Absence of Hope

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 janitorial work.  A 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 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 in high school, but an accidental pregnancy kept her from finishing other studies.  There had been several men through the years.  All of them were mean and abusive, and none of them 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 lean closer to her, it strikes me how large this woman is. 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 of her knee cartilage.  She could no longer trust her knees to hold her when she went down steps.  The pain was constant.  She needed to sit or lie down most of the day.

This is a common story.  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 not venture into this arena.

Halfway through the visit I got a feeling that this woman was different.  The more we spoke, the clearer it became that she was very articulate.  She knew her medical history up and down.  She expressed herself clearly and concisely.  She obviously understood everything that I said, and she asked good questions.

You’re very smart.

She looked at me like I had just told her that she had three heads.

“Thank you.” Not really a thank you; just something that she felt needed to be said.

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 sponsor 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.

“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.


“Can’t you just sign my disability forms?”

I explained to her that all I do is provide medical records to 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 a lot.  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 in the future.  She had been raised to just get through today.  Nothing that your eyes cannot see exists. She was locked in; 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 extremely unusual for a person that has been awarded disabled status to go back to work. A large part of this disappointing statistic is due to the fact that 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 better alternatives within reach. These people have had a traumatic exposure to the workplace: measly wages, rude bosses, no benefits, no transportation, no security. They do not want to go back. It will take a daunting effort to bring them into society as productive citizens. Whether we are ready to commit to making this change is an open question.

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  1. Maria Dolores Gonzalez

    Your story reflects a problem that is global. Women that fall into a cycle of depression and dependency due to lack of means to incorporate themselves in the work force. In this case, as in many others, they don’t finish high school because of early pregnancies. Mayra is a very intelligent and capable woman that comes a few days a week to clean my house. She is young and on shape since she worked on a gym as a personal trainer, but decided that she wanted a fix income and to relate herself on a personal basis with her bosses, as she calls us. On that first week she came crying desperately, she could hardly work, so I sat her down in the kitchen to have a good talk. Something terrible was going on, I could sense that. “My daughter is pregnant, and she is such a good student that wanted to go the University to be a professional. No matter how many times I told her that getting pregnant would finish her dreams, she did it. Now she is living in my house “waiting” while this young fellow, good for nothing, thinks he is also going to come to live with me, but no way. An abortion was not an option in this very religious family, even though Mayra was abandoned by two men who never contributed a cent to support their siblings. Mayra’s daughter is doing her Master’s degree and married a young man that appreciates her and adopted her daughter. My remark is she was lucky because her mother back her up to finish her high school, put her in the road to enter the University, and from there on the girl got a part time job, finish her college, and on the way met a man that could help her accomplish her dreams of living a family life with hope in the future.

  2. Felice Chatman

    I see this story so many times. Disability as “earned income”. It is sad because SSI was not created as earned incomed, but a way to assist those who are truly unable to work. Usually the amount awarded under the case mentioned above is about $698 per month, which is not enough to support an individual, however, with the additional assistance such as Medicaid and food stamps, it seems like the trouble to secure this money could be worth it. Also, it is not as simple as just getting a signature from the doctor. Actually getting approved for disability can take years and there is no guarantee that it will ever be approved. The individual does not get any temporary assistance they just wait.

    I think some of this is a pattern or poverty which runs from generation to generation and is very difficult to break, but not impossible. Education is of course the key.