The Working Poor (36 page)

In 2001, the suspicions were reinforced by the delay in providing medical care to 1,700 Washington, D.C., postal employees, most of them black, after two anthrax-laden letters passed through the Brentwood facility where they worked. When the letters arrived on Capitol Hill, public health officials quickly mobilized to evacuate congressional office buildings, test staffers, and administer antibiotics. But the postal facility was not closed immediately, and workers were left untested and untreated until two of them died. One of the dead had been refused antibiotics by his HMO.

From real injustice fantasy may spring, and African-American folklore is replete with tales of doctors experimenting on blacks, kidnapping them for their organs, draining their blood for medicines. Even if such stories are not taken literally, they form a backdrop for mistrust and aversion, used in one case to discipline a child. An African-American boy in the Grow Clinic had no toys to play with. He asked to color, but his mother had brought no crayons. So he started to make toys out of items in the examining room. He climbed up and down on the table and fiddled with the lid of a big trash can. “You want a shot?” his mother threatened. “The doctor
come give you a shot? Nasty! Leave it alone!” So the boy went to the curtains at the window, pulled on them, and ducked behind them. “Doctor gonna give you a shot! Want him to give you a shot?”

Even without giving a shot, the doctor can give offense. “For Latinos, there’s a big emphasis on
respeto,
which means ‘respect,’ and
fatalismo,
which is ‘fatalism,’ ” said Dr. Glenn Flores, co-director of the Pediatric Latino Clinic at the Boston Medical Center. This can set up a culture clash between the Latino parent and “the harried, hurried medical care provider in the United States,” he noted. “If you feel that you’ve been slighted, you’re not going to follow through with therapy, you’re not going to come back for a return visit, and that will affect your health.” Fatalism figured in “a classic study showing that Latinos are significantly more likely to believe that a diagnosis of cancer is an act of God and there’s not much you can do about it,” he said. “They probably won’t screen themselves as much, they won’t adhere to therapy, and they’ll present in the later stages of the disease.”

Language also divides, sometimes dangerously. Tape-recording doctor-patient conversations through interpreters, Dr. Flores found that serious errors were made “if you just bring in a sibling to translate, or you grab somebody in the waiting room, or you grab the custodian.” When one pediatrician treating a child’s ear infection instructed the mother to give liquid antibiotics by mouth, the untrained interpreter told her to put the medicine into the ear. It did no harm there, fortunately, but it did no good either. Trained translators minimize misunderstandings: “It’s time for us to start reimbursing interpreter services through Medicaid,” Dr. Flores argued. He and other physicians believe that many hospitalizations, especially for asthma, diabetes, and certain kidney infections, could be avoided if language, culture, hunger, and access to care were addressed—if patients could afford medicine, took it according to instructions, and returned for follow-up appointments.

In cases of malnutrition, poverty alone is not always the cause, but it exacerbates the affliction. Nutritionists believe that a toddler should eat six times a day—three meals and three snacks—but no disrupted family can make that happen. Multiple caretakers can’t keep track. The household may not have healthy snack food on hand, and the older siblings may hog what there is. A single mother working odd hours, scrounging for cash, confronting the neighborhood dangers of drugs and crime, may not have the patience or energy to create an atmosphere conducive to proper feed-
ing. One skinny Boston child with five siblings suffered because “the other children would just kind of barrel over him,” said a nutritionist, Michelle Turcotte. “It’s time to eat, they ate, everything was gone.… Where the household system can be a little chaotic, sometimes you need to educate that mother that you need to pay attention to the one that’s not growing.” Mary Silva treated two children whose complaints of hunger simply did not register on their mother, a supermarket employee whose severe depression made her oblivious to their needs.

“There are stressors in any family,” said Dr. Frank, “but they wouldn’t cause failure to thrive in an economically secure family. And there are also stressors that are so bad, like a psychotically depressed parent, that even in an economically secure family the child may fail to thrive. Or a child can have a medical problem that’s so severe that even in an economically secure family they would fail to thrive. But there’s this continuum where the problems that would be real but not overwhelming in a framework of economic security become overwhelming and catastrophic” in an impoverished home.

