Case Study #1: Pills for Stomach Aches
It is almost six o’clock when Ms. A finds her heels dragging themselves lifelessly past the automatic doors and into a vestibule of champagne-colored tile. Her forehead is plastered with matted hair, one hand applying continuous pressure against her abdomen, the other wrestling with the fingers of her child. Was it an intestinal blockage? For the past week, the tumor-like masses and sporadic cramps in her gut screamed affirmative.
Inside, the halls are bustling like mid-summer drones in feverish toil. Staff is lax, security easily penetrable.
One of the attendants who has paused from hurrying to and from the emergency room registers Ms. A in front of the admitting station1. Her teeth chew on the dialect of a foreign language until the tangle of words tumble out as unintelligible whispers. A makeshift translator, her daughter salvages the dialogue and refashions it to mention the days of unrelenting constipation, the receipts for laxatives and stool softeners and suppositories, the botched hemorrhoid surgery performed in her motherland2.
It takes 20 minutes for the triage nurse to escort the pair to examination room two and another 15 for him to sync up the cardiac monitor: 93 bpm, 132/85, 96 percent O2 saturation. Ms. A is alert, and in spite of a mildly inflated blood pressure, her vital signs are stable. Once the ER physician greets her, half an hour is gone.
He prods her backside, barely stretching the amateurishly stitched flesh before her hungry, exhausted eyes force shut, and she is drifting in and out of reality, jaw tetanic, lips squeezed thin. Facing a bundle of muscles that refuse to yield, tender, yet impossibly tense, he orders a CT scan.
Here, the receptionist enters to address payment—prim and proper, no doctor’s coat. No conflict arises regarding her type of provider or network copayment, but the out-of-pocket maximum remains high, easily more than a month’s salary, more than two months’ mortgage payments, more than three months’ expenses in food and groceries3. Ms. A waits an hour for the contrast dye; another hour passes, and the images come back negative4.
Case Study #2: Pills for Back Pain
The chiropractor of the clinic is more of a salesperson than he is a practitioner.
Amongst lurid magazine faces advocating wellness, plaques framing obscure certifications and documentaries haranguing cultish health claims, vitamins clutter the countertops. Beside this, powders line the shelves; probiotics overwhelm the front desk. At the other end, posters substitute as wallpaper with sponsored pieces of medical propaganda. His authored paperbacks populate round coffee tables as the centerpiece, depicting a waistline crop of a tan visage and graying hair: a man in his late 50s or early 60s—suited, rugged. “America’s Health Care Crisis: What the Food, Pharmaceutical, and Bio-Tech Industries Don’t Want You to Know,” the front cover reads. His books sell for $30 each.
Biweekly meetings with him exceed pain management. The chiropractor has adapted to treatment beyond repairing wiry frames or ossified bodies5: With a merchant’s timbre, his character peddles the benefits of an alkaline diet, extols the virtues of veganism, and praises stress management via detoxifying nutrition.
At her appointment time, V’s adjustments follow routine practice: As she positions herself prone, the chiropractor breaks the tension from C1 to L5, twists the 15-degree curvature in her upper vertebrae, and bends the 20-degree distortion in her lower spine back into alignment.
Secondary evaluations create a prismatic pressure chart. Yellows paint the inward rotations of knobby knees; oranges sketch out the irregular weight between soles. A moody scarlet like theater curtains, the bases of her feet are most criminal.
The chiropractor does not marvel at the calcium wreckage. Her body is a graveyard, and he has robbed all of her skeletons. It is his mission to blame consumers for their own carelessness and rebrand it as patient-centered care. It is in his best interest to prompt purchase of sole inserts, one under his trademark, professionally endorsed, chiropractor-recommended. She loves herself up until the moment he wrests back her brittle-bone wings and leaves her form flightless for refusing the transaction.
His orthotic supports sell for $380 each.
Case Study #3: Pills for Respiratory Arrest
It is after lunch when his oxygen saturation plummets below 90 percent. It is not until the physical therapist notes the man to be unresponsive that the nurse calls a code blue.
