domingo, 22 de diciembre de 2013

I don't wanna be Oskar Schindler


Sometimes I find it troublesome to exert a medical specialty close in touch with what it is already and will surely be a limiting factor for survival and quality of life in the present century. Many of you may still be unaware of the fact that I'm an experienced endocrinologist holding a special interest for diabetes and metabolic disorders. I do my job every day in the greatest and most sophisticated hospital existing in the southern half of the Iberian peninsula (Spain and Portugal), some few center meters away from Las Vegas - something equivalent in Spain to the worldwide famous favela Rocinha in Rio -. That puts my job directly deep in the heart of the problem and in zone zero epicenter. I will clarify mi words.

If I write that income makes an inverse correlation with all-cause mortality, you'll show no astonishment at all. That mechanism works at a global scale, but it is especially painful in my country, where some decades of democracy and decentralization did nothing against national inequality. Moreover, inequality has sharpened as a consequence of the economic depression of the second decade of the present century. Probably, we now see a dim light or an outdoor for macroeconomic problems, but there seems to be no relief for personal and family day-to-day economic problems. At least on the medium term.

It is quite obvious to insist in the existence – in Spain - of a vector north-east to south-west in which income diminishes, unemployment grows, education offers poorer results and you find a higher prevalence of overweight, obesity, diabetes, hypertension and morbimortality of cardiovascular origin. Epidemiological maps say everything about these issues.

Such data allow me to state what I