Black Man in a White Coat (6 page)

“Do you plan to talk to her about getting her tubes tied today?” Carla asked Dr. Garner.

Dr. Garner frowned. “She's nineteen. She just lost a pregnancy. That's probably not the most appropriate conversation to have with her right now.”

Carla would not be deterred. “I disagree,” she shot back. “I don't think we should take the risk of sending her out to get pregnant again. A few months ago, we had another crackhead here who delivered her fifth kid. All of them are in foster care, and I bet they all have some kind of serious disability. I don't think people like her should be allowed to get pregnant again.”

Carla's view had once been official policy in North Carolina and in over thirty other states. Beginning in the early twentieth century, forced sterilization programs typically targeted criminals and those in mental hospitals, but North Carolina expanded its reach to include the poor, many black. All told, more than seven thousand people were officially sterilized under North Carolina's laws until the practice was abolished in 1974. While the government had repudiated this policy, Carla was not the first or last person I heard who continued to embrace it.

“We talked about that case on M and M [morbidity and mortality] rounds a few weeks ago,” Dr. Garner replied. “That patient was almost forty and probably had CNS [central nervous system] lupus and neurosyphilis. This girl is healthy and still has time to get her life together.”

“You're still new to this,” Carla said. “You'll see. These crack people don't change.”

“Or maybe you've been doing this for too long,” Dr. Garner countered, visibly irritated, as she motioned for me to follow her.

Carla said nothing, although her narrowed eyes and clenched jaw suggested she had a good deal more that she wanted to communicate. She had worked in nursing for over two decades, much of it in obstetrics. I had seen how comforting she could be to women and their nervous family members, but as with many of us in medicine, drug addicts seemed to bring out her worst side. I wondered how long she had been so openly cynical and hostile toward drug-abusing pregnant women. More important, had her opinions affected her clinical judgment?

Leslie had come in with painful vaginal bleeding during a second trimester pregnancy; in hindsight, I wonder whether this was an appropriate case for a medical student to begin seeing without a physician present. Had Carla's negative assumptions about Leslie affected the way she communicated the urgency of the case to Dr. Garner? Would she have allowed potentially precious time to pass with a different patient, or would she have insisted that Dr. Garner, or even a more senior doctor, attend to Leslie immediately to salvage any chance of saving the fetus?

Had race played a role? Carla, a white woman from the Northeast, seemed especially focused on crack, a drug widely known to be used more often by black people. A national survey in the mid-1990s revealed that black women were ten times more likely than white women to use crack during pregnancy. The same survey, however, found that pregnant white women were more likely to abuse alcohol, a substance that can produce its own distinct set of severe problems: fetal alcohol syndrome. Would Carla have reacted the same way if Leslie had been a married, white suburban schoolteacher who drank three glasses of wine every night?

Much of the hysteria surrounding this feared crack-baby epidemic, which ultimately turned out to be more fiction than fact, fed off preexisting negative beliefs about irresponsible black welfare moms draining the system. This seemed to be Carla's perspective. Yet if accused of racial prejudice or bias, Carla surely would have denied it. Her comfort in voicing her opinions around me indicated as much. She had always been pleasant with me, certainly not treating me any worse than my white or Asian colleagues. Nor had I seen her interact with minority nurses or other hospital staff with anything less than appropriate respect.

When it came to Leslie, however, Carla had a different attitude. And she was not alone. Dr. Garner had accused Leslie of drug use in a confrontational manner I have never seen from a doctor before or since. Years later, I would work in both private substance abuse and eating disorder clinics where some of the well-to-do clients were equally self-destructive, but no doctor there would ever have dreamed of being so aggressive. Still, to her credit, Dr. Garner did make an effort to defend Leslie and encourage Carla to see beyond her prejudices.

And, if I had to be honest with myself, I too felt disdain toward Leslie, perhaps on some visceral level, even more powerfully than Carla did. As a crack-abusing pregnant woman, Leslie had put the worst face of black America on full display for this white medical audience. Much of my life had been devoted to combating and defeating vicious racial stereotypes. But in witnessing the pathology of Leslie's behavior and the doctor's and nurse's reaction to it, I suddenly felt naked, as if someone had stripped me of my white coat and left both of us to share the same degrading spotlight.

