Featured artwork by Danielle Hark
Author’s Note: The stories of the women in this essay are distilled from fifteen years of medical practice in the Appalachian foothills of eastern Kentucky. Like a patchwork quilt, the assembled pieces are sewn together into a new whole that is both representative and transformative. While these are the stories of real women, names, unique identifying characteristics and details have been altered to protect both their privacy and confidentiality.
The practice of medicine is based on the physician’s ability to gather story from the patient. Our story is our human identity and our humanity. It is also the gateway through which we enter into a relationship with our physician and how be begin the journey to healing ourselves. Appalachia is a birthplace of storytelling through music, through preaching, through food, through craft. Centuries of melancholia and darkness linger over these mountains and the Appalachia I know is a dangerous place for women. The people of the counties I serve have the shortest life expectancy in the nation. No where is there greater need for my skills and knowledge as a physician.
The lives of my patients are completely different from my own. I have never been physically abused or sexually assaulted. Most of these women grew up in chaotic, dysfunctional families in deep hollers with neighbors who weren’t within yelling distance. My patients cannot imagine living in a duplex house in a town like I did growing up. The very idea of living that close to the neighbors triggers their nerves. Many of the women in my practice never graduated from high school. Most have never worked outside the home or traveled more than an hour or two from where they were born. They are intensely curious about my life and experiences I share with them when it feels appropriate to me. In exchange, I ask about childhoods spent running in the woods, about life without indoor plumbing and about families whose brothers, daddies and papaws spent their lives working in darkness of the coal mines. Through storytelling, I can make a visceral connection to my patients that transcends our differences.
I’ve only ever wanted to be a rural, old fashioned, one-stop-shop doc who treated everyone and everything regardless of their ability to pay my bill. I was willing to work for firewood, homemade pie and fresh eggs and couldn’t wait to start making house calls. Now, seventeen years after graduating from medical school, I’ve built a life and practice on those principles. My practice changed me too, and in an unexpected and fundamental way. My patients’ lives – their stories, the chaos, the deprivation – no longer shock me. Brutality and cruelty are woven into the fabric of my patients’ daily lives and so they are in mine too. I am dismayed by the level of turpitude, bizarreness or depravity it takes just to raise my eyebrows. Violence is so pervasive that when I share my experiences with colleagues in practice anywhere else, I realize just how distorted my lenses have become.
I am not cynical or hardened to the pervasive cruelty or the shameful and demeaning treatment of women, but rather, I’ve become accustomed to it. I still can’t control my temper when I learn how or who in the legal or welfare safety net failed one of my patients. I send emails to disinterested politicians and write letters to bureaucrats that never get read. I lobby Frankfort and I vote in every election. I am never without empathy, grief or compassion for my patients and their experiences, I just long ago stopped being shocked by them. I wish I knew when or how I transformed from an ingenuous bookworm, to a veteran doctor with a finely tuned bullshit meter and a journeyman’s knowledge of the Kentucky legal and welfare systems. But there was no sentinel event. It has been an insidious evolution born from years of long days listening to patients tell their stories and my need to make sense of it all.
Knowing patients like these women has fundamentally changed the way I view and practice medicine. Seventeen years ago, when I was just starting my career, I thought being a doctor meant making diagnoses, writing prescriptions, setting broken bones and sewing up split lips. To a certain extent it is, and I do all of those things every day. Those are the mechanics of medicine: teachable skills learned in school and honed by practice. Care of these patients, and hundreds more like them, taught me the art of healing. A patient once told me, “No one ever asked me about my life before. I guess no one thought I was important enough to ask.” Her story included a childhood robbed by years of incest and rape. When I met her as a young adult she was selling or trading sex for drugs. She wanted a different life, but didn’t know where to begin. Telling her story for the first time started the process.
I have a deep and abiding empathy, respect and affection for the women represented in this essay. They are all survivors and they all fought back in their own way. Today, they are in recovery: from the abuse, from the drugs they used so they could forget the abuse, and from a lifetime of deprivation and isolation. They want a better future for themselves and for their children. It is a privilege to know these women and to play a role, no matter how small, in bringing them back from the abyss.
