The Good Doctor and the Broken Poor

Reflections on Poverty in the 1980s

by David Levine
June 2013

In the 1980s Dr. David Hilfiker practiced what he called “poverty medicine” in the nation’s capital.  It was a special brand of medicine.  No doctor at that time, including Hilfiker, had pursued a residency or specialized training in the field.  Hilfiker just made it up as he went along; he improvised and did the best he could.

His 1994 memoir, Not All of Us Are Saints: A Doctor’s Journey with the Poor, details Hilfiker’s experience as a physician living in Adams Morgan, a despair-ridden and impoverished neighborhood two-and-half miles north of the White House in Washington, DC.  Hilfiker moved his wife and three children into an apartment on the floor above a thirty-four-bed medical recovery clinic for the homeless.  Called Christ House, the clinic took shape in an abandoned building where Mariel Boat Lift refugees in the 1980s had squatted.  At the same time, Hilfiker worked about a mile away in Columbia Heights at the Community of Hope Health Services medical clinic.  On the floor below the family’s apartment, indigent and homeless patients were fed, cared for, and housed.  

Hilfiker draws the reader into the reality of 1980s inner-city poverty.  It was a moment when the Reagan administration had degraded a substantial part of the social safety net, turned out thousands from mental institutions and hospitals and left them to fend for themselves on the streets. They lacked healthcare, housing, food, employment and any semblance of governmental support.  They brought a toxic mix of pathologies and hopelessness right into the middle of increasingly fraying communities.  Unaided, unsupported by any public largesse or family networks, these castaways gravitated to the inner city—including Adams Morgan, a one-time streetcar suburb lined with rowhouses built in the 1880s.  

Hilfiker is a middle-class white Midwestern who trained to practice a medicine designed for middle-class people.  Hilfiker didn’t belong in Adams Morgan and he was ill-equipped for what he found there.  Still, with the detached and objective viewpoint of a physician, Hilfiker offers insights in his memoir into the lives of his poor patients: “…the causes of poverty must not blind us to the fact that an unjust society produces a kind of brokenness that cannot always be redressed simply by removing the injustice.”[1]  Having treated and lived with the poor, Hilfiker is showing us the point of no return:  the structures of oppression and built-in poverty are so strong that the poor are actually “broken” by poverty.  A broken person cannot really move forward.  Given a pair of boots, they are unable to find the bootstraps. 

Even today, nineteen years after his book’s publication, Hilfiker’s insights on the “brokenness “created by poverty still ring true.  Our national anti-poverty policies typically focus on only one factor of poverty, joblessness, while ignoring all its other factors.  These policies reward only those recipients who are able to move “up-the-ladder” through paid employment.  Passed in 1996 (two years after Hilfiker’s book), the welfare-reforming Personal Responsibility and Work Opportunity Act (PRWOA) codified the notion that employment was the way out of poverty.  PRWOA would help those poor persons who exhibited gumption and “stick-to-it-ness.”  The language of PRWOA could have been drawn from the drunken chitchat of a local Rotary event.


In research from the Center for American Progress [2]published in 2013, it was pointed out that Temporary Aid to Needy Families (TANF)—under PRWOA, the successor to the cash assistance program called Aid to Families and Dependent Children (AFDC)—has been applied inconsistently and sparingly in many states.  TANF caseloads nationally have dropped 60 percent in the sixteen years since PRWOA’s passage into law.  Still, in households headed by single women, poverty rates are nearing 42 percent.  At the same time, deep poverty rates among children are quickly approaching one in five.  In other words, the two primary targets of PRWOA, poor women and their children, are enduring poverty at rates equal to those in 1996 when the welfare-to-work reforms were first put in place.

These statistics undercut the long-term sufficiency promised by PRWOA.  Forcing single mothers off cash assistance to flip burgers does not solve poverty.  These jobs pay poverty wages and offer the jobholder no possibility for advancement.  Even the soft skills of employment—one of the “collateral” benefits imagined to exist in these crummy jobs—do nothing to end the economic vulnerability of these families.  Away from the home and their children, the newly working mothers have to pay for expensive childcare and long bus rides to work.  None of this is covered by their wages.  It never will be.  Sunk deep into their “deep poverty” (under half the poverty level), many of these mothers will never find a way to self-sufficiency and long-term stability.

Writing before PRWOA, Hilfiker sounds remarkably prescient in 1994 when he poses this question: “What is it like to grow up in a neighborhood where those who struggle against all odds…are consigned to a lifetime of working two jobs at minimal wages just to eke out, at best, a subsistence living…where the expectation of a persistent, degrading poverty pervades?”[3]  He is seeing and recording the meaning of deeply rooted poverty in his fragile community.  For the individual exposed to it day in and day out, external impoverishment is taken to be an internal truth.  The psychology of poverty contributes to the “brokenness.”  Once enmeshed in poverty, having taken in its messages, it is a rare individual who can escape from it.

The answer does not lie in humiliating work programs.  Rather, for Hilfiker, the answer appears to be a social contract between society and its poor citizens.  (In his book Urban Injustice: How Ghettos Happen, published in 2002, Hilfiker draws out the meaning of that contract by which individuals are expected to contribute value to society, the best they can, while in return the government guarantees them a minimum standard of living.  He points to examples of European social contracts—including in Finland where he lived for two separate year-long periods—between the governed and their government.)  Given this social contract, anti-poverty policies should support work by providing meaningful job training, childcare assistance, subsidized work transportation, free healthcare, mental health treatments, and housing.  These supportive anti-poverty policies look to create better outcomes for individuals.  They will optimize the talents of people living in impoverished neighborhoods.  Supportive anti-poverty policies are a better approach than a one-size-fits-all employment policy—namely, that any job is better than no job.

If widely accepted, the view of the social contract will alter our thinking on the poor.  It will change the messaging and meaning for those who live in poverty.  It is about changing what Hilfiker imagines poor children read into the larger societal messages surrounding them.  All told, these messages say to them:  “their very poverty becomes one more irrefutable bit of evidence of their worthlessness.”[4]  If we come to understand the cause of their “brokenness,” it will be in large part due to this remarkable, and healing, physician.  With a better understanding of poverty, we can fashion policies that will actually reduce it.


D. Levine works in a human services agency.  All views and opinions expressed herein are his own.

[1] Hilfiker, David. Not All of Us Are Saints: A Doctor’s Journey with the Poor (New York: Hill and Wang), p. 24.

[2] Center for American Progress, “Post-Welfare Reform Trends Plus Deeper Spending Cuts Could Equal Disaster for the Nation’s Poor,” February 7, 2013.

[3] Hilfiker, David. Not All of Us Are Saints: A Doctor’s Journey with the Poor (New York: Hill and Wang), p 141.

[4] Hilfiker, David. Not All of Us Are Saints: A Doctor’s Journey with the Poor (New York: Hill and Wang), p 141.