“Want to hear the joke about insulin?” goes the bleak gag about America’s drug prices. “You have to go to Canada to get it.”
But even that’s not an option anymore.
Pandemic travel restrictions have made Americans prisoners of their country. Even within North America, Mexico and Canada have closed thousands of kilometres of border to all but essential travel, roiling plans for vacation, work, and school. For cash-strapped Americans, it has also cut off access to medicines and health-care services that they can’t afford at home — at a time when money is tighter than ever.
Stephanie Boland’s nine-year-old son was diagnosed with diabetes in December. Travelling to Canada to fill his insulin prescription took a half-day’s drive from where they live in Brainerd, Minnesota, but it was worth it — the purchase was a simple, over-the-counter affair. One pack of injection pens, which would last several months, cost less than a hundred dollars, she says, compared to a list price of $530 at home.
As their son’s disease began to rewrite the routines of daily life, the Bolands planned to cross into Canada again to restock. Then the pandemic hit.
Boland, a masseuse, was forced to stop working. Her husband, a self-employed financial adviser, found his income hit by pandemic-related turbulence in the markets, too. Then their source for affordable insulin vanished behind a border that had never been closed before in the history of U.S.-Canada relations.
“We were going to make a trip north, one more trip in March, but then they closed the border,” she said.
BUYING INSULIN ABROAD
Only 1.5% of American adults who take prescription medications buy their drugs abroad, according to a June analysis by researchers at the University of Florida Gainesville, based on a 2015-2017 National Health Interview Survey.
Many medicines and medical services are cheaper in neighbouring Canada and Mexico, thanks to price controls and the power of the U.S. dollar. The difference is great enough that U.S. insurer PEHP, which covers Utah’s state employees, offers partially paid trips to Vancouver and Tijuana “to help you save money on your prescriptions.”
In popular Mexican resort towns like Cabo San Lucas on the West Coast, or Tulum on the East Coast, pharmacies, doctors and dentists targeting U.S. clientele dot the main drag, their prices on bright display. And the difference between those prices and the costs of the same drugs at U.S. pharmacies can mean life or death.
No drug is a better-known example of that calculus than insulin, a vital hormone in the body’s metabolism. Seven million American diabetics don’t produce it naturally — or not enough of it — and need to inject it throughout the day. Without it, dangerous levels of glucose build up in the blood, damaging organs and producing a painful stupor. In a worst case scenario, lack of insulin can kill within three days.
Americans have been going to Canada for insulin since scientists learned how to produce it in labs at the University of Toronto in 1921. One of the first patients to try it was an American: Elizabeth Hughes, the teenage daughter of then-U.S. Secretary of State Charles Evans Hughes.
“I’m so happy and elated,” she wrote in a letter to her mother from Canada, describing her first self-injection and the “enormous” meal she enjoyed afterward. Before crossing the border, the 15-year-old had managed her condition by starving herself — the only life-prolonging trick available to diabetics before insulin. Five feet tall, she weighed only 45 pounds.
A hundred years later, and after national soul-searching over the soaring cost of insulin, some Americans are still starving themselves. Daniel Carlisle, a Type 1 diabetic in Texas, has sometimes tried not to eat for days at a time, in an attempt to ration insulin. When he was 18 and short on cash, he even contemplated robbing a pharmacy, he says.
“I always do the math about how many days’ supply of insulin I have in the refrigerator,” the 60-year-old Texan says.
“That’s how I know my lifespan at that point. My lifespan is measured in exactly how many days’ worth of insulin I have in hand — plus three days.”
NUEVO PROGRESO
For the past three years, buying insulin in Mexico has brought Carlisle security.
His trips started with a split tooth in 2017. “I went to a dentist near where I live, and he said he could repair it for like $10,000,” says Carlisle, who is uninsured. “So I told him, ‘Look I can’t afford to send my kids to Harvard. Sure can’t afford to send yours.”
He tried to ignore his aching tooth, but at the urging of his family, eventually drove several hundred kilometres south from his home in Houston to the busy Mexican town of Nuevo Progreso.
