Tag Archives: Economy

How does one deliver healthcare justly in an unjust system?

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I recently cared for a patient with a life-threatening bleed. They bled because their blood thinner level was too high. They were on a blood thinner to prevent stroke in the setting of a chronic abnormal heart rhythm (called “atrial fibrillation” or “Afib” for short). Afib requires life-long anticoagulation to prevent strokes. Afib puts you at risk of stroke because it increases the risk that clots will form in your heart and then travel to your brain causing stroke.

The patient’s blood thinner was called “warfarin.” Warfarin is an old, cheap blood thinner. The problem with warfarin is that its blood levels are affected by many things such as diet and other medications. Because of its fluctuating levels warfarin requires frequent monitoring (with blood testing at a clinic). Warfarin is notoriously difficult to manage. This patient’s warfarin levels were high likely because of a different medication they were prescribed for a short time.

For Afib, we have several other equally effective blood thinners that are a lot easier to manage than warfarin. The patient wasn’t on one of these alternative blood thinners because they couldn’t afford them. The most common alternatives to warfarin for use in Afib are Xarelto and Eliquis.

The manufactures of Xarelto and Eliquis each offer a one-month free coupon once in your lifetime. So, if you use each coupon (the two medications are similar enough you can use them interchangeably in this situation), you can get 2 months of free blood thinner. After that, there are programs that might help you either get a reduced price or free access to the Xarelto/Eliquis for 1 year. So, maybe you can get 14 months of cheap Xarelto/Eliquis. Let’s say you’re 50 when you are diagnosed with Afib. You’ll be 51 or 52 when you must figure out how to pay for your blood thinner for the rest of your life (likely 20-40 years).

You might ask, “Can you use GoodRx (or a similar application that compares drug prices and offers recurring discounts) and figure out the cheapest place to get Xarelto or Eliquis?”

Answer: You can. When I wrote this you could get 30 tablets (one month’s supply) of Xarelto at Wegmans for $555. This was the cheapest option on GoodRx. Eliquis was similar in price.

With the above information on Xarelto’s cost you might then ask, “How does the price of warfarin compare?”

Answer: When I wrote this you could get 30 tablets (one month’s supply) of warfarin for $4 at Walmart.

The decision (in this case) between Xarelto and warfarin isn’t really a decision because your finances determine what you can afford regardless of the medically recommended option or the comparative risks/benefits of the medications.

The average American salary was $59,500 in 2024. Xarelto at the above price would be $6,600 a year or about 11% of that average annual salary. The price of Xarelto/Eliquis doesn’t change regardless of how much money you make. Your other expenses including other medications, food, transportation, and housing don’t change regardless of how much your blood thinner costs.

I use this case as an example, however the list of medications that are too expensive for people to afford when they don’t have insurance or when the medication is not covered by insurance is lengthy. If you’re curious, check out GoodRx. You can look up any medication there, see what discounts they offer, and look at the retail prices of that medication. You’ll notice that the retail prices and the discounts are different at every pharmacy (Walgreens, Walmart, etc.). That’s how corporate healthcare works. Each corporation negotiates drug prices with drug companies. Some countries regulate the prices of medications sold in their country to help ensure more equitable access to medications – the US doesn’t.

How does one deliver healthcare justly in an unjust system?

You don’t.

You try.

You fail.

You try again.

References:

Forbes Average annual salary: https://www.forbes.com/advisor/business/average-salary-by-state/

GoodRx: https://www.goodrx.com/

Tropical Paradise Has Challenges Too

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“I didn’t have power for 4 months. My daughter got lice because we couldn’t bathe properly; with my long hair, I got them too when I picked them out for her. We washed our clothes by hand. During those months, some areas started to get power and I was able to bring my big items (like bedding) to a laundromat. I lived in a place where I wasn’t allowed to have a generator. But even the rich people with generators didn’t have power because you need gas to run generators and we didn’t have that. I couldn’t keep food all that time because my fridge didn’t work. It was hard… So, I think we all have a little PTSD when it comes to hurricane season,” a Puerto Rican said, recalling her experience during Hurricane Maria. She’d just given me a tour of San Juan’s primary hospital campus, including pointing out the street where they used to have shipping containers lined up to hold corpses during Hurricane Maria because they couldn’t identify them fast enough.