This is the third time Mr. S has seen Death so close, first while comatose from a semi-truck hit-and-run back in 1996 and second on the operating table in 19996. It had no reaper’s cloak nor plague doctor’s mask, just fangs mottled with the red of bloodborne iron, a flesh-eater like Kronos, a seductress like a Siren.
A waterlogged heart hiccupping, beached lungs gasping, he is ghosting again, hearkening to deceased voices from 18 years prior, as the resuscitative team restarts chest compressions. With ventilation rate close to nonexistent, they intubate Mr. S and wheel him to intensive care. He regains consciousness on the fourth day and stays under surveillance for the next week: breathing treatments daily, kidney dialysis triweekly, a cocktail of antibiotics to fend off the pneumonia.
The tube eventually gets removed, and he is a fish, breathing through crude gills when the lungs shriveled and flower-pressed behind his sternum remain enervated by the cobwebs in their attic. While a family member is spooning thickened nectar into his mouth, Mr. S asks for a retelling of last month. It is almost recidivist in nature, a revolving door. He can only differentiate days with pain and days without pain, having eclipsed his sentience like the moon waning and waxing.
“This time, they’re keeping me here until they can remove the gallstones, image my stomach, and unblock the blocked artery.”
“Can your body handle this?”
It can’t. The lone invasive procedure done midway through his stay is an endoscopy, which accomplishes nothing more than snapping high-definition, state-of-the-art pictures of his six-year-old ulcers that have gone untreated7.
Five weeks of inpatient care and three weeks in rehabilitation, the bill totals more than $118,0008.
Case Study #4: Pills for Anxious Pickings
AS THE SUN THROWS OUT its last flames at the dawn of dusk, C and her father begin their excursion across town in an engine sputtering soured gas and doors creaking with oxidized hinges. Her mind sublimates to the pus-scented vapors. She is worried less about any prospective amputation to separate diseased appendage from hand9, more about the discomfort in her own husk, a tenant outgrowing a chambered cell. How she wishes to molt and melt and everything in between. She wants to pack up her ribs, curl her backbone inward like a coiled nautilus, shrinking, spiraling until all the potential makes her into a part-time demolition project, a full-time spring-loaded gun of a person.
Today, tingles alighting skin, she cannot feel her fingers, but she knows the nails have been bitten to the root, cuticles excoriated until they seeped wine.
“Mental illness is a luxury we can’t afford.”
Mouths scream, but she is louder: “Dad, I can’t help it.”
Today, it is different. Today, she continues to strip away old skin, convinced she is unraveling herself like rolls of cellophane. Today, he sees the body teetering, off-kilter, and soon, they’re coasting down the street at 50 miles an hour.
C looks to the doctor’s forehead and the sickly white of his lab coat as he punctures the fluid-filled pocket with a medieval bloodletting instrument. He is silver-tongued, ready to devour his prey whole. There is no trust here.
“Most people would have cried by now.”
She does not cry because this is the fourth time her fingers have been engorged with discharge. She does not cry because her brain is still wired from seeing her father hand over 60 green singles to the front desk when the woman rejected their Medicaid10. She does not cry because the snake-eyed physician is already starting to dress the messy wounds.
“All better.” It is not a question.
“All better,” she repeats.
Somewhere between the electricity in her hands flaring on the drive home and her father asking what she wants for dinner, she stifles a sob. In another universe, she is a 14-year old girl with soft hands and soft elbows and soft knees—no bruises, no scars. Instead, she is wrapping and unwrapping, unwrapping and rewrapping the series of bandages, a stampede in her ears, splinters under her viscera, ready to detonate11.
Final Case Study: Coda
Firstly, consider why there is no food insurance. What if the milk spoils before its due date? What if the steak is undercooked? Despite being necessary sustenance, there is no heavy financial risk associated with food purchase since the demand is stable and foreseeable. Rather than a need for something, it is the possibility of a rare or unpredictable threat that makes insurance desirable.
Secondly, ponder if health insurance is similar to any other existing indemnity plan. It is comparable in its use of rate estimations, but there is no such thing as existing solely for catastrophic damage. Health insurance protects against most or all forms of its use, and because there is not foresight as to when care will be needed, when required, it is very, very expensive.12
Light is both a particle and a wave. Health care is governed similarly: It is not supposed to make sense. It is inherently paradoxical, spurring creation from destruction, trading rebirth for death. The Ouroboros devours its own tail to sustain a life of cyclic renewal.