“As soon as you come across the bridges, hawkers are saying “Need a dentist? Need a pharmacy? It’s just constant,” he says. First he got his tooth fixed — a root canal, bridge and crown altogether would end up costing him just $750. “The dentists aren’t marble palaces, but they’re clean,” he says.
Then he dipped into a pharmacy to ask the price of a vial of Humalog insulin, one of two kinds he takes. The answer: US$70. He checked the expiration date on the box, and then offered $20.
“You’ve got to negotiate!” he says. “I just tell them I’ll die without it and then they’ll lose a customer. They don’t put up a fuss.”
A vial of the same insulin in the U.S. has a list price of $274.70.
Since then, that’s the only place where he buys insulin, Carlisle says, and he’s never had a problem with its quality. But with the borders closed, he doesn’t expect be back any time soon.
A VAST GREY AREA
Pharmacy staff in several drugstores in border towns in both Canada and Mexico tell CNN that they’ve seen significant drops in foot traffic since their countries’ borders with the U.S. closed. Though American scofflaws have been accused of crossing into Mexico for nonessential errands, overall border crossings have plummeted.
One young man working at a pharmacy near Tijuana told CNN that business had fallen about 40% since the border closed. He asked to remain anonymous because he was not authorized to speak about the business.
Technically, bringing prescription drugs into the U.S. is illegal. But the U.S. Food and Drug Administration (FDA) has created a grey area for small amounts: Importation “might” be allowed, according to the agency’s website, if the medicine doesn’t exceed a three month supply.
Staff at Mark’s Marine Pharmacy in Vancouver, Canada, less than an hour’s drive from the U.S. border, typically fill hundreds of orders for U.S. customers each day, general manager Jordan Rosenblatt says, and rarely have any problem shipping it. With the borders closed, online ordering has spiked, he adds.
Reviews over the years on their Facebook page compare prices of all kinds of prescription drugs to those in the U.S., with commenters from as far as New Jersey and Texas. “They sell and send me my asthma inhalers at a price that is non-predatory, unlike here in the U.S. Happiest gal today! Thank you!” reads one.
But ordering online isn’t for everyone — there is always a risk that the medicine will be confiscated or that temperature-sensitive drugs like insulin could go bad waiting at customs or in U.S. Postal Service delays.
And as the frustrations of border closures highlight, foreign health systems make a poor fallback no matter how you access them.
“For any given individual in the short run, going to Canada is a decent solution, but it’s not a systemic solution,” says Dr. Vikas Saini, a Harvard-trained cardiologist and president of the Lown Institute, a nonpartisan health-care think tank.
U.S. President Donald Trump has called to allow larger scale importation from Canada, among a raft of recent proposals to reduce the prices of certain U.S. drugs. But that’s unlikely to make a dent in the U.S. market, Saini says: “Canada is a country of about 30 million people. It doesn’t have enough medication to provide all those prescriptions for the U.S. — a nation 10 times the size.”
Some Canadian health industry groups and patients agree. Since 2019, they’ve warned that Trump’s importation plan could lead to drug shortages for Canadians — a fear likely sharpened after witnessing global shortages of vital medical equipment in the early months of the COVID-19 pandemic.
A CRUMBLING ECONOMY
As the pandemic wears on, the options are dwindling for Americans who can’t afford to be sick in the United States — especially after the cratering economy erased nearly 13 million jobs, taking health insurance options with them.
Even at Canadian prices, some are struggling to pay for their prescriptions. “Recently, we’re hearing about all the financial issues of people laid off,” says Rosenblatt, the Vancouver pharmacy manager. “We have American customers that have been working with us for years, and under these circumstances, we’ve sent what they needed and we tell them, ‘Pay us when you can.'”
To make insulin more accessible, some U.S. states have pushed for price caps on copays. The three companies which control the U.S. insulin market offer discount plans, including new programs to which Americans who were financially impacted by the pandemic can apply for temporary access to cheaper or free insulin. And Walmart offers cheap insulin over the counter (though this is an older formulation that can make blood sugar management more complicated than newer, prescription versions.)
Yet many are still struggling — and not just the nearly 28 million Americans who don’t have health insurance, a number estimated by the Kaiser Family Foundation. Even Americans with health insurance, who benefit from negotiated prices that are lower than the list prices, sometimes still can’t afford all the costs of living with diabetes.
