For Adams, who lives in West Baltimore, that meant four bus rides, a stop for a doctor’s signature, two visits to a downtown pharmacy for other medical supplies, a detour to borrow money for a copay, a delay when a bus broke down, and, at last, a purchase at a pharmacy on the east side of town.

The one-way, 7-mile trip took 5 1/2 hours. Then she had to get back home.

She seemed unfazed. For Adams, this is what it takes to follow a doctor’s recommendations.

Adams’ neighborhood is not far from where Freddie Gray grew up and died after being injured in police custody last April, an event that triggered a riot. Incomes here average less than $28,000 a year, according to the U. S. Census. Drugs and violence plague the area.

Adams’ story is not about huge barriers to medical care but about a series of hurdles that block access to help for her and many other low-income residents. Those hurdles add up to large health care inequities.

Adams, 55, has no car, no computer and no credit card. Her insurance will pay for a blood pressure cuff, but only with a prescription. She doesn’t have the ready cash that would allow her to pop into a drugstore and pick up a $40 blood pressure cuff off the shelf.

Adams acknowledges she used to use illegal drugs, but that, she says, ended years ago. Yet when doctors hear she used crack, she says, they sometimes dismiss her complaints.

“You have some of them that, they treat you like dirt, really, because they think you’re the scum of the earth anyway,” Adams said.

She’s been treated for mental health problems including bipolar disorder, and she has been homeless — a time when she never saw a doctor. She tries to stay healthy, but she is working with limited resources and against a lifetime of ignoring her health. She expends a lot of effort and she intends to do right, but she fails as often as she succeeds.

She is diabetic but isn’t clear on exactly when to test her blood sugar levels. She doesn’t like needles and doesn’t want to take insulin. She wants to eat better but says the food her doctor recommends costs too much. She wants to lower her blood pressure but she smokes.

For Adams, seeing a doctor or filling a prescription or scheduling a medical test is an exercise in frustration that middle-class patients don’t have to deal with. She knows that, and she resents it.

When Adams needed a colonoscopy, for example, a doctor referred her to a center in Pikesville, about 8 miles from her home on N. Bentalou Street.  Adams says she can’t get there.

“We don’t have the opportunity to get things like some other people get,” she said. “You lost. You run around, you don’t know if you have cancer.”

The Journey Begins

Adams has rented a front-porch house on N. Bentalou Street since December 2014 using a housing voucher, which subsidizes her payments. One Monday morning last fall, she pulled on a pair of brightly patterned leggings and topped them with a pink zip-up jacket.

Her long, fake nails were painted with ornate patterns, and she wore earrings. She was ready for the long trip she hoped would end with the purchase of a blood pressure cuff.

Adams went out the door of her rent-subsidized, porch-front brick rowhouse and headed to the bus stop at the corner of W. North Avenue and N. Bentalou.

Along the way, Adams seemed to know everyone. She said “hi” to the women with children clad in school uniforms, to the men sitting on their porches sipping cans wrapped in black plastic bags.

She asked every one of them for a cigarette or for some spare change to buy a loose cigarette for 45 cents from a former Army medic who lives next to the bus stop.

“I can’t start my day without a cigarette,” Adams said. She knows it’s bad for her, but quitting is low on her list of priorities.

The quest for a blood pressure cuff had been initiated the week before, when Adams visited her primary care doctor at University Family Medicine on Redwood Street.

During her examination of Adams, Dr. Kerry Reller had to use the 20 minutes she allows for an appointment to discuss Adams’ two dozen prescriptions, monitor her blood sugar and pressure, make sure she was scheduled for a mammogram and colonoscopy and attend to Adams’ seemingly endless list of ailments, from her eyes to her ankles — all while investigating Adams’ diet and asking if she’s getting the right kind of exercise.

Reller told Adams she had to start monitoring her blood pressure daily along with her blood sugar. Medicaid, the health insurance plan for low-income people that covers Adams, would pay for a blood pressure cuff.

But there was a problem with the paperwork. Later in the week, when Adams called to check on her order, the pharmacy where she was to buy the cuff told her they’d need the doctor to sign a new prescription and fax it over again.

That missing signature was the reason Adams was once again heading downtown. She had left her house a little after 11 a.m. She watched three No. 13 buses, part of Baltimore’s notoriously unreliable public transportation system, go by. It would be 45 minutes before a No. 91 bus would come to take her downtown.

Bus riders with smartphones can use an app to track the buses and see what time they will really arrive, but the app is of no use to Adams. She does not have a smartphone and cannot access the Internet.

Before getting to the doctor’s office, she stopped at the University of Maryland Pharmacy to pick up lancets for her diabetes test monitor. Adams is supposed to check her sugars, in West Baltimore parlance, every morning, fasting until she draws her blood and writes down the results.

