This article was first published in the third quarter 2016 edition of Personal Finance magazine.
Think about it: acquiring a pet dog or cat could entail a financial and emotional commitment of anything up to 20 years. To put it another way: the cat you present to your child in grade three could still be around when she graduates from university, by which time it will undoubtedly be frail and cranky, requiring frequent – and probably expensive – visits to the vet.
Evidence suggests that many people underestimate the cost of caring for their pets. Whereas they might be diligent in budgeting for items such as home maintenance, car repairs and their children’s education, they remain surprisingly cavalier about the costs incurred by the animals that share their homes (and often their favourite chairs).
Consider this scenario. Having acquired a kitten, you decide to do the responsible thing and book an appointment with your local vet. This initial consultation, during which the vet will proffer useful advice on feeding, behaviour, growth expectancies and everything else you need to know about your new dependant, entails a detailed examination and vaccination costing upwards of R400. Not too bad, you think. Now little Tigger is good to go.
Not so fast. As an adoptive parent, you need to know that the ball of fluff who’s destined to dominate your household is no less vulnerable to microbial and other nasties than our own species (not to mention Fate’s intervention in the form of accidents and other unpredictable events), and will need your help to stay healthy and happy for a long time to come.
Personal Finance asked Dr Ingrid de Wet of the Country Animal Clinic in Somerset West to provide a few specifics.
“Cats require three vaccinations as kittens. We advise vaccination at nine, 12 and 16 weeks. The week-nine vaccination (R410) covers snuffles, viruses, feline panleukopaenia and the feline leukaemia virus. The week-12 vaccination (R445) does the same, but includes rabies, and the week-16 vaccination is against rabies (R240). The price includes the vaccination, a full examination, weighing the pet, examining eyes, ears, teeth, confirmation (in essence, whether your pet conforms to breed standards), listening to the heart and lungs, palpating the abdomen, checking temperature and examining for congenital defects. We also spend time talking to the owner about preventative care, nutrition and any breed-specific problems they may encounter.
“We advocate de-worming at each vaccination (costing about R20, depending on the size of the cat). External parasite control is also advised (about R90, again depending on the size of the cat). After the initial vaccinations, de-worming is advised at three-to- six-month intervals (more often if the cat is allowed outdoors) and external parasite control monthly.
“Against this, it’s worth considering the cost of not vaccinating your cat. For starters, it is more susceptible to snuffles (upper respiratory tract infection), and should it fall ill, it will need a consultation and anti-biotics at the very least. The consultation costs R285, and antibiotics can cost anything between R150 and R250. If not treated quickly, the kitten may need hospitalisation, which could result in a bill of R2 000 to R4 000,” De Wet says.
“If the kitten should contract feline panleukopaenia virus, it would also need to be hospitalised (at a similar cost). Feline leukaemia virus is a huge problem in some areas and often leads to the death of a cat, despite intensive treatment that could involve ongoing chronic treatment or hospitalisation (R3 000 to R10 000, depending on what is required).
What about dogs?
“Puppies require vaccination at six to eight, 10 to 12 and 14 to 16 weeks,” De Wet says. “The six-to-eight-week vaccination is against canine parvo virus, canine distemper virus, canine infectious hepatitis and canine parainfluenza virus, and costs about R330. The second two vaccinations include one for rabies, as well as the other viruses, and cost R360. As with cats, the visit includes a full clinical examination and discussion of relevant issues. De-worming costs between R10 and R60, depending on the size of the dog, and external parasite control will set you back R80 to R150, again depending on the size of the dog.
“Once again, you need to consider the cost of not vaccinating your puppy. The two most prevalent viral diseases are the parvo virus (also known as cat ’flu, although it affects dogs) and distemper virus. Both are highly contagious and spread very quickly to unvaccinated animals, and both carry a poor prognosis, requiring intensive treatment.
“Treatment of a parvo virus case can cost anything between R4 000 and R15 000, depending on the level and duration of treatment required, and we normally warn clients that only about 50 percent of the patients survive, despite the intensive treatment. Distemper cases may incur similar hospitalisation costs, but the mortality rate is higher.
“In general, we recommend that females are sterilised at six months. Small-breed male dogs should also be sterilised at about six months. There is some controversy about the best age of sterilisation, and there may be some advantage in delaying sterilising large-breed dogs until they are 12 to 18 months old in order to prevent some cancers and arthritis later in life.
