The dirt-floor houses. The lines of orange extension cords running from homes to a shared generator. The barren pipes that won't muster a drop.
Crystal Shannon has witnessed all of it over the last two decades. Not in a developing nation.
“I've seen those examples in my caregiving over the years,” she said. “We have that right here in Lake County. We just don't realize it.”
Shannon, a nurse and assistant professor at Indiana University Northwest in Gary, spent the bulk of her career working in community health and still does home health care outside her teaching duties.
“Going into people's homes,” she said. “On the outside, they look fine. When you get indoors, they're without so many of the basics.”
The basics, she means, are electricity, running water and flooring.
And while most region residents cursed the frigid and seemingly endless winter, those without cold-food storage were content leaving perishables outside, she said.
“Some people were quite happy with the winter,” she said.
Good physical health tends to slip a rung or two in priority when people are saddled with the burden of poverty.
“It ends up being a domino effect,” Shannon said. “What always comes to mind is: How do they live healthy when they don't have what they need in order to live healthy?”
Nurses who work in medical settings see the patient in clean, modern surroundings.
“You don't really see where they're coming from,” Shannon said. “Little do you know they came to you from an environment that didn't have the basic necessities -- and you're sending them back there with this laundry list of things to stay healthy.”
Health care workers have to think creatively to help people help themselves, she said.
“You have to meet them where they are, in their own setting,” she said.
If a person has no running water but has a doctor's order to wash a wound, Shannon tries to help them find a way.
“We can look for alternatives,” she said. “Can you get access to a water hose or something we can sterilize?”
Some can access well water, which they can boil.
“I visited one community with one generator,” she said, describing the system of extension cords. “They had a sophisticated system of community use. It was very normal to them.”
Bringing medical service to the people is key, said Lynn Miskovich, associate professor of nursing at Purdue University Calumet in Hammond.
"You have to bring it to their community, because transportation is a problem," she said. "Many of our patients sometimes walk a couple miles to get here for their visits."
"Here" is the Catherine McAuley Clinic, where Miskovich is a nurse practitioner. A Hammond volunteer-based clinic for uninsured Northwest Indiana residents, the clinic has more than 40,000 patient visits annually.
"Unless you have clinics to see and treat the homeless and medically uninsured, usually the only option is the ER," she said.
"We've socialized individuals to think the ER is the only place. It runs up the cost of health care."
Many people will go without primary health care for sometimes decades. Something that could have been prevented or caught early, such as hypertension, spirals into something worse, Miskovich said.
"Even with some of the new access to care with the Affordable Care Act, for many individuals, there's still a charge, and they can't afford that," she said.
"Individuals who are the working poor, making minimum wage -- it's cost-prohibitive."
Most McAuley patients have multiple health issues.
"Our patients, 99 percent have a multitude of chronic health problems," she said. "Hypertension, diabetes, obstructive lung disease. The list goes on and on."
Working poor still can't pay for doctor visits, medicine
"Most of our patients are working at least part time," Miskovich said. "They're the working poor."
Others have full-time jobs but earn minimum wage and have no insurance, she said.
"Employers are cutting their hours so they don't have to give them insurance," she said. "Now their hours are being cut, so they're getting paid less. That's a very, very big problem."
Miskovich conducted a diabetes research study at McCauley when she was earning a doctorate. She found people in lower socioeconomic groups do better with more frequent medical visits, she said.
Miskovich brings her students to observe in clinics.
"As I teach, I make sure to bring students into areas where they're exposed to vulnerable populations," she said.
Students' journal entries submitted at the end of class are telling.
"I never realized, right next door, there were people living like this," one student wrote.
"I don't think the average person has a clue how so many of our brothers and sisters are living," Miskovich said.
Miskovich started a medical home at Sojourner Truth House in Gary, collaborating with Community HealthNet to bring health care to women and children in need.
She told the story of a woman discharged from a local hospital with a list of prescriptions for multiple health problems, including diabetes.
"She said, 'I'm supposed to be on insulin, but I have no money. I can't pay for these prescriptions,' " Miskovich recalled.
"What Sojourner Truth (House) does and more of what we need to do, is work with these individuals, help them fill out paperwork to access. There has to be better coordination of services, especially for individuals living near poverty level. You have to almost walk them through the system."
The initial focus of Sojourner Truth House was on social services, but it expanded to provide health care, Miskovich said.
"That's a success story," she said.
Social services, clinics and federally qualified health centers serve as safety nets.
People are just one circumstance away from needing social services, said Gary Olund, president and chief executive officer of Northwest Indiana Community Action.
"It's your neighbor, it's my neighbor," he said. "It's just regular folks who are just trying."
The recession has changed the picture of people who live in poverty.
“Economic issues have relegated them to a lower socioeconomic status, and they don't have the funds to sustain the lifestyle they use to have,” Shannon said.
Those new to poverty are facing big choices for the first time: food or medicine?
Food usually wins, Shannon said.
A growling stomach is tamed with food. Medical treatment may not provide immediate results, she said.
Money is a hurdle that governs even regular grocery-store decisions. Shoppers could buy produce — often expensive and with a short shelf life — or something cheaper and laden with preservatives that will go further for their family.
“It's hard to tell people to make a better choice when it's not an option,” Shannon said.
Shannon is confident that if people have the knowledge to prepare food in a healthful way, even if they do not have a lot of money to spend, they will make the right choices to ensure better outcomes.
"We can take the things they currently have and walk through meal plans that are tasty but also very nutritious, appropriate for their health," she said. "That's key: helping them manage what they have access to."
Nurses need to take their role as educators to help their patients, she said.
"You have to be prepared to think on your feet and teach them to do it themselves," she said. "It empowers them."