Imagine this decision: Medications or food?

From 1990 to 2000, Jerry and Sandra Smith, of West Brownsville, Washington County, had little income, but faced a $600 expense each month for medications and supplies to treat their various conditions, including diabetes.

That total didn't include fees for doctor visits.

Mr. Smith no longer could work because of a heart condition, but needed medication to survive. So Mrs. Smith, diagnosed with type 2 diabetes in 1997, made the tough decision and quit taking diabetes medications.

Soon, she began feeling fatigued. She was drinking water and urinating frequently -- telltale symptoms of uncontrolled blood sugar. But she said she had no choice. After going to Centerville Clinics in Washington County for blood work, the nurse realized what she had done.

"You're not taking your medications, are you?" the nurse said.

In 2000, Mr. Smith finally qualified for Social Security disability benefits amounting to $1,333 a month. But the income did not resolve their financial woes.

Combined, the Smiths are using 14 prescriptions. Mr. Smith, 62, has heart problems and, since 2004, type 2 diabetes. Mrs. Smith, 63, has diabetes, high blood pressure, high cholesterol, thyroid problems and chronic heartburn. That doesn't include strips both need to test blood-sugar levels, lancets to draw blood or vitamins that Mr. Smith must take.

So the Smiths were paying $600 a month -- almost half their income -- for medications. Once again, Mrs. Smith considered going off her medications to make ends meet.

But not before Centerville Clinics stepped in to help.

Headquartered in Centerville with 12 sites in Washington, Fayette and Greene counties, the clinic is familiar with the crunch that medical care has on people of low income. Thirty-eight percent of its 40,000 patients have no health insurance.

So officials made arrangements for the Smiths to receive medications for free or reduced rates through various programs.

In recent months, Patty Johnson, a diabetes educator employed by the University of Pittsburgh Diabetes Institute, arrived at the clinic. The institute deploys diabetes educators to rural hospitals and medical centers with funding through U.S. Rep. John Murtha, D-Johnstown.

Ms. Johnson has helped the Smiths improve their diets and provided them blood-sugar testing monitors, while assisting them in getting medications for free or nominal fees.

As a result, the Smiths have reduced medication expenses to less than $100 a month.

"I'm doing better than I was doing," Mrs. Smith said. "We do our shopping and buy things without salt, and we look for low this and low that and nothing with sugar. But that costs more."

But they remain concerned about losing benefits. Mrs. Smith said she's decided to wait until she is 65 to receive Social Security, and Mr. Smith will begin receiving $300 a month in pension when he turns 65 from his 25 years working as a barge painter.

Additional income, they say, will push them into a higher income bracket and force higher fees for medication that could more than wipe out anticipated increases in income.

"We wouldn't be able to be on medication without Centerville Clinics," Mrs. Smith said. "They have helped an awful lot."

If 9 percent of the clinics' 40,000 patients have diabetes -- a low estimate given diabetes prevalence in rural areas -- Ms. Johnson is a scarce source of diabetes education for more than 3,600 patients, not counting many others at high risk of developing it.

"Diabetes is one of the top diagnoses here, along with obesity," said James R. Quinn, director of Centerville Clinics.

"Most of the patients we get here already are out of control," Ms. Johnson said. "These are people without resources, with no medications."

She described one commercial truck driver between jobs who was diagnosed with type 2. "He actually threw up his hands," she said. "It was very devastating for him, in his mid-40s, and he was not sure how he would do it.

"Frustration comes in and patients give up, and their blood sugar is not the best to begin with," Ms. Johnson said. "I tell them to take one thing at a time."

And that is what the Smiths have done, one step at a time. Along with medications, they have improved their diet and are considering ways to exercise.

"We have improved a lot in the last several months," Mrs. Smith said. "I'm glad Patty [Johnson] is up there now."