By Tali Woodward

WHEN PUBLIC HEALTH nurse Martha Hawthorne arrived at Bill Schruba's apartment Nov. 12, the 92-year-old heart attack survivor was sitting on a step just inside his front door, surrounded by pastries wrapped in cellophane.

It's not unusual for Hawthorne to find her patients, whom she visits at home, in odd situations – and this one was certainly one of the least alarming. But it still took some time to sort things out.

First she persuaded Schruba to put on his "ears" – earphones attached to a small amplifier and microphone. ("I keep forgetting that I'm deaf," he said with a laugh.) Then she asked him why he was hanging out at the bottom of the stairwell. He explained that his landlord had set off pesticide bombs to rid his apartment of roaches and that he needed to get away from the chemicals. Hawthorne looked perplexed. She's been seeing Schruba for six months and is involved in practically every aspect of his life, so she pointed out that the fumigation was scheduled for another day, when Schruba would have somewhere to go.

But Schruba seemed unfazed by the change of plans, explaining that he spent the morning wandering up and down his bodega-lined stretch of 24th Street, "going into stores, though I had no intention of buying anything."

Even with his ears on, Schruba can barely hear. This month he also has an eye infection, a runny nose, and a hacking cough. But he's spunky and generous – he repeatedly offered me some of his much-loved pastries, even before we'd been introduced.

When Hawthorne explained that I was the reporter she said might be coming along, he was incredulous, saying, "You're the reporter? I thought you would be a man – but you're a woman. Women are in everything these days."

But he soon composed himself and took the opportunity to tell me, "They're doing wrong when they don't allow the budget to do what Martha and the others do. It's very important."

Schruba had obviously been informed that the city plans to soon eliminate home care for patients like him who are chronically ill yet mobile. These patients are now treated by a team of 36 public health nurses (PHNs) who also tend to new mothers and their babies. They deal with pink eye and cancer, paranoid schizophrenia and newborns who can't seem to pick up breast-feeding, severely asthmatic children and elderly people with failing organs. The nurses head off medical problems before they become more serious, and they also act as caretakers – navigating what can be a daunting web of government programs and social service agencies for their clients.

"A combination of medical and social difficulties make it hard for them to take care of themselves," Hawthorne said of her patients.

Now that city voters have rejected two ballot measures that would have increased local sales and business taxes, Mayor Gavin Newsom has asked the city's Department of Public Health to make cuts that DPH director Dr. Mitchell Katz admits will be difficult for the populace to take. "The only choices I had were bad choices," he told me. The cuts – including 13 positions at the notoriously strained Tom Waddell clinic – will go into effect Jan. 15, 2005, unless the Board of Supervisors can find the money elsewhere.

While the PHNs who focus on pregnant women and babies will keep their jobs, the 22 nurses who mainly see chronically ill patients will be reassigned or laid off. These nurses aren't concerned about finding work – after all, there's a national nursing shortage. But they say this cut will leave a precarious population without service and will weaken the already-overwhelmed maternal health program. Despite the efforts of Service Employees International Union Local 790, the once-robust program (there were almost 80 PHNs in the late 1970s) has been whittled away, and many fear this could be its death knell.

And although cutting chronic service could save DPH almost $2 million over the next 18 months, the long-range costs, both to the city and to patients like Schruba, could be far higher.

As PHN Linda Muller, who works exclusively with seniors in the Tenderloin, said, "There are lot of people who are going to fail without the support and are going to end up being institutionalized, or making a lot more emergency room visits, which costs more."

'I don't have long to go'

Schruba likes to talk.

Soon after learning that I'm a reporter, with the three of us still huddled at the bottom of his stairs, he launched into a description of growing up the eldest of eight children in Pennsylvania. With little prompting, Schruba told stories about how he went all over the country looking for work during the Depression and how he built a life in San Francisco. He worked as a painter, mostly at City College, until he was 65.

Schruba said that there aren't any family members who come to see him anymore, and that the one friend he expects to visit hasn't stopped by in three weeks. Most of the 40 or so patients Hawthorne sees are similarly isolated. She's been doing this for 17 years and has endless tales of finding a diabetic in hypoglycemic crisis and babbling nonsense, or a teenage mother who doesn't realize her newborn is turning yellow with jaundice that could cause brain damage, or a family without electricity. In some ways, she told me, Schruba is one of her better-off patients – he's independent and obviously still enjoying life.

Hawthorne asked about his recent appointment at a city clinic and got an earful. "Oh brother, did I wait – kind of like an insult to injury: please come a half hour early. Ha! The appointment was for 9:15, so I came at 8:45. I was out of there at 4:15."