“It was bad. Help didn’t come or it was delayed,” she said. I remembered this; it was all over the news. Hurricane Maria hit Puerto Rico in 2017. You might remember the politics of the US then; there was a lot of news about the hurricane’s effects and how the US government delayed or didn’t send aid. Perhaps 3,000 Puerto Ricans died, but we’re not exactly sure of the true number. Many more lost their homes.

I remember someone asking me if Puerto Rico had been rebuilt since Hurricane Maria when I left for Puerto Rico. At the time, I found the question odd because it’s been 6 years since that hurricane struck. But I have an answer now and have come to realize that it was a good question. The answer is: yes and no. If you visited Puerto Rico today, your first impression would be that it’s a tropical paradise and you might fall in love with the place. There’s a reason why Puerto Ricans are so proud of their home. As a tourist you’ll enjoy both friendly hosts and living accommodations equivalent to those in the continental US. But if you dig deeper than the average tourist experience, you’ll discover that the island has challenges. Despite the beauty of the island and its strong identity people are leaving Puerto Rico. This Washington Post article describes the situation of Puerto Rican’s leaving their home (and people leaving other US territories too).

If you explore beyond San Juan (Puerto Rico’s capital and biggest city), you will see shadows of Puerto Rico’s complicated situation. In the town where I’m staying (and all throughout the island), you find deserted houses on most blocks. A coworker explained that sometimes people just leave their homes and move, often to the continental US. The pay here is lower than in the continental US (often in general) but especially in industries of interest to me such as healthcare. Infrastructure throughout the island, like healthcare, is much like in rural regions of the continental US, which is to say that many people don’t have easy access to the healthcare they need.

My husband and I visited a small island just off Puerto Rico’s coast called Vieques. It’s where the brightest of the 3 bioluminescent bays in Puerto Rico is and that’s why we visited. Being me, I had us walk the 5ish miles from the ferry to the town in which we were staying. Again, being me, I googled to see if there was a hospital on Vieques and the number of beds it has (as I do everywhere I go) just in case I wanted to move there and work. I learned that Vieques doesn’t have a hospital because it wasn’t rebuilt after being destroyed in Hurricane Maria. I also noticed signs demanding that the hospital be rebuilt on a chain-link fence as we walked across the island. On our walk back to the ferry from our Airbnb, a local stopped to offer us a ride because it was hot. We accepted. I can’t remember if I asked about the hospital or if it came up naturally in conversation, but the local explained that the hospital hadn’t been rebuilt and it was a point of political tension. Further, in 2020, a teenage girl died because there wasn’t available transport to San Juan when she needed it and Vieques didn’t have a ventilator to help her breathe. According to the local, even the family of the girl helped manually give her breaths (with a bag-mouth mask which is what EMTs use on ambulances until they get to the hospital), but she died anyway.  

From these conversations, I’ve learned that Puerto Rico has a complexity that can be overlooked as a tourist. Living here a few weeks has not made me an expert (or even a novice) in Puerto Rican anything…except maybe dengue because I’m doing an internship about it and fruit juices because they are delicious. But my time here has allowed me to see that beyond the beautiful beaches, blended frozen beverages, and seafood Puerto Rico has a historical, political, and economic reality. Puerto Rico reminded me of the confusion I had while living in DC: It is odd to me that there are territories that are part of the US where the inhabitants aren’t granted the right to vote and to have congressional representation because it seems rather undemocratic. I don’t know if it would change anything in Puerto Rico if they were represented in US congress or participated in US presidential elections. I also I don’t know if that is something Puerto Ricans want. But, at the very least, I’ve come to see that I have a lot to learn about Puerto Rico’s history, its current governance, and its relationship with the US before I can fully unpack my experience living here.

