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Jennifer Boyd pulls a pen out of her white coat pocket and pricks the sole of Yvonne Dempsey's pink, puffy foot. "Can you feel that?" asks Boyd, a physician assistant at the New River Health clinic in Beckley, West Virginia. She grabs Yvonne's ankle in her left hand and pokes again. "How about this?" No response.
Boyd snaps a wooden spatula in half and tries poking with the jagged edge.
"Can't feel that?" she asks again, tapping from heel to toe.
Silence.
"Are you feeling anything?" Boyd asks. Yvonne lowers her head and glances furtively across the room at her older sister, Ester Hinte, a spry 67-year-old. But Ester can't help her.
Boyd stabs Yvonne's fleshy hand. "How about this?" she asks. "Can you feel it here? Not really, huh?"
"Nope," comes the muffled response.
Ester, watching it all unfold, is stunned.
Her younger sister's diabetes has deteriorated to the point that at age 57, Yvonne has no feeling in her feet and is rapidly losing sensation in her calves, arms and hands. Yvonne has developed a fungal infection and continues to have chest pain and dizzy spells. On this particular day, her blood pressure is up to 150/76 and her blood sugar level is twice the target range of 120.
Yvonne is seriously ill and getting worse. A devout churchgoer with a droll wit, she tries to follow Boyd's advice and improve her health. But her good intentions bump up against major obstacles, ranging from a troubled childhood to economic barriers of rural West Virginia.
Money pressures course through everyone's struggle for good health, complicating every decision, spiking stress levels.
“I don’t want pity, but I would like people to know what it’s like to try to work and make a home when you are sick.” –Yvonne Dempsey
The sisters live in the center of a spiral of ill health compounded by harsh socioeconomic realities. Yvonne's 71-year-old husband is recovering from two strokes. Ester, after beating uterine cancer in 2000, was diagnosed in February with colon cancer that has spread to her liver and lymph nodes. Her husband, who was hospitalized this fall, is bedridden with nine stents in his chest.
Ester's son, Derryl Hinte, was born deaf. Now 43, he has high blood pressure and borderline cholesterol exacerbated by a lifelong smoking habit.
And it goes on. Derryl's twin sister, Sheryl Elkins, has an autistic son. Her husband, Dean, has a body battered by countless injuries after a quarter century of volunteer firefighting in the small town of Oak Hill.
"For the longest time, I thought I was accident prone," says Dean Elkins, 43. "But I'm just the first one to arrive on the scene a lot of the time."
Money pressures course through the extended family's struggle for good health, complicating every decision, spiking their stress levels.
When Sheryl decided six years ago to stay home and raise Keith, the couple lost her bank salary and good health insurance that went with it. Now they pay $540 a month for coverage that does not include preventive checks such as an annual screening mammogram.
Sheryl Elkins works with Keith on his “picture cards,” an exercise that helps the boy match words and images. ???My main focus in life is him now,” she says.
Last month, the Elkinses spent $278 on nutritional supplements for Keith, and, on a doctor's recommendation, they trek to Charleston, to buy pricey gluten-free foods for the boy.
In a culture where fatty pulled pork and buttery biscuits are staples, low-calorie, nutritious foods seem like exotic luxuries.
"We West Virginians don't always do what's best for our health," says Dean, noting that virtually every family member has smoked or chewed tobacco for decades. "I don't eat many vegetables. I don't like cold foods like salad."
Yvonne likes salad, but at a cost of three dollars for two bags, she can't buy it often. And a 1.1-ounce box of Splenda packets costs $3.89, compared to $2.89 for a 4-pound bag of sugar.
"They want me to do fruits and vegetables," she explains. "I go and price these things and have to decide, what bill am I gonna pay? What medicines am I gonna buy?"
Yvonne's trailer is falling apart and park managers recently raised her rent and utility bills by nearly $100 a month. With just a high school diploma and no car, her job options have been severely limited. For 19 years, she has worked part time at the Value Plus grocery story. When she was healthier, Yvonne walked the one mile to the store. But as the diabetes progressed and she lost most feeling in her feet, it became impossible to make the trek and then stand on her feet at work all day.
"I don't want pity," she says, "but I would like people to know what it's like to try to work and make a home when you are sick."
It's been a while since Yvonne visited the clinic, and both patient and provider have bad news to deliver.
Yvonne confesses that she's not taking two of the seven medicines Boyd prescribed because even the discounted prices are more than she can afford. She doesn't test her blood sugar either.
"I can't afford those little strips," she says. A month's supply can run as high as $50.
Boyd wants Yvonne to take heart medication, would like to send her to a blood specialist to investigate her persistent iron deficiency and feels compelled to broach an unpleasant subject.
