A Review of Not All of Us Are Saints

by Robert Pear
Washington Correspondent for the New York Times

A Doctor in the Inner City

Increasingly, the national debate over health care has focused on the question of how best to help the middle class. The very rich and the very poor will always have access to health insurance, Presi­dent Clinton and his allies say, but the middle class is continually in danger of losing coverage.

Not All of Us Are Saints, Dr David Hilfiker's account of ministering to poor people in the inner city of Washington for several years, is a useful cor­rective to that argument. Dr Hilfiker, a physician, practices what he calls poverty medicine, a specialty that has only a remote resemblance to the healing arts he learned in medical school and practiced in rural Minnesota.

The author's prose is spare, precise and muscu­lar. His message is grim. He has a deep personal and religious commitment to helping people who are nearly helpless, who can barely describe their com­plaints, much less follow a doctor's regimen. De­spite the strength of that commitment, Dr Hilfiker finds his patience sorely tested by a health care sys­tem, a bureaucracy, a society that seem to conspire at every turn to frustrate his efforts.

Police officers will not remove a husband abus­ing his wife. Paramedics will not transport certain psychotic patients to a mental hospital. The detoxifi­cation unit of the city's public hospital will not admit a man who walked off  20 months ago "against medi­cal advice."

The title, Not All of Us Are Saints, refers to Dr Hilfiker's sense of his own limitations and inadequa­cies, measured against the seemingly infinite needs of poor people in the nation's capital. "I was hardly Mother Teresa," he writes. "Not all of us who work with the poor are saints, but maybe we don't have to be. Perhaps sainthood isn't a prerequisite for the job." There is, to be sure, a repetitive quality to the narrative as Dr Hilfiker tells of his experiences with patients who come to see him at a clinic and infir­mary called Christ House. But the repetition vividly evokes the doctor's experience, and helps explain why he often feels discouraged and dejected. Dr Hil­fiker starts with certain premises that readers may or may not share. He believes that poverty results more from injustice than from personal characteristics or bad luck; that "the poor were—by virtue of their op­pression—'deserving,'" and that "the collective wealth of the middle and upper classes is necessarily built on the collective deprivation of the poor."

But he is often irritated with his patients, who regularly flout his instructions. His compassion for patients sometimes gives way to feelings of anger and resentment, and he is tempted to "blame the poor for their plight." The candor with which Dr Hilfikeracknowledges such feelings is one of his book's great strengths.

Among the poignant passages are those where the author confronts the contradictions of a white middle-class family living in the inner city of Wash­ington among poor black alcoholics and drug addicts. His own children sometime reproach him for indulg­ing his commitment to social justice at their expense. His 13-year-old daughter does not understand why he works for less money than he could earn, or "why we live here in the middle of the city with all these poor people." Dr Hilfiker's answers do not entirely satisfy his children. But, he says, "living one floor above 34 homeless men teaches our children that every person has worth and value despite external circumstances." More generally, he writes, "our obedience to the de­mands to justice can bring us the possibility of a far deeper happiness, security, and sense of integrity than can any commitment to individual wealth or personal comfort."

Bill and Hillary Rodham Clinton should read Not All of Us Are Saints, and so should all those who believe that some variant of "managed competition" combining free market forces with Government regu­lation will solve the nation's health care problems. Dr Hilfiker suggests that some of those problems are deeply rooted in the culture of the inner city where it is difficult to imagine private health plans competing for business.

David Hilfiker does not dwell on politics. But, he says, political realities are such that President Clinton's proposals "are likely to have little positive impact on the care available to the poor." Indeed, he says, some proposals advanced this year "could make things worse for certain groups of poor people" — if, for example, Medicaid recipients are shifted out of a public program and enrolled in private health main­tenance organizations, or if the standard package of health benefits is less than what Medicaid now of­fers.

If Not All of Us Are Saints shows the limits of mainstream medicine, it also suggests the limitless rewards of faith and compassion. And Dr Hilfiker argues persuasively that "each of us is inextricably bound to—indeed, tangled up with—the pain of the poor."

Robert Pear is a correspondent in the Washing­ton bureau of the New York Times