“We recommend that cats are sterilised at six months, prior to coming on heat. The cost is R650 for males and R1 100 to R1 200 for females. It costs about R1 200 to sterilise a male dog and R1 300 to R1 600 to sterilise a female, depending on her weight.”
The consequences of not sterilising your cat go far beyond possible unwanted litters. De Wet says: “Unsterilised animals are more likely to roam and are thus more likely to be hit by cars or get into fights, which can result in costly vet bills for bite wounds, broken limbs, and so on. Cats that get into fights are more likely to contract feline immunodeficiency virus (FIV, similar to HIV) or feline leukaemia virus, which can require veterinary care and, in many cases, can result in death. Behavioural problems may result from not sterilising your pet, including higher rates of aggression in male dogs and urine marking indoors.
“Females that are allowed to have more than two heat cycles are more prone to mammary cancer, which may result in surgery and chemotherapy. Estimating the cost of this is difficult, but it could be anything from R2 000 to R6 000, depending on the severity of the problem. Females are also more likely to contract uterine infections (pyometra), which can be life-threatening and require emergency surgery costing R5 000 to R8 000,” De Wet says.
Annual health checks
“We also recommend annual health check-ups, during which we perform a full clinical examination. We also assess the animal’s nutritional status and advise on diet. The cost is R285 to R450 for dogs and R285 to R445 for cats (the higher price is a consultation fee plus vaccination). For senior pets, we may recommend screening tests for common diseases, which may include kidney function tests for elderly cats. The cost is about R350, while X-rays for older large-breed dogs – to look for signs of arthritis – would cost R1 500 to R2 000.
“Animals on chronic medication are required by law to have six-monthly check-ups, costing R285 a time. During these visits, further testing may be required to monitor the patient and ensure that the medication is achieving its goal, and that there are no side effects. The cost of the tests varies from case to case, but R300 to R600 would be a good general guideline. De-worming is recommended every three months. The cost for cats is about R40, whereas dogs cost between R20 and R80, depending on size.
“External parasite control (ticks and fleas) is recommended monthly: cats cost R80 to R100 and dogs R80 to R160, depending on size.”
What happens if you don’t control ticks? This could be quite scary: an “uncomplicated” case of tick bite fever (biliary) can cost anything from R500 to R1 000 to treat, whereas a complicated case resulting in hospitalisation could set you back anything from R2 000 to R10 000, depending on what treatment is required, De Wet says.
“Notwithstanding treatment, this can also result in the death of the dog or cat. Both dogs and cats can get biliary repeatedly: in other words, they are not immune after the first infection.”
The best of everything
It’s not surprising that the uninitiated sometimes find it difficult to understand why people would spend so much money on an animal, and when shown a large vet’s bill, will exclaim: “But that’s more than a human’s treatment would cost!” However, that’s not really the point, says Colin Daniel, Personal Finance’s illustrator and cartoonist and owner of four dogs and two cats. If you love an animal, you’ll do whatever it takes, he says.
He cites the case of a much-loved cat that developed a melanoma on its only functional eye and underwent radiation treatment at Tygerberg Hospital (this was carried out under strict conditions, and obviously only when the equipment was not required by human patients). It was expensive, Colin concedes, but he didn’t hesitate to do what was necessary.
“We spend more on our pets’ health care than our own, but it’s an integral part of our budget. I suppose it’s different if you have kids.”
A Cape Town art director, Natalie (not her real name), who has adopted five mature dogs over the past 20 years, says she has been “lucky”, in that her charges have not incurred any very large bills in that time ... then reveals that her latest rescue dog has epileptic seizures and requires blood tests at R1 000 a time. She also cites a hind-leg ligament rupture than required a R10 000 operation, and costs of R330 per dog every three months (that’s R1 650) for flea and tick treatment, dog food at R800 a month, and annual check-ups at R500 for each dog.
How is this lucky? “Well, I heard about a couple whose two dogs were bitten by a Cape cobra while walking in Tokai forest a few months ago. One dog died, and the final vet’s bill came to over R35 000.”
