The Working Poor (35 page)

“Any vomiting on Tuesday?” Silva inquired.

“A little bit,” said his mother, Jaqueta Oliver. Silva asked what time he had been given formula before he went to bed. Oliver fumbled for an answer and settled on one uncertainly. Silva then asked what time before that, and before that, and before that, until Oliver was reduced to guessing. The nutritionist had seen partly consumed bottles standing around the apartment, so she suggested feeding him less each time but more frequently. “It might help him keep it down to get less more often.”

Silva then happened upon the key question, one asked routinely in malnutrition cases: “Do you have any allergies?” No, said Oliver. And the subject might have been closed right there had the father not been sitting in the corner of the examining room. He was a smiling man named Jeffrey Bigby, a truck driver earning six-something an hour, not married to Oliver but very attentive to his son. Allergies often run in families, and Bigby offered a clue. He was allergic to bananas, apples, and oranges, he said, as well as pollen, cat hair, and dog hair. “I had bronchial asthma when I was a
baby.” Silva was taking furious notes—a textbook case of how critical the involvement of both parents can be.

Next came the pediatrician. Gripping the baby’s chart, Dr. Frank entered in a state of extreme worry. “His weight is really at a dangerous level,” she told the parents. “I think it’s really not safe for him not to be in the hospital. You were back and forth to the clinic almost every day. He could get very sick very fast.” She checked the boy’s reflexes, put him on his stomach to see if he could push himself up; he could, but barely. She stood him up to see if his legs would hold him. “He’s not very strong, is he?” she asked. The parents said nothing.

So little Jequan was kept in the hospital, where tests revealed an intolerance for Enfamil, the only formula that the family had been able to get from WIC, the federal government’s Special Supplemental Nutrition Program for Women, Infants, and Children. During six days of hospitalization, he gained a whole pound. “The kid probably would not have failed to thrive had he not had the food allergy,” the doctor concluded. “On the other hand, if he’d had the allergy in a privileged home he would not have been dependent on the fact that the only formula that WIC supplied was the one that he was intolerant to. Now, with some special letter-writing and stuff we can get WIC to supply some of the other kind,” the much more expensive Pregestamil, “which is a very hyper-hydrolyzed formula,” she said. “The proteins are chopped up in it so that they’re not as allergenic.”

As a rule, the Grow Clinic was able to give families a little high-calorie formula and other food for free, plus $10 gift certificates to a supermarket and vouchers for taxis to and from the medical center. Beyond that, the total cost of each examination of Jequan and every other child, including all the time and attention with salaries and equipment, ran to hundreds of dollars per patient. The insurance carried by Jequan’s father paid only $40. The hospital donated its facilities. The bulk of the clinic’s $600,000 annual budget came from extensive fundraising: donations from individuals and private foundations, and annual grants by the Massachusetts Department of Public Health.

Boston is a city with substantial wealth alongside the poverty, and Massachusetts is a relatively enlightened state. In a less affluent part of the country, a malnourished child lies in deeper trouble, well beyond the coordinated expertise of a practiced team. And even in Boston, if a parent does
not or cannot cooperate fully with the Grow Clinic, she might as well be in rural Mississippi.

“Donald,” for example, could not be helped fully because his mother wasn’t getting the clinic’s instructions on the carefully supervised feeding that the boy required. Her unreasonable boss would not let her off work, so she had to send her son with a great-aunt who seemed unreceptive to the staff’s advice. Donald was so tiny that he looked only half his age of forty-three months, and he was gaining little weight. The staff gloomily predicted that he would be a “lifer,” meaning a kid who never caught up to where he should be. This was a case where a call to the employer from the pediatrician might have helped, but nobody thought to do it.

Few doctors ever do. One exception, Joshua Sharfstein, a young pediatrician who has called about a dozen employers so far in his brief career, saw a baby with a severe rash one day. “When I told her mom she needed follow-up on Monday,” he said, “the mom burst out into tears and said that she would lose her job if she took more time off.” The next morning, Josh called her boss, who was a physician himself, “and had a long discussion about the girl and the need for follow-up.” He didn’t have to mention job security. “Once I discussed the medical situation, he said he totally understood how important it was for her to follow up in the hospital,” Josh said. “I got the sense he would not punish her, and that turned out to be true. The mom called me back very grateful and said she was not going to lose her job.”

