It was the third time in a week that I'd seen my patient, a 12-year-old girl with asthma. Her family knew what to do when she started wheezing -- take the prescribed medicines: Albuterol, two puffs, every four to six hours, and QVAR, two puffs, twice a day. But this time they didn't seem to be helping. Now, towed back in by Mom, every time the girl spoke she was interrupted by a staccato of coughs.
She didn't have a fever and she had a normal chest X-ray, so I knew she didn't have pneumonia. Could she have whooping cough? I doubted it, since I gave her a booster vaccine last year.
This time, the family had the foresight to bring her medicine in with her. The girl reached into her backpack, pulled out her inhalers and handed them to me. I shook them both. They seemed to have enough medicine in them. That's when I noticed both drugs were past their expiration dates. Sometimes medicines can last beyond their expiration date, but apparently not this time.
"Did you know your medicines have expired?"
Mom answered. "Yes, but they're not that old. Besides, we're trying to save some money. Our drug deductibles are very high."
This isn't a poor family. They're a typical middle-class one from Pleasant Hill, Calif., a nice suburb 25 minutes east of Oakland. But like a lot of other families, they're under pressure and must decide whether healthcare takes precedence over paying the mortgage or buying food. Many families, having to care for both children and aging parents, likely have to decide whose healthcare needs -- child or grandparent -- are greater before spending their dollars at the doctor's office.
The Pleasant Hill family isn't among the 50 million uninsured to whom politicians keep referring. They represent everyone else -- those employed and insured. But they've got a lot of skin in the game with high deductible plans that are affordable to their employers but tough on their own pocketbooks.
I thought of this suburban family as I was reading a raft of recent newspaper articles about how a poor economy is supposedly good for our health. While that theme may have a Freakonomics appeal to it -- the kind that sparks interest at a cocktail party -- in my experience as a physician, it is far from our current economic reality.
The newspaper articles refer to a 2000 journal study, "Are Recessions Good For Your Health?" by economist Christopher Ruhm. Ruhm reviewed two decades worth of economic and health data and concluded that U.S. society as a whole is healthier during economic downturns. He showed that, among other things, fewer people die during recessions from heart attacks and traffic accidents, and that smoking and obesity rates drop. On closer examination, however, his conclusions say little that's reassuring or helpful.
First of all, his studies don't examine rates of mental illness, like anxiety and depression, a fair barometer of down times. However, Ruhm did note suicide rates rose 1.3 percent for every 1 percent increase in state unemployment rates, an accurate proxy for psychiatric illness. Second, he attributes most of the decreases in mortality to people under the age of 44. This group usually dies from injuries suffered in accidents (most often car accidents). It's easy to accept his conclusion that a down economy means less traffic and fewer accidents. But what about diseases that affect older age groups? Those are the folks about whom we have to be particularly sensitive, given our aging population, and given they require a large portion of healthcare resources.
During the period that Ruhm looked at (1972-1991), deaths from cancer, influenza and pneumonia increased. These are diseases that could be prevented by seeing a doctor or, in the case of many common cancers, be detected by screening tests like mammograms and colonoscopies. Flu, too, is a preventable illness -- just see your doctor and get a flu shot each year. Those who don't are more likely to become a statistic -- a person who gets pneumonia that requires hospitalization, an infection that sickens and kills many elderly adults every winter.
Finally, the drop in mortality that Ruhm documents is only a short-term change. He predicts that between 2 to 4 years from the onset of a recession, those rates begin to rise again, either exceeding or offsetting earlier gains. That's bad news, given the depth and breadth of the economic problems we seem to be experiencing right now.
Back in reality, there's more up-to-date and discouraging news about healthcare in these tough times. Recent surveys by the Kaiser Family Foundation tell us that a third of Americans reported having problems paying their medical bills, up from a quarter the previous year, bills that typically run in the thousands of dollars. How do they cope? Almost half took actions like postponing healthcare, skipping medical tests or treatments, not filling a prescription, cutting pills or skipping doses of their meds altogether.
Unfortunately, fears about healthcare seem to rule people's lives. According to the Kaiser survey, an increasing number of people are basing their job decisions on whether they can get healthcare benefits. Often, they stay on a job longer than they would like to keep their healthcare, or change jobs solely because the benefits are better elsewhere. It's hard to look at that kind of data and not worry about people who feel forced to put healthcare dollars above the potential they may have to enjoy and grow in their choice of work.
During tough economic times, tried and true advice about staying healthy bears repeating:
• Make those little decisions to stay healthy on your own: Try your best to eat well and keep your gym membership.
• Get shots and screening tests. Prevention is the backbone of good health, so if you have to spend a bit more to get these things done, you can avoid serious trouble later on.
• Ask for more when you see your doctor. If you're going in for a sore throat or other minor complaint, ask your doctor if you need any vaccines or other preventive care.
• Get a 21st century doctor. There are a lot of things you don't need to see a doctor for. So find one who allows you to e-mail him or her. Have a rash? Just attach a picture of it and hit send. That's going to be cheaper (if not free) than going in for a visit with the doctor. Studies have shown that e-mail communication between doctors and patients saves both time and is highly satisfying for both parties.
• Go to Walmart. Really, do it. If there's one company that's made getting healthcare cheap and convenient for consumers, Walmart is it. Over the past two to three years, the company has cut the price of many generic drugs down to $4 to $5 a month. It's also been opening retail health clinics in its stores, which cost a lot less than seeing a doctor in the office or ER.
• Outsource your drug purchases. For example, do a little Internet shopping at Canadian pharmacy Web sites. I know it might sound sketchy but it's not, and it does save money.
As for my 12-year-old patient with asthma, I was able to dig up some samples of her medicines and get her on her way. A couple of days later, her mother called to tell me that her daughter was doing better. I only wish it were that easy all the time.