, John once more runs outside, and I, once again,follow. As usual, Columbia Road is busy in the late evening: Latin music blares from small knots of Salvadoran men; the sidewalk café of the Ethiopian restaurant next door is full of black people laughing and talking in foreign tongues; well-dressed couples walk past beggars; children from a nearby housing development twist their way through the crowded streets even near midnight. Wading into this human sea, I catch up with John, but this time he is not about to be turned around."No way I'm goin' to St. E.'s. I thought you was my friend, Dr. Hilfiker. You ain't my friend." He stares straight forward and marches on, shouting epithets at me as I trail behind. "You just like all those other white motherfuckers. You don't care for no niggers. You get paid all that money to take care of us. We don't get nothin'."I follow along in silence for almost a mile. What am I doing here, well past any reasonable bedtime, chasing a drunk down this street? Finally I stop and call to him. "John, I'm going back. I want you to come with me."He continues walking, but fifty feet later turns. We stare at each other for a full minute. Finally his tall body wilts like a limp doll's, and he drags himself back toward me, defeated.I have no idea why he's changed his mind. Perhaps it is the residue of the trust I thought had bonded us over these years. Perhaps he simply feels powerless and enraged. Trying to start a conversation, any conversation, to keep John's mind off St. E.'s, I ask him whether he ever thinks about going back home, to the South. "I never knew my mother," he says, apparently answering some question of his own. "She was crazy, spent most of her days in the state hospital. 'Paranoid schizophrenic,' they called it. My father, he drank a lot. I never saw him till I was six, and he came back home just to beat me. He kept telling me I was bad, just like her. He said I was crazy, too, and belonged in a hospital just like her. He hated me. Never said nothin' good about me. I lived at different places, but mostly I just raised myself. I started drinkin' when I was twelve. Iknew I had found something there. It made me feel good. When I drink, I ain't afraid to say nothin'. When I'm sober I can't say what's on my mind. I couldn't tell you any of this if I wasn't drinkin'." I have learned more about John's past in these two minutes on the street than in two years of interviews. He looks at me and grins ... that wide smile with those white teeth almost luminous against the dark night ... but fear lies behind the eyes.Back at Christ House sometime around midnight, I put John into a room and continue the process of committing him for psychiatric help. First, I call the public Crisis Resolution Unit, which is specifically mandated to intervene in situations like this. The receptionist says they are currently "short-staffed" and won't be able to help. She suggests calling the police. The police dispatcher says a unit will be "right over." When--after half an hour--nothing happens and I can hear John getting restless, I call again. "Well, you didn't say it was an emergency," the dispatcher says testily. Ten minutes later, John runs from his room. I catch up with him for what feels like the tenth time just as he lurches into the street and sprawls in front of an automobile, which jerks to a halt.A moment later a squad car pulls up. I explain the situation to the officer and show him the commitment papers I have completed. The officer looks troubled. He tells me the police are not allowed to transport psychiatric patients from a "private facility" unless the police officer himself witnesses the patient being a danger to self or others. He says he didn't see John lying in the street. We will have to find our own transportation.How could he not have seen John lying in the street? I can't believe it!Asking the officer to wait, I call Crisis again. The head of the unit confirms my understanding that once I have filled out appropriate forms the police are obliged to transport. He asks me to wait a few minutes while he calls the precinct captain to straighten matters out. The officer and I wait. John goes into his room and passes out. Icall Crisis back. They are still "working on it." Well after one o'clock in the morning, the officer leaves, John lies passed out in a room, and I go upstairs to bed. No one ever calls back from Crisis.I'm not surprised to be awakened the next morning by the night nurse reporting that John has left.Later that morning, Lenora calls me at the clinic. John has returned to Christ House, she has called Crisis, and this time a team has come and taken him to St. Elizabeth's. She asks me to call a certain psychiatrist at St. E.'s."Dr. Hilfiker, I have just examined Mr. Turnell," reports the doctor. "I feel that his suicide gestures are really the result of his drinking. I don't think that he requires mental hospitalization but rather alcohol detoxification."I notice my hands shaking as I grip the telephone. "Doctor, John's suicide attempts are obviously caused by his drinking, but he's nevertheless