Her black pigtails, coarse and perky, were arranged in childish multiples around her head. Moldering yellow eyes, traversed by a network of fine red veins, contrasted starkly with her dark skin. Her breasts were pendulous under her soiled T-shirt, and her bare legs were splayed out in front of her.
“Well, I gotta be honest with you, Doctor,” she said. “I been using crack every other day.” She went on to request that I refill her mood stabilizer for bipolar disorder and Ambien, her sleeping pill, for insomnia. She had been discharged from inpatient rehab just a few months earlier.
“Check my record,” she said. “I been here last week, and the other doctor already done my referral to psychiatry. I just need my appointment, but I’m gonna run out of medicine in a couple a days.” She leaned back in her chair.
Shernette had waited for several hours to see me at the small free clinic in south central Los Angeles where I have been working for the past three months since leaving the Navajo Reservation. Further investigation quickly yielded the referral in question, but the only follow-up offered was the toll-free number for free county services. Obtaining these services typically requires the patient to make many phone calls over months. Our benefits coordinator confirmed that her Medicaid plan did not offer mental health services.
At any rate, the least of Shernette’s barriers was her poor insurance coverage. She explained that her children needed too much attention for her to seek full-time rehab, and she didn’t like Narcotics Anonymous. When I pointed out that her children were both adults and that it was unlikely she offered any significant parenting when high on crack, she said that she planned to go for mental health care whenever we could make that appointment available.
Marisol, in contrast, eagerly sought out mental health services. At 62, she wore her thin hair dyed auburn and swept back. Her overly bright makeup was carefully applied. At her first visit, she presented me with her Mexican diabetes medications. Although she had been living in Los Angeles for nearly one year, she still relied on cheap Mexican medications to self-manage her illness. She had moved to this country to live with her daughter. But, a few months after she arrived, her daughter disappeared without a trace. Marisol was distraught. Without relatives or friends in this country, she sat alone in her apartment waiting in vain for her daughter to return.
A week later, Marisol came back to see me. “Como esta?” I asked her, but when she replied, “Mala, doctora, mala,” and burst into tears, I ran for an interpreter. The mental health services at our clinic are limited to crisis interventions, and the clinic she was referred to for ongoing services would charge her $45 for the initial evaluation and then $35 for each visit. “Pero, no tengo trabajo. No tengo dinero.” Without a job, she had no way to pay for the services. Instead, she planned a trip to Tijuana, where she could pay $10 for two weeks of intensive therapy. “I need help,” she told me through an interpreter. “I can’t live this way.” She meant this as her last visit to adjust her diabetes medications and obtain refills before her trip.
Humberto’s stated reason for visiting our clinic was trivial. A slight Mexican man, he stared at the floor with arms folded in his lap. When I commented on how sad he looked, he gave a faint chuckle and said that the woman across the street from his home had said the same thing. Humberto had left his wife and children in Mexico five months previously when he crossed illegally into the United States. Now despondent and homesick, he had difficulty finding work. His sister-in-law wanted to kick him out of her home because he could not pay rent. Humberto sent what little money he had back to his family in Mexico and often went without meals himself. His brother suggested that he find an American wife, “but I already have a wife and family that I miss in Mexico,” Humberto said.
“Oh, he’s in the totally homesick phase. He’s going to just have to get himself through it,” said my clinical assistant, who was translating. There was little we could offer by way of services. Legal aid was fraught with risk for deportation, and counseling was out of the question. Even though his mood was depressed, it was an appropriate response to his situation. He didn’t need pills. He needed help, and I had none to offer.
I was powerless to provide these patients what they needed most. We offered Humberto the addresses of a local food bank and soup kitchen. I haven’t seen Marisol in several weeks, so I presume that she has gone back to Tijuana. Shernette considered her options as it became clear that after waiting so many hours for the doctor, she wasn’t going to get the Ambien prescription she desired. Though she struggled to maintain an impassive facade, her watery eyes betrayed her as she momentarily vacillated between the various possibilities for her response—angry, indignant, disgruntled. Finally, she opted for meek. “I thank you very kindly for helping me, Doctor. You have a blessed day.”
Ellen Rothman, HMS ’98, practices medicine at a community health center in Los Angeles.
The names used in this column are pseudonyms, and the opinions expressed are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
