Illusions of Progress

This appeared in the Sunday London Times:

A woman has conceived Britain’s first baby guaranteed to be free from hereditary breast cancer.
Doctors screened out from the woman’s embryos an inherited gene that would have left the baby with a greater than 50% chance of developing the cancer.

A few months ago I attended the funeral of an amazing woman who died of breast cancer. She was in her thirties when the disease was diagnosed. She valiantly fought this disease for six years. However, she did not live her life centered upon her cancer. She raised four children. She volunteered at school. She sent notes of encouragement to teachers. She was a loving wife and a faithful friend. Her funeral Mass was so packed with people it looked like Easter Sunday.

Do these people in Great Britain really think it would be better if this woman had never been born?

Another Community Reading Idea

Last week I suggested that developing a shared reading experience within a parish could be a valuable effort at both community building and catechesis. My pick to start this out was Because God is Real by Peter Kreeft. Let me add to the community reading list by recommending Catholicism and Society: Marriage, Family, and Social Issues written by Rev. Edward Hayes, Rev. Msgr. Paul Hayes, and James J. Drumey.

A couple of weeks ago I attended Mass at St. Raymond of Penafort Catholic Church. The pastor’s note in the bulletin included a recommendation of this book for summer reading. The parish uses this book for the ninth grade religious education program thus prompting the pastor to include an admonition to all parents who allow their children to stop attending religious education classes once they are confirmed in eighth grade: Read this book and see what your children will not be learning!

The subject of marriage and family are near and dear to my heart so I took a look at the book. I noticed it was published in 1997. I wondered just how relevant it would still be as we near the end of the first decade of the twenty-first century. I have now completed the first four chapters. I can tell you that it is not only relevant but it is outstanding. I can see why this book is used for high school religious education but I think it should be included in Pre-Canna classes as well. In fact, as the traditional institution of marriage and the concept of family are under assault by the secular forces of society, this book is an excellent primer for everyone on the Church teaching concerning marriage. These are not just random thoughts by the authors. They back up their assertions with references to Scripture, Second Vatican Council Documents, the Catechism and a myriad of papal writings.

Here is a sample:

Marriage is a sacred vocation. It is the state in life to which husbands and wives have been called by God from all eternity. Their meeting, attraction to each other, and decision to set up a Christian home are not the result of blind chance, but are part of the Creator’s divine plan. As instruments of God, husbands and wives are involved in a holy and noble undertaking. They have a responsibility not only for their own salvation, but also that of their spouses and their children. How important it is then that husbands and wives understand the earthly and heavenly ramifications of their state in life, and work to mold their marriages into the supernatural unions that God wants them to be.

Imagine an entire parish community that has taken the above paragraph to heart. Marriages would be strengthened. Families would be strengthened. Catechesis within the home would be strengthened making the parish religious education program richer. There is really no aspect of parish life that would not benefit from a community wide commitment to the principle of marriage as a sacred vocation. I urge you to read this book then pass it on to your neighbor. It makes an excellent gift for a newly engaged couple or anyone who is contemplating marriage.

Government, Health Care, and the Principle of Subsidiary Function

The comments in my last post on health care were thought provoking and insightful. I especially pondered Jonathan’s questions about “subsidiarity”. He referenced the papal encyclical Quadragesimo Anno by Pope Pius XI. I was not familiar with this document so I perused it on the Vatican web site. I think Jonathan’s comments refer specifically to this component of the document:

79. As history abundantly proves, it is true that on account of changed conditions many things which were done by small associations in former times cannot be done now save by large associations. Still, that most weighty principle, which cannot be set aside or changed, remains fixed and unshaken in social philosophy: Just as it is gravely wrong to take from individuals what they can accomplish by their own initiative and industry and give it to the community, so also it is an injustice and at the same time a grave evil and disturbance of right order to assign to a greater and higher association what lesser and subordinate organizations can do. For every social activity ought of its very nature to furnish help to the members of the body social, and never destroy and absorb them.

80. The supreme authority of the State ought, therefore, to let subordinate groups handle matters and concerns of lesser importance, which would otherwise dissipate its efforts greatly. Thereby the State will more freely, powerfully, and effectively do all those things that belong to it alone because it alone can do them: directing, watching, urging, restraining, as occasion requires and necessity demands. Therefore, those in power should be sure that the more perfectly a graduated order is kept among the various associations, in observance of the principle of "subsidiary function," the stronger social authority and effectiveness will be the happier and more prosperous the condition of the State.

