Undocumented caregivers

Dr. Louise Aronson, geriatrician and author of Elderhood, says, “Caregiving is hard work. More often than not, it’s tedious, awkwardly intimate, physically exhausting and emotionally challenging. Sometimes it is also dangerous or disgusting. It is women’s work and immigrants' work.” Most old people get care from their children, spouses, other relatives, or non-relatives. The remaining caregivers are paid, but not much. The median hourly wage for all care workers was $16.72 in 2023—lower than the wage for all other jobs with similar or low entry-level requirements.

The New England Journal of Medicine notes that “immigrants are a vital part of the U.S. health care system: at least one in five U.S. health care workers is foreign-born, including 29% of physicians, 17% of nurses, and 24% of direct care workers.” Of the 37% of foreign-born direct care workers who are non-citizens, nearly half may be undocumented. The Journal also reports a shortage of direct care workers, estimating that the shortage will grow to 860,000 by 2032, and that 8.9 million positions will need to be filled over the next decade to meet the demand.

Raids by ICE have made matters worse. As the Journal noted, “Just four days after the inauguration, 25 undocumented Filipino direct care workers were arrested in an ICE raid at a senior care facility in Chicago; at least eight have been deported.” In one case, a cancer patient, living alone at home, had fallen but wasn’t found for days because “his home health aide had stopped coming to work for fear of deportation.”

Non-immigrants are unlikely to fill the void. Direct care workers “are often subject to exploitative work practices, including wage theft. The physically demanding nature of direct care work, combined with low pay and high susceptibility to exploitation, makes these roles unattractive to U.S.-born and highly skilled foreign-born workers.”

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Tamper-proof packaging

You might remember this: In September 1982, seven people—whose ages ranged from 12 to 35—died after consuming Extra-Strength Tylenol capsules laced with potassium cyanide. Subsequently, several more people died because of copycat crimes. Predictably, these events led to nationwide panic and prompted significant changes in product safety regulations.

The incident sparked a massive recall of over 31 million bottles of Tylenol and a halt in production by Johnson & Johnson, the manufacturer. The Tylenol murders inspired the pharmaceutical, food, and consumer product industries to develop tamper-resistant packaging, such as induction seals (photo).

 Moreover, product tampering was made a federal crime, and the FDA established guidelines for tamper-resistant packaging of over-the-counter medications. The changes in packaging together with the new legislation supposedly made pharmaceuticals and food safer for consumers.

I don’t know about you, but I’d rather take my chances at being poisoned than having daily struggles opening things. Sometimes I use my teeth. Sometimes a knife or other tools—plenty of opportunity for injury. Maybe with the new anti-regulatory fervor in Washington something can be done!

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Tweezer “surgery”

I am not making this up. A twenty-something young man went for his regular eye checkup. The ophthalmologist casually mentioned that a stray lash was grazing the man’s eye and suggested that he, the doctor, remove it. The man gave the go-ahead. Using a pair of drugstore tweezers, the doctor plucked the lash.

A few days later, the bill arrived. It said “Revise eyelashes, forceps. Surgical $335.” The young man was responsible for $198.97 of that.

The doctor’s office was in network. The ophthalmologist had billed the man’s insurance for $1,085 for the office visit, and the insurer paid $545.20. But the eyelash pluck was extra. It never occurred to the man that he’d be charged for it. He filed grievances, both with the physician’s billing office and his insurer. Both were denied.

Insurers negotiate rates with their in-network providers. Patients are usually not responsible for the difference between the provider’s full charge and the amount the insurer pays, something called “balance billing.” The insurer had agreed to pay $198 for the eyelash pluck, but since the man’s deductible hadn’t been met, he owed that amount out of pocket.

Taking pity on her son, the man’s mother took on the case. She called the physician’s billing department and was told that the patient should know what’s covered. Nevertheless, the mother dug in and finally prevailed. The doctor’s office rescinded the charge.

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Screening for cancer

The information in this post comes from an article in a recent New Yorker magazine written by Dr. Siddhartha Mukherjee, an oncologist and author of the Pulitzer Prize-winning book, The Emperor of All Maladies. It deals with efforts to find satisfactory methods to detect cancers.

Mammography is especially problematic because it “reveals only the shadow of a tumor—it cannot divine the tumor’s nature.” That is, mammography can’t tell whether the tumor is aggressive or has already spread or will remain inert. Added to this ambiguity is the prevalence of false positives—test results that indicate cancer where none exists. Only nine percent of people who test positive actually have cancer. People with false positives are sent for biopsies, “a risky, invasive process—which can involve a punctured lung, bleeding, or other complications—with no benefit.” At the same time, aggressive cancers can be missed because their detectable symptoms don’t appear at the time of a screening. Patients with such cancers can even die between annual tests. The apparent benefit of screening, Mukherjee says, is misleading because it disproportionately detects tumors that are less likely to be lethal in the first place. In contrast to the dubious benefits of mammography, colonoscopies pay off. Studies have proven a fifty percent reduction in deaths from colorectal cancer among those who received colonoscopies.

Now, scientists have found that cancer can be detected with blood tests. Fragments of our DNA circulate in our bloodstreams. Using this fact, researchers have found concrete evidence of tumor-derived DNA in cancer patients’ blood. They’ve developed a multi-cancer early detection blood test—one that can identify more than fifty types of cancer, including pancreatic and ovarian. To determine the value of blood tests as a screening tool, they conducted a major study in the UK, enrolling more than 15,000 participants. One result of the study showed that only six of the 1,254 cancer-free participants received false positives—a remarkably low rate. Unfortunately, the test’s ability to identify Stage I cancers was meager—just above 16 percent. It did better on more advanced cancers. But, of course, the whole point of screening is early detection.

Cancer screening is clearly a work in progress. Mukherjee hopes that “Perhaps, in time, we’ll build tools that can not only detect cancer’s presence but predict its course…that may one day tell us not only where a cancer began but whether it’s likely to pose a threat to health.” Stay tuned.

For an introduction to this blog, see I Just Say No; for a list of blog topics, click the Topics tab.