a danger to himself at this time. As you know, they won't be able to force John to stay at the detox unit. He'll just walk out of there."Despite my protests, the psychiatrist refuses to hospitalize John, referring him instead to the detox unit. John promptly walks out.Over the next year John returns to my office several times. He no longer needs to wait until he is sober to visit. At one point he steals $250 from Angela, our receptionist. He marries a Haitian refugee with a two-year-old child. At the time of their wedding, he has known her just a month and has been drunk--as far as I can tell--the entire time. Just before the wedding, John comes, drunk, to my office with his prospective wife and child. While in our waiting room John starts hitting the boy, threatening to kill him. We eventually have to call Child Protective Services just to protect the boy. Since then I have seen John and his family several times on the street, he always walking fifteen feet ahead, she dragging the child behind, like a scene from an old foreign film.
I am a family physician who practices in Washington, D.C., a city replete with the most advanced medical technology in the world. But the reader who hopes to encounter clever medical sleuthing, rare cures, dramatic surgical interventions, or even a glimpse of the medical wizards who perform such heroics might as well close the book here. For I practice "poverty medicine," a profession more like the medicine practiced in the Third World than what is ordinarily considered "modern medicine."Since 1983 I have worked at Community of Hope Health Services, a small, church-sponsored clinic in the inner city, and since 1985 also at Christ House, a thirty-four-bed medical recovery shelter for homeless men too sick to be on the streets yet not sick enough to be in the hospital. The medicine I now practice looks very different from what I did during the first seven years of my career, when I was a country doctor in a small town in northeastern Minnesota. There in Minnesota, the reassuring model of traditional medicine I had learned in my medical training still obtained: While other aspects of the patient's life were certainly important, illness was a distinct phenomenon that could basically be treated in and of itself. As "the Doctor" I assumed a role of real importance. My scientific medical expertise was useful, valued.As soon as I entered the world of the inner-city poor, however, my "power" as a physician succumbed to the same forces that dominate the lives of my patients, and I had to learn what is really a new specialty--poverty medicine. I did not understand at first, but poverty medicine is in a sense about everything but medicine, about everything but doctoring as it is normally experienced in the middle-and upper-class world in which I was reared, trained, and first practiced. Disease as usually defined by medicine is prevalent and, by and large, worse among the poor of the inner city than among the more affluent. But health, in the world of my patients, is not simply a matter of disease and treatment; indeed the "strictly medical" is not the crucial factor in most healing.By the very nature of my patients' circumstances, much of mywork does not even feel like the proper use of my training and abilities. I spend my time listening to stories about shelter conditions, dangerous neighborhoods, economic hardship, family tragedies that I can do nothing about ... except listen and care. I spend other large blocks of time finagling treatments for which another doctor would simply write a prescription: finding free medications, urging a specialist to volunteer care, traipsing by telephone through the maze of the public hospital to secure the results of a single test. Even in my day-to-day work, I am a "clinic doctor," dispensing routine medical care that--as far as the science of it is concerned--someone with far less education and experience could easily do.Poverty medicine, of course, isn't recognized as a field within the profession of medicine. It's a medical specialty without schools, standards, accreditation, journals, or associations. Its few practitioners frequently do their own fund-raising and band together for support in loosely knit alternative organizations without funding or power. It's a specialty with an enormous population of patients in America, yet virtually no practitioners.Like my specialty, this book is, in a sense, about everything but medicine, for in working with people of poverty the simplest medical act reveals the deepest social contradiction.This book is less about medicine than about class. My wife Marja and I are solidly middle-class. As a physician I could easily command a salary in excess of $100,000; as even a beginning teacher Marja could earn more than $27,000. Everything about our lives--our upbringing, our education, our level of consumption, the vacations we take, the church we attend, our prejudices about who deserves what and why--is deeply rooted in the middle class. This book explores what it is like for a middle-class doctor to work with the poor; what it is like