"I'd like you to think about insulin shots," Boyd says gently as Yvonne grimaces. "I know you don't like to think about this, nobody does. But it's a really quick way to get your sugar under control."
Before the sun rises, Yvonne Dempsey arrives at her job at the Value Plus grocery store via taxi. Because of her diabetes, she has lost feeling in her feet and can no longer make the one-mile walk to work.
One more thing, Boyd adds. "I'd like you to use Lotrimin cream" for the fungal infection. "It costs about $15 a tube. Can you afford that?"
Before Yvonne can respond, Ester rescues her: "If she can't, we'll get help from the church."
Boyd is also concerned that the family's medical woes have taken a toll on Sheryl, the only family member with more than a high school education. She is the family chef, chauffeur and cheerleader.
She drives Yvonne and Ester to doctor's appointments, hosts Sunday supper, has given her diabetic father insulin shots and changed her mother's colostomy bag. In the past six months, the already-slender blonde has lost 17 pounds.
"God's kept me busy," she says with characteristic good cheer.
"Caretaking of the extended family is a very strong value here and Sheryl handles it with incredible dignity and grace," Boyd says. "But this sort of thing has a huge impact on the caregivers. It leads to depression, interrupted sleep; it's difficult to make plans. Many times a person goes from being the caregiver to being an unhealthy patient."
Sheryl and her mother have both raised disabled children. A few years ago, a stranger at the mall suggested Sheryl's son Keith was autistic.
"That hurt her feelings," says Ester. "I could see her not wanting to accept it. I went through that with Derryl. It's just hard."
Ester Hinte helps her husband Cliff with everyday tasks such as walking, bathing and eating. The couple will celebrate their 50th wedding anniversary in September 2008.
Initially, the Elkinses were in denial, then they began scouring the Internet for clues to the mysterious illness that has left their child unable to utter even the simplest phrases. His verbal skills began to diminish before his fourth birthday.
"I thought I was having a mid-life crisis," recalls Dean. "We've been healthy, stayed away from drugs, don't abuse alcohol. I just thought, 'Why is this happening to us?'"
The lack of information, the self-doubt are all too familiar to Ester, who totes her medications in a purple velvet Crown Royal pouch.
"We grew up dirt poor," she says, while receiving chemotherapy at the Raleigh Regional Cancer Center. Young Ester was raised by her grandparents because her mother's second husband didn't want the child.
As she speaks, chemicals run through a clear plastic tube into a port just above her right breast-"let the juices flow," she jokes.
"Without education you don't really understand how your body works, and if you don't understand how your body works, you don't really know how to take care of it," says Ester in her typical down-to-earth candor.
"Without education, you don't understand your emotions, which goes to mental health," she adds. "And when you're poor, people look down on you and that affects a person's health."
Ester picked up bad habits from her mother, and grandmother before her, who didn't believe in preventive care. "She always said, 'Why would I go to the doctor when I'm not sick?'"
In that respect, the sisters are alike. Yvonne never went for checkups and was mystified three years ago when doctors said her blood sugar level was a near-fatal 414.
"That meant nothing to me," says Yvonne. "It was just a number and I didn't realize it was a bad number."
In 1999, Ester ignored vaginal bleeding for 13 months-the first signs of her endometrial cancer.
"Cliff [her husband] was sick," she says, recalling why she kept her symptoms secret. "I just couldn't be sick; I needed to take care of him."
Even now, as she goes for chemotherapy three days a week every other week, Ester cannot focus solely on herself.
In addition to keeping an eye on Yvonne and her grandson, Keith, she bathes, shaves and dresses her husband every day. This morning, he awakened her at the unpleasant hour of 5 a.m. "I just want to say, 'Now who is the sick person here,'" she says.
But Ester is chipper. Doctor Rajiv Khanna has given her good news.
"Without education you don't really understand how your body works, and if you don't understand how your body works, you don't really know how to take care of it," -Ester Hinte
An entire family is involved in the fight for good health. From left, Yvonne Dempsey, Sheryl Elkins and Ester Hinte on Hinte’s front porch in Oak Hill, W.Va.
"My feeling is the cancer has probably stopped growing," he says. "We'll continue with the chemotherapy for six months just to be sure."
"Yesssssss!" Ester cheers.
She reaches for a cell phone, dialing a special "relay operator."
"Hi, this is mom," she says slowly, as the woman on the other end of the line types a message to Derryl. "The doctor gave me a wonderful report. It looks like the cancer cells have stopped growing. Isn't that exciting?"
But Ester is already on to life's next challenge.
"Would you go by the house and check on dad?" she asks her deaf son. "Last night his mind didn't seem real good. If he hasn't got up, will you get him up and give him breakfast?"
"Okay," she tells the operator. "Signing off."