Black Man in a White Coat (7 page)

Still, it is hard to dispute that most black children born to young single mothers enter life at a distinct disadvantage. Nowhere was this more evident than in the teenage moms-to-be that I saw in these public health clinics; they were, in the detached terminology of the labor force, unskilled and uneducated. Born into poverty and lacking the resources to escape it, these young women and their soon-to-be children faced an assortment of challenges. And although the rate of teenage pregnancy for all groups declined for a fifteen-year period starting in the 1990s, the rates among black teens remained more than twice that seen among white teens.

The sobering medical and social realities of early pregnancy were cemented for me by Tanya, a sixteen-year-old girl who arrived at a Duke clinic as a walk-in complaining of early contractions. She had been seen once before at the same clinic about two months earlier, at the twenty-five-week stage. She looked so young that a part of me wanted to cling to the fantasy that her distended belly was a costume for a role that she was playing in a sex-education campaign.

Her mother sat beside her as I gathered the relevant history. Tanya reported having regular contractions for the previous four hours and thought her water might have broken. The medical issue at hand was whether she had gone into pre-term labor. As I looked down at the record from her twenty-five-week clinic visit, however, I realized that we needed more information. The report indicated that she had tested positive for gonorrhea and chlamydia. She'd been prescribed the appropriate treatments, but had not returned for a two-week follow-up visit as recommended to ensure that these potentially dangerous sexually transmitted infections had cleared such that her growing fetus was safe from any further harm.

Needing to navigate this delicate terrain, I asked Tanya if I could speak with her alone; she insisted that her mom stay with her. As gently as I could, I tried to ask her about these infections. But her mom cut me off before I got halfway through.

“She got all that taken care of,” her mom said dismissively. “We're not here for that.”

After finishing the interview, I left and found my supervisor at the nearby work area. He sat at a computer terminal with his old tennis shoes propped across a chair. I explained to him the presenting concern, the history of infections, and the mother's resistance to discussing this.

“It sounds like she's scared and is pretending to be innocent around her mom,” he said, “and her mom is in denial about what's been going on, but it's way too late for any of that.”

I returned to the room with my supervisor, who confirmed the information I'd obtained, and more, in a fraction of the time. As he performed the pelvic exam, it took him less than a minute to decide what was next: “We need to transfer her to the labor and delivery unit,” he said to Tanya's mother, before standing up to look at Tanya. “You're in early labor.”

Within five minutes, the nurses had situated Tanya in a wheelchair, ready for transport to the main hospital. As they whisked her away, the resident told me that she was likely to deliver in the next day or two, meaning that, at thirty-three or thirty-four weeks, her child would be premature. Early births, 60 percent more common in black women than in white women, are a large contributor to the reality that, despite remarkable medical progress in the past thirty years, the infant mortality rate in the United States among blacks remains twice as high as among whites. In Tanya's case, her recent history of sexually transmitted diseases was a separate risk factor for premature delivery, a concern further complicated by her spotty record of prenatal treatment.

In the end, despite these many risks, Tanya delivered a borderline low-weight daughter otherwise in good health, and made it through the delivery unscathed. They were lucky. Tanya was still legally underage, however. Did she simply have poor judgment in picking a sexual partner, or had she been the victim of something more sinister? The next morning, the social worker, a middle-aged white woman, filled in the details. She did her usual rounds with the medical team, which on that day consisted of two thirty-something white female doctors. The father of Tanya's child had just turned eighteen, the social worker told us, which meant that no North Carolina statutory rape laws had been violated at the time of conception. Like the other boys I'd heard about in the community clinics, this one had no desire or intention to be an involved father.

I found myself becoming angry at this unnamed, unseen young black man as I thought about the absentee dads from my extended family and childhood neighborhood. While I knew all the usual explanations for this behavior—joblessness, alienation, and poor role modeling, to name a few—I still sided more with my parents' philosophy that it was truly a moral failing for a man to go about his life and not have anything at all to do with his children.