On this morning, she was out of lancets, the tiny needles she uses to prick her skin to get the blood sample, so she hadn’t done the test. Because she hadn’t yet checked her blood sugar, she hadn’t eaten — dangerous for a diabetic. But Adams was trying to follow the doctor’s instructions literally.

This was another miscommunication between Adams and her doctor, something that happens regularly. Adams has a short attention span and says she doesn’t read well, problems that make it difficult for her to fully understand doctors’ instructions.

She says she is like many other people she knows.

“A lot of people don’t understand the words they use. Half of them don’t know the meaning. Half of them can’t even read. Half of them can’t even spell. Half of them are partially illiterate,” Adams said. “Basically they are going to be lost.”

Doctors, she said, “give them needles and they don’t know why they are getting needles. And to me it don’t make no sense.”

Adams used to use crack cocaine. But now, she says, she tries to take care of herself. She weighs herself at exercise classes she attends at a community center Mondays and Wednesdays, and says she stays away from fried foods and salt. Sweets are her weakness — one cookie can turn into 24 — and she hates the whole wheat bread that nutritionists suggest. She says she often can’t afford the foods and sugar substitutes that Reller recommends.

“It is kind really of confusing and hard because prices are so high. You don’t get that many [food] stamps, the check’s not that big, you are barely making it to pay your bills,” Adams said. “And you go to pantries and they don’t have food that you basically can eat as a diabetic.”

At The Doctor’s Office

By 12:30 p.m., Adams had left the pharmacy and walked a block to her doctor’s office on Redwood Street to begin the process of getting a signed prescription faxed over to the medical supply store. It would take an hour and a half.

While Adams waited, Reller faxed a refill for a diabetes prescription to a downtown pharmacy — the same one Adams had just been to for lancets. At 2 p.m., Adams was out of the clinic, walking back to University Pharmacy to pick up her pills. But they were not ready. She would have to return another day.

At 2:15, Adams boarded another bus for the trip to East Baltimore to the medical supply store where she now had a prescription to buy a blood pressure cuff.

But she first had to make another stop, this time at a friend’s house to borrow money in case the pharmacy demanded a copay. The friend lives next door to Adams’ daughter, Shardaye.

The friend gave Adams a cigarette and $11, seven of which were in rolls of coins.

They chatted a bit, so that Adams could be updated on the comings and goings at her daughter’s house. Then Adams went back up the street to catch a bus to Northern Pharmacy & Medical Equipment on Harford Road.

There would be another complication.

The bus broke down on the way. It got rolling again, but it would be 3:30 before the bus finally dropped Adams off outside the pharmacy.

Searching For Instructions

Inside the store, Adams browsed the aisles of medical equipment like a budget-conscious shopper in a high-end department store. She muttered to herself about getting her Medicaid plan to pay for diabetic socks and canes.

There was a bowl of old Halloween candy on the counter. Adams picked up a mini chocolate bar. It was the first thing she had eaten all day.

At 4 p.m., a woman in a short lab coat and high heels handed her a box holding the cuff and moved on to the next customer. Adams stepped back and opened the box, unwilling to leave until she understood the equipment. She hunted down another staff member and, trying the cuff on, asked if it fit correctly. The clerk assured her that it was big enough.

Three bus rides, three trips to two pharmacies, a stop at the doctor’s office and five hours later, Adams had her blood pressure cuff.

Now she’d have one more bus ride to carry her home. She left the pharmacy and crossed the street. But before the bus arrived, Sharlene Adams strode over to a gas station, pulled out the rolls of coins her friend had given her, and bought a pack of cigarettes.

This story is part of a reporting project of and University of Maryland’s , which operates Capital News Service.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).

They called it “Bon Se-Killer.”

Ross says the reputation is based partially on urban myth, spread largely by people who’ve never walked through the hospital’s doors. Bon Secours’ current mortality data don’t support the disturbing label, though it has endured in the community.

But Joyce Smith, who has been an activist in West Baltimore for 30 years, said the nickname reflects larger problems with medical services in her neighborhood.

Patients here, Smith said, tend to be sicker.

“The people who go to Bon Secours, they are already on their last leg when they get there,” said Smith, president of Operation ReachOut Southwest, a coalition of businesses, churches, residents and community groups. Many of the patients don’t have a primary care doctor.

“There’s no prevention,” she said. “There’s no maintenance.”

Bon Secours Hospital, which sits amid blocks of West Baltimore row houses, lacks the prestige of the giant Johns Hopkins and University of Maryland hospitals, with their renowned teaching staffs and research facilities. It lacks the sprawling glass pavilions of southwest Baltimore’s St. Agnes Hospital, which looks like a suburban medical center.

It’s been a fixture in the neighborhood since 1919, when it was opened by an order of nuns who served middle-class patients from across the city.