There are veterinary and related specialists who offer expertise in every conceivable discipline from dentistry and orofacial surgery to ophthalmology, orthopaedic surgery, artificial insemination, internal medicine, ultrasound therapy, and much more. Some might be labelled “para-veterinary” and none of them comes cheap:
* If your dog is injured and the vet recommends underwater treadmill therapy, be prepared to cough up about R290 per session. (Before you scoff, it’s worth knowing that this treatment reportedly works quite well; some facilities actually have a waiting list.)
* Laser therapy (for the management of pain and inflammation) costs R114 per session; rehabilitation treatment will set you back R600 for the initial session and R456 per session thereafter; dental scale and polish (under general anaesthetic) costs R1 300 for cats and R1 500 for dogs; pre-anaesthetic blood tests (which includes checks for kidney and liver function, electrolytes, diabetes and stress) cost R660.
Too mainstream for your taste? Then how about acupuncture and homeopathy? Some veterinary practices offer “complementary” therapies for the treatment of long-term and relapsing disorders, asthma, allergies, skin disorders, anxiety, nervous tension and shock, and managing the side-effects of conventional treatment, such as nausea following chemotherapy.
Going back to everyday life, Dr Paul Bernhardi, a vet based at the Blue Cross Veterinary Hospital in Newlands in Cape Town (and “dad” to four dogs, five cats, three birds and a tortoise), says the way an animal is homed and fed is critical to its well-being.
He says the arrival of the so-called “super-premium” foods has resulted in a noticeable increase in lifespan, justifying their claims of superiority and premium price. “These companies put a lot of money into research and development for the different life-stages of pets, and prescription diets also make a massive difference when treating chronic conditions and prolonging the life of chronically ill pets.”
On the other hand, many animals are still being homed inappropriately, he says. Mismatches often occur between the needs of an animal and the size of the home, the amount of exercise available, and the behaviour of other animals and family members – especially children – in the home.
If you’re about to acquire a dog and live in an urban area, you’ll need to ensure that it cannot escape your property and wander into a busy road. You may need to extend an existing wall or fence, and this will obviously cost you money.
Next, your dog’s sleeping quarters: will a dog be sleeping inside the house, in the garage, or in a kennel on the veranda? Unless you’re a keen DIY type and determined to build it yourself, you could end up spending anything from a few hundred rand to R1 000 or more on a wooden or plastic kennel. Then you’ll need a basket and blanket; a nice wicker basket for a medium-sized dog costs anything from R250 to R800 or more, and a blanket another R100.
It’s not over yet … not by a long shot. Now you’ll need to think about pet identification. Some owners settle for a collar, which could cost as little as R50 at your local supermarket, plus a little more for engraving a metal or plastic tag with your contact details.
More sussed owners will opt for an Identipet or Virbac microchip, which is implanted just beneath the surface of the skin, usually in the scruff of the neck. The tiny chip contains an individual identity number that can be picked up by a scanner at the SPCA or local veterinary surgery, who will alert you when your lost or injured pet is located.
Expect to pay anything from R120 to R280 (the higher cost is for chips recommended by vets when their clients are emigrating). Some providers charge once-off fees and others levy a small annual membership fee. The main products are GetMeKnown, FiveStar ID, Virbac BackHome and Identipet. (For the record, De Wet believes micochipping should be considered a basic prerequisite of pet ownership.)
A course of puppy socialisation classes (recommended by vets) can cost R1 000 or more, depending on the breed, location and other factors, and obedience training slightly more. If your dog has serious behavioural issues, start saving now: animal behaviourists don’t come cheap.
Planning to go for a weekend or longer? Unless you take your dog with you, you’ll need to book your pet into a kennel – and this is where the costs begin to get quite serious. Depending on the establishment and the services it offers (grooming, exercise, sessions with an animal behaviourist, and so on), the cost could be anything from reasonable to downright terrifying. (Christmas and Easter holidays? You’ll probably need a stiff drink to cope with the quoted fee.) Remember that before a kennel will admit your pet, you’ll need to produce proof that it’s up to date with all vaccinations, particularly kennel cough.
How about toys? If you want to keep your dog or cat physically fit and mentally stimulated, you can choose from a huge and occasionally bewildering variety of playthings, ranging from Frisbees to electronic mice and even a kitty jungle gym-cum-scratching post (recently spotted on Takealot at a marked-down price of R2 299).