I believe these paragraphs capture very well the principles that I think should guide government involvement in health care. Human dignity is preserved when personal responsibility is demanded. The function of the government is to act as a safety net. This net needs to be strong and tightly woven to ensure that everyone has access to a rationally defined minimum level of health care. This rational definition of the minimum acceptable level of health care needs to be based on science, principles of natural law, and the common good.

As I said, this is a safety net. I believe market forces will offer those who want to spend the money an alternative. Consider the government health care option a functioning un-air-conditioned Yugo. Private health care payment options are almost any other functioning vehicle on the road. Both will get you from point A to point B. The Yugo just doesn’t give you the style, comfort, gizmos, and gadgets of those other vehicles. If you want style, comfort, gizmos, and gadgets, the cost should come out of your pocket—not the taxpayer’s pocket. The task of designating which health care is standard equipment on a Yugo and which health care is optional equipment will require the wisdom of Solomon and a spine with Herculean strength.

In the comments of my previous post, Jim suggests that this has already been accomplished with the Medicare/Medicaid program. Not so. The Medicare system is focused on the care of senior citizens except for cases of premature disability. These senior citizens have contributed to the funding of their care through their payment of payroll taxes. Medicare is not a program of care for the indigent. It is not meant to be a bare bones program. These citizens have a right to expect some semblance of a return on their investment. Even so, many seniors do opt for a private insurance alternative. They assign their Medicare benefits to be paid to a private insurance company because they feel they get more for their money by joining one of these private HMO’s. Others want the luxury of getting more personal attention from their doctor. They pay a premium fee to join a concierge medical practice. They want more than the government can provide and are willing to pay for it.

Medicaid is a hodge-podge of programs mandated by the federal government and administered by the individual states. Eligibility and benefits vary from state to state. The benefits are highly influenced by local politics and emotions at the expense of rational deliberation. I believe trying to impose a government-funded program using Medicare and Medicaid as models would result in an overwhelming tax burden. I also believe that while private industry may not have your good health as its primary objective, the market incentives to produce a quality product (health care) in an efficient manner will serve patients better than a socialist styled government program.

An example of this is evident in my experience trying to arrange physical therapy appointments for my daughter. Tricare stated the local military physical therapy facility has the capacity to provide care for my daughter. Therefore, they will not pay for her to receive care from a civilian provider. Fair enough. However, when I call the military facility to schedule her initial appointment that needs to be within five days of her surgery, I am told there is nothing available for at least two weeks. I go back to her surgeon who puts pressure on Tricare to either have my daughter seen within five days by the military provider or refer her to a civilian provider who can see her in the appropriate time frame. A second call to the military provider then produces an appointment. What changed? My daughter’s appointment was labeled as a new post-operative evaluation. The computer template for appointments did not have any slots designated for new evaluations available. When I called the second time, the front desk employee got up from his desk and obtained the authorization needed to change one of the follow-up slots to a new evaluation slot. My first phone call had reached someone who was unwilling to make that effort. Instead, she just insisted there was no available appointment in the prescribed time frame. She was willing to let appointment slots go empty and physical therapists stand idle instead of doing what it takes to appropriately serve the patient. In a privately run facility those empty appointment slots are directly reflected as a negative factor on the balance sheet. Such indifference to filling appointments would not be tolerated. It really doesn’t bother me that the motivation is profit instead of an altruistic vision of providing health care. The result is the private facility is more responsive to a patient’s health care needs. The patient is better served.

Therefore, to return to the idea of subsidiarity, I think the government does have a role in providing a safety net of necessary health care for every American. However, this safety net should not be considered the standard for health care. It should be the minimum amount of health care each individual is entitled to based on the principles of human dignity, natural law, and the common good.

Of course, in a topic this big and controversial, this is not the end of the discussion. I think we need to look at how those not utilizing a government run safety net pay for health care. I do not think the employer based insurance system works because workers change jobs too frequently. I like the idea of individual health savings accounts because it incorporates portability with personal responsibility. I'll save further discussion of this for a future post. Let the comments begin!