So, while I thought of many things to say to Carla at that moment, I kept quiet, trailing behind Dr. Garner as we prepared to remove Leslie's dead fetus.

*   *   *

Leslie's room was at the far end of the hall in the labor and delivery area. It was about twice the size of her previous one in the triage wing, large enough to accommodate several medical providers who could tend to the delivering woman and, under normal circumstances, the first minutes of her infant's life.

Two nurses stood on either side of Leslie, as she stared vacantly from her bed at the overhead television. The local news report showed clips from Duke's basketball game. Earlier in the evening, watching this matchup had been the highlight of my day; now it held no more interest than looking at a group of random kids shooting hoops at a local park.

“How are you feeling?” Dr. Garner asked.

Leslie glanced up at her before looking back at the TV without saying a word. Unfazed, Dr. Garner explained what we needed to do and asked Leslie if she had any questions or concerns. More silence. Dr. Garner then turned to the older nurse. “How do things look?”

“She's starting to dilate. We've got a little time.”

“Okay,” Dr. Garner said. “Call me when it's getting close.”

We turned around and walked back to the unit's central nursing station area, where the fetal heart rate output from each pregnant woman on the floor was displayed across several monitors. Dr. Stone, a senior resident and Dr. Garner's immediate supervisor, soon joined us. Dr. Garner updated him on the list of patients, including Leslie.

“What a mess,” Dr. Stone said, shaking his head as he learned about Leslie's case. “I would've hated wasting my time operating on a damn addict for a baby with no chance.”

It sounded like he was relieved that Leslie's baby had died when it had, as this outcome had spared him the trouble of having to perform an emergency C-section. After Carla's diatribe, his words didn't shock me. This was not the place for compassion if you had a drug problem. “Call if you need me,” he said. “I'll be up for a while.”

Dr. Garner was about to check in on a patient in the early stages of labor when the older nurse from Leslie's room approached her: “I think it's time.”

Moments later, we sat at the end of Leslie's bed, ready to receive the motionless image we'd seen on the ultrasound. The labor-inducing medications had taken effect, and Leslie's contractions caused her to writhe in pain once again.

“I know this is hard,” Dr. Garner said. “But I need you to push.”

Sweat trickled across Leslie's forehead as she grunted and strained. Nothing came out. “Take a break and try again in a minute,” Dr. Garner said.

During her next contraction, Leslie pushed again. This time, the tiny head was visible.

“Good,” Dr. Garner said. “One more big push.”

Leslie complied, and in a few seconds, a miniature infant was delivered into Dr. Garner's gloved hands. I looked down at it. This infant was less than half the size of the other newborns I'd seen during my rotation. Unlike all of the previous deliveries I had attended, Dr. Garner did not suction the baby's nose and mouth to remove excess fluid, nor did she rush to hand the child over to the nurses or the pediatrician. Instead, she used a cloth to wipe off the excess blood and other fluids and examined the silent, stillborn infant as if we were in a first-year pathology class.

“It was a male,” Dr. Garner said to me.

My legs felt rubbery as my vision blurred. I had fainted in college during my first rat dissection but had never come close since. Only this was far more shocking: A tiny human life was gone before it had any chance. I needed orange juice or water, or better yet, a bed. I was about to tell Dr. Garner that I had to leave when the older nurse's voice distracted me. “She'd like to see it.”

Dr. Garner looked up from her inspection. “Is she sure about that?”

The nurse nodded, her frown accentuating her heavily lined face.

“Okay then.”

Dr. Garner handed the dead infant to the younger nurse, who cleaned him further and wrapped him in a fresh cloth so that only his small head was visible. She then handed him to Leslie. We knew what was coming, but her reaction was still heartbreaking.

“I'm … so … sorry…” Leslie repeatedly cried out, as she cradled her dead child in her arms. Inconsolable, her raw pain consumed all the air in the room.

The younger nurse began to cry—the first time I had seen a medical person cry in the hospital—as she and her older colleague cleaned the delivery area. Dr. Garner stood up and looked directly at me. She wanted to say something, perhaps to offer comfort that this was as bad as it got in medicine. Until then, my time on the obstetrics service had been a perpetual celebration of new life, and maybe she wanted to remind me of that. Instead, her eyes began to cloud as she gazed down at her bloody gloves. Without uttering a word, she walked away.