CHRISTINE HUYNH B'21 goes to Cuba for healthcare.
1. In the United States, the uninsured disproportionately frequent EDs for issues able to be addressed in a primary care setting. Because the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) mandates screening and treatment for every patient regardless of ability to pay, 24-hour walk-in accessibility and wrongful assessment of the severity of injuries exacerbate the issue of overrunning hospital services. Fewer than half of visits necessitate emergency care.
2. Medical tourism turns a lucrative profit when comparing affordable care in foreign embassies to the States. Despite the low cost of procedures, when situated in a country rife with bribery and corruption, accreditation becomes much more nebulous than ubiquitous. If something goes amiss, the same legal recourse is oftentimes not available. Unfortunately, the private practice that operated on Ms. A closed one week following the visit, and the most she ever received in compensation was missed phone calls and deleted voicemails.
3. Referring to Ms. A as healthy reads a bit as a gross overstatement, but this informed her decision to enroll in a high-deductible health plan ($1850) to reap lower premium benefits ($68 monthly) after passage of the Affordable Care Act. These facts are emphasized here to ground two details: (1) Ms. A has been insured since 2014; and (2) she does not want to see a primary care physician.
4. After leaving with a prescription for painkillers and a referral to a general surgeon who agreed to schedule a meeting on her earliest availability (two weeks from the ED check-in), Ms. A’s follow-up care ended with one appointment. She opted to not get the additional operation to fix the maladroitly sewn tissue. The throbbing eventually lessened, and abdominal blockages subsided after incorporating a healthy serving of MiraLAX into her everyday diet.
5. While the dominant form of healing in the United States is founded on allopathic practices, complementary and alternative medicine has been popularized in mainstream media. Chiropractic has evolved into such a craze that while it should revolve around managing chronic back or neck pain, some patients delegate overall health maintenance to chiropractic care—much to the delight of the chiropractic circle and much to the possible detriment of humanity.
6. Similar to Mr. S, a large portion of health spending in the States is allocated to high-need patients—people harboring chronic conditions and comorbidities. Cost shifting is not a matter of the wealthy financing the poor but the healthy subsidizing the sick. Those in the top 50th percentile account for 97 percent of costs.
7. Countless people are being prescribed drugs that don’t help, operations that will not make them better, and scans and tests that sometimes prove more hazardous than valuable. The United States is a country of three hundred million people who are submitted to fifteen million nuclear medicine scans, a hundred million CT and MRI scans, and almost ten billion laboratory tests annually. Hundreds of thousands more are being treated each year for diseases, yet only a miniscule reduction in death, if any, can be noticed.
8. I would like to say that Mr. S’ condition does not relapse, but it takes a mere two weeks before he gets hospitalized again: Whether the culprit was his blood pressure or blood sugar, something takes a dramatic plunge while he is idling in line at the bank. Nearby, someone phones the ambulance. Currently, he is in back-and-forth correspondence with an insurance company that demands recompense for transportation services. Larger cities like Los Angeles or Houston usually average over $1000 per ambulance ride. That is close to his monthly stipend.
9. Commonly related to obsessive-compulsive disorder, two to four percent of the population is affected with pathological skin picking. It is not uncommon for these episodes to result in a felon—an abscess formation at the fingertip due to an acute bacterial infection.
10. Health insurance does not transfer across state lines.
11. There is no officially established mental health care system in the States. What does exist is an informal amalgam of four disjointed sectors. In the US, like many industrialized countries, severe mental illnesses remain undertreated, diagnosis unstandardized.
12. While the United States is often cited as spending exorbitantly—even ostentatiously—on medical care (nearly twice as much as other high-income countries at 17.8 percent of its GDP in 2016), its returns are consistently mediocre. Of the industrialized nations, it remains the sole proprietor without universal health care, instead financing the widespread presence of a system that imposes limitations on treatment for impoverished and suffering communities.