Book Review

Health Care Politics

Not All of Us Are Saints: A doctor's journey with the poor

N Engl J Med 1995; 332:194January 19, 1995

Article

Not All of Us Are Saints: A doctor's journey with the poor
By David Hilfiker. 259 pp. New York, Hill & Wang, 1994. $20. ISBN: 0-8090-3921-4

David Hilfiker's book is an important one for doctors (and students) who need to appreciate the breathtaking scope and impact of poverty and disenfranchisement in our nation. Well written though it is, it is not an easy book to read, because the people, their conditions, and the hopelessness of some of the real-life cases Hilfiker describes are painful to absorb. The book describes in detail the personal and professional aspects of a doctor's life and practice in Washington, D.C., one of America's most depressed and squalid inner cities.

The vast majority of physicians have only brief exposure to the ravages of poverty in the United States. During medical-school rotations and residency training, the lives of profoundly disadvantaged people provide us with clinical opportunities to learn and practice the art and science of medicine. Yet we rarely have a chance to appreciate the full effect of social and economic deprivation on the well-being and functional capacity of human beings. For one thing, physicians almost never experience such conditions personally. For another, most of us end up practicing, teaching, or doing research in environments that insulate us from the crushing realities of poverty in our country.

This book is unrelenting; case after case describing complex socioeconomic and medical challenges is presented in a nightmarish mix of occasional success stories and much more frequent human and systemic failures. More than simply a compilation of anecdotes, the book includes Dr. Hilfiker's view of the social and historical context, with hard data about the extent and causes of poverty and homelessness. In a chapter titled ``Body Counts,'' very grim statistics and a short review of recent U.S. social policy provide useful insights into the state of the inner cities.

It should be noted that Dr. Hilfiker came to his 10-year odyssey among some of the nation's poorest urban citizens under a mantle of religious zeal, seeking to cloak himself and his family in a strange, though ambivalent, involvement with the culture of his patients. On the one hand, he decided to live above a shelter for the homeless in a horrendously distressed neighborhood, working for subsistence-level wages. On the other hand, his apartment was large and well appointed. There is a sense in this book that he is trying to convince his family, and perhaps himself, that his values are pure and that his professional commitment remains true to his religious world view. He feels helpless and alone, unable even to gain allies among his own colleagues.

As Hilfiker well knows, racism, poverty, homelessness, and other such conditions are pervasive, long-standing problems in our society. These social ills underlie, aggravate, and sustain the complex and enduring medical problems of economically disadvantaged populations. Although Hilfiker understands this concept intellectually, he seems disappointed, if not surprised, that charity, philanthropy, and religious purity do not seem to make much of a difference in the big picture.

Perhaps, in the ever more challenging political and cultural realities of our time, physicians can have an effective voice in determining health care strategies for the poor. Organizations of health care professionals, including our great academic centers and teaching institutions, can and should be active proponents for substantial reform of the health care system. The goals should include truly universal access to both primary and advanced health care for all citizens, as determined by medical need. This will not cure poverty and homelessness, but it will certainly give doctors who are advocates for the poor a voice of moral authority that is highly consistent with the goals of our profession.

Irwin Redlener, M.D.
Montefiore Medical Center, New York, NY 10021