Children often fail to thrive because parents fail to comply with instructions. One mother, who had recently arrived from Vietnam, was so misled by advertising that when she ran out of PediaSure, the nutritious formula that had been prescribed, she substituted Coke and Pepsi. “I told her Coca-Cola and Pepsi-Cola is a trick,” Dr. Frank said. “We see it on TV, but the bubbles take away their appetite. What would happen if she just didn’t buy it? She said she didn’t have to. There are no other children in the house. Added a can of PediaSure. That was the Intervention of the Week.”

“Intervention” is the operative word. At critical junctures, the professionals can only recommend, urge, intervene to nudge a family’s behavior onto a different course. The result can be especially uncertain with newcomers who are plunged into the unfamiliar junk cuisine of America, and whose insufficient English may filter out the good advice. “My classic
story is one about an immigrant family where the nutritionist spent, I don’t know, a good half hour explaining to them that they shouldn’t feed the baby potato chips ’cause he could choke and also it took away his appetite and didn’t have good food value,” the doctor said. “And they got it, we thought. So they came back for the next visit and proudly held up a bag and said, see, no more potato chips—and held up a bag of Cheese Curls.… These are folks who, if they’d been home in wherever they came from, would probably have shopped perfectly competently in their own market for their own traditional ethnic foods. But they’re clueless in this country.”

So are some Americans, who also make the mistake of filling a kid with soda, chips, and fruit juice, which provide little nutrition and suppress the hunger pangs that make the youngster want to eat good food. Dr. Frank and her team do constant battle among native-born Americans, typically with “the young mom who often lives with her mother and lots of other younger sibs,” she said, “and the baby just worships all the big kids, and the big kids are sipping their sodas, and the baby goes up and makes eyes at them and they give the baby the soda and everybody laughs and claps and says, ‘See how grown the baby is.’ ” The syndrome may not be caused directly by insufficient funds, but it flourishes amid the disrupted family life and lack of knowledge that are frequent landmarks of the low-income world.

One young mother, a white American appearing in a Baltimore clinic, didn’t know how to scramble eggs; the nutritionist had to teach her. Families in New Hampshire visited regularly by Becky Gentes and Brenda St. Laurence displayed inexperience with basic healthy foods, as a dialogue between the two caregivers illustrated:

Becky: “Some of these kids don’t know what fruit is. We ask them.”

Brenda: “They get no fruit, no vegetables. None of my kids I work with get any vegetables or fruit.”

Becky: “A lot of hot dogs.”

Brenda: “Hot dogs, bologna.”

Becky: “We’re talking about convenience and history of what has been role-modeled to them. They don’t know how to peel and cook a carrot.”

Brenda: “And they won’t.”

Becky: “And they won’t. It’s too much work.”

Brenda: “I got a family a fifty-pound bag of potatoes ’cause welfare, they’ll give me free potatoes, you sign their name up and stuff. You know, those potatoes rotted. They will not peel a potato. It is not convenient.”

It is not a matter of money alone, obviously, since fresh fruits and vegetables are often cheaper than hot dogs and other processed foods. But finances play an insidious role in a parent’s incapacity to provide adequate nutrition. Some slumlords won’t replace malfunctioning refrigerators, which won’t keep milk cold enough. Some families are crammed into shared apartments where the single fridge is rifled by residents who steal others’ food. The needy are frequently intimidated by government bureaucracy; those who go off welfare often believe, wrongly, that they are no longer entitled to food stamps, although in some states families remain eligible even as their incomes reach 200 percent of the official poverty line.

Many legal immigrants are reluctant to accept food stamps or Medi-caid or the Children’s Health Insurance Program, to which they may be entitled, because they are afraid they will be judged “public charges” and therefore denied permanent residence leading to citizenship. Under an executive order issued by President Clinton, only cash payments such as welfare checks and SSI count against the immigrant in this regard. Food stamps and health insurance do not, in a distinction poorly understood by both immigrants and immigration officers.