In Dayton, Ohio, Mindi Patterson’s family gets health insurance through her job as a Costco clerk. But even then, keeping up with the cost of insulin for both of her teenage sons and her husband is still a tightrope walk. “We have had to dig through the trash for (discarded) reservoirs from insulin pumps, when we haven’t had the money to buy the next bit of supplies,” she says.
“Right now I have a refill for (my son’s) insulin waiting, but I really don’t have the funds just yet to pick it up. So they’re holding onto it for me until payday,” she said.
Sabrina Renaud, a 22-year-old dietary aide in South Carolina, works fulltime at a hospital that offers health insurance to employees — but she earns about $1,300 per month after taxes, and says she simply can’t afford the deductible, premiums, and copays of the company plan and still make rent. “So I thought, I’m just going to have to wiggle through this without health insurance,” she says.
Renaud hasn’t seen a doctor to renew her insulin prescription in more than a year. Instead, every couple of months, she messages a woman she’s never met in real life, with a list of what she needs. So far, the life-saving supplies she needs keep turning up in the mail.
The woman, who asked to remain anonymous because redistributing prescription drugs is illegal, tells CNN that she has shipped insulin to hundreds of people over the years — an effort that she describes as a “necessary evil.” People from the U.S. and abroad send spare vials and injection pens to her, and she says she sends them for free to any American who asks for it.
“I personally do this, gosh, an average of four times per week,” she says.
“I could put out a tweet right now that someone needs (insulin brand) Humalog, and I’ll probably get 100 responses saying “I have extra,” from all over the country,” she says. “Folks are willing to pay $50 to overnight it to someone who’s in a really bad situation.”
She has even received large insulin donations from Canada.
AN INCREASINGLY BUSY ‘BLACK MARKET’
More than a dozen diabetic Americans interviewed for this article said they had participated in such an informal insulin exchange powered by social media, widely referred to as the “black market.” Organizers are nodes in the network, using their prominence on platforms like Twitter to connect people who have insulin to those who don’t.
“We have been left with no other choice,” says emerging Minnesota politician Quinn Nystrom, whose campaign for Congress emphasizes affordable health care. A Type 1 diabetic herself, Nystrom helps distribute insulin donations and — before the pandemic — organized “caravans” to Canada to purchase insulin.
“Am I willing to break the law to keep American citizens alive? Yes,” she says.
Demand for black market insulin has spiked since the pandemic began, said another organizer in Colorado, who asked to remain anonymous due to the illegality of the work. In the last week of July alone, she facilitated $24,000 worth of insulin donations, she estimates.
“Prior to this whole COVID-19 crisis — let’s say just six months ago or eight months ago, I might hear about someone who needed insulin maybe once a month,” she says. “Fast-forward to now, when people are losing jobs: In the last seven days, I have heard from 15 different people who are almost out of insulin and have no way to afford their next purchase.”
Daniel Carlisle, the Houstonian, has sometimes donated some of his own supply to fellow diabetics in Houston and Dallas. “If someone died because they were lacking and I said I won’t share with you, well, I’ve got a real moral issue with that,” he says. “If you were living in Houston and needed some insulin, I would drive over and give you a vial.”
But he does have cash flow limits, he adds. And if he can’t restock in Nuevo Progreso soon, he’ll have to ask for help on the same black market he once gave to.
“Right now I’m looking at February. If I can’t make it to Mexico by then — and have the money to make the trip — I’ll be in trouble,” he says.
NEW YORK (AP) — The U.S. syphilis epidemic slowed dramatically last year, gonorrhea cases fell and chlamydia cases remained below prepandemic levels, according to federal data released Tuesday.
The numbers represented some good news about sexually transmitted diseases, which experienced some alarming increases in past years due to declining condom use, inadequate sex education, and reduced testing and treatment when the COVID-19 pandemic hit.
Last year, cases of the most infectious stages of syphilis fell 10% from the year before — the first substantial decline in more than two decades. Gonorrhea cases dropped 7%, marking a second straight year of decline and bringing the number below what it was in 2019.
