Medicine for the Forgotten

The sign above the door used to say Carter's Hardware. Now it says Bill Hudson, M.D. in letters that were painted by someone who had never painted a sign before, and the D is slightly smaller than the rest of the letters, which makes me look like I can't spell my own name if you're standing far enough away to see the whole thing.

I don't mind. Most of the people who come here can't read anyway, or they can but reading isn't what they need.

The waiting room is one room, formerly the sales floor of the hardware store. There are two chairs, a folding table with magazines from 2014, and a poster about opioid addiction that has been partially torn, leaving only the word "forgotten" visible, which seems fitting.

I am thirty-one years old and I am the only doctor in McDowell County, West Virginia. That is not quite true. There is another doctor, Dr. Patricia Wells, who practices in Welch, twelve miles away. But Welch is twelve miles away, and the roads in these mountains are not roads in the way people in the city understand roads. They are narrow, winding things that drop off into hollows and climb up into ridges, and in winter they are covered with ice that never melts because the sun doesn't reach them.

So for most practical purposes, I am the only doctor.

My clinic opens at eight. I arrive at seven-thirty to make the coffee and check the supply cabinet. The clinic runs on a grant from a foundation that may or may not renew next year, and the grant pays for the building, the basic equipment, and a fraction of my salary. The rest I make up by billing insurance companies, which is to say I bill insurance companies and they pay some of it and I write off the rest.

Today, the supply cabinet is low on naloxone. Naloxone is the drug that reverses opioid overdoses. We always run low on it. It is like trying to bail out a leaky boat with a teacup.

At eight on the dot, the door opens and Roy walks in. Roy is fifty-four and has worked in the coal mine for thirty-six years. Thirty-six years of breathing coal dust. His lungs are coated in it, layer by layer, like sedimentary rock, and the condition is called pneumoconiosis, which is the medical term for what everyone in this town calls black lung.

"Morning, Doc," Roy says. He doesn't sit. He never sits. He stands in front of the examination table and tells me his problem the way a soldier reports for duty.

"Chest feels tight," he says. "Worse than last week."

"Last week you said it was worse than the week before."

"Yeah. It is."

I listen to his lungs. They sound wet. Not the clean wheeze of asthma but the heavy, congested sound of fluid in the alveoli, the tiny air sacs where oxygen enters the blood. His lungs are filling up with scar tissue, turning to stone, and there is nothing I can do about it except prescribe an inhaler and tell him to slow down.

"Keep using the inhaler," I say. "If it gets worse, come back immediately. Don't wait."

"I will, Doc."

He leaves and the next person is already waiting in the chair, and then another, and the morning passes the way mornings pass here, which is to say it doesn't pass so much as it accumulates, layer by layer, like coal dust.

At noon, I eat a sandwich at my desk while reviewing a patient chart. The sandwich is from the deli in town, two dollars, turkey and cheese on white bread. It tastes like the other sandwiches I've eaten here, which is to say it tastes like this town, which is to say it tastes like things that are not quite fresh but are good enough.

DeShawn Brown comes in at half past twelve. He is twenty-five and he has been coming to this clinic for opioid treatment for eight months. He takes suboxone, which is a medication that reduces cravings and blocks the effects of other opioids. He comes twice a week to pick up his prescription and talk to me, or to the nurse, Teresa, who does most of the talking because I am not very good at the talking part.

"Morning, Doc," DeShawn says. He sits down and crosses his legs and swings them a little, the way young people do when they are trying to look casual and are not quite succeeding.

"How you doing, DeShawn?"

"Good. Good. Been good."

"That's good."

We sit for a moment. He is waiting for me to ask him something, and I am waiting for him to say something, and the silence between us is the kind of silence that exists between people who are trying to be honest with each other and are not sure they know how.

"My boy got in trouble again," he says finally.

I put down my sandwich. "Your son?"

"He's sixteen. Shouldn't be sixteen and already doing this stuff, but here we are."

I don't offer advice. I don't tell him it will be okay or that he's a good father or any of the things that people say when they don't know what to say. I just listen.

"We found pills in his mattress," DeShawn continues. "Oxycodone. Where he got them, I don't know. He won't tell me. He looks at me like I'm the enemy, like I'm supposed to be mad at him instead of the people who sold him those pills in the first place."

I nod. "What do you want to do?"

"I don't know. I'm his father. That's supposed to mean something, but sometimes I don't think it means anything at all."

It doesn't. Not in this town. In this town, being a father means watching your children make the same mistakes you made, only worse, because the world has gotten worse since you were young. The mine closed in 2011. Before that, you could get a job with a high school diploma and make enough money to raise a family and buy a house and take your son to work on Fridays and show him what a man does. Now the mine is a hole in the ground, and the houses are empty, and the sons are dead or dying or waiting to die.

"I'll prescribe him an appointment," I say. "With a counselor. If your boy will come."

DeShawn nods. "I'll try to convince him."

At seven in the evening, I lock the clinic door and drive home. The road home goes through a hollow that has no name on any map, just a dirt track that winds between mountains so steep that the sky is a thin blue line between them. I drive slow. The roads are bad.

My house is a small thing, two bedrooms, one bath, with a porch that sags on the left side. Nancy, my wife, is in the kitchen making dinner. She is a postwoman for the postal service, and she has been delivering mail in this town for eight years, which means she knows everyone in it, which means she knows all their problems, which means she brings some of them home with her every night.

"Rough day?" she asks. She doesn't look up from what she's cooking. She knows the answer before I give it to her.

"Rough day."

She nods, and that is enough. That is everything.