for a middle-class family to "live with" the poor in what must be one of the very few experiments of its kind in the United States today to put doctors and homeless patients under the same roof; what it is like to walk between the worlds of the rich and the poor.This book is less about medicine than about race. My patients are overwhelmingly black because poverty in our nation's capital is primarily a black--although increasingly a Hispanic--phenomenon.1 Everything a white doctor does--from choosing to practice in a black community in the first place to admitting patients to the large, mostly black community hospital rather than the small, wealthy, mostly white hospital across town to writing about his experiences for publication--brings the questions, confusions, and problems of race in America rushing to the fore.This book is less about medicine than about culture. Great is the distance between a Yale-educated, third-generation white American and a poor, probably undereducated black person born in the rural South. From the entertainments we choose to the religious traditions we uphold, from our child-rearing practices to our beliefs about healing, from our family structures to our celebrations, my patients and I live in very different worlds. We struggle to share even a language.This book is less about the medical treatment of esoteric diseases than about medical helplessness before the drugs of choice lodged so deeply in our society. When we think of inner-city addictions, most of us think of crack cocaine or heroin. In fact, the drug the reader will encounter most frequently in this book, the drug of most concern to me as a physician, the drug that--even in our neighborhood--does more damage than all the others combined, is alcohol.This book is less about bold prescriptions for political or societal change than about what it's like to find oneself suddenly enmeshed in the crumbling relationship between government and the poor. It's about the grim consequences of two decades of governmental withdrawal and the deliberate underfunding of social agencies, about the helplessness of helpers running into the closed doors and cul-de-sacs of social policy. It is about the wholesale abandonment of the poor.At its heart, then, this book is about the nature of poverty and its awful power to break the spirit. There are many poor people in thecity of Washington who, with great courage, resist that power, get by more or less like middle-class people ... only without money. Some of them are in this book. But because of the particular places at which I work and because of my focus on the homeless, this book is more about brokenness and failure, frustration and hopelessness than about successes and the hope they allow us.I don't claim to have sorted out the complex linkages among race, poverty, and class in America any better than the many scholars and thinkers who have generated such a profusion of books on these subjects. In fact, although I've written many articles and stories about my work, although I've lectured widely to medical students and physicians about poverty medicine, I've found it difficult indeed to write this book. Because my form of medical practice tends to bring up virtually every large and confusing social issue and because life next to the poor revealed one contradiction after another in my own life, it was sometimes impossible to work out the nature of this "medical" book "about" a doctor. At several points I was simply unable to proceed for months on end, once for an entire year. My difficulties in writing only mirrored my problems as a poverty doctor. No matter how "simple" the medical problems I faced, I often found myself hopelessly lost in a forest of uncertainties.What I can offer is primarily that I, a middle-class, white professional, have been there in that "other land"--a land that most of us see only when we stare into the face of a beggar insistently accosting us on the street or in brief, sanitized television reports that can be zapped off the screen--and that, with whatever hesitations, I want to be where I am.
I came to the inner city in part because I believed that poverty in our country was more a matter of injustice than of personal characteristics or bad luck, and because I believed in the possibility of justice. I came because I was aware, to some degree, of my privileged background, of the inherent power of a white male in oursociety. I came with the conviction that we who had grown up with education and opportunities had not so much deserved our affluence as inherited it and that the poor were--by virtue of their oppression--"deserving." I came, in other words, with hope: If poverty were the result of oppression, then even a small group of affluent people could make a difference by providing--through well-run service projects (subsidized housing, health centers, day-care and education institutions, job training, and other services)--the beginning of a way out. If injustice were the cause of the poverty, then my presence as a health care provider would in some small way help my patients climb the "ladder" I