Prayers for a Safe Journey are Continuing

Sometimes you just have to say a prayer of thanksgiving and believe that your guardian angel was on duty. My parents are making the drive back home to Texas after spending some time with me here in Virginia. This afternoon stopped at a Cracker Barrel in Tuscaloosa for a bite to eat. While they were eating my dad glanced out the window and noticed a policeman was checking all the cars. They had left their dog in the car so my dad went outside to make sure all was okay. He was greeted by dozens of law enforcement officers, guns drawn and ready for action. They instructed him to immediately get in his car. He tried to explain that his wife was still inside and was told not to worry. They would get her out. Don’t worry—right! He called my mother on her cell and told her about the police and instructed her to leave immediately. Of course she found a manager and asked to pay her bill first, but he told her to just go on ahead and not worry about it. He didn’t tell her why. She cracked the main door to the restaurant and the police whisked her out. My parents quickly left the scene as the SWAT team was arriving. A police helicopter was circling ahead. When my mother called to tell me about the events she said it all seemed like a dream. She had no idea what was behind the police activity. A few hours later I found this on the internet. I’ve got a candle lit and am continuing to pray that the rest of their journey is uneventful.

A Community Reading Experience

I just finished reading Three Cups of Tea by Greg Mortenson and David Oliver Relin. It is a very interesting and inspiring book. It recounts the amazing mission of Greg Mortenson as he builds one school after another in the remote reaches of Pakistan. There are many thoughts to ponder after reading this book: Fear of failure should never stop us from trying to minister to the needs of others. We cannot impose humanitarian aid upon others. Rather, we must offer it within the context of their culture. The road to peace requires a universal respect for human dignity.

The reason I happened upon this book is that Rice University sent it to all the incoming freshmen so my daughter received a copy. The intent is to have all the freshmen read the book before arriving at Rice so that they will all have a common experience. This reading experience will cut across ethnic, gender, and geographic boundaries in the hopes of forming a stronger community.

A common reading experience by itself is probably inadequate to change community dynamics, but I do appreciate the principle behind this initiative. In fact, I think a parish could benefit from something similar. I envision the parish designating a book as a parish reading project. Everyone in the parish is encouraged to read the book, including the priests. Hopefully the priests could work the reading into their homilies every now and then. An occasional reflection about the book could be put in the parish bulletin.

If I were going to pick a book for my parish to try for such a project, I would begin with Peter Kreeft’s Because God is Real. I’ve written how this book is being thoroughly enjoyed by thirteen and fourteen year old boys. My seventy-something father picked it up this past week and found it a worthwhile read as well. Therefore, this is a book that will span the age ranges and speak to a wide variety of parishioners.

I know that the designation of a parish book is not going to suddenly turn our parishioners into religious bookworms. But I do think this project may pick up a new reader or two. It may be just the baby steps we need to foster a culture of adult religious education. As I stated above, fear of failure should not stop us from trying.

Recovery has begun

My heartfelt thanks to all who offered prayers for my daughter. I truly felt supported by your prayers. Her surgeon has proclaimed her ACL reconstruction a success. There were no surprises during the surgery. He said it was a textbook ACL injury and a textbook repair. Now comes the months of rehabilitation. I guess she can feel that she is in good company as she forges ahead. The next few months will be a painful struggle. There will be a lot of "offering it up". But at least the first steps have been taken on the road to recovery. Thank you again for your prayers.

A Sacrament of Service

I know I said I would be posting more on health care and I most certainly will do so. There are some great questions and perspectives to discuss in the comments of my last post. However, this weekend brought another topic to mind: vocations. Sunday’s Gospel reminds us the harvest is abundant and the laborers are few. On Saturday our diocese added three new priests to its cadre of laborers. Yet Holy Orders is only one of two sacraments of service. The sacrament of Holy Matrimony is the other sacrament of service.

This past Saturday we were honored and blessed to celebrate the 50th wedding anniversary of my parents. Our parish pastor celebrated their marriage at the morning Mass. The readings were those that are often used in the wedding Mass. Father’s homily spoke of the tremendous grace of the sacrament of marriage. Having all of their children as well as many of their grandchildren present was a testament to my parents’ legacy of love. More importantly, the public celebration of this wedding anniversary at a parish Mass served as a powerful witness for this sacrament.