Then there’s the grooming thing. It’s up to you whether you stump up for a salon wash, dry and cut, or a vision of trimmed whiskers and blow-dried pom-poms, but you could also do it yourself, thereby saving a bomb. The Fluffs-n-Tufts Training School in Bryanston offers comprehensive grooming courses from “basic” to “advanced”, the latter aimed at people who want to launch their own grooming business. (The company also runs a cattery featuring webcams that allow signed-up clients to watch their cats at play.)
But do consider a comment from a pet owner who went the whole hog, deciding that his French poodle deserved the best. “When I went to collect her, she actually looked embarrassed, and I swore I would never do it to her again.”
Finally, be aware that, as demonstrated by Michael’s story (see “Case study 1”, below), the outflow of cash may not end when your beloved pet closes its eyes for the last time. Cremation and burial services are available in a number of major centres, offering a one-stop facility that may include the preservation of the pet’s ashes in a “unique handmade pottery urn” and individual or communal (read: landfill) burial. Engraved tombstones are an optional extra and cost several thousand rand.
Legacy Pet Crematorium (with branches in Gauteng and KwaZulu-Natal) charges R550 for collection and communal cremation, R1 650 for the return of your pet’s ashes (smaller creatures such as birds, hamsters and rats cost about a third of that) and R6 500 for cremation with a granite memorial. If you would like your late pet’s ashes embedded in glass, or preserved in the form of a “LifeGem diamond”, they would be delighted to provide a quote.
In Cape Town, RIPets owner Karin Mathews says her firm collects deceased pets from more than 80 veterinary practices and from private homes when required. Mathews says: “This provides great comfort to distressed pet owners who have lost their pet at home, and the vehicle is on standby 365 days a year.”
The company has imported a specialised three-chamber pet crematorium from the United Kingdom that’s believed to be the first of its kind in South Africa. If you wish to keep your pet’s ashes, it will be cremated separately; otherwise, it will be cremated with others. Pricing depends on criteria such as the service required, the weight of the pet, and the collection point.
Are vets’ fees a rip-off? Veterinarian Dr Ingrid de Wet says the prices charged by veterinary practices are determined by many variables. “For example, ours is a two-person practice in a middle- to upper-class suburb, and we offer most services, including consultations, basic and relatively advanced surgery, in-house laboratory testing, X-rays, ultrasound and hospitalisation. We need the space, expertise and equipment to offer those services, and these contribute to the price.
“Some practices are basic or primary-care clinics that do only vaccinations and sterilisations, so they have less equipment and fewer staff, and their prices are correspondingly lower. Against that, some clinics are 24-hour centres with specialist facilities and more advanced equipment, so their prices will be higher.”
Specifically, De Wet says “a full complement of equipment” required to run a practice like hers includes a consultation room, microscope, in-house laboratory “to provide almost instantaneous results”, an X-ray machine, dental machine, ultrasound machine, surgical equipment, sterilisation equipment for surgical instruments, and more.
“This equipment alone costs about R1 million and is equivalent to what you’d find in many hospitals, enabling us to offer a one-stop shop for most patients, unless they need specialised care. We have a staff of nine, so our monthly salary bill is quite high, and this is just to run our clinic for 10 hours a day; 24-hour centres have much larger staff complements.
“Our drug and consumables bills can be as high as R250 000 to R300 000 a month, and these costs are constantly increasing because most of our drugs are imported and dependent on the rand-dollar exchange rate. As a result of all this, the profit margin for a veterinary practice is very small. Most of our income goes towards covering our costs.
“Most veterinarians are very compassionate about their patients and clients and go out of their way to subsidise essential preventative care in an effort to save their clients money. For example, if we were to charge out a sterilisation properly – including all the man-hours, equipment, consumables, rent, and so on – it would end up costing three to four times what we actually charge. But we know that sterilising an animal prevents a host of other problems, so we cut the prices significantly in order to make it more affordable for our clientele and to benefit our patients.”
What happens when cash-strapped pet owners simply cannot afford expensive treatment for their ill or injured pets, and experience a crisis of conscience when they have to choose between euthanasia and crippling debt?
De Wet says: “This creates a crisis of conscience for us, as well as for the owner, because we wish we could do things for free. That’s why it is so important to budget for your pets, and to make the right decisions when choosing a pet. If you don’t have a large income, don’t get a large-breed dog; rather get a smaller-breed dog or cat – they are generally cheaper to treat.