knew was there.I also came with a desire to help the poor, but (if I am honest) there was an element of obligation as well. For better or (usually) for worse I have operated much of my life out of a sense of "oughtness," and within my religious and cultural tradition there was certainly an ethical imperative to help the poor. Any relationship works both ways, however. What happens to a person when he--as an affluent, comfortable, well-intentioned physician--walks next to some of the barriers that ordinarily separate rich and poor? What happens when one who is wealthya lives next to and works with people whose poverty is the result of the very structures that have brought him his wealth?This, then, is a book about a journey, a journey that began both as a struggle against injustice on behalf of those abandoned by the rest of us and as a search for my own spiritual center. Though I knew the journey would be difficult, I thought that its goals and direction at least would be clear. I could not guess how deeply the struggle with the misery of the inner city would be mirrored in thechaos of my internal quest. My desire to understand the nature of that misery led me by turns to blame the rich, the poor, and myself for what I saw, and it led me also to a painful encounter with the limits of what I was capable of, and who I was.My journey, of course, began long before I ever arrived in Washington, D.C. From 1975 until 1982, my family and I lived in the middle of a vast wilderness area in northeastern Minnesota, where I practiced family medicine. Marja, our three children (Laurel, Karin, and Kai), and I delighted in the stark beauty of the natural environment and in the intimacy of our small town. A rural community offers profound blessings to the doctor: I shared the joy of childbirth and the grief of illness or sudden death. I cherished the opportunity for trust between doctor and patient, and basked in the gratitude bestowed on the country doctor.But the stress of rural medicine also took its toll. Living and working over one hundred miles from the nearest specialist, I needed to practice constantly at the limits of my competence--and frequently beyond: placing an emergency intracardiac pacemaker in a patient with a severe heart attack, although I hadn't done the procedure in years; performing a cesarean section on a friend, despite my inadequate surgical training; treating complex medical problems while repeatedly second-guessing myself about not referring the patient to a specialist's care in Duluth.I found it difficult to be "the Doctor" in a small town where one could never be quite off-duty. When I was on call, I was not only the family doctor taking the late-afternoon telephone plea from the distraught mother, but also the emergency room physician evaluating the child's acute asthma attack later that evening. If necessary, I then became the pediatrician who admitted the child to the hospital a little before midnight and, sometimes, the house officer called down in the middle of the night to treat the worsening shortness of breath. If my pregnant patient came to afternoon office hours in labor, I could be sure to be up most of the night as I took turns being office doctor, telephone consultant, admitting physician, labor room nurse,delivering obstetrician, neonatal pediatrician, and finally honorary godfather. A few hours later I would be a pediatrician again, doing morning rounds on the newborn, and then general physician back in our clinic. It was wonderfully exhilarating ... and unbearably exhausting.It took me seven years to realize that the constant stress of my work no longer allowed me to receive the blessings of rural practice. I found myself frequently depressed, almost always anxious, sometimes terrified of going to work. I had chosen medicine in order to be of service to others, but I was unable to find the fulfillment I wanted from my life of service. I needed to leave.2Our family moved for a year to Marja's home in Finland. There --amid natural beauty so similar to Minnesota's yet so far from the stress--I managed to recover my balance. Before leaving Minnesota, however, Marja and I had been introduced to Church of the Saviour, a small, ecumenical religious community in Washington, D.C., dedicated to working with poor people of the inner city. We thought of it often while we were away, and particularly of the efforts of one member.In 1976 Janelle Goetcheus, a physician, and her husband, Allen, a Methodist clergyman, while waiting for visas (which were ultimately not forthcoming) for traditional Christian missionary work in Southeast Asia, had visited Washington, where they witnessed the desperation of inner-city life and the absence of available medical care. The Goetcheuses were permanently detoured. Initially, Janelle worked in an emergency room and volunteered at various clinics, but soon she called together a group from Church of the Saviour to found Columbia Road Health Services, a small neighborhood clinic that burgeoned from a second-floor walk-up into the complete family-practice clinic that now sees over