The social worker told us that Tanya lived with her mother and that together they would raise the child. Only they had company. Tanya's eighteen-year-old sister had a kid of her own. This placed their single thirty-five-year-old mother, herself a former teenage mom, as the head of a home with two small kids and two jobless teenagers living off public assistance. In becoming pregnant during high school, Tanya had followed the path laid out for her by her mother and sister. Maybe the pattern went back further.

Despite what seemed to be genuine concern for Tanya's situation, I felt increasingly distressed by the dynamics of three middle-class white women discussing the stereotypical perils—teenage motherhood, absentee dads, life on public assistance—of Tanya's black family. As I'd felt sitting in the classroom a year earlier listening to my professors recite statistics on race and health, I wondered if hearing about Tanya's family negatively affected their views of black people, or merely reaffirmed preexisting biases. I hated thinking and feeling this way, never more aware of the two worlds I represented.

In contrast to Tanya's family and the girls I met at the public health clinics, I'd mostly lived a prudish adolescence. Part of that stemmed from the influence of my parents, who preached abstinence-only and were unwaveringly conservative on all sexual matters. The rest was the result of my personality, which was profoundly anxious and socially awkward, especially around women. Despite being a popular basketball player, I was a college freshman before I kissed a woman, and several more years passed before I ventured into anything sexual. At times, I found myself more judgmental than white people might be, as these racial stereotypes about Tanya and others felt like they were also stereotypes about me—even though my life bore little resemblance to theirs.

Ultimately, however, the more patients I saw, the stronger my desire was to learn more about their surrounding worlds and how their environment influenced their overall health.

*   *   *

After delivering her stillborn infant, Leslie stayed on the postpartum unit for monitoring.

Over the next day, her blood tests all returned to normal levels and her vital signs remained stable. From a purely medical standpoint, she was ready to leave the hospital. But where would she go? Was she ready to face her world, whatever it was, given what had transpired?

During morning rounds, we spent a significant amount of time reviewing her case. Barbara, the same social worker who earlier had revealed the pattern of recurrent teenage pregnancy in Tanya's family, once again took the lead. As before, her main audience consisted of two white physicians—an older man and a younger woman this time—while I listened in on their discussion.

Barbara had gotten some information from Leslie directly and the rest from the uncle who had dropped her off at the hospital. Her background was even more sordid than I imagined. She spent her first decade in an East Baltimore housing project, where her mom neglected her while hooked on heroin, and a series of her mom's boyfriends molested her. When Leslie was around eleven, her mom walked in on her having sex with her sixteen-year-old brother. She blamed Leslie, and severed all ties to her. Leslie then spent several years in the foster care system, where she endured more abuse until her uncle took her to live with him and his wife in North Carolina.

According to the uncle, she did well for a while, so much so that she talked about going into nursing and one day having her own family. But when her mom, clean from heroin after a prison stint, tried to get back into her life, everything fell apart. Leslie took up with a man who dealt drugs. She dropped out of school, and before long, broke off contact with her uncle.

“For the past year, she's been on the streets, prostituting herself for money and drugs,” Barbara summarized.

We stood silently for a second or two before Dr. Adams, the senior physician, spoke: “It's hard not to feel sorry for her.”

Dr. Raynor, the junior physician, and Barbara nodded in rueful agreement. While her stillborn child was the ultimate victim, after hearing her life story, we all felt that Leslie was a victim too. How could she get beyond this?

With Dr. Adams in the lead, we entered her room. Leslie did not respond, staring out the window at the prison-like view of brick buildings. The overhead television was tuned to a morning talk show.

“How is your body feeling?” Dr. Adams asked, choosing his words carefully, I suspected, to avoid any discussion about emotional or psychological concerns.

Leslie made eye contact with him for an instant then looked away. “Okay,” she said.

“Are you having any pain?”

“Just a little,” she said.

The two doctors did a brief exam, listening to her heart and lungs, feeling her abdomen, and briefly inspecting her pelvic area for any signs of continued bleeding or infection. Leslie was motionless, only shifting in compliance with the doctors' requests.