I wanted to escape too. But I could not think of anywhere to go to ease what I was feeling. So I stood there, frozen. As Leslie continued to cry, I realized that, despite our many assumptions and heated words, we knew very little about her. The initial medical urgency of her case and her unwillingness to answer questions had kept us in the dark. Now, with her pregnancy over, I wanted to understand what kind of life, what kinds of choices, had led her to become a pregnant crack abuser at nineteen. Alone with her grief, grappling with her horrible loss, Leslie, in her own way, was a lost child too.

*   *   *

While Leslie's case stood alone as the most disturbing during my time in obstetrics, it shared several troubling features with other patient encounters. A few weeks earlier, under the supervision of one of Dr. Garner's colleagues, I had rotated through prenatal clinics at Duke and at a handful of county health centers, both in Durham and in nearby counties. These sites offered the trade of services so commonly seen in poor urban and rural settings: The patients allowed us medical trainees the chance to learn and practice our clinical skills, while we provided medical care for which they might not otherwise have had access.

The women at these prenatal clinics were all black, just as they were at many community clinics back then, even those in cities that were 50 percent white. For prenatal visits, the demographic skewed young, mostly adolescent. Approaching my twenty-fourth birthday, I was still a novice when it came to sex, yet found myself in a white coat giving clinical services and medical advice to a group of sixteen-to-twenty-year-olds who, as pregnant women, knew more about sex—or at the very least, had more experience with it—than I did. I would have felt less ridiculous instructing Larry Bird on how to shoot a three-point jump shot or Tiger Woods on how to sink a winding thirty-foot putt.

But their real-world experience did not translate into mature decision making. At one clinic, about an hour from Durham, I interviewed an eighteen-year-old high school senior who was about twenty weeks into her first pregnancy. When I inquired into her overall feelings about the pregnancy, she gave the perfectly reasonable answer that it had come as a surprise but that she planned to make the best of things. Did she hope to continue with school or find a job after she settled into life with her baby, I asked?

“I'm not sure,” she said. “I'm stayin' with my mom for now.”

“Is the father around?”

“No. We're not together,” she replied. “He said he ain't ready to be a dad.”

A moment of silence followed while I jotted notes and tried to think of a transition from what I assumed was unpleasant news. But she had moved on. “Do you have a girlfriend?”

The pen slipped from my hand onto the floor. Afraid of what else she might ask if I said otherwise, I lied and told her I was dating someone. I became acutely aware of the awkwardness of being alone with her in a clinic room in which I was soon going to perform a pelvic exam. As male medical students, we'd been told to have a female staff member, usually a nurse, present whenever we examined a woman. That did not typically include the beginning question-and-answer part, but it was time to interpret things more strictly. “I'll be right back,” I said, toppling over the chair as I dashed away in search of reinforcement.

Another woman at a different clinic—also under twenty, probably twenty-five weeks pregnant—avoided direct questions about me and instead asked if I knew any nice single black men at Duke or at other area colleges. She too had parted ways with her former boyfriend shortly after becoming pregnant. Over the next few weeks, I met several other young women who had similar stories and queries. As embarrassed as I sometimes felt, their questions about eligible men probably weren't the product of them being hyper-sexualized or immodest. I was there, I was black, I seemed to have a good future—so why not inquire about me and my friends?

Of the dozens of patients that I saw in those clinics, not a single one came with a man—no husband, no boyfriend, or anyone else with a Y chromosome. Nor did any report having a male figure that would be involved in their child's life. Each woman was destined to become part of an oft-repeated yet still staggering figure: More than 70 percent of black children are born to unmarried women. That's more than twice the rate among whites, and consistently ranks as the highest among all groups in America. Many people use these numbers as a statement about the breakdown of black families and communities, framing it as a criticism of welfare entitlements, hip-hop culture, and their purported contribution to moral decay. While those critics raise many valid points, the situation they describe is more complicated. For one thing, the statistics on single mothers include emotionally healthy, well-educated women with good salaries who seem fully capable of raising a child as a single mom. They also include stable couples that, for whatever reason, choose not to marry. Further, being married does not assure a healthier family: We've all seen or heard about marriages so chaotic or abusive that the kids would almost certainly be better off raised alone by the more suitable partner.