“I’m encouraged, and it’s been a long time since I felt that way” about the nation’s epidemic of sexually transmitted infections, said the CDC’s Dr. Jonathan Mermin. “Something is working.”
More than 2.4 million cases of syphilis, gonorrhea and chlamydia were diagnosed and reported last year — 1.6 million cases of chlamydia, 600,000 of gonorrhea, and more than 209,000 of syphilis.
Syphilis is a particular concern. For centuries, it was a common but feared infection that could deform the body and end in death. New cases plummeted in the U.S. starting in the 1940s when infection-fighting antibiotics became widely available, and they trended down for a half century after that. By 2002, however, cases began rising again, with men who have sex with other men being disproportionately affected.
The new report found cases of syphilis in their early, most infectious stages dropped 13% among gay and bisexual men. It was the first such drop since the agency began reporting data for that group in the mid-2000s.
However, there was a 12% increase in the rate of cases of unknown- or later-stage syphilis — a reflection of people infected years ago.
Cases of syphilis in newborns, passed on from infected mothers, also rose. There were nearly 4,000 cases, including 279 stillbirths and infant deaths.
“This means pregnant women are not being tested often enough,” said Dr. Jeffrey Klausner, a professor of medicine at the University of Southern California.
What caused some of the STD trends to improve? Several experts say one contributor is the growing use of an antibiotic as a “morning-after pill.” Studies have shown that taking doxycycline within 72 hours of unprotected sex cuts the risk of developing syphilis, gonorrhea and chlamydia.
In June, the CDC started recommending doxycycline as a morning-after pill, specifically for gay and bisexual men and transgender women who recently had an STD diagnosis. But health departments and organizations in some cities had been giving the pills to people for a couple years.
Some experts believe that the 2022 mpox outbreak — which mainly hit gay and bisexual men — may have had a lingering effect on sexual behavior in 2023, or at least on people’s willingness to get tested when strange sores appeared.
Another factor may have been an increase in the number of health workers testing people for infections, doing contact tracing and connecting people to treatment. Congress gave $1.2 billion to expand the workforce over five years, including $600 million to states, cities and territories that get STD prevention funding from CDC.
Last year had the “most activity with that funding throughout the U.S.,” said David Harvey, executive director of the National Coalition of STD Directors.
However, Congress ended the funds early as a part of last year’s debt ceiling deal, cutting off $400 million. Some people already have lost their jobs, said a spokeswoman for Harvey’s organization.
Still, Harvey said he had reasons for optimism, including the growing use of doxycycline and a push for at-home STD test kits.
Also, there are reasons to think the next presidential administration could get behind STD prevention. In 2019, then-President Donald Trump announced a campaign to “eliminate” the U.S. HIV epidemic by 2030. (Federal health officials later clarified that the actual goal was a huge reduction in new infections — fewer than 3,000 a year.)
There were nearly 32,000 new HIV infections in 2022, the CDC estimates. But a boost in public health funding for HIV could also also help bring down other sexually transmitted infections, experts said.
“When the government puts in resources, puts in money, we see declines in STDs,” Klausner said.
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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.
WASHINGTON (AP) — Scientists can’t know precisely when a volcano is about to erupt, but they can sometimes pick up telltale signs.
That happened two years ago with the world’s largest active volcano. About two months before Mauna Loa spewed rivers of glowing orange molten lava, geologists detected small earthquakes nearby and other signs, and they warned residents on Hawaii‘s Big Island.
Now a study of the volcano’s lava confirms their timeline for when the molten rock below was on the move.
“Volcanoes are tricky because we don’t get to watch directly what’s happening inside – we have to look for other signs,” said Erik Klemetti Gonzalez, a volcano expert at Denison University, who was not involved in the study.
Upswelling ground and increased earthquake activity near the volcano resulted from magma rising from lower levels of Earth’s crust to fill chambers beneath the volcano, said Kendra Lynn, a research geologist at the Hawaiian Volcano Observatory and co-author of a new study in Nature Communications.
When pressure was high enough, the magma broke through brittle surface rock and became lava – and the eruption began in late November 2022. Later, researchers collected samples of volcanic rock for analysis.