“I always recommend the gold standard of testing and treatment, but if the client cannot afford it, I suggest alternatives if they are available. Unfortunately, these will not have the same outcome, so we may have to compromise on certain things. Ultimately, the pet’s quality of life is the most important factor and cannot be compromised. In some cases, euthanasia is the only way to go.
“We also encourage owners to invest in pet medical aid. This makes treating your animal a pleasure, particularly when they are very ill, or have been involved in an accident, because we know we can do the best for your animal without financially impacting on the family.
“Many vets have stopped offering account facilities, because many people do not pay their bills as promised. Even in our practice, where we require payment on the day of service, our debts run into hundreds of thousands of rands.”
THE CASE FOR PET INSURANCE
Most of us belong to a medical scheme so that we are covered for the treatment of illnesses and major procedures (including hospitalisation) that may cost thousands of rands. That prompts a perfectly legitimate question: shouldn’t the same thinking be applied to our pets, allowing us to give them the best possible care when something goes wrong?
There are about 10 million pets in South Africa (probably many more, according to some vets), of which only a fraction of one percent are insured.
However, evidence suggests that more and more canny pet owners, alarmed by the ever-increasing cost of veterinary care, are taking out insurance – and they have the backing of vets everywhere.
Dominating the field is Medipet Dog and Cat Veterinary Insurance Brokers, founded in 2007. The comprehensive range of options provides cover in the event of accidental injury, all manner of illnesses, surgery, dog-fight lacerations, gastric torsion (twisting of the stomach, caused by an accumulation of gas), tumour removal, snake bite, hip replacement, dental work, and more. The company offers two options for cats (starting at about R220 a month) and two for dogs (from R256 a month). Maximum cover is R35 000 and the excess is R250 (or 15 percent of the claim).
Clients may consult any vet of their choice, and cover may be taken from the age of eight weeks.
The policies provide R50 a day for kennels, catteries or pet sitters (not living with you) if you fall ill or are unable to look after your pet for another reason, advertising-and-reward cover of R250 a year, and R150 a month for prescription food needed to treat an illness (valid for up to six months, on the recommendation of your vet).
In addition, you receive R2 000 worth of “behaviour cover” for the lifetime of your pet, R2 000 per policy year towards complementary treatment and R1 500 per policy year towards supplements. There are no specified limits, other than a general cover cut-off at R35 000.
Medipet claims to be the only pet insurance broker to offer chronic-care cover, subject to certain conditions, and requiring pre-approval.
These case studies illustrate how insurance can help:
* Dexter has benefited from pet insurance cover via Medipet since February 2014, and his premiums to date total R5 900. In April this year, he was diagnosed with spirocerca lupi (an endoparasite that lives in the dog’s throat). Dexter’s treatment amounted to R9 146. His owners paid the excess of R1 392 and Medipet paid the balance of R7 774. That single claim effectively recouped the premiums already paid, as well as the excess.
There’s more to Dexter’s story, though. A month earlier, he had a “foreign body” removed from his stomach, incurring an insurance claim of R7 329. Dexter’s owners paid the excess of R1 099 and Medipet paid out R6 230. In essence, according to Medipet, over a 30-day period Dexter’s veterinary costs came to over R16 000. Of that, the cost to Dexter’s owners was less than R2 500.
* Isis was taken to a vet with a lame left foreleg. It was decided she needed an MRI (magnetic resonance imaging) scan. Medipet paid for the procedure, and Isis’s veterinary costs eventually totalled R8 118. Medipet paid out R7 356.
* Tessa developed a lump (the treatment required a fine needle aspirate), had to be tested for erlichea (a tick-borne disease) and was diagnosed with immune mediated neutropaenia (a rare blood disorder). She ended up spending seven days in hospital and subsequently contracted pneumonia. The bill for her treatment came to R22 867; Medipet paid R19 437.
PetSure, another major pet insurance provider often recommended by vets, also has a choice of plans to suit individual needs, and makes the point that it doesn’t impose an upper age limit for accidental injury, “so even senior-citizen pets are covered”.
Not surprisingly, pet insurers do not cover congenital or hereditary defects, or conditions that are apparent before taking out cover. Check the small print before signing up and be sure to shop around.
