When a rabid fox bit nine people by the Capitol Hill grounds last week, D.C. Health called on anyone who had interacted with the creature to get in contact to determine whether they should undergo rabies treatment.

The series of shots is the only known way to prevent a rabies infection from taking hold — rabies itself is considered universally deadly once symptoms begin.

But while it is essential for survival, the first treatment alone can cost more than $15,000 in D.C., leaving patients with unexpected bills and medical debt.

Caitlin Bergstrom woke up early in the morning at her Mount Pleasant group house to a bat flying around her bedroom five years ago. Through internet searches and advice from doctor friends, she learned that bat bites aren’t always visible and that medical professionals advise undergoing rabies treatment for any close interaction with the flying mammals.

First, Bergstrom took a ride hailing service to an urgent care facility. That’s where she learned that she needed to seek treatment at an emergency room, because ERs are the only places that reliably have the necessary shots. She was living paycheck-to-paycheck at the time and was concerned about what the bill might be. Ultimately, though, she sought the treatment.

“For something like this, the alternative is death so what are you going to do?” says Bergstrom.

Dr. Tenagne Haile-Mariam, an emergency medicine physician at George Washington University Hospital, says the medical community sees rabies as a “uniformly fatal disease to humans … with incredibly rare, heroic exceptions.”

Without treatment, the virus travels from the bite up the nerves, heading towards the spinal cord, and ultimately the brain.

The infamous “foaming at the mouth” symptom is “not really so much foaming as it is the throat muscles spasming, which is incredibly painful,” says Haile-Mariam. “From the time it enters your body, you need to be fighting it so that it doesn’t take root in the central nervous system.”

The first step in the multi-part rabies treatment includes two drugs: a rabies vaccine and a shot called rabies immunoglobulin. The latter medicine is an antibody made from human donors’ blood and essentially prompts the immune system to fight off the rabies virus until the vaccine kicks in, explains Haile-Mariam. The immunoglobulin is injected directly into the wound or bite — or as close as is possible. Then, patients receive three more vaccine shots over the course of the next two weeks.

The immunoglobulin is the most expensive part of the treatment. Bergstrom’s immunoglobulin cost about $8,000, she says, which her insurance covered. Each dose of the rabies vaccine averaged around $500, plus emergency room fees. Even after she hit her insurance deductible, she still had to pay thousands of dollars out of pocket. She put a lot of those charges on a credit card, which took months to pay off.

Her experience tracks with a Vox investigation that found American families incurred “significant medical debt from rabies treatment.”

Elena Humphreys had an encounter with a bat on the C&O Canal this past August. Like Bergstrom, she wasn’t sure whether the bat bit or scratched her, but was advised to undergo the rabies treatment. After going to the emergency room, her insurance was billed $16,430 for the initial immunoglobulin and shots. The Centers for Disease Control says that, across the country, a course of rabies immunoglobulin and four doses of vaccine typically ranges from $1,200 to $6,500.

Humphreys’ insurance and the hospital are currently in a claims negotiation, she says, and she’s waiting for the other shoe to drop. “There is that $16,000 expense out there that I think partially should be covered, but I’m not sure how much,” she says.

Foxes, like raccoons and bats, are considered “reservoirs” of rabies, says Haile-Mariam. Basically, whenever animals that are generally wary of people seek out interactions with or act aggressively towards humans, medical professionals will most likely advise rabies treatment, especially if the animal can’t be observed.

D.C. Health tracks its annual rabies testing results. (The only conclusive rabies test requires brain samples from the creature, which is why the animals are euthanized prior to testing.) The vast majority of tests come back negative. Bats are most frequently tested in D.C. — 105 in 2020, per D.C. Health, 99 of which were negative — and raccoons mostly commonly have positive results. (Bergstrom says she wishes she had trapped the bat to undergo rabies testing — if it had come back negative, she could have forewent the treatment.)

Haile-Mariam says that rabies treatments are reliably found in emergency rooms because there isn’t enough demand to keep the shots in every doctor’s office or urgent care clinic. According to the Centers for Disease Control, about 55,000 people annually undergo the treatment.

But that arrangement also contributes to the cost of the treatment. “When you have to go into a hospital, even for only the emergency room part of it, that’s certainly likely to be a higher cost than an urgent care center,” says Jack Hoadley, a research professor emeritus at Georgetown University’s McCourt School of Public Policy.

D.C. Health did not respond to repeated inquiries about whether all nine people bitten by the fox had begun rabies treatment, or whether there was any assistance available to them.

Ximena Bustillo, a Politico reporter who was one of the nine people bit by the fox on Capitol Hill grounds last week, received a call from D.C. Health on Wednesday after the animal’s rabies test came back positive. (The fox was captured and euthanized last Tuesday to perform the rabies test. The fox was a mother whose three kits were discovered Wednesday and euthanized over rabies concerns.)

Bustillo went to the emergency room on Tuesday after the fox nipped at her ankle from behind, and received the first dose of her rabies treatment — or so she thought. After talking to DC Health, she realized that she got the immunoglobulin and a tetanus shot, but didn’t receive her first dose of the rabies vaccine.

On Wednesday, she returned to the hospital to get the rabies vaccine. Sorting through all of the confusion took the better part of the evening, but now she is on track to complete her treatment on time.

So far, Bustillo has paid a $60 co-pay for one of the emergency room trips and has filed for worker’s compensation, because the fox bit her while she was on the job. She expects to spend many more hours sorting through all of the bills and logistics, long after the rabies treatment itself concludes.

“I’m still in the process of figuring out how insurance and worker’s comp will handle all of the visits, and that’s unfortunately a time-consuming process that no one has time for,” she says. “Luckily, Congress is out of session, so hopefully that will give me some time.”