Broken Lives, Tattered Safety Net


By David Hilfiker

Hill & Wang x 259pp x $20

In the space of remarkably few years, David Hilfiker contends, there has been an abrupt and distressing turn in our relationship with the poor. Numbed, even overwhelmed by poverty's sheer scale, we have moved from denial to hopelessness "without ever passing through that intermediate stage when personal or political indignation might lead to action."

I don't know. I suspect many of us simply remain comfortably untouched by poverty. It's far less troubling, after all, to believe that the poor citizens of a wealthy nation are not treated poorly--that our taxes and charitable bucks provide an ever-widening safety net. Surely, we must be caring for these people.

That the net isn't catching everyone is made clear in Hilfiker's Not All of Us Are Saints: A Doctor's Journey with the Poor. Out falls Leroy Solten, treated in an emergency room for his third bout with tuberculosis, then released to a crowded homeless shelter with only haphazard follow-up care. Walter McRae, homeless and an alcoholic, has his broken jaw wired shut and is discharged; unable to eat, he is found weeks later on the street, severely dehydrated and unconscious.

Hilfiker's is a stunning book for those exhausted by the health-care debate. It returns us, relentlessly and compellingly, to the problem that begot mandates, alliances, premium caps, and the rest: Many Americans don't receive decent medical care.

In 1983, Hilfiker left his rural medical practice in Minnesota, the setting of his 1985 book, Healing the Wounds. He moved to inner-city Washington to work at a small, church-sponsored clinic--and, eventually, to found a recovery shelter for homeless men needing care between the hospital and the street.

Not All of Us Are Saints catalogs the urban desperation he discovered--the alcoholics and drug addicts, the battered and the delusional. There is the woman who suffers from outrageously high blood pressure, living with her children in an abandoned tenement, seeking medication that she never takes for more than a few days at a time. There is the man who throws himself drunkenly before an automobile, then refuses psychiatric care.

These people are, of course, exceptional, and Hilfiker admits as much. Most of our poor lead lives considerably less dramatic than that of the dying one-armed heroin dealer Hilfiker portrays. But their lack of glamour, for want of a better word, doesn't make it any easier for them to get food, housing, and a doctor's care. Welfare and public-assistance payments don't make anyone rich, and in any case, like Medicaid reimbursements, they have been declining. Low-income housing initiatives have dropped off dramatically.

And for Americans without money, the health-care system doesn't work very well. Those who qualify for Medicaid may be better off than the working poor without insurance. But both groups tend to get shunted from one care provider to the next. The apparatus that delivers poverty medicine is obscenely bureaucratic, underfunded, and overwhelmed. Increasingly--though not conclusively--studies suggest that people on Medicaid or without insurance enter hospitals sicker than those who can pay, leave sicker, and get inferior treatment.

Would health-care reform make a difference? Not the way Congress is shredding it now. And even in their purest form, "the Administration's proposals are likely to have little impact on the care available to the poor," Hilfiker says. To treat these people, we must address transportation, housing, and education needs; often, we must overcome generations of neglect and family dysfunction.

Even when we acknowledge the inferiority of care for the poor, it is tempting to write it off as a justly Darwinian outcome. "As a culture, we are deeply invested in the belief that the individual can determine his or her own destiny," Hilfiker observes. "So the poor who do not have the obvious disabilities we acknowledge must be somehow less worthy than the affluent."

One of the more fascinating strands of Not all of Us Are Saints, in fact, involves Hilfiker's own confrontation with the notion of individual responsibility. Are the travails of the impoverished all society's fault? Can't we blame people for being weak enough to retreat to a bottle, for abusing their children, for not taking their medicine, for refusing care? "Those who have suffered the emotional and physical deprivation of the ghettos are not automatically `beautiful souls,"' Hilfiker writes at one frustrated juncture.

Amid the despair, there are glints of hope, rendered more powerful by their scarcity. Toward the end, Hilfiker writes of the miraculous resolution of his long, seemingly impossible relationship with a chronic alcoholic named Clint Wooden. After months of detox, relapse, and mutual bitterness, the two men wordlessly celebrate Wooden's sobriety. It's hard to do these four paragraphs justice except to note that they constitute one of the most moving, joyous passages I've ever read--the finest moment in a deeply passionate account of what it is to be a doctor, and what it is to be poor.

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