fifteen thousand patient visits a year, predominantly from the refugee Hispanic community. She also helped to establish Community of Hope Health Services, another family-practice clinic on nearby Belmont Street, and a third small clinic at SOME (So Others May Eat), a soup kitchen sponsoredby the Catholic Church. Although sponsored by separate organizations, the three clinics functioned as a loosely knit group practice providing health services to the poor. In early 1983 I accepted the invitation to join her in her work.Even after a year's rest and contemplation, my motivation in coming to Washington was not clear to me. I experienced a vague sense that my own fulfillment was to be found in a life among the poor, but I was not sure whether I felt that way or merely wanted to feel that way, whether my motivation was simply an internalization of certain biblical texts and childhood messages or whether it was really my own belief. I certainly couldn't talk about what I was doing without becoming quickly confused, all the more so since a move from an idyllic wilderness area to inner-city Washington hardly made sense: If I had not been able to tolerate practice in a small, supportive town, how was I to survive the inner city?In some ways, however, practice in the city actually proved easier. My partners and I soon realized that what the city's poor really needed was access to the health care system, frontline doctors offering primary care who could help them connect with the wider system. With an abundance of specialists around, I no longer delivered babies, set fractures, or took care of complicated medical problems. When patients called in the middle of the night, I remained a family doctor and referred them to an emergency room for evaluation. I soon stopped hospital practice and the acute care of seriously ill people altogether.Not only did the changes in my role give me some hope of surviving the stress, but I also entered into a community of persons all engaged in similar work, and we were remarkably supportive of one another. For all its drawbacks, it seemed that poverty medicine might suit me better than any "normal" practice.Despite my eagerness, however, there was no way to prepare myself to face the unraveling of the social fabric, the larger loss of community that was the truth of inner-city Washington. I was initially shocked and angry at a system that had abandoned those leastable to help themselves. There was no housing; medical care was inaccessible; public education was a disaster; jobs with living wages were unavailable. Most of my new patients had the same kinds of medical illnesses I had tended in Minnesota, but they also suffered from a kind of neglect I had not imagined possible.That shock, though, I could at least see coming. What caught me completely off guard was my patients' internalization of their abandonment. Children who had not been adequately loved now saw themselves as unlovable; young people who had been inadequately trusted could now trust no one; adults who had been pushed down too many times now saw failure as inevitable; addicts for whom no treatment was offered had now--for practical purposes--given up on the possibility of a meaningful life. I was not prepared for the hostility, the seeming ingratitude, the noncompliance, the irrationality that is so much a part of the inner-city reality.This was a journey into a strange and threatening world.
There are a variety of obstacles any middle-class reader is likely to face in accompanying me on this journey. Not the least, for some readers, will be its religious aspect. I am the son of a clergyman, reared in a mainline Protestant church. Although as a young adult I left the church for over fifteen years, I always felt a vocation to serve others. The decision to enter the inner city was born of a conscious desire to move into closer relationship with God. When Marja and I joined Janelle Goetcheus, we did so as much for the opportunity to live and work within a Christian spiritual community as for the chance to practice a certain kind of medicine.Some readers, coming across names like "Christ House" or "Samaritan Inn," may feel imposed upon, even though ours is an ecumenical church community that emphasizes spiritual growth and acts of mercy and advocacy rather than doctrine or theological correctness. Isn't it enough, some readers may nonetheless feel, to bring oneself to a book on homelessness and poverty--a book that hasevery possibility of being amply guilt-inducing--without having to deal with the self-righteousness of the church? I often discover such wariness when I talk to medical audiences about poverty medicine. For some, the very existence of a religious mission at the core of my practice is grounds for dismissal: of me, of poverty medicine, of the homeless, of any connection between the middle class and the poor. For others, the spiritual dimension to our doctoring can evoke images of paternalistic missionary work, of the white man and his culture ultimately disempowering poor people of color by "serving" them. If this were the "religion" hawked