Roberta stumbled into my clinic, filthy, barefoot and bleeding. She’d been tied to a chair, and beaten and raped by her boyfriend during a drug-fueled fugue. When he finally collapsed, she managed to free herself , then walked two miles to our office, the only medical facility in the county. I delicately examined her bruises and abrasions. Roberta had at least a dozen cigarette burns on her trunk and she was dehydrated. I spoke to her in hushed tones and touched her as gently as I could. No, she had no place to go. No, there was no one to call. No, she wasn’t on any birth control. Yes, I could call the police. Yes, she’d like something to eat. I didn’t ask her if she was all right, because I knew she wasn’t.
When I finished my examination, I walked down to the break room where many of the staff were on their lunch hour. I got out my debit card and tried to ask if someone would be willing to go to the Dollar General to buy toiletries and clean clothes for Roberta. But try as I might, no words came out of my mouth. All I could do was sob.
Over the next couple of hours, we got Roberta fed, hydrated, clean and clothed. I treated her for every sexually transmitted infection I could, gave her emergency contraception and hugged her gently. I handed her an envelope with just over a hundred dollars in it. It was as much as we could collect on short notice. Then I left her in the hands of the sheriff’s office and the social worker from the women’s shelter.
I never saw Roberta again.
I saw Wanda a few months after her husband Roger died. I asked her how she was coping. “You know, he made me stronger by being mean,” she said. “From the get go, Roger taught me to hang my head. But I decided a long time ago to lift my head up anyways, stop cryin’, and look him straight in the eye. If I didn’t, I couldn’t see the gun comin’ and I couldn’t save myself. Now, I’m strong,” she said pointing to her heart. “I’m strong. I make eye contact at everyone and I smile. I have no fear. I won’t hang my head or cry no more. No ma’am. No ma’am, not me.”
I asked her what she was doing now. “It’s like steppin’ out of prison,” Wanda said. “These days, there’s not a soul between me and the door and the car. So I go. I go even if it’s ten o’clock at night. If I want to go, even if it’s to get a pop or a pack of cigarettes, just because I can, I go.”
With great trepidation and curiosity, Wanda started dating. Through church and the local dance hall, she met and dated several sweet and well-mannered widowers. A man’s kindness was a strange and giddy sensation. She never allowed herself to get intoxicated on affection though, so she wouldn’t be ‘a damn fool’ and marry again. In the last part of her life, Wanda discovered the fun of dating and falling in love. This sixty year-old woman gushed and acted like a teenager during her visits with me. I listened and giggled and pumped her for more details like her sixteen year-old best friend. I could have burst with happiness for her.
But, for all of Wanda’s strength and courage, she never did get used to a man pulling out her chair or opening her door or sitting near her on the sofa. Wanda flinched reflexively every time she saw a man in her peripheral vision.
Thirty years of muscle memory could not be erased.
Alma’s daddy, Vernon, taught her how to shoot heroin when she was twelve. When he’d tired of hustling copper and pawning stolen electronics for dope money, Vernon hustled his strung-out teenage daughter in exchange for Roxie 30s and heroin.
“You wouldn’t believe how many dirty old men there are out there,” Alma whispered to me. A drug deal gone bad left Vernon dead, a vehicle on fire and Alma with a bullet through her left flank. Vernon’s toxic legacy lived on through the Hepatitis C he passed to Alma through the needles they shared to inject dope.
I met Alma, a forty-two year old woman, bereft. Her mother and brother had both died from liver cancer, choosing to forgo treatment at the university medical center two hours away for a couple of quiet months at home, smoking cigarettes, weed and dope until their last days. Alma sat in my office, arms wrapped around her knees, rocking, back and forth, back and forth. There was no bitterness, no self-pity, just grief and loss. She was alone in this world and had no idea what to do next. We talked about her worthiness, about her intrinsic value as a human being. I asked her to think about something that might soothe her. I gave her a few examples, including going for a walk, taking a long bath, coloring or praying. She thought for a few moments, lips puckered, eyes closed.