But today, few patients are affluent. The hospital, outpatient and wellness centers that comprise the system primarily serve neighborhoods including Sandtown-Winchester and Harlem Park, predominantly black communities made famous in pop culture by TV shows like HBO’s “The Wire.” The death of Freddie Gray, who was injured in police custody last April, brought even more unhappy attention to the area.

Residents of these neighborhoods are 35 percent more likely to die from heart disease than the city as a whole, according to an assessment of community health needs published by Bon Secours in 2012. Life expectancy in Baltimore City is 73.5 years, according to Census data, but in parts of West Baltimore it is 66.

Dr. Marcia Cort worked at University of Maryland Medical Center downtown and later in her career at Bon Secours, a mile and a half away. She observed striking differences in the condition of people who came in for medical care.

“I realized that in that very short distance between the University of Maryland and Bon Secours Hospital that the patients at Bon Secours are pretty sick,” said Cort, now chief medical officer at Total Health Care, which operates clinics for low-income people in West Baltimore.

“They’re actually sicker than the patients that I was seeing at the University of Maryland hospital, just separated by that very short distance,” she said. People were being diagnosed with diseases at younger ages and showing up for care later in their illnesses.

When adjusted for the severity of patients’ illnesses, Bon Secours’ mortality rates are little different from state averages for all hospitals, according to collected by the Medicare program for seniors and posted by .

In recent years the hospital has reduced the rate at which patients contract potentially deadly in-hospital infections, such as those of the lungs, blood or urinary tract, state data show.

But Bon Secours has fallen short in several important quality measures. Patients undergoing surgery were less likely than those at the average Baltimore hospital to get clinically recommended treatments to protect them from infections and blood clots, according an analysis of the most recent data from the U.S. Department of Health and Human Services.

For instance, just 88 percent of Bon Secours’ patients were given an antibiotic within an hour before surgery to prevent infections, the lowest rate among Baltimore hospitals, records show. The average for Baltimore hospitals is 98 percent, and for the state, 99 percent.

In response, a Bon Secours spokeswoman noted that data was from 2014 and that the hospital has improved its processes, tools and monitoring to achieve better patient outcomes. “Our goal is to deliver the right care, at the right time, and in the most effective manner to all patients,” she said.

Now, in an effort to improve the health of its neighbors and keep them out of the hospital, Bon Secours has bought a neighborhood church and is spending $7 million as it renovates the building to create a center for primary care.

Providing basic health care for the community should help decrease rates of disease and eventually benefit the hospital’s bottom line as Maryland revamps its approach to hospital payments.

The Bon Secours Health System’s operating revenue in 2014 was $122.4 million. It has nearly 800 employees and two years ago reported 4,660 admissions to its hospital and 104,000 outpatient visits.

In 2014, Maryland changed its Medicaid reimbursement system. Instead of reimbursing individual procedures, the state awards hospitals a set amount of funding for the year. No matter how many patients the hospitals see or how many tests they run, each hospital has a fixed budget to cover its costs. Hospitals get to keep any surplus funds.

The new system is meant to be an incentive to provide primary care outside of the hospital so people are less sick when they walk through the door. Half of Bon Secours’ admissions are people arriving at the emergency room.

Ross and Smith, whose organizations partnered in 1997 to work on neighborhood problems, want to expand the definition of what constitutes a health problem.

It’s not just diseases, residents tell Smith. “The community said, ‘Our problems are rats and trash.’ ”

Ross knows the problems people have with his hospital, whether real or imagined, will take more time to resolve. No new ad campaign will scrub years of “Bon Se-Killer” away. Ross says only hard work and good results will do that.

But the lack of trust goes beyond his own hospital.

“I grew up in a small town in Texas, and I can tell you there’s just a basic distrust of white people,” said Ross, who is black. “And it was a lot of fear of if I go into this environment and if I don’t come out, then it’s just all a mystery.

“The distrust for health care institutions was as much as the distrust for a lot of other situations — police and others,” he added.

While Ross hopes to gain residents’ confidence, Smith said the hospital must in turn begin to trust the residents. She said it is important for Bon Secours staff to believe people do care about health and want to be part of the change. And she wants the community and Bon Secours to make sure resources are spent on what people really need.

Smith envisions a model in which health care practitioners can refer their patients to specialized community-organized workshops.

Ross also embraces collaboration, especially in maximizing primary health care. He envisions turning church basements into places where residents get their blood pressure checked.

“There’s an African proverb — if you want to go fast, go alone, if you want to go far, go together. And we have to go together with our other partners here in West Baltimore,” Ross said. “We’re going to keep hope alive.”

This story is part of a reporting project of and University of Maryland’s , which operates Capital News Service.

ºÚÁϳԹÏÍø News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

USE OUR CONTENT

This story can be republished for free (details).