Black Man in a White Coat

by Damon Tweedy, M. D.

  “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.

  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?