Like Holy Orders, Holy Matrimony is a sacrament that requires discernment. It is a calling. It is a ministry. It is a vocation. Too often this vision of marriage is lost. Instead of seeing marriage as a calling to serve God through marriage, couples focus on the romance, the pageantry of a wedding, and the promise of earthly pleasures. Faithfully living the vocation of marriage is not a guarantee of earthly happiness, but it is a pathway to eternal joy. Just as God made each of individually to love Him, to serve Him, to adore Him here on earth so we can be joyful with him forever in Heaven, God calls the married couple to jointly love Him, serve Him, and adore Him here on earth so they can find true joy with Him in Heaven.

I think of my husband’s and my own pre-Cana classes. There was a great deal of checking out our compatibility with each other, but there was very little if any discussion of what we were supposed to do with that compatibility. I don’t remember any reference to marriage as a vocation. It is readily apparent that a man is not necessarily called to the priesthood because he thinks the job looks like fun and he enjoys hanging out with priests. A man and woman are not necessarily called to marriage because they enjoy each other’s company. Rather, they are called to the sacrament of Holy Matrimony if they feel compelled to join their lives in the service of God’s will. Are they ready to emulate the Blessed Mother and respond, “Fiat!” when God presents them with the twists and turns of life? Are they ready to humbly obey and faithfully live this vocation as it is revealed by Holy Mother Church? Are they ready to accept the demands, responsibilities, and sacrifices of married life? Do they see their marriage as the founding of their domestic church?

Our secular culture has perverted the institution of marriage from a sacrament of service to a pathway to earthly pleasure. The fragility of marriages, the high divorce rate, the number of couples cohabiting and the push for homosexual marriages are the consequences of this hedonistic view of marriage. If the only purpose of marriage is to be a pleasant past time, why should a couple work to strengthen and preserve their relationship through hard times? It is so much easier to move on and look for happiness elsewhere.

That is why we need to celebrate anniversaries like my parents. Their marriage began standing before God and proclaiming their willingness to serve Him together. This landmark anniversary is celebrated in the same way. After fifty years they still stand before the Altar of God and offer their assent to His will. Their response to the vocation of marriage serves as a model for those of us who follow in their footsteps.

I Humbly Request Your Prayers

Scheduling my daughter's surgery to reconstruct her ACL has resembled flying on space available status. Originally we were told to expect surgery during the first week of July. However, the surgeon's travel schedule necessitated it be moved to June 20. We went in for the pre-op visit yesterday and found out that the operating room schedule was too full on June 20 so they have moved the surgery up to tomorrow. Please say a prayer for her and for all those taking care of her. I will keep you in my prayers as well. Thank you.

Framing the Health Care Debate

I posted about my Twilight Zone experience of navigating access to military health care for my daughter’s knee injury. My point in the post was not to lambast the military health care system. Rather, my intention was to point out that a government run system is not the panacea for our ailing health care system. That our system is ailing cannot be denied. Health care providers are not happy. Patients are not happy. And nobody’s pocketbook is happy.

In 2002 I spent a year in an academic setting studying the American health care industry. It was a very informative year. I had been practicing medicine for over fifteen years at that point and I had witnessed first hand the evolution from standard fee-for-service medicine to the managed care rationing of services. This year of study gave me a much broader picture of the American health care system.

Let me begin by saying there is no universal definition of health care. Everyone is shouting for universal health care but I haven’t heard anyone define what that means. There are true health care needs and then there are health care wants. Defining what is a need and what is a want is fraught with political perils. Childhood immunizations are a need. Basic prenatal care is a need. However, does every pregnancy need an ultrasound? Probably not. That is sometimes a want.

Every disease and affliction has a lobbying group demanding government support for their specific ailment. It is the role of the government to provide for the common good of the governed. However, not all health care is for the common good. The challenge is to adhere to the principles of natural law and the dignity of each human being and meet the true health care needs. There also must be an element of personal responsibility in providing for health care. Lack of insurance coverage does not always mean lack of access. This is a very small-scale example of what I mean: I had a mother bring her feverish child into the emergency room. After diagnosing her illness I was able to give her samples of an antibiotic and we had given the child a dose of acetaminophen for the fever in the ER. The mother was furious with us because we had no acetaminophen to give her to take home. She complained bitterly that she had no money to buy acetaminophen for her child. My nurse noted that for the cost of the cigarettes in the woman’s purse she could buy acetaminophen. This woman made a personal choice to buy cigarettes for herself instead of medicine for her child yet she was angry that someone else wasn’t taking care of her child’s needs.

