Illustration by Tianyu Tan ’26.
Tianyu Tan is a biology major and a 2024-25 health care ethics intern at the Markkula Center for Applied Ethics at Santa Clara University. Views are her own.
A Bat Attack
On November 17, 2016, Ally McNamee, a student at Keene State College, was attacked by a bat in her house. McNamee was not only traumatized by the sudden attack but began to worry about a deadly threat: Rabies.
What is Rabies?
Rabies is a deadly virus that is carried by mammals like bats, dogs, and raccoons. Transmission to humans occurs usually from a bite or scratch. The virus travels from the bite site to the brain through nerves, during which its lack of symptoms lead patients to a false sense of security.
When the Rabies virus reaches the brain, mild flu-like symptoms such as headache and fever start, but eventually escalate into hallucinations, insomnia, seizures, and the complete loss of motor and emotional control. The Rabies virus forces its victim to experience hydrophobia, excruciating spasms in their throat whenever they try to drink water. The outcome of an untreated Rabies infection is almost always a very slow death, usually after weeks of unbearable thirst and hunger but a complete inability to drink or eat.
End of the Dog Days
Fortunately, there is a treatment, known as Rabies Post-Exposure Prophylaxis(PEP) developed against Rabies that is amazingly effective when applied before the virus reaches the brain. The treatment includes rabies immunoglobulin and a vaccine. The vaccine was first developed by Louis Pasteur in the 1880s and injected into a little boy named Joseph Meister as a last resort. Nearly everyone believed that Joseph Meister will suffer the same painful death as other Rabies victims as he has been bitten by a rabid dog. However, Pasteur’s Rabies vaccine worked and Meister survived. The Rabies vaccine has been rightfully championed as a powerful silver bullet against the brutally fatal virus.
Therefore, McNamee sought to get the Rabies vaccine at the emergency room (ER). However, McNamee was shocked to see on her bill that the Rabies treatment cost $6,017. What’s more shocking is that McNamee’s bill is considered the low end of the cost of Rabies treatment. Sabrina Daswick had to pay $25,000 for Rabies PEP after being bitten by a cat in her backyard.
It is absolutely shocking that McNamee and Daswick, neither of whom asked to be attacked by a bat, have to pay thousands of dollars just to save themselves from a terrible death.
Taking a Bite Out of a Wallet
PEP is especially expensive because the immunoglobulin that’s needed to curb the progress of the virus is derived from human blood, and therefore requires multiple careful screenings to ensure that it is free of disease.
The Rabies vaccine is very costly due to almost no price regulations in the U.S. In addition, visiting the ER is already extremely expensive, yet the ER is often the only place where people can access the PEP. While the cost of the Rabies vaccine is shared by both the patient and their insurance companies, many patients who do not have access to health insurance, which is one in every 10 Americans, will be forced to pay out of pocket.
Introducing a Bioethical Framework
In Bioethics, four vital principles are used to evaluate whether a situation is ethical or not. A situation is ethical when it is just, allowing for patient autonomy, beneficent (doing good), and non-maleficent (not doing harm).
Just?
Many people across the U.S. who are financially struggling, especially BIWOC (Black and Indigenous Women of Color), are unable to access proper health insurance to pay for Rabies PEP. For every $1 that a White, non-Hispanic man makes, a White woman makes 75 cents, a Black woman makes 64 cents, an Indigenous American woman makes 52 cents, and a Latina makes 51 cents.
In addition, housing barriers force BIWOC into communities lurking with rabid bats and stray dogs. BIWOC folks are more likely to be exposed to rabid animals but also less likely to receive the proper lifesaving treatment. Therefore, the high cost for PEP is a double whammy for those very vulnerable communities in the US.
The Rabies vaccine is often not available at all in Southeast Asia, South Asia, and Africa because it is believed people there would not be able to pay for the proper treatment. Heartbreakingly, people in those developing countries are most exposed to Rabies. In the Democratic Republic of Congo where rabid stray dogs are commonly found in the streets, the rabies vaccine is often unavailable even as in 5,579 people dying from the disease per year.
Inhibiting Patient Autonomy?
When given a vaccine against such a terrifying disease like Rabies, everybody would accept. When the high cost of PEP makes it inaccessible to so many, people might resort to desperate measures to make money to pay for PEP. Patients are forced to choose between becoming bankrupt from treatment, possibly leaving them homeless and unable to support families, and dying a painful death. The high cost of PEP stops many patients from making their own decisions regarding their health just because they don’t have the financial means to do so.
Beneficent/Non-Maleficent?
The high cost of the expensive PEP would be beneficial for its developers. The developers would rightfully receive money to support themselves and their loved-ones for creating such an effective, lifesaving treatment.
The high cost of the PEP is undoubtedly less favorable for patients who desperately need the vaccine in time in order to survive. Too often, many patients have to suffer an agonizing death because they are unable to afford the PEP. The high cost of the PEP fails to prevent harm in those who are financially struggling.
Fighting For The Underdogs
Your money or your life–a crime when said by a masked man in a dark alley in your face, a way “things just are” when said by the national healthcare system. More and more people, and even more wonderfully, people in positions of power, are seeing this gross injustice.
Rep. Ami Bera MD of California has proposed a bill known as the Affordable Rabies Treatment for All Act of 2023 that will reduce the financial barriers of the PEP after he himself was bitten by a rabid fox and only survived through accessing prompt medical treatment. Rep. Bera will establish a reimbursement program for healthcare providers who provide PEP to uninsured individuals.
In addition, the Global Alliance for Rabies Control (GARC) has been advocating for eradicating rabies by 2030, especially in vulnerable countries in South Asia, Southeast Asia, and sub-Saharan Africa. Not only does GARC provide free medical clinics where people could access the Rabies vaccine, they also provide educational materials on animal bite prevention and treatment for children.
The fight against Rabies–and the socio-economic barriers in healthcare access can really make one feel as sick as a dog, but it is worth fighting for, for the 60,000 Americans who are trying to receive PEP, for the 70,000 people in Asian and African countries who are dying of thirst. Through education on animal safety, voting for bills that reduce medical costs, and even supporting clinics that provide PEP in underserved communities, we can teach this old dog of a healthcare system some new tricks.