mercredi 20 juin 2012

THE AMULET EFFECT: SOCIAL ASPECTS OF DIABETES CARE


WHAT IS AMULET EFFECT IN THE CONTEXT OF MEDICAL/HEALTHCARE  (dedicated to Dr SB at Pine Ridge Indian Health Services)
Health is not an absence of Disease
Medical Care or Disease Care is not synonymous with Health Care.
Disease care providers, mostly MDs, and more and more Nurses and other mid level providers  (in the USA there are Physician Assistants, Nurse Practitioners) and other technical staff including Pharmacists are in the picture when there are manifestations of DISEASE are present in the individual BODY of a patient (A person is converted into a Patient when such manifestations are present). There is any consideration for CULTURE, Society, and Explanatory Models of Sickness of the individual patient.
Health care on the other hand, goes beyond the individual, in our case, involves the entire tribe and the extended family in the kinship system. A person has ILLNESS and he resents the attempts by the Disease Care Provider to objectify it into a DISEASE without proper explanation. (This contributes to the non-adherence to medications and other prescriptions_
In our context, the Disease Care Provider has to take into account that our patients do not exist in a vacuum and there are extended effects of the words of the Provider and their actions and their medications.

On a recent visit to the Pine Ridge Indian Reservation, we were involved in a long discussion about Culture, Disease and Illness in the context of Diabetes Epidemic among the Indians.
I happened to mention that regardless of the state or status of the provider in various parts of the world, the measures of Diabetes Control varies only by a little
Control of Blood Sugar is defined, generally, as HgBA1C below 7% and it is around 30 % all around the world:
Whether it is a Primary Care Provider in Miami or
An Endocrinologist in Private Practice in Los Angeles
Indian Health Service Clinics and Hospitals in any part of the USA or
VA Hospitals and Clinics in the USA
What was surprising to me was that it was very similar in many other situations, some very dire, around the world!
The rule-crazy, diligent Singapore; war torn Basra in Iraq, where trying to get medical care might get you killed or Qatar where they are eating themselves to death!
Then the erudite doctor, S.B, listening to my talks asked,
Could it be an Amulet Effect? That a patient, or at least some of them feel well with the encounter with the Doctor, Nurse, Nurse Practitioner or Physician’s Assistant or Pharmacist or Technicians?
Being a cultural anthropologist, I had to say YES!

The uniformity of the results shows the effect what we can call the Amulet Effect- as a result of that encounter some persons have made changes in their quality of life to achieve the result, and in others the Amulet Effect did not work for more than just symbolic reasons.
American Indians have always told me that of all the ingredients in their health care, what is the most important is the Relationship they establish with the provider regardless of the status of the provider.
Most of the patients with Diabetes in this world, do not have access to the newer Insulin or the newer injectable or oral medications such as the Incretins but all of them can have access to Metformin (shown to be the most effective drug in the treatment of Type 2 Diabetes, especially in the first few years of diagnosis, one months supply can be had for about one dollar in many poor countries)
The Amulet Effect encourages Lifestyle changes, improves the quality of life, thus the uniformity of the results

To get better results than this, we do not need the newer medications that bring down the A1C a fraction of a percentage at an extreme cost but we need changes in the society that increases the quality of life for the society as a whole
Whether it is in the war zone in Iraq or
In an Indian reservation where they have no access to good food

Or the United States of America where an average person ingests close to 100 pounds of chemicals per year
If Diabetes Type 2 or Cardiovascular Diseases are labelled and touted as Lifestyle Diseases, then the answer is Lifestyle modification made easy by creating appropriate societal conditions.
Social Illnesses are not healed by newer Incretin medications. The answer for these diseases is not in the Doctor’s Offices, Clinics or Pharmacies.


Dr Emerson, CMAJ, 1986, talking about Disease and Illness:
For terms whose meanings

are not clear and whose uses are partly judgemental, a proper definition should be required.
Prof Marshall Marinker, Medical Humanities, 2000
Disease then, is the pathological process, deviation from a biological norm. Illness is the patient's experience of ill health, sometimes when no disease can be found. Sickness is the role negotiated with society. 

 BBC showed part 1 of 3 The Men who made us FAT. I will upload the link later.