Let me offer a very rough analogy. Auto insurance offers coverage for damage incurred in an accident. It does not cover routine maintenance. Therefore, automobile owners must budget for oil changes, tires, and other maintenance. Health insurance offers a wide variety of coverage options. Depending on the product you buy, some medical options will be covered and some will not be covered. Somehow many have gotten the idea that we should never have out of pocket health expenses. The truth is the cost of health care will always come out of our pockets. It will either be a direct payment to the provider, a tax payment to the government or a premium payment to the insurance company. Do you really think a government bureaucracy will provide a higher quality service, more efficiently and at a lower cost than a private enterprise?

I do believe that it is objectively possible but politically perilous to define what is basic health care. Governments have a responsibility to ensure each of their constituents receives this basic health care. I also know that if basic health care is accurately defined based on scientific evidence, there will be great wailing and gnashing of teeth as people find out their favorite medical option is not included in a taxpayer funded medical plan. A great deal of the health care Americans receive is actually elective care, and not medically necessary care. Taxpayer funding should only go to necessary care. I also believe every American should then feel free to purchase whatever bells, whistles, and frills he wants for his health care. Whether it is purchased by direct payment to the provider or by indirect payments to private insurance doesn’t really matter.

This approach means that not every American will receive the same level of medical care. But it does mean that every American is entitled to and will receive some basic level of care. Our current system has by default set the safety net at life-threatening acute conditions. Anyone with a gunshot wound, blunt force trauma, or cardiovascular collapse will be whisked to the local emergency room and medically stabilized without regard for payment ability. What is not available and should be available to every American is primary care and prevention for illnesses like hypertension and diabetes. When it comes to primary care medicine we have a system of “haves” and “have-not’s”. We need to move to a system of “haves” and “have-more’s”. This is very hard to sell, politically. However, to demand uniformity in health care delivery is to ensure mediocrity for all and excellence for none.

There is much more to say on this topic and I will be posting more in the near future. Consider this post as the initial foundation for a more detailed discussion later.

Powerless

I was going to post this picture a couple of days ago. I picked my first blue hydrangea of the season. The timing is just about right. The peonies have finished and now the hydrangeas are stepping in to fill my vases. This little vase also holds an Our Lady of Guadalupe rose and some stems of penstemon, also known as beard tongue.

So why the delay in posting? Around 3:00 PM on Wednesday we had a horrific storm sweep through the area. I have never seen such a powerful storm develop so quickly. It seemed like only a matter of seconds that we went from partly cloudy skies to dark menacing clouds, driving rain, and 70 mph wind gusts. Of course we lost power and we weren’t alone in our powerlessness. Close to 300,000 households were affected. I was busy lighting candles and not just for illumination. As the storm swept through my older son was driving home, my youngest son was at his piano lesson, and my husband was at work. I was sending up a lot of prayers since we were so scattered. My older son made it home safely and once the worst of it passed through I used his car to go retrieve my youngest from his piano teacher. Believe me when I say the prayers continued. The entire area was without power, many roads were closed due to fallen trees and power lines, and most of the traffic lights were not functioning. When I say they were not functioning, I do not mean they were flashing red or yellow. I mean they were dark. Driving in the DC metro area with functioning traffic lights can be a challenge. Navigating without traffic lights was a nightmare. I am certain the guardian angels were on high alert to get us home in one piece. My husband made it home after the first storm and before the second band of severe storms passed through. We hunkered down for the night.

Nights like this remind me of the absolute joy of family time and make me resolve to push for it more often. With no electricity there was no email, IM, Facebook, or internet games. Even our cell phone service was hampered by the storm so the text messaging was curtailed. My college aged son, my high school senior, and my middle schooler all sat around and played Sorry! by candlelight. My husband and I just relaxed and enjoyed their happy conversation.

The power returned after we went to bed. We are the lucky ones. Many are still without electric power and we are expecting dangerously high temperatures this weekend. Please keep all those affected by these storms in your prayers.

I am praying for all those who are still dealing with the aftermath of these storms. I am offering prayers of gratitude that we came through unscathed. I am also offering thanks for the reminders this storm provided. Our joy does not depend on the electricity flowing through the power lines and all the technology that it fuels. The inconveniences of the electric power outage are insignificant compared to the happy times generated by the power of a loving family.

