BOX 4-1
A Bigger Picture of the Cost of Violence: The Case of Lily

Lily was a patient from Hot Springs, Arkansas, who moved to Chicago to care for her 16-year-old grandson because her daughter, his sole caregiver, was incarcerated. Lily suffered from a number of medical problems, with arthritis and diabetes as her most prominent complaints. Because of the severity of her arthritis pain, she was eventually prescribed a medication called Dilaudid, which is a hydromorphone that is stronger than morphine. Dilaudid comes in both pills and a sublingual form that can dissolve rapidly without entering the gastrointestinal (GI) tract.

In Chicago, Lily obtained employment in the mailroom of an office. About 3 months after her second visit to her physician, she complained that her pain seemed to be getting worse.

As it turned out, her grandson had been taking her medication and selling it on the street (Dilaudid in the sublingual form, such as the one she had been taking, has fairly high street value because it provides a rapid “high” and has no GI side effects). Her grandson was performing poorly in school and experiencing difficulties with other youth. He also tried to steal money from Lily for drugs and other illicit uses.

Because Lily’s pain was not well-controlled, she began to experience difficulty at work, arousing the suspicion of her supervisors that she was falsifying claims of pain in order to obtain disability. She also began to experience harassment in the workplace and worried that she would be fired with no recourse available.

One day there was a fire drill in the building, requiring everyone to take the stairs. In the stairwell, someone pushed Lily and she fell, and she broke her hip. She had a complicated intratrochanteric fracture that took her to the hospital, where she underwent a difficult surgery. She experienced excess bleeding and a skin infection and developed pneumonia. Both her cognitive abilities as well as her physical function deteriorated rapidly, and she was admitted to a long-term care facility.

Because Lily was no longer at home, child protective services was called and her grandson was placed in foster care. Since she was no longer able to work, she could not pay her medical bills and had to sell her house and stay in the nursing home. About a year later, she passed away from a complicated pulmonary embolism, a clot from her legs that went to her lungs.


SOURCE: Vignette presented by XinQi Dong, Rush University Medical Center.

costs, details of which can be found in Chapter 6. Overall, he noted that in 2000, the total cost of interpersonal violence was $37 billion in the United States, a number that speaker Phaedra Corso of the University of Georgia also referenced (Corso et al., 2007). This total included medical costs and productivity costs only. The same study also stated that suicide and self-directed violence accounted for $33 billion in productivity loss and medical

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