The chemical makeup of certain crystals within the lava indicated that around 70 days before the eruption, large quantities of molten rock had moved from around 1.9 miles (3 kilometers) to 3 miles (5 kilometers) under the summit to a mile (2 kilometers) or less beneath, the study found. This matched the timeline the geologists had observed with other signs.
The last time Mauna Loa erupted was in 1984. Most of the U.S. volcanoes that scientists consider to be active are found in Hawaii, Alaska and the West Coast.
Worldwide, around 585 volcanoes are considered active.
Scientists can’t predict eruptions, but they can make a “forecast,” said Ben Andrews, who heads the global volcano program at the Smithsonian Institution and who was not involved in the study.
Andrews compared volcano forecasts to weather forecasts – informed “probabilities” that an event will occur. And better data about the past behavior of specific volcanos can help researchers finetune forecasts of future activity, experts say.
(asterisk)We can look for similar patterns in the future and expect that there’s a higher probability of conditions for an eruption happening,” said Klemetti Gonzalez.
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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group. The AP is solely responsible for all content.
Waymo on Tuesday opened its robotaxi service to anyone who wants a ride around Los Angeles, marking another milestone in the evolution of self-driving car technology since the company began as a secret project at Google 15 years ago.
The expansion comes eight months after Waymo began offering rides in Los Angeles to a limited group of passengers chosen from a waiting list that had ballooned to more than 300,000 people. Now, anyone with the Waymo One smartphone app will be able to request a ride around an 80-square-mile (129-square-kilometer) territory spanning the second largest U.S. city.
After Waymo received approval from California regulators to charge for rides 15 months ago, the company initially chose to launch its operations in San Francisco before offering a limited service in Los Angeles.
Before deciding to compete against conventional ride-hailing pioneers Uber and Lyft in California, Waymo unleashed its robotaxis in Phoenix in 2020 and has been steadily extending the reach of its service in that Arizona city ever since.
Driverless rides are proving to be more than just a novelty. Waymo says it now transports more than 50,000 weekly passengers in its robotaxis, a volume of business numbers that helped the company recently raise $5.6 billion from its corporate parent Alphabet and a list of other investors that included venture capital firm Andreesen Horowitz and financial management firm T. Rowe Price.
“Our service has matured quickly and our riders are embracing the many benefits of fully autonomous driving,” Waymo co-CEO Tekedra Mawakana said in a blog post.
Despite its inroads, Waymo is still believed to be losing money. Although Alphabet doesn’t disclose Waymo’s financial results, the robotaxi is a major part of an “Other Bets” division that had suffered an operating loss of $3.3 billion through the first nine months of this year, down from a setback of $4.2 billion at the same time last year.
But Waymo has come a long way since Google began working on self-driving cars in 2009 as part of project “Chauffeur.” Since its 2016 spinoff from Google, Waymo has established itself as the clear leader in a robotaxi industry that’s getting more congested.
Electric auto pioneer Tesla is aiming to launch a rival “Cybercab” service by 2026, although its CEO Elon Musk said he hopes the company can get the required regulatory clearances to operate in Texas and California by next year.
Tesla’s projected timeline for competing against Waymo has been met with skepticism because Musk has made unfulfilled promises about the company’s self-driving car technology for nearly a decade.
Meanwhile, Waymo’s robotaxis have driven more than 20 million fully autonomous miles and provided more than 2 million rides to passengers without encountering a serious accident that resulted in its operations being sidelined.
That safety record is a stark contrast to one of its early rivals, Cruise, a robotaxi service owned by General Motors. Cruise’s California license was suspended last year after one of its driverless cars in San Francisco dragged a jaywalking pedestrian who had been struck by a different car driven by a human.
Cruise is now trying to rebound by joining forces with Uber to make some of its services available next year in U.S. cities that still haven’t been announced. But Waymo also has forged a similar alliance with Uber to dispatch its robotaxi in Atlanta and Austin, Texas next year.
Another robotaxi service, Amazon’s Zoox, is hoping to begin offering driverless rides to the general public in Las Vegas at some point next year before also launching in San Francisco.