in this book, I would have none of it either.A reader who does not personally experience religion as a source of strength may be tempted to dismiss the "religiously motivated" as saints or lunatics (the distinction is not always obvious to the uninitiated) whose purposes and life experiences have little to do with one's own. Medical students with whom I talk sometimes say, "I can see how you might survive in the inner city, with your Christian community and your faith in God and God's healing, but what about me? I have no religious faith and no community. How is your experience in any way relevant to mine?"I usually answer that each of us is on a spiritual journey, articulated or not, and our deepest beliefs invariably shape who we are. My religious beliefs do inform my decisions to live and practice in Washington's inner city, but that makes me little different from any other person trying consciously and reflectively to live according to his or her convictions. God, according to all religious traditions, lives within each of us. Any person trying to live by attending to that "deep stillness within"--whether expressed in Christian, Jewish, Islamic, Buddhist, Native American, or absolutely secular language--should find him- or herself at home with the spirituality (and, I hope, with the language) in this book.More practically, if one dismisses spiritual (or even explicitly religious) motivation for medical work with the inner-city poor--in Washington, at least--there's not much left to talk about in the1990s except the leaching of all care from the ever-growing worlds of poverty and homelessness. In the 1980s, as government money was withdrawn from the ghettos, as private investment never entered, as community organizing petered out, as a few private practitioners struggled (too often unsuccessfully) to make ends meet while caring for the indigent, often all that was left were church groups and other parareligious organizations trying against overwhelming odds to address even the barest, most basic needs of the poor.My own hope is that even those who find religious labels and beliefs embarrassing or irrelevant will find something for themselves here. "Religious" or not, conscious of it or not, safely ensconced in the suburbs or not, each of us is inextricably bound to--indeed, tangled up with--the pain of the poor. My hope is to reveal some of those bonds, to acknowledge our common community.One last concern: It is dangerous, and ultimately misleading, to speak--as I frequently do in the pages to follow--of "the poor," for this implies a homogeneity that does not exist. Poor people are not an indistinguishable mass, and the causes of poverty are multiple.I have, in fact, only a single fear in offering this book, but that fear almost keeps me from publishing. It would be easy for the reader to infer from many of the specific poor or homeless people I write about that virtually all inner-city people are addicted, mentally ill, incompetent, or otherwise severely damaged. It is possible that a superficial acquaintance with the people I introduce here will only reinforce stereotypes and prejudices about the poor as lazy, hostile, ungrateful, inadequate. If this book results in such an extension of our already sizable hatred for the poor, I will have contributed to the problem rather than to its solution.Like any other group of people, my patients vary enormously in talent and ability, health and intelligence. But the nature of my work as an inner-city physician is to attend to those particular urban poor people who are doing the least well. The reader will not meet too many inspiring people in this book, not because there are no suchindividuals in my practice but because it is the others who have had such a profound impact on my life. There are obviously many poor people--and many in my practice--who need little else but justice: a temporary place to stay, a decent education, a chance to work, access to health care, affordable housing. But there are also multitudes so broken that such improvements will have little overall effect on their lives. The "liberal" inclination to see in economic and political oppression the causes of poverty must not blind us to the fact that an unjust society produces a kind of brokenness that cannot always be redressed simply by removing the injustice.All of the stories in this book are stories of real people. Because the writing often occurred years after the events, certain details and dialogues may not be exact, although I have done my best to make them so. With the exception of colleagues and some public officials, however, the names of those who appear here have been changed and details of their stories have frequently been intentionally altered, sometimes enough to make individuals unrecognizable even to themselves. Where this was not possible, I have shared the stories with those involved and they have not only given me permission to tell their stories but have actively encouraged me to do so. To them I am grateful.Copyright © 1994 by David Hilfiker
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