One of the most talked about books of the summer was Hillbilly Elegy by J.D. Vance. It's the story of how an impoverished white kid from Ohio maneuvers through a tragic cultural existence to graduate from Yale Law School.
The book's popularity has skyrocketed in large part because of Donald Trump's incredible rise to Republican presidential nominee. The book provides insight into one of the most interesting questions of this election season: Why do relatively poor, working-class whites strongly support Mr. Trump for president? They seem to be voting against their own economic interests.
I found the book even more intriguing on a personal level by providing insight into a question I have asked a thousand times on ED shifts during my career: What is the matter with these people?
It is mind-boggling how many of our patients present with the most screwed up set of circumstances one can imagine. Why are people so self-abusive in so many ways? Whether it is obesity, smoking, domestic violence, gangbanger shootings, heroin addiction, or a combination, these destructive themes are encountered again and again in our patients despite living in a society rich with opportunities to avoid these lifestyles.
What drives these patients to behave like this? How does someone eat, drink, shoot up, and smoke themselves into a state where basic hygiene becomes optional and their kids will be fine by eating at McDonald's and Taco Bell daily? Why do folks think it's OK to ride around on the highway with their kids in the back of their pickup? Why are arguments or gang conflicts settled by gunfire? This is nuts.
Read Mr. Vance's book to understand some of this. He was only 31 years old at the time it was published, and he candidly articulates his childhood experience of poverty, domestic violence, and horrible drug abuse. He selflessly opens his world to a point that I despised his mother, a raging borderline who seeks out men and drugs while young J.D. is moved from home to home. The description of these events provides searing insight into the life of a child without stable parenting.
But there is another equally destructive force in Vance's life, the Scots-Irish culture of the Appalachian Mountain communities from Western New York to Northern Georgia that touch at least a dozen states. Mr. Vance goes into ruthless detail of communities steeped in patriotism and loyalty but self-destructive in their traditions.
I found myself comparing Mr. Vance's experiences with so many of the patients I routinely see in my practice. His intellect allows him to articulate the vicious cycle of predictable events that lead to the continued poverty and bizarre behavior of “our people,” patients that visit us in the ED. They include the standard issues we see all the time: teenage pregnancy, poor school performance, insatiable violence, alcoholism, and rampant opioid abuse.
But Mr. Vance pulls no punches with “his people,” and the insights are fascinating yet brutally frustrating. He plays down government solutions, rips the sense of entitlement among his neighbors, and opens the book with an example of the profound laziness of his peers. He describes in detail the flawed people in his life that kept him going and how so many events had to occur in the right place at the right time for him to escape to his new world. He travels a meandering path through a variety of forced religious experiences, and delays college out of high school to find maturity and leadership in one of the great saviors of poor people in our country, the United States military.
You could insert any of the groups we see struggling for economic and cultural stability in the hillbilly's place. Ethnic and cultural differences aside, poverty just sucks, and it's difficult to get out of it when the people who raise you are a mess.
Sympathy can be a tough sell with some of the characters we meet in our EDs, but Mr. Vance's book is a great opportunity to reflect on how these people show up at our door. It would be natural for you to think reading this book would be a depressing experience, but read it anyway. Mr. Vance's path to the lifestyle that many physicians take for granted is an incredible combination of luck and persistence, and you will find it exhilarating and deeply thought-provoking. It will be one of the most important textbooks of your career.
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