Dizzying Loops of Government Health Care

As the political candidates make more and more promises this election season, please add a very large grain of salt to any promise for government sponsored health care. The following is an account of how I spent my morning:

At 6:00 am I called the central appointment scheduling at the National Naval Medical Center in Bethesda to schedule a follow-up/pre-op appointment for my daughter. I did this because when I tried to make the appointment last week, the call center clerk told me my daughter’s doctor’s appointment template would not be available until today. The clerk who took my call today informed me that she could not make this appointment because it had to be made with the clinic directly. Of course, I had specifically asked the doctor, the orthopedic clinic technicians, and the front desk personnel how I should make my follow-up appointments and they had all told me to call the central appointment scheduling. Nonetheless, this call center clerk told me I must call the clinic and she gave me a phone number. When I called this phone number I was directed to “press one” to schedule an appointment. I did so. This directed me back to the central appointment scheduling number where the same clerk again said I had to call the clinic. I spoke to the call center supervisor who confirmed that his clerk could not make this appointment. In fact, he told me that he didn’t see anything in the system that showed my daughter was entitled to care so the clinic had the option to refuse to see my daughter but probably wouldn’t since they had seen her before. He had no idea who had taken my call last week and insisted that it was not one of his employees. He said I must have called a different call center. I only have the phone number for one call center. I only know one number to call. He had no idea how I could have called his call center number and spoken with someone that didn’t work for him. He had no interest in helping me obtain appropriate care for my daughter. His only concern was for his call center employees and stonewalling any attempt for me to get help through the call center as I was told to do by the orthopedic clinic. Please note this was all done before I had my first cup of coffee for the day. I think it was only by the grace of God that my response was no harsher than a tersely spoken “Thank you very much.” At this point I am in an infinite loop. I call the central appointment scheduling center that refers me to the clinic that refers me back to the central appointment scheduling center.

Being somewhat resourceful, I call the phone number on the doctor’s business card. This takes me to the voice mail of the nurse manager for my daughter’s doctor. You cannot leave messages at this number. This number directs you to call another number for all patient concerns. I call this number and actually talk to a real person. He tells me he cannot help me. He is just the front desk receptionist and is only there to answer phones and direct the calls to appropriate people. He directs my call to “the person who can help me”. My call is directed to the voice mail of the nurse manager who directed me to the front desk receptionist who routed my call back to the nurse manager. This is infinite loop number two.

I do have a fax number for the clinic. I faxed a letter with a plea for help to the clinic. The fax did not go through. The clinic has been open for over an hour, but they have not turned on their fax machine. I called that nice front desk receptionist and he directs me to the office with the fax machine. The young lady on the phone sounds somewhat helpless as she tells me she is not sure why the fax machine is not accepting faxes. She promises to give my name and number to the nurse case manager. It has been over an hour and I have not heard anything.

I did find email addresses for both the nurse case manager and the doctor. I emailed them both.

I have no doubt the doctors, nurses, therapists, and other health care providers at the National Naval Medical Center in Bethesda are top notch. I also know that accessing these providers for anything other than routine health maintenance is a Herculean challenge. In addition to a follow-up appointment with her doctor, my daughter needs pre-operative physical therapy. The Tricare referral system cannot get her into this therapy for at least three weeks. This experience is not unique to this facility. In fact, the National Naval Medical Center is by far the best-run military medical center I have ever worked with in the last twenty-seven years. This includes the time I spent as an active duty Air Force physician. I assure you the nightmare scenarios I have seen at other facilities make this twilight zone experience of infinite loops seem efficient.

I am not sure what the answer is to make sure every American gets access to the health care he needs. I do know that putting everyone into a government run health care system will ensure that no one gets the health care he needs.

UPDATE: I didn't realize that when my fax machine gets a busy signal or no response, it tries again later. Several hours after I tried to fax my plea for help getting an appointment my fax successfully got through. My written plea must have sounded pretty desperate because I have had three phone calls from different clinic personnel wanting to help me. I now have an appointment scheduled. As I said, there are some great folks providing very good health care at NNMC. It is just the bureaucracy that governs access to this health care makes me feel like a solid stone wall is between me and the care I or my family needs. The only way to reach this care is to climb over or tunnel under the wall.