Welfare reform has also taken a toll on the food budget, especially through its “family cap” provision, which bars welfare payments for any child born while the mother receives welfare, or for a certain period thereafter. About one-third of the malnourished children Dr. Frank sees in the Grow Clinic are family cap babies or their siblings. Furthemore, while doctors think that breast milk is the healthiest, working mothers can’t provide that all day without a breast pump, which Medicaid usually won’t pay for unless the child is hospitalized.

To be the mother or father of a malnourished child is a most painful price of poverty. Feeding a child is the most intimate responsibility, closest to the heart of a parent’s duty. Other essentials feel less controllable. Even the most frugal mother cannot reduce the rent, but when she runs out of money for adequate food, she often blames herself for mismanagement. And so, at the end of a long string of repeated failures—in school, in work, in relationships—her inability to nurture a child seems a final failing at the core.

Embarrassed and humiliated by their children’s plight, many parents become delicate clients of the malnutrition clinics, defensive and easily offended. So it was with the mother and father of “Doris,” the only white child that day in the Boston clinic. They were very young, both worked
part-time at a sandwich shop, and they would not permit home visits or keep records of Doris’s food intake. The staff found them resistant to suggestions, and Mary Silva, the nutritionist, thought the only reason the little girl was gaining any weight was the “jet fuel formula” she was getting free from the clinic’s pantry.

Doris was six months old and weighed 89 percent of the median for that age, a good recovery from the 73 percent when she was first referred to the clinic. But her developmental test showed serious lags. “She’s not moving the way she should,” said Silva. “She is not sitting up, not cognitively doing what she should be doing.” One remedy would be a variety of good toys, said Wanda Grant, the psychologist who examined her, but she doubted that the parents had the means or the interest to buy such toys. The mother called the developmental test “a load of crap.”

Yet the parents cared enough to bring Doris again and again. The mother, wearing her light brown hair pulled back in a plain bun, decorated herself with multiple rings on all but one of her fingers. The father had a button in his left ear and tattoos on both arms: one, a serpent around a knife with the letters “P.O.W.” Tattooed on each of four fingers of his left hand was a letter spelling the word “H A T E.”

Silva asked for the food records the mother was supposed to be keeping. She didn’t have any. Silva asked how many bottles the baby had a day. The mother didn’t know. The father guessed eight or nine. Silva suspected an uncoordinated suck, a neurological problem in some babies, so she asked detailed questions about Doris’s feeding, spitting up. She got vague answers, as if the parents were reluctant to reveal anything that might suggest failure.

So Silva tried to find ways to praise. “She gained two pounds in a month,” the nutritionist said. “Does it make you feel good?”

“Yes,” said the mother.

“Does it make you feel that making all those bottles and doing all that work is paying off?”

“Yeah.”

“We continue the same formula,” Silva said. “We continue her cereal. Two times a day is fine. If she wants it a third time, fine. You feel like giving her a little fruit?”

“Yes.”

“Which one would you like? You’ll get only one, so pick wisely.”

“Applesauce?”

“Sure, that’s fine.” If Doris had a reaction like a rash, skip a day and try another fruit, Silva advised. Then she asked if the parents had any questions. The sullen mother shook her head. “Are there things you’re worried about?” She shook her head again. “Sure?” She nodded.

After Silva left the room, the mother read the psychologist’s two-page report on Doris’s development lag and slapped the paper angrily at the words “only minimal alcoholic intake” during pregnancy. The information had come from her medical record.

“They made a mistake,” she snapped. “I didn’t drink at all during pregnancy.”

Class, culture, and language place barriers between patients and doctors. Looking up from the lack of wealth and education, many working poor people see an impersonal establishment of white coats and glistening instruments, of incomprehensible vocabulary and condescension. For blacks in particular, anxieties are sharpened by memories of the federal government’s Tuskegee experiment, in which treatment was withheld for 399 poor black men with syphilis from 1932 to 1972.