“We're at the crossroads. Down one road is a European centralized bureaucratic socialist welfare system in which politicians and bureaucrats define the future. Down the other road is a proud, solid, reaffirmation of American exceptionalism.”
-Newt Gingrich
“The more you can increase fear of drugs and crime, welfare mothers, immigrants and aliens, the more you control all the people.”
-Noam Chomsky
One of my colleagues referred her. He volunteers at the free clinic ten miles away. He asked me if I would see her as a favor. She had no insurance, her knees were giving her a lot of pain, and he knew that I would not charge her.
She is in her forties; at least six feet tall. When she sat on the exam table, she towered over me. She wore a worn out, wrinkled blouse, maybe the best item that she owned. Discolored jeans; no makeup; no effort had been made at taming her hair. She occasionally flashed a tired smile. It was clear that there was nothing this poor soul had looked forward to for months, maybe years.
She lived with her mother, who collected social security and a tiny pension from a lifetime of janitorial work. Her daughter and a grandchild shared these tight quarters. When her daughter's boyfriend had no money, which was a frequent occurrence, he slept in the apartment. The only source of income was her mother’s flimsy income and the occasional babysitting job that her daughter could land.
When she was younger, she had also worked as a cleaning lady, or she babysat. She had done well with the academics in high school, but an ¨accidental¨ pregnancy kept her from attempting other studies. There had been several men in her life through the years. All were mean and abusive, and none ever stayed. She had borne two daughters. One of them left when she was 16 and did not keep in touch.
What can I do for you?
"It's my knees."
As I leant closer to her, it struck me how large this woman was. We could not weigh her accurately, because our scale is not reliable past 300 pounds. Years of going up and down steps, and kneeling to clean floors and change diapers, had worn out all her knee cartilage. She could no longer trust her legs to hold her when she went down steps. The pain was constant. She needed to sit or lie down most of the day if she wanted to be comfortable.
This is a common story. As people gain weight their knee joints deteriorate. The resulting pain keeps these patients from walking, which in turn leads to more weight gain. A small percentage of these patients respond temporarily to cortisone or other injections into their knees, but the only definitive treatment is a knee replacement. But she had no insurance. Even had she been covered, the risk for a knee replacement in a patient this obese is significant. The synthetic materials that we use are not meant to withstand severe loads for many years. Many surgeons will refuse to operate on patients like her.
Halfway through the visit I got a feeling that this woman had something going for her. The more we spoke, the clearer it became that she was articulate. She knew her medical history up and down. She expressed herself clearly and concisely. She understood everything that I said, and she asked good questions.
You're smart.
She looked at me like I had just told her that she had two heads.
"Thank you." Not really a thank you; just something that she felt needed to be said. She did not believe me.
Why would this be important? For almost every disease entity the prognosis improves (a lot) as the level of education rises. Part of the reason is obvious: better educated people are more likely to be insured and to follow doctors' advice. But even after adjusting for these variables, educating yourself is the next best thing to having good genes and not smoking if you wish to live a long and productive existence.
I got excited. Maybe this woman had a chance in life. If we could get her trained, we could help her find a job that would insure her. I visualized her as an able receptionist in a professional office. We could get her to join a gym and refer her for dietary counseling and physical therapy sessions. Her pain level may even decrease enough that she would not need surgery.
I mean it. I do not say this just to make you feel good. You can go to the community college. They will test you to see what you can do best. Then they will tell you which classes to take.
The sad smile came back. A lot of it. As if she really, really wanted me to be pleased with her, but she was not convinced that I was being realistic.
"I don't have any money for this."
I will pay for it. Just watching you succeed will be my reward.
“We do not have a car.”
We can find a way. I can reach out to some volunteers; I can see if the state will help.
"That's very nice of you..." I could sense a "but" coming my way.
But?
"Can’t you just sign my disability forms?"
I explained to her that all I do is provide medical records to the employees at Social Security. I do not make those decisions. I told her that she was 45. If she were awarded disability, for sure she would never exercise or lose weight (because if she lost weight and her condition improved her check would be taken away). I told her that most of us live to be 85. Did she really want to sit on a sofa and do nothing for the next 40 years?
She nodded.
The more I talked, the sadder her smile turned. When I finished my speech, she was almost in tears.
“I can't move. We have no money for gas. I cannot do this. I worked for my disability; it is not too much to ask...”
The pleas and excuses came in desperate waves. I could see in her face that she thought that I had not heard anything she said.
You can do this. Just go for an evaluation. I will find a way to get you there. I did not say it would be easy. Think of the plusses! Your grandchild will have someone to look up to. He may end up going to college. You do not have to be poor the rest of your life. You want to be able to go to a movie and a restaurant; to own a car…
She looked to the floor. The final sign of surrender. Her eyes closed for a few seconds.
I injected her knees with cortisone. I told her that I could do this until we could find some way to insure her. I asked her to keep in touch.
I still think about her. Maybe I overreached. In retrospect, it was obvious that no one had ever believed in her: not her parents, or boyfriends, or employers; even her daughters. It was unrealistic to expect her to see herself as having a future. She had been raised to just get through today. Nothing that your eyes cannot see exists. She was locked in a windowless room. There is a flashing red light in this room that says “EXIT” in large letters. She does not see it. She cannot see it.
She is one of millions. It is unusual for a person that has been awarded disabled status to go back to work. A large part of this disappointing statistic is because most disabilities are permanent. Yet there are many people who cling to the handicapped plates and the monthly (small) check as if giving them up would mean losing their life. Even if there are good jobs or painless cures available, welfare recipients seldom grab these opportunities.
These people have had a traumatic exposure (or none) to the workplace. Measly wages, rude bosses, no benefits, no transportation, no security. Their earnings are not enough to provide for minimal comfort. They do not want to go back to these environments. It will take a daunting effort to bring them into society as productive citizens. Are we ready to do this? Shouldn’t our first duty be to give all our citizens hope?
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