“Nutritionists go in and find no place for the baby to sit and eat,” the doctor continued. “The baby is standing on an adult chair leaning against the wall trying to eat off the adult table, or there’s not even any table and the baby will be sitting in the middle of the floor on a newspaper. Or maybe the mom is using one spoon for three kids.” The Grow Clinic sometimes gives a highchair to a family that can’t afford one.

In Baltimore, a desperately poor city, there was no longer enough staff to make home visits from the University of Maryland’s Growth and Nutrition Clinic. The $20,000 a year for a half-time social worker disappeared from the budget, so conditions in patients’ homes had to be gleaned from careful questioning.

That was the goal of an interrogation by Maureen M. Black, a psychologist who directed the clinic on the ground floor of the University of Maryland’s Hospital for Children. She sat in an examining room with a nineteen-year-old who already had three children, one a boy who was three years and four months old but weighed only twenty-two and a half pounds. He had gained merely two ounces in the previous month.

Because of the clinic’s budget cuts, the only home visit had been from Child Protective Services, which looked at the basics but not the nuances. The caseworker’s report was in the clinic’s file: a dirty house but adequate food; nothing about feeding techniques. The children were back from foster
care, where they had been placed because their mother had been using drugs. Now she was working at McDonald’s at just above the minimum wage, supplemented by $72 a month in food stamps. While she worked, her mother took care of the children, and her boyfriend helped, too. He looked about sixteen, his head bound in a blue bandanna. He wore baggy jeans, a nose stud, and a camouflage jacket. The conversation went like this:

Psychologist: “Where does ‘Barry’ sit when he eats?”

Mother: “He sits on the floor.”

Boyfriend: “And I’ll be sitting there with him.”

Psychologist: “Does he sit there for a long time?”

Mother: “Sometimes.”

Psychologist: “Barry is at an age where he should be feeding himself. Where does your daughter eat?”

Mother: “On the floor.”

Psychologist: “Where do you sit when you eat?”

Mother: “On the edge of the bed, watching TV.”

Psychologist: “Do you have a table?”

Mother: “Yes.”

Psychologist: “What would it take to get you to eat without the TV? Why do you think we don’t want the TV on while kids eat?”

Mother: “ ’Cause they be watching TV and not eating.”

The psychologist was white, the mother was black, and it was hard to tell how the mother was taking this faintly judgmental lesson. The psychologist urged her to make mealtimes more structured and suggested that the clinic might buy a booster seat for her son. She hadn’t enough chairs at her round table, however, so she would have to buy more for the family to sit down together.

“If he’s focused on the TV he’s not focused on eating,” Dr. Black explained. “I don’t want him sitting there for two hours. How would the rest of your family feel about eating without television?”

The mother laughed, shot a glance at her boyfriend while he played cute hand games with Barry, and said the other kids would probably throw fits.

“Who’s bigger in your home?” Dr. Black asked.

“I am,” the mother said.

“You can decide,” the psychologist coaxed. “Say the TV goes on afterwards. You can absolutely make the rules. You think it’s possible to try?”

“I’ll try,” the mother replied dutifully.

“Tell me what you’re gonna try.”

So, as if she were doing a recitation in a classroom, the mother gave the required answer: She would go downstairs, eat dinner, then go back up and watch television afterward. Not only was Dr. Black instructing, but she was also trying to empower a young woman who may have felt helpless. “The first time, they’ll whine,” she told the mother. “What are you gonna do?”

The boyfriend answered: “Let ’em whine.”

“A re you gonna yell?” the psychologist asked.

“No,” said the boyfriend. “They’ll be scared.”

“Think you can give it a shot?”

“We’ll give it a shot,” the mother promised. It would be nice to have the kids “eating at the table, not hollering and yelling,” she said. “I’m going to school all over again,” she added, a little sadly. Perhaps she meant simply that she had to be taught again, this time how to be a parent. Or perhaps she was reminded of that awful feeling when a teacher disapproved.

