“Causes” – A Short Story by Michael Fine

By Michael Fine, contributing writer

© 1990, 2025 by Michael Fine

This is a work of fiction. Names, characters, businesses, places, events, locales, and incidents are either the products of the author’s imagination or used in a fictitious manner. Any resemblance to actual persons, living or dead, or actual events is purely coincidental.

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He thought of her as a slug, a plain grey-brown garden slug who didn’t even have a stripe down her back. She moved from place to place on a trail of mucus.

She was thirty-four, his age, and weighed two hundred or two hundred and fifty pounds. She smoked, drank, and had five children. She lived on welfare, had no teeth, and was starting to get diabetes. Now her older children, at fifteen and sixteen, were having her grandchildren. There would be more like her, multiplying like rabbits. Alan Goodwin knew her kind.  Dr. Alan Goodwin now.

Her kind. These people for whom there was no responsibility, not even a hint that there might be any order in the world, any connection between people and events. They just subsisted. Feeding. Multiplying.

Rhode Island.  Alaska.  Arizona.  Wisconsin.  Cleveland, Ohio. The hill country of Tennessee. The South Bronx.  Here he was in Connecticut, the richest state in the Union, where the fields were green, the houses white and freshly painted, where there were carefully built stone walls everywhere.  Unitarian Universalist Churches and Friends Meeting Houses in three-hundred-year-old villages of clapboard houses. It was unbelievable. They were here as well.

She didn’t look at him. She was looking at a wall.

His opening question, “How can I help you today?” elicited no response, as though there was no person, no human being, hiding inside this bag of flesh with eyes, this body that sat half-dressed on the table.

She sighed. She was wearing a paper gown over a dirty pair of jeans, and she was chewing gum. She smacked her lips.

“Ah got the headache. Ma eyes hurts, ma stomach hurts, ma monthly don’t come regular. And ma back, it hurts all the time. Ah can’t hardly breathe, and ah got these bites all over. What causes that?”

He could smell the cigarettes on her — a burned up, dirty smell.

What causes that?

That morning, another, older doctor had lectured him because his practice was failing, overwhelmed by too many poor people, who seemed attracted to him like flies. “You’ve got to take care of your family first,” the older man said.

“Medicaid doesn’t even pay enough to cover expenses. These people, they think they have rights, entitlements. They drink and smoke and fornicate, but they don’t want to work. They get into trouble and they expect you to fix it for them. I had a high school teacher who used to say, you don’t have rights, you earn them. They think the world owes them a living. They’ll bury you, sink you if you let them. If you don’t kick them out, if you let them take advantage of you, then it’s your own fault. There’s no one else to blame.”

“Your family first,” the older man said. “You’ve got to take care of your own family first.”  He had become angry as he talked, and was shaking his finger, lecturing.

Alan heard himself agreeing.

What causes that?

He thought about her question for a moment. How complicated the world really was. He looked at the woman on the exam table and began to get angry himself. She sniffled, apparently uninterested in what he thought or felt.

Did she really want an answer?

What causes that?

 

Did she really want to hear about, for example, the innervation of the facial musculature? About its vascular supply? How about the role of H2 blockers in controlling acid secretion in the stomach or stress-induced peptic ulcer disease. About H. Pylori, the bacteria that causes ulcers? About differential diagnosis or physical examination or the hundred thousand other things Alan had to know, as a doctor?

Perhaps she was more interested in the effect of centuries of exploitation on working people? Or about how a free market always requires the real wages of working people to be driven down, how a capitalist economy is best driven by a work force that is hungry and ignorant. But perhaps, with the changes in Eastern Europe, she thought that kind of rhetoric was passe, disproven, now that capitalism had so clearly won the day.

Perhaps she preferred to discuss Women’s Rights or Reproductive Freedom. How about the struggle for freedom in El Salvador, the collapse of the health care system in the US or any of the other zillion things that worried him, that made things appear so much worse than they needed to be?

“What causes that?” she asked again.

The truth was, his practice was failing, killed by people like her, the very people he had been trying all his life to help, to speak for. When he left town, there would be no one left to listen to her troubles. She probably wouldn’t notice the difference.

All at once, it struck him that there would be no difference.

All his bright ideas, all his so-called knowledge, hadn’t made the world any better. He knew words, explanations, the names of theories and excuses, but no causes, nothing that could be fixed.

Suddenly it struck him that the deep structure, the secret meaning of things, the root cause, if there was one, was way beyond his ability to understand.  It was way beyond his ability to understand anything.

She stretched out her hand for him to see. He took it and turned it over. Between her second and third fingers was a red bump with a small line in the middle of it.

He would describe it differently in her chart. ‘At the web space between the second and third digit was an erythematous papule, 0.5 by 1 cm, with a central linear pallor.’

But how he described it didn’t matter.

All her other complaints probably didn’t matter either. It was the itch from this red bump that was bothering her, that was giving her no rest. She just didn’t know how to put a name on it.

The rash was just scabies, the bite of a tiny insect which multiplied where people were dirty, crowded, and poor.

Please make the rash go away, she was saying. I need to get some rest.

Please tell me it isn’t my fault.  She didn’t say that but that was likely what she was thinking.

But it was her fault.

Alan held her hand in his and turned it over once more.

He could make the rash go away, but to do that she would have to follow his directions, which she would most likely would not.  Even if it went away, the rash would likely come back, because of how she lived.  Because of who she was.

It was her fault. If she lived a better life, this wouldn’t happen, not any of it. He might as well tell her to take a bath and get a job.

She wasn’t listening.  She wasn’t paying attention long enough.  She’d never hear him, regardless of what he said or what instructions he wrote out for her.

The truth was, she just wasn’t able.

None of it mattered. He was wasting his time, his life.

He turned her hand over in his again. Her hand was warm and sweating, plump, even soft. The fingers were stubby, as if their growth had been stunted by her hard life, and the nails were yellow and streaked — nicotine stained.

Yet her hand was not as repulsive as he might have thought.

Despite its imperfections, her hand had lines where his hand had lines.  It had ridges and hollows where his hand had ridges and hollows. As he turned her hand over in his, he could not help noticing how similar his hand was to hers.

Suddenly, the anger drained out of him.

It didn’t matter, not any of it. Suddenly he was aware of a feeling that could best be described as unconditional love, or perhaps, overwhelming humility. Suddenly he was ashamed.  Suddenly, he understood that there was no difference between them, that he could just as well be living her life, and she his.

Suddenly, all he wanted was to make it better, to touch his hand to her cheek, and comfort her, or perhaps, to press his hand to her neck, to feel the warmth of simple human companionship in a place where there will never be any justice and no peace.

What causes that?

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Many thanks to Carol Levitt for proofreading, and to Lauren Hall for all-around help and support

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