“I ain’t never had a lay-down tub bath,” she declared, eyes popping wide open. “I ain’t got a water hook-up at the trailer most of the time, and I ain’t got no bathroom no how. I take me a bucket bath on the stove.” She paused, suddenly lost in a daydream. Then she let out a bark of laughter. “I’d be so clean I’d squeak,” she grinned.
Her delight at this absurd and extravagant fantasy made my day.
Geneva was in a physically and emotionally abusive marriage for 31 years. “My husband would come up behind me with a gun and threaten to shoot me when I went out on my porch to smoke,” she said. Her husband would also wake her from sleep by rubbing the barrel of a gun up and down her body and then rape her with the pistol pointed at her head. He called her a dyke any time he saw her having a conversation with another woman.
“I thought a man was supposed to beat his wife until I started watching Sally Jesse Raphael. She tore my world apart,” Geneva recalled. It was too painful to watch Oprah, she said, because she didn’t dare have that much optimism or hope. Geneva, finally, literally, walked away from her marriage eleven years ago. She filled a laundry basket with the family Bible, a few photos, one of the pistols from under their mattress and four clean outfits. She walked out the door and down the road to freedom. “I lost everything I worked for in thirty-one years,” she told me without regret.
She hadn’t lost everything though. Geneva was hypersensitive to noises, light and unexpected sounds. She suffered flashbacks, nightmares and disturbing thoughts that stole her sleep. She never could turn the lights off in her bedroom after dark. “I’m at war with myself all the time. I don’t ever have no peace.”
Despite my best efforts, I never could bring her a good nights’ rest.
Three weeks into her marriage, Paula wanted to die. Her husband, Dennis, taped the outside of the doors and windows when he went to work, so if she left the house, he’d know she’d gone out. He had cameras installed around the periphery of the house and the property. When Paula was allowed to run errands, she had a time limit in which to pay bills and grocery shop. She was beaten and harassed if she was late. “In three lives I couldn’t do everything that man accused me of,” she said. From time to time, Dennis would accuse her of stepping out with another man instead of running errands, then use it as an excuse to punish her. He would choose one of the family’s dogs and then torture and kill it in front of her.
“It’s queer though,” she said, “when he took the cancer, I took care o’him right up until he got the death rattle. I took care o’him like he was my one and only. I didn’t think nothin’ of it.” She paused and shook her head in disbelief. “Even when he was layin’ there, moaning and fussin’ and waitin’ on Jesus, he couldn’t spare a kindness.” She paused again. “He’ll’ve answered for it though. No doubt in my mind. I ain’t gonna be lookin’ around real hard for him when it come my time to meet Jesus.”
Sherry was thirteen and living with an aunt because both of her parents were in prison. Sherry’s aunt had a friend who took a liking to Sherry. Each month he paid her aunt to rent Sherry and Sherry’s bedroom. Within a few months, Sherry was withdrawn from school and she had three children with him before she was seventeen. When the man tired of her, Sherry fell in love with a man almost thirty years her senior. She had three more children with him. She was twenty-five when this man left the house one morning and didn’t come back.
Sherry struggled to be a good mother. She struggled to make her way in life without depending on a predator. She wanted a better life for her children than she had, but she had no idea how to give it to them. I asked her if she’d ever considered getting a GED.
“I ain’t smart enough,” she said. “I did real bad in school, and I only went to part of the sixth grade.”
“You ARE smart enough,” I replied.
“You really think I’m smart?” she asked, just like a little kid. “Ain’t nobody ever said that to me before. Ain’t nobody ever said they thought I could do anythin’ other than fuck.”
I sat there a moment, in silence, imagining this woman’s horrific life. Such a simple encouraging statement, a never heard before compliment, and there was the little girl who never learned to read.