Maureen Black’s clinic spends considerable effort on parents’ interactions with their malnourished children. When youngsters fail to eat sufficiently and parents get anxious, angry, and defensive, mealtime becomes associated in the child’s mind with sheer misery. The spiral downward into confrontation can be very steep and fast, as videotapes reveal. On every family’s first appointment, a video camera is set up on a tripod in the room, food is brought in, and the family is left alone to feed the child. “You see an amazing array of behavior,” said Dr. Black. “You have moms smacking their kids, cussing their kids, ignoring their kids, begging their kids, being very nurturing to their kids.” When the tapes are then shown, the staff looks for something to compliment, but many parents are shocked by their own behavior, the psychologist has discovered. “I’ve had people cry when they’ve watched themselves.”

One session recorded a mother destroying what would have been a reasonably successful meal. While her little daughter, “Cathy,” sat at a table that came up to her chin, the mother sat eating pizza and giving commands: “Eat your food. Eat your food.” Cathy reached for a piece of pizza, began to eat quite well, then dropped a small piece. “No!” her mother scolded. “Makes a mess! Eat your food!” But Cathy
was
eating, with an empty spoon in her right hand, pizza in the other. She got no praise, only reprimands. When she reached for a carton of chocolate milk meant to be
saved until after the food, her mother snapped: “No! Eat! Eat!” So she reached for another piece of pizza, without having finished her first one, and her mother yelled, “No! Eat that! Eat that!”

In fact, Cathy had been eating quietly and happily, but the repeated scolding was finally too much, and now she burst into tears. The mother tried to save the day by handing her daughter two more pieces of pizza, but it was too late. The abrasiveness had rubbed the mealtime raw, and Cathy was in a state. All the mother could say was, “Cathy, hush! Hush! Hush!” Cathy ran off camera, her mother followed, there was the sound of a slap, and then a little girl’s scream. The mother yelled: “Cathy! Stop that crying and hush!”

In a later session, the mother took a different tack and withdrew. Cathy spooned macaroni and cheese, blew on it, then ate it mostly with her left hand while holding the spoon in her right. Very little macaroni actually went into her mouth, and the spoon was hard for her to handle. Empty, it became more of a toy than a utensil; she licked it, then bit it. Her mother had nothing to say but, “Eat your food!” Cathy again piled a lot on the spoon, too much for her mouth, so she picked a piece of macaroni off with her left hand, and the rest fell back into the bowl. The struggling little girl could have been helped had her mother noticed what was happening. Instead, the mother sat watching but not seeing, apparently. Finally, when Cathy reached for the carton of chocolate milk, her mother came to her assistance by putting a straw in it.

Another mother on camera, labeled by the clinic as “authoritarian,” spoke to her toddler in an ugly voice as she jabbed a spoon at him. “Eat your food! Now eat it! Eat your food, eat it!” She handed the child the spoon; he just played with it. She snatched it away roughly. The boy squirmed off the chair. She seized both his wrists and yanked him, arms above his head, back onto the chair. She smacked his hand, and he cried. Then she tried to force a spoonful of food into his mouth, which sent him into a blood-curdling wail.

“You’re gonna eat whether you like it or not!” the mother said harshly. She slapped his cheek and tried again and again to force the spoon into his mouth. Every time, he turned his head away, so she grabbed his head with one hand, twisted it around, and tried to push food in with the other. The boy wriggled out of the chair once more and crawled under the table. His mother jerked him up by his arm, and he wailed. She wiped his face roughly.

The Baltimore clinic saw the boy for years. He was the sixth child of a single mother who had dropped out of school after ninth grade, received welfare, and was obviously overwhelmed. His medical file recorded a loss of weight beginning at six months, and he remained at only the fifth per-centile of weight through age eight. Testing showed his cognitive abilities below normal; in second grade, his math and reading were about a year behind.

The damage that malnutrition does to brain development and physical health is stealthy, because it precedes the retarded growth that usually sounds the alarm. “For a child to actually not be growing, you have to have many, many, many episodes of missed meals,” said Debbie Frank. “But the health and behavioral effects of hunger, of involuntary lack of access to food, show up, it turns out, before the growth effects.” Or even without growth effects. Even with enough protein and calories to maintain body size, a child can suffer from the absence of “micronutrients that are reflected in food quality like iron and zinc, for example, that can affect your immune function, your learning, and all sorts of stuff,” she noted.