How can patients get better if they live in homes tailor-made for disease?

I’m new to the job of coroner. Though I’m sure it won’t surprise anyone to hear that it’s nothing like C.S.I.; you measure the wait for test results in months, not minutes. It’s not like Quincy, M.E. either, where the same person responsible for the autopsy hops about cracking a case that somehow befuddles police. Most deaths are natural, with a good number of accidents and suicides, despite the media’s frenzied reporting on murders. It’s unglamorous, methodical work, less about solving a puzzle than making sure the details line up and the story make sense.

Recently I was called to investigate the death of man in his 40s, though his body had seen more wear and tear than most his age. He was an ex-addict. The assumption was that he’d died by overdose after one more relapse of the many he’d suffered over the years. Not surprisingly, the story was more complicated, and as the details unfolded an overdose seemed ever more remote as the cause of death. While most of the story could be gleaned from his medical records, I decided to take a visit to the late man’s home.

He lived in a social housing complex not far from the hospital. It reminded me of the complex my wife and I stayed in during our out-of-town stints in residency, a complex reserved for visiting med students, nurses, and residents. The buildings were drab and barren in design, the flooring old and lifting, the hallways dim and poorly ventilated. The walls transmitted noise, the cabinetry intact but cheap, the fixtures functional but dated. The place was adequate for breakfast and sleep, but no way could I live like that long-term, even on a resident’s wage.

The deceased and his girlfriend did live in such a place, though, and had lived there for years alongside family members elsewhere in the building. The air, stale and rank, mixed the pungency of pet odor with the funk of old cigarettes. The hallway — if you could call it that — between bedrooms had walking space measurable in inches, the sparse floor space taken up by bags of pet food and fans. The rooms were filled with haphazardly strewn junk, everything from broken old TV sets to empty bottles to aquarium supplies, piled from wall to wall and floor to ceiling. Somewhere in this mess were supplies brought by home-care workers — bags of IV antibiotics, suction pumps, wound dressings – tossed among ashtrays and piles of dirty clothing.

And everywhere was food. Open boxes of cereal, half-eaten bags of stale snacks, empty juice boxes, fragments of sandwiches, and wrappers with unfinished fast-food … on every piece of furniture and every square foot of floor.

The man had spent most of the prior season in hospital, treated for drug-resistant infections and pockets of pus all through his body, unhealed wounds from decades of abuse. The hospital stay wasn’t enough, though, and it looks like the infections are what ultimately did him in. As the saddest punctuation mark on the story, the man’s girlfriend — herself a recovering addict and victim of trauma, and the one responsible for administering his prescribed pills — found solace in her partner dying of natural causes. At least it wasn’t her own actions that killed him, that left her living alone in squalor.

I’ve made many house calls over the years, some in trailer parks or otherwise sketchy neighborhoods. Ironically, it wasn’t until I dealt with someone dead that the question finally struck me: How can we — as doctors, nurses, citizens — expect people to get better, living as they do in homes tailor-made to breed disease? A nurse changing a dressing, an instruction to “see your doctor” … this is a “dedication to community-based care”?

I’m not arrogant enough to think I have the answers. I’m not even sure I could tease out all the questions. But somewhere amidst all the fretting over politicians throwing money, athletes throwing punches, and celebrities throwing up, it’s time we took a hard look at the lives of our patients before the coroners need concern themselves with their deaths.

Franklin Warsh is a family physician who blogs at Impatient Care and can be reached on Twitter @drwarsh.

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