"I'm 92, so I don't have long to go," he told me matter-of-factly. "What gets me – when I go to the hospital and see so many people in middle age waiting around."

The idea of waiting around is apparently still distasteful to him, so Schruba eventually agreed it was time to go up to his apartment. In the shabby but clean kitchen, every surface was covered in newspaper and upside-down lids that had been filled with some sort of white powder. It took a few minutes for Hawthorne to establish that this was Schruba's attempt to cope with his cockroach problem.

Under the newspaper, the kitchen table was stacked with medical charts and a pill key Hawthorne made that tells Schruba the size, shape, and color of each of the many medications he's supposed to take. Hawthorne had already filled his pillbox – a foot of plastic with tiny compartments – with the appropriate dosages for coming weeks. Inspecting the box, Hawthorne discovered that despite his assurances, Schruba neglected to take his morning complement. He shrugged and explained that he lost track of what day it was. Hawthorne shook her head and said to me, "Without this program, where would he be? He would be in the emergency room over and over and over again. They could tell him to take his medicine, but he would still forget."

Dr. Todd May – who sometimes calls on PHNs to assist him with patients he sees at San Francisco General Hospital's Family Health Center – said PHNs are "really an integral part of the safety net fabric."

As an example, he told me about a 60-year-old patient who is diabetic yet petrified of giving himself insulin shots. The man's treatment is crucial, because he also has severe liver disease and is on the list for a transplant. So his PHN is working to train his family members to give him the shots when he's on breaks from selling Popsicles on the streets of the Mission District.

"These folks really would fall through the cracks, because they wouldn't qualify for [a program for the homebound], yet we couldn't take care of their needs in the clinic," he explained.

Failing to treat these patients in the community will likely lead to more hospitalizations. But Katz told me that even though hospital visits are expensive, a higher number of them wouldn't necessarily increase DPH's bills. That's because the federal and state governments contribute more to acute care than to community-based services. "I don't know it'll mean more costs. It'll definitely mean worse care," he said, describing the state and federal funding emphasis as "counterproductive."

Of course, it's Katz's job to focus on DPH's financial realities, and he can't possibly quantify the larger societal costs incurred when the feds have to pay more to keep hospitals afloat or the state must build additional nursing homes.

But the system frustrates doctors like May, who told me, "We're all – including Dr. Katz – really being forced to turn away from our mission."

'I want to stay here'

Schruba was adamant that "something's not right" with his health and kept inquiring if there was a new flu epidemic. Once Hawthorne took his temperature and listened to his breathing with a stethoscope, she was reassured that he was probably just fighting a cold. She phoned to see if someone might be able to check in on him over the weekend.

"I don't know how she can do her job," Schruba told me. "There're so many things involved. I think she's very good at what she does." In a confessional tone he added, "I may act like I'm capable, but I'm not. This is all new to me."

He soon caught me staring at a shelf in his kitchen that was crowded with small tools: knives, a geometry compass, rulers, a glistening magnifying glass, and at least one pair of scissors. They were all arranged in an intricate puzzle, with nails that functioned like tiny fencing staking out each object's space.

"I like working with my hands," he explained. "If you like that, you're really going to like the rest of my apartment. It's not a normal apartment." When Hawthorne finished her calls, Schruba gave us a tour of his home, showing off a coffee table he constructed years ago and explaining that if you rub the stomach of his red Buddha figure, you'll get lots of money. Then he took me into his workroom, which was jam-packed with tools – hundreds of them, of every sort imaginable – hung on floor-to-ceiling boards and stowed in drawers. Each hanging tool had a pen outline marking its spot.

Last summer Hawthorne persuaded Rachel Walker, a case manager at the Bernal Heights Neighborhood Center, to take Schruba on, even though he lives in the Mission. "This man didn't have any services from the city – and he's 92," Walker told me. She has since arranged for meal delivery and transportation help and is trying to teach him to use a new telephone equipped with a text screen.

But she fears that, without Hawthorne's help, he won't be able to stay in his apartment: "It's a real shame she's not going to be able to work with him anymore. I don't know what we're going to do." Walker has begun looking for an assisted-living spot for him, although the waiting lists for subsidized housing are two to five years long.

Suspecting that I already knew the answer, I asked Schruba how he might feel about moving. "No, I want to stay here," he said, before explaining, in his rambling but rational way, that he would just be taking a spot that could be more useful to someone else. "Why should I get that if I can go to the store myself?"

The Coalition to Save Public Health, which is organizing to fight the cuts, meets Wednesdays, 5:30 p.m., SEIU Local 790 office, 11th fl., 1390 Market, S.F. (415) 575 -1740.

E-mail Tali Woodward at tali@sfbg.com.