“Yes,” I said softly. “I think you’re smart and you have a lot of potential to be whatever you want to be.” I paused. “Sherry, do you understand that it was wrong for your aunt and that man to do what they did? You were a child, Sherry. Your aunt should have been protecting you from men like him, not selling you to him.”
“Oh, he didn’t try to sell me nothin’. We just stayed there in the house. He wasn’t really mean to me or nothin’. He bought me presents and he never hit me none. He was real nice.”
“Do you understand that what he did was against the law? That you were a child when he had sex with you?”
“Kinda. I mean, I know I don’t want my girls to have babies so young, I want them to finish school first.”
“I think that’s a great goal,” I said kindly.
“Dr. Zook, there’s someone here to see you.”
I saw a man who was probably only in his late fifties, but a lifetime of working in the sun and smoking hand-rolled cigarettes gave his skin deep lines and the burnished color of weathered pine that made him look at least ten years older. He wore bib overalls and a clean shirt and his hair was still slick from the shower. I saw he’d left his work boots at home and put on his polished leather Sunday-going-to-church shoes. His jacket had ‘Roy’ embroidered on the pocket.
“Hi, I’m Dr. Zook. May I help you?” I said, smiling and trying to put him at ease.
“I know who you are ma’am,” he said, with no disrespect. “My name’s Roy Eckert, ma’am. My girl, Patsy? Ma’am, she’s your patient. She’s told me and my wife all about you and about how much you helped her.” He paused and sniffed a bit. “She said you was the one talked her into leavin’ that piece a shit.’
I raised my eyebrows at him.
’Scuse my language ma’am, but there ain’t no other word for him.”
“No worries. But I didn’t talk her into anything; she made up her own mind.”
“Well, she said you fixed her up more than once after that bastard beat the shit outta her and she was too dumb to leave.” He paused, the twitching muscles along his jaw betraying his anger. “Pardon me, ma’am.”
I silently waved a pardon.
“You was the one that got her glasses fixed when he broke ‘em and got her thinkin’ ‘bout goin’ back to school.”
“It took a lot of courage for her to leave. She was terrified. We were both worried she might die, that he might hunt her down. She didn’t want you to worry about her.”
“She don’t never have to worry about him comin’ after her, I’ll see to that.” He shifted his weight and looked down at the floor. “Patsy says you got a youngin’, ma’am. A boy.”
“I do,” I said, smiling. “His name is Sam.”
He bent down, picked up a small wooden bench and handed it to me. “This is for your boy. I got a little wood shop in my garage.” The bench was maple, planed, sanded and varnished so that it felt like satin as I ran my hand along its length. The finished piece was more a work of art than a tinker’s project. “Ma’am, it ain’t much, but, I sure am grateful to you for helpin’ my girl.”
“You’re welcome and thank you,” I said and gave a nod at the bench. “It’s beautiful and Sam will love it.”
“You ever need anythin’, ma’am, you call me. I’m in your debt.”
“Yessir, I will.”
And with a bob of his head, he turned and walked out of the clinic.
There is no medicine or surgery that will make these women whole again. I cannot suture their souls, patch up their hearts, or surgically cut out their memories. But I can help restore their dignity and self-esteem. I can help them work through their shame and guilt. I can tell them what remarkable strength and courage they have. I also have resources to share: a shelter, legal aid, psychotherapy, parenting classes. Sometimes I have just what they need in the moment: food, a box of tissues and a quiet space.
I am angry at the perpetrators, the legal system and the families for hiding in shame. I am disgusted by the culture of violence and discrimination and the depraved indifference of so many stakeholders. I am frustrated by the learned helplessness that is so deeply ingrained in these mountains from generations of poverty.
But, I can’t dwell on what I can’t control.
So I will continue to listen to my patient’s stories without interruption or judgement. And I will do more. I will write stories that bring these terrible truths to light. Perhaps one day, through the transformative power of storytelling, my patients will live in fear no more.