Editor's Note: This story, is part of a series exploring the impact of the recession on health care for poor people. Dr. Sanjay Basu, MD PhD is a resident physician in the Department of Medicine at the University of California San Francisco.
Herman, a 61-year-old black man, sat on an exam table at San Francisco General Hospital’s General Medicine Clinic. He nervously tugged at the felt edge of his fedora hat. As his doctor, I asked him -- as tactfully as possible under the circumstances -- if he would submit to a drug test.
I had been Herman’s doctor for almost three years, but I could tell that this was clearly the first time anyone had asked Herman if he was taking drugs.
Herman was not pleased.
Increasingly, physicians are asking elderly patients like Herman -- patients near or even past retirement age - -if they have been taking illicit drugs. According to the Centers for Disease Control, the number of positive tests has increased by over four-hundred-thousand during the recession, especially among the elderly who have experienced the greatest number of home foreclosures.
A few years ago, at our first visit together, I asked Herman about his life. He was divorced. His mother lived in Oakland; his daughter had moved to the Midwest after getting married. He was alone and not exactly alone -- the way many elderly Americans find themselves.
He showed me what he did for a living -- sketching out an architectural diagram of the Bay Bridge reconstruction -- the complex physics of moving massive metal panels. It was Herman's way of telling me how proud he was, as a black man who went to segregation-era schools in Alabama, to have become a civil engineer.
But after the start of the recession, Herman quietly asked our receptionist to change his insurance designation to “self pay.” He had been handed a pink slip at work.
The Great Recession did not undermine his life in one blow, but with many humiliations and defeats, over weeks, then months. One day, Herman stood in the door of the clinic holding two Samsonites, his chihuahua in tow, clicking its paws across the white office tiles.
“Foreclosure,” Herman sighed as he sat down. “Everything I have left is in these bags.”
He was on his way to the East Bay to live with his mother. But -- always being prompt -- he hadn’t wanted to miss his usual doctor's appointment. He apologized for having nowhere to put his belongings.
Herman appeared unkempt for the first time. Like many of the clinic's oldest patients, he was the type of person who had always been meticulous about his appearance -- wearing a sport’s coat to the doctor's office. The week of his foreclosure marked a transition. He was perspiring, his hair tousled and his shirt dirty and partly unbuttoned. The foreclosure of his home completed, the foreclosure of his body was apparent.
Hypertension is often a medical consequence for persons facing financial distress. Herman had been diligent about taking his medications, but suddenly his blood pressure recordings crept upwards. “I’ll be honest,” he explained. “At this point, it’s the pills or the poultry.” He meant that he was forced to sacrifice his prescription co-payments to pay for groceries.
At subsequent visits, Herman casually asked whether medical research had found a cure for insomnia, then laughed at the suggestion that he might be depressed. He started nodding off in the middle of his doctor visits. He began to mumble, and complained of abdominal pain and chronic constipation.
After he had taken offense at my suggestion of a drug test, he complied and submitted a urine sample. Like many other elderly patients, he tested positive for drugs.
According to a statistician at the Department of Public Health, who wished to remain anonymous in an interview, San Francisco has been witnessing a “geriatric crack epidemic.” Particularly at the start of the recession, many emergency room doctors saw the resurgence of a variety of drugs and of drug use -- once only associated with the young and out-of-work -- now common among the elderly who have lost their pensions and property.
In Herman’s case, his urine wasn’t positive for crack, but for oxycodone, a painkiller. A few weeks after having moved to his mother's house in Oakland, Herman had found his mother’s pill bottle in the bathroom cabinet, stashed away from after her hip surgery. At first, the pills let him sleep. Then they made him numb. Then he "just needed them."
Confronted with the positive test, Herman just sucked in his lips, like a child after a misdeed confronted by evidence from an adult. His chihuahua shuffled under the chair and lowered its head to its paws with an exhausted snort.
Herman entered a rehab facility. He was one of the lucky ones. The rehab facility has been overwhelmed with patients since the recession began. He spent several sweaty nights there, emerging clean again.
But he is still without his home, or a job. Each time he comes to clinic with a forced smile, often averting the eyes of our staff.
He utters only a few words at the start of each visit to my office. "Doc, we can talk about my high-blood pressure again," he says. I oblige.
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