Ghost Buildings

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On the 2-hour bus ride from my home to the Peace Corps office are many sights that have come to symbolize Paraguay in my mind, but the most vivid is a vacant lot it which stands several incomplete apartment buildings. Those buildings don’t have roofs or windows and the walls are unfinished. The brick, mud, and cement skeleton of what might have been the home of generations of families grays with age. The grass grows tall and a sign that probably announced the development project when someone broke ground on the construction is too faded to read.

When I first saw the buildings I thought of a war-zone or a devastating fire. I wondered, “What happened here?” I still don’t know why that complex stands destitute until the rain washes the structures away, but I now know enough about Paraguay to be confident it wasn’t a tragedy that condemned the place. Most likely, the person funding the project ran out of money and walked away. Just as was the case with so many little houses I see scattered about when I travel—some with finished walls, some with partial roofs.

With little access to credit and varying access to good-paying jobs across the country improvement projects and development move slow. Paraguay is a place of dreams. A dreamland where the bridge between reality and aspiration is still being built. Some people are able to paddle across the gap, and some decide to dream on and live as they always have. Paraguay is a land of opportunity, but only the lucky and the determined make it big.

The Route aka the Ruta

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I live on a “ruta,” which is to say I live on one of the biggest roads in Paraguay—don’t let your imagination get away from you…it’s two lanes. What makes it a big deal is that it’s paved. Most roads are dirt or cobblestone.

My ruta has a steady stream of traffic. Where I live, a distance for any major urban area, the traffic never backs up. Vehicles are always on the horizon, but crossing isn’t difficult. You might be interested to learn that Paraguay has a robust trucking industry. The most commonly moved things (according to my observation) are cattle, yucca, whatever fruit is in season, and construction materials like bricks.

A note about cattle. I’m not talking about moving a couple of cattle and nor am I talking about already dead cattle already cut into nice little stakes. I’m talking about diesel-billowing trucks with two carts behind them each with maybe ten or twenty cattle. The cattle aren’t tied in or in individual stalls, they’re jammed into the carts side-by-side. The only reason they don’t fall over is because they’re packed in there only a little less cozy than sardines. They are not your dainty Jerseys or your stubby Angus. They’re a breed that ranges from white to light brown with large ears and skin dangling from their necks. They’re large, taller than many breeds, more like Holsteins than Herefords. Here cattle always have their horns, and they can sometimes be over a foot long, though usually they’re closer to six inches.

The ruta makes my community more prosperous than many communities that is hidden on some dirt road out in the boonies of Paraguay. Why? Because we have buses that allow us to leave more than once or twice a day. I have a bus out every 20 minutes from 4 o’clock in the morning to 7-ish in the evening. Buses come back to my community as late as 10 pm. That means people can work in other towns and cities if they want to commute.

But, like most things in life, the ruta brings a little bit of bad with the good. It is noisy. That’s one. It brings “extranjeros,” which is a term for anyone not born in the community and in Paraguay is the catch-all scapegoat. Extranjeros are the perpetrators of all bad things. But, more subtlety and interestingly, the ruta divides the community in half. The people who live on one side talk to the other side infrequently. This communication divide is good when trying to avoid gossip, but not ideal for fostering cooperation among all members of the community.

The ruta plays an important role in my community, and it’s a new role. It was only about five or so years ago that the government built it. Before that, my community was secluded and hardly known. The ruta opened up a world of economic opportunity and reduced the time it takes to get to Asunción, the capital of Paraguay, by something like 50, 60 percent.

Maybe it’s the newness of the ruta, but the people view it with wariness. Even young women, not just children and parents, often hold hands when crossing the ruta. Rightfully, mothers worry about their children when they cross the road. You might too. We have the trucks and cars speeding along, passing whenever they want. On top of that, we have dirk bikes flying along the curb, sometimes in the right direction and sometimes in the wrong direction. Sometimes dirk bikes use lights at night, sometimes they don’t. At least they’re deafening so I know when they’re coming.

The chickens, which run free, don’t cross the road…probably wise.