Social Amputation

Roger N. is a stolid American working-class guy.  He's a little overweight, he wears shapeless t-shirts and blue jeans, he has a mop of salt-and-pepper hair and a black moustasche.  He's divorced and lives with his seventeen-year-old son, who's finishing high school.  He has an expressive face which is capable of surprising nuance and an irrepressible, if somewhat dark sense of humor.  He's worked a lot of jobs - he's been a shop floor supervisor with other men working under him, a union employee, and most recently a hazardous materials truck driver and instructor.  Now he's unemployed.

Most of my patients are on one side or another of the line dividing the working poor from the irretrievably destitute.  People on the right side of the line are HMO refugees who lost their jobs and have found new ones which don't provide insurance, elderly people who spent their lives working low-pay jobs with no benefits who now subsist on social security, and illegal immigrants who get paid under the table.  The people on the wrong side are those for whom that last critical thing failed to happen - they didn't get the job before they were evicted, they couldn't get loans from family or stay on friends couches any more, they couldn't hack the inpatient drug rehabilitation program, whatever - they are the people who define the "safety-net" because they are underneath it. 

I am watching Roger cross the line.

I first saw him as an inpatient when he was admitted with a diabetic foot ulcer.  Back then he was only recently unemployed.  He had been forced to quit his job driving "hazmat" trucks because of the expanding sore on his foot.  By the time he came to the hospital it was big enough that there was some concern that it might extend to the bone and have set up osteomyelitis, a chronic bone infection which is hard to treat.  Fortunately these worries were unfounded.  At the time, his foremost priority was getting out of the hospital in time to see his teenage daughter graduate from high school. 

After discharge he struggled to make ends meet on disability, until that ran out a few weeks ago.  He has no savings left, and will have to get unemployment.  He told me in clinic this week about the humiliating ritual he had to go through at the unemployment office, where they grilled him as to any saleable assets or unnecessary expenses he might have - jewelry worth over $100, life insurance, sporting equipment, expensive furniture, etc.

"I've always been able to get work," he said, "always been able to provide for my family - my son.  And now it's like things are just falling apart, and none of that matters." 

Having ascertained that he is destitute, the State is offering him 800 dollars a month - enough, maybe, to get a studio apartment in a remote and/or dangerous neighborhood for himself and his son. 

"You be good, doc," he said, flashing me a poignant smile, "and keep your job."

He has an appointment with podiatry tomorrow for his non-healing foot ulcer.  His plan is to plead with them to certify him as fit to return to work, even though he can't really do anything with his right foot.  The problem is, he tells me, that if he takes a job without his work restrictions being lifted by a qualified doctor, the State will demand the disability money back.

I had a frustrated conversation with my clinic supervisor about Roger - I already put him in touch with our Social Worker, who didn't have a whole lot to offer him, and from a medical point of view he is (somewhat surprisingly) doing pretty well.  It's his inexorable slide towards social marginalization, bad living conditions, refractory poverty, and understandable depression that are the real problems - not ones I'm equipped to do a lot about.

My supervisor, who has worked in this environment for longer than me, had a creative solution.

"How bad is his foot ulcer?" she asked.

"Pretty bad," I said, "why?"

"Well, because if it's bad enough, they could amputate his foot."

"I'm not following you."

"Well, if they amputate his foot he could get permanent disability."

I refrained from passing on this macabre suggestion to Roger.  I wish I could say that I didn't tell him because it would be completely insane to encourage him to be permanently, unnecessarily mutilated in order to ensure a life of slightly more comfortable penury than he's otherwise faced with.  That choice may well come up.  It's just that I think if I suggested it to him now, with things going the way they are, he might take matters into his own hands.  And to be fair, if I had to choose between my right foot and my dignity and self-respect as a man and a father, well... they make very good prostheses these days.