“Is there anything we can get you?” Dr. Adams asked.

She shook her head and continued to look at the television. He told Leslie that she was doing well from a physical standpoint and that someone would come by later to discuss the next steps. Leslie made no acknowledgment that she had even heard him. We then left to discuss her case outside the room.

“I think we should call Psych,” Barbara said. “She may need to be admitted to their unit. I'm worried about suicide, given what's happened to her and how unresponsive she is.”

“I agree,” Dr. Adams said, as he looked to Dr. Raynor, who would carry out this order. “We've done all we can from our end. It's time for our mental health colleagues to take over.”

After we finished seeing the remaining patients on our unit, I spent the rest of the morning and early afternoon in the hospital prenatal clinic. When I returned to the postpartum unit that afternoon, I met up with Dr. Raynor to get updates on our patients. As we talked, she saw a doctor carrying Leslie's chart to the physician workroom. It was the psychiatry resident; their team had just finished seeing Leslie. “So what do you think?” Dr. Raynor asked the psychiatrist.

“She's clearly depressed,” he said. “We talked about her options, and she doesn't want to go to the state hospital. I don't think it would help her to force her to go there against her will.”

During my rotation at this facility, the most common cases I saw were paranoid and indefatigable states of psychosis and mania. I tried to visualize Leslie in that setting; it seemed like a bad fit.

“The state hospital,” Dr. Raynor said with a frown. “What about the psych unit here?”

“She doesn't have health insurance,” the psychiatrist answered. “For those people, the state facility is the only option. Besides, I doubt our unit would have taken her even if she had insurance, given how prominent cocaine is to her presentation.”

It's a common practice in the mental health world to treat substance abuse as a distinct entity from other mental illnesses, such as severe depression, bipolar disorder, or schizophrenia, although drug use frequently overlaps with these disorders.

“So what about a residential substance abuse program?” Dr. Raynor asked.

“As far as the twenty-eight-day private rehab kind, it's the same problem of her being uninsured,” the psychiatrist said. “The state-run rehabs require her to get into outpatient counseling before they would authorize her treatment. That's what we will set her up with.”

“So that's the best she can get?” Dr. Raynor asked, incredulous.

“Sadly, yes,” he said, his exasperation indicating he felt the same frustration that we did. “The odds are stacked against people like her. We talked about her going to a women's shelter, as those sometimes can provide the needed structure and support, but she wasn't too keen on that. I talked with her uncle, who seems like a decent guy. He is willing to take her back, and she's okay with that. We'll get her an intake appointment set up. In the meantime, we recommend starting her on Prozac.”

With that, Dr. Raynor began work on Leslie's discharge papers. It was time for her to leave. Under the current system, the hospital had done all it could for her. As we tied together the final loose ends, I thought back to the heated exchange between Carla and Dr. Garner before we delivered Leslie's stillborn infant. Much of Carla's anger, and to a lesser extent Dr. Garner's and my own, had been targeted at Leslie for selfishly taking a drug that she must have known could be harmful to her growing fetus. But learning her life story had made that judgment a little less fair. The world she grew up in had clearly not been on her side. Perhaps nature had not been either, given her mother's heroin use and what is known about genetic predispositions to drug abuse.

Still, Leslie had chosen poorly, and her baby had paid the ultimate price. She would have to face the emotional consequences of what had transpired. As far as I could tell, the health care system—where she was easily maligned—wasn't prepared to provide her much help with that.

Within a few hours, Leslie's uncle and his wife came to pick her up. They both hugged her fiercely. One could hope that with their support, and with the mental health care we had initiated, this episode might trigger something within Leslie to steer her on a path toward a stable, drug-free life. But with the ashes of this trauma piled atop the many others she had endured in her short life, I wondered where she'd go from here. As a future physician, I was also beginning to think more about the limitations of medicine and where my responsibility to patients might begin and end.