Global Doc: Convergent Paths

Author: Dr. Vincent DeGennaro Jr. ’02

Vincent DeGennaro

Different paths brought two patients to the same place, a shared space and time. One had a heart transplant at age 2 and had lived a relatively healthy childhood since. The other had been an IV drug user since she was 13 and was both mentally and physically addicted to the substances that destroyed her life with each injection. One was born with a physical issue, the other with a mental issue. Both are young, sick and my patients and, most important, both will be unable to afford the care that they need and, therefore, neither will get better.

Vanessa, the young woman with the heart transplant, had developed clogged arteries in her heart, a condition that happens at an accelerated pace in transplanted hearts compared to God-given ones. After only 24 years of life, the arteries in her heart looked like that of a 65-year-old, clogged to the point that her heart has started to fail. She’s not obese, doesn’t smoke or do drugs, and she takes her anti-rejection medications religiously, but the vagaries of living with a transplanted heart are catching up with her. She’s tired when she walks a few hundred feet. At some point, she’ll need another heart transplant or will die before she reaches 30. “I’ve had the heart transplant since I was 2 years old,” Vanessa said proudly before adding, “I’m close to setting the world record for longest living patient with a transplanted heart.” She beamed and giggled with a full body laugh that filled the room.

Vanessa works at a local grocery store and makes enough to contribute to the household where she lives but not enough to buy health insurance. Until Obamacare, she was nearly uninsurable because of her pre-existing condition. Now she’s eligible for insurance through the online exchanges but still can’t afford the $400 a month that the plans cost. Geography and politics continue to play into her quest to continue to live. Since Florida is one of 25 states that have refused to expand Medicaid (government insurance for the poor) under Obamacare, she is still not eligible for the social program. If she lived in any of the 25 states with expanded Medicaid, she would be covered; as it stands, she’ll continue to languish in the limbo of the working poor. She’s too wealthy to qualify for Medicaid in Florida since she has a minimum wage job, but she is too poor to pay a quarter of her salary for health insurance premiums.

“The drugs are both generic and cheap — probably less than $20,” I said to Vanessa as I prepared her for discharge from the hospital. Vanessa looked at her mother, unsure if they could afford the cost. She receives the medications that keep her body from rejecting the transplanted heart through a charity program. As a child, the hospital performed her transplant as a charity case, but she’s now an adult and no longer covered by state insurance programs for children. Florida spent $500,000 to transplant her heart but won’t invest the $20 to maintain the body in which that heart is housed.

On the other hand, Heather never had any physical health problems, but she grew up in a rough environment, rife with physical and sexual abuse. She popped her first pills at the age of 12 and injected drugs shortly after that. She had one child at 17 and another at 20, both with an ex-boyfriend who is also a user. At 22, she started exchanging sex for money to support the habit. Now, at 23, her body is covered in carbuncles, like a nastier version of a pimple, caused by drug-resistant staph bacteria.

“I need help. I want to get help. I’m done shooting. I’ve had two friends die of staph and I’m not going out like that. Put me in rehab before you put me in a casket,” Heather fired off rapidly, fidgeting with her fingers, touching every part of her body as she described a symptom related to it, her racing hands mirroring the pressured speech. She wiped her brow of the sweat that had accumulated in the last few minutes of frenetic conversation, her pupils as wide as dinner plates. The urinary toxicology test had been negative for any illicit substances, meaning the throes of opioid withdrawal still lingered since her last injection from four days earlier.

I stood silently next to the bed, content to listen to her confessions, part priest and part psychiatrist. As she spoke, I surmised how the situation would end. The social worker would visit her to discuss the options for inpatient substance abuse rehabilitation. However, Heather doesn’t have health insurance, and a patient who sells her body for $20 worth of narcotics will not have the thousands of dollars needed for a rehab stay. Without any publicly available rehabilitation facilities, her options would be limited to free Narcotics Anonymous meetings. She might qualify for Medicaid, but mental health services are poorly covered, if at all, by most insurance companies, public or private. Patients can be hospitalized at psychiatric hospitals for threatening to harm themselves but usually don’t receive any on-going psychiatric help after discharge. Similarly, an addict might qualify for acute, inpatient detoxification, but once discharged days later, no psychologist or psychiatrist will talk through their issues with them, leaving unresolved the demons that drove them to drug use in the first place. Unfortunately, despite the convictions she rapidly espoused to me, Heather will likely return home to the same environment as before and fall back into the same habits.

Heather’s story reminded me of Vanessa’s, if she’d taken a slightly different path. The two divergent paths converged at the same hospital with the same doctor and rooms right next to each other.

Neither patient will pay the hospital bill since neither can afford even the antibiotics in their veins, let alone the bed they sleep in. The hospital will absorb the cost of the hospitalization and increase the price on those with insurance in order to offset the loss. They’ll both attempt to fill their prescriptions and then will be left to their own devices for their medical follow-up upon discharge. Neither will receive the care they need and both will be hospitalized more frequently. Vanessa may die of a broken heart and Heather will never have access to care for her mental health disorder to get her life on track. Heather’s children will grow up either without a mother or with a mother who is a drug addict. For them, the cycle of poverty and poor health care will continue.

Vincent DeGennaro is an internal medicine doctor and a global public health specialist at the University of Florida’s Division of Infectious Diseases and Global Medicine and works half time in Haiti with the nonprofit Project Medishare. See his An American Doctor in Haiti blogs.