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vendredi 29 juin 2012


I have just attended a fabulous professional meeting of the (American) Endocrine Society in Houston, Texas. Believe it or not, there were 8000 participants, divided among Clinicians and Researchers.
All the Endocrine systems were covered in detail.
Race and Culture do matter in metabolic diseases where there is a huge lifestyle component. While admitting that Type 2 Diabetes is the worst treated disease in the USA, Professor Davidson, was able to show multiple differences in obesity rate, treatment adherence rate, outcome rate among various groups of Spanish speaking immigrants and their children, the so called, “Hispanics”.
Surprisingly, Asian Indians living in America (belonging to Pakistan, India, Nepal and Bangladesh) had the highest rate of Type 2 DM of all the residents of the USA! Obesity rate among Asian Indians born in America is at the same level as the American born Mexicans!  I have a cultural explanation on why “Indians” die fifteen years earlier when they migrate to the west.  Acculturation leads to unhealthy behaviour.

A plethora of new drugs to combat Type 2 DM were paraded by professorial peons from the academia. None of the newer drugs can quantitatively improve Type 2 DM control at a level comparable to Lifestyle modifications: whether it is prevention or treatment. The apologists for the newer drugs that improve Diabetes control by a mere 0.7 % begin their drama: When the Lifestyle is no longer feasible…as if Lifestyle is just another pill which has lost its efficacy.

Why are Metabolic Diseases such Obesity and Type 2 DM are (a) so poorly treated and (b) so poorly controlled?
(a)        Responsibility of the doctor
(b)        Responsibility of the patient
There seems to be a discordance between (a) and (b)
It seems that what the doctors are capable of doing does not chime very well with what the patients of capable of…A Medical Anthropologist would call it, a Conflict of Explanatory Models.
The fact that there exists programmes (such as in Cambodia) peer educators who themselves were patients once upon a time, advise and educate the patients in a non-clinical setting. And the fact that the control of Diabetes at is higher than what one can find at the offices of a Family Practitioner or Endocrinologist in the USA or in the Diabetes Clinics at Universities in the USA.
With MINIMAL medications (Metformin, Insulin and Sulfonylureas) and MAXIMAL counselling and comforting, better control has been achieved in one of the poorest countries on earth (Cambodia) than the richest country in the world. It is accomplished at a cost that is only a minute fraction spent on this disease in the western countries. When the sugar does not come down, the first consideration is counselling about Lifestyle since it is what contributes most to the control in this programme, among other social forces.
The cost of Health care is driven up by the Disease Care providers (the doctors) than by the DISEASE.
I will give you an example.
My sister who has survived one breast and two lung cancers went to see a Dermatologist about a small patch of alopecia areata (bald spot in the hair), came back with orders for the following blood tests, which included:
FH.LSH, PROLACTIN, DHEA, ESTRADIOL, TESTOSTERONE, T4, T3, TSH, UPTAKE along with normal tests (CBC, Metabolic Panel etc.)
My sister and I along with her Family Practitioner is concerned that the Dermatologist may have received a hefty proportion of these tests thus ordered, the total costs may be between 1000-2000 dollars! Irrelevant tests to the problem of Alopecia Areata! Who is driving up the costs of care for Alopecia Areata? The disease or the dermatologist?
Let us talk about the patient. Why are they reluctant to listen to the patient? Various studies in many countries have revealed a similar pattern.
-Perceived prejudice of the doctor against your culture (no wonder Vietnamese patients choose to go to Vietnamese doctors)
-Lack of trust in the knowledge of the doctor. Medical advertisements and the media play up drugs and weight loss programme and increase the expectations of the patients. The approval of a new anti obesity drug, Lorcarserin, was covered by all major news channels as well as all the on line news agencies! Lorcarserin can make you loose 3% of your body weight, so if you weight 180 pounds, you can expect to loose at the end of one year of swallowing the pill at a very high cost, about 5 pounds. Lifestyle changes are much cheaper and healthier to boot. Internet, Media has increased the chasm of lack of trust in the provider.
-Inability to pay for the unnecessary or irrelevant drugs even when you have insurance
Lantus is the trademark of Glargine Insulin, long acting insulin; it can be bought in the form of a pen with prefilled syringes that may last a patient 10 to 15 days. Cost is over 600 dollars and even if you are billed 20 per cent by the insurance companies, you may have to pay nearly 100 dollars. For people with limited incomes, 200 or so dollars per month for medications is certainly burdensome… here in the richest country on earth!
Instead of reaching out for the prescription pad (supplied to you by the drug companies in many cases) Doctors could spend (and learn to) on advice to change the lifestyle of the patients. (An overweight or obese doctor is very seldom effective; it goes without saying, in persuading the patient to change his or her lifestyle)
It is cheaper for the doctor to reach out for the prescription pad and write the newer medication, justifying that lifestyle and other medications have all failed. But the failure may not be due to medications. However effective a medication may be, as one Surgeon General had reminded us, it is only good if it is taken!
(Capitalism American Style, an ad in Financial Times for Investment company)
Responsibility for health is a shared concern. Patients occupy a different space-financially, culturally –than the providers. Patients need a little help with COACHING to improve their HEALTH, they need an advocate. They turn to their doctors looking in them for a Coach and Advocate but they are deeply disappointed.
As my colleague among the Indians has repeatedly said: It is with the heart that one looks after a patient with Diabetes and not with the mind.