CASE STUDY 1: THE FIGHT TO SAVE FERGUS
In 2015, Sharon and Michael and their family lost a long battle to save their Scottish terrier, Fergus – one of two in the family, the brother of Bonnie. Fergus was eight when he developed a persistent eye infection, which, despite continued treatment over some months, wouldn’t go away.
Michael recalls: “Between March and May, Fergus seemed increasingly listless, and was reluctant to eat. It was clear something was the matter. Initial tests showed he had an infection of some kind, associated with a high temperature. The first round of treatment – antibiotics – brought little improvement, and, as his condition worsened, he was admitted to a veterinary hospital.
“By this stage, he was in a bad way – not even a blood transfusion did much to change his condition – and it was clear something was very wrong. A battery of blood and other tests eventually revealed that he was suffering from a terminal condition; bone marrow failure. There was little we could do but make him as comfortable as possible and try to make him feel loved and cared for.
“Poor Fergus died at home in June. He was cremated and we have his ashes at home. Caring for a pet can never be reduced to a cash value; it always seemed worth whatever it was going to take to save Fergus. But it is pricey. All told, his treatment, and subsequent cremation, cost about R12 000.”
CASE STUDY 2: WHATEVER IT TAKES
Johannesburg retiree Diana Whitman has first-hand knowledge of the high costs involved in saving the lives of pets. A few years ago, she acquired a month-old rescue puppy from the SPCA, paying R400 for the privilege.
The collie-Alsatian cross, named “Shoes”, had been confiscated from a traffic-light vendor in terrible condition. The puppy spent a week in a veterinary hospital over the busy Christmas period, during which time it ran up a bill of R7 000. Against all odds, the puppy survived and thrived – until the day it snatched a chicken kebab off the kitchen table and promptly swallowed it, skewer and all.
Alarmed, Diana rushed Shoes to her vet, where he was X-rayed. Unable to spot anything, the vet ordered a gastroscopy, followed by a CAT scan, at which point the missing skewer showed itself. Lodged deep inside the dog’s digestive system, it clearly needed to be removed via an operation if Shoes was to survive. That cost a cool R12 000. Fortunately, the operation was a success, and Shoes continues to steal food from the table at every opportunity.
But the Shoes medical saga is not quite over. According to Diana, he has since exhibited symptoms of an auto-immune disease (probably traceable to his dodgy ancestry) and needs to be treated with cortisone. The cost? Anyone’s guess. And there’s more. After a second rescue dog, this one a Staffordshire bull terrier, showed signs of distress, it was determined that he needed a knee replacement. The bill: R17 000.
Diana says: “The vet told me that adopting a rescue animal is a wonderful thing, but, sadly, the widely held assumption that mixed-breed animals are tough and resilient is no longer true. These animals are often inbred, fed the most horrible rubbish and pick up diseases that are passed on from one generation to another.”
She doesn’t begrudge the money, though. “My pets have brought me great happiness. Shoes doesn’t get cross with me and never talks back.”
CASE STUDY 3: IN PURSUIT OF THE ‘GOLD STANDARD’
A one-year-old Labrador cross is brought in for chronic limping on his left hind leg. The initial consultation fee is R285, to which R1 500 is added for X-rays under sedation. The X-rays reveal that he has severe hip dysplasia and arthritis, and will require treatment for the rest of his life.
Next up: blood tests to determine baseline values before starting chronic medication, at a cost of R350. This is followed by monthly pain medication at a cost of R300 to R500 a month. A recommended diet to keep the dog’s weight under control and to slow down arthritis adds anything from R800 to R1 000 to the monthly bill. Physiotherapy is recommended, at a cost of R300 a session (for two to three months). Chronic medication consultations and blood tests every six months will cost between R300 and R700 a time.
It’s not over yet. After about a year, it becomes apparent that the pain medication is no longer controlling his symptoms. There are two options for surgery: a femur head and neck excision that can be carried out by a general practitioner (R5 000 to R6 000) or a total hip replacement that can be performed only by a specialist (at a rough estimate, R25 000 to R30 000).
After the surgery, it is likely that the dog will need physiotherapy and possibly further medication and regular check-ups. The treatment specified in this case represents the “gold standard”, according to Dr Ingrid de Wet, who is telling the story of her own dog.
“Unfortunately,” she adds, “this is an all-too-common scenario, and due to the costs involved, there are very many dogs that don’t receive even the basics of pain medication, let alone all the other treatments that are required.”