The Working Poor

by David K. Shipler

  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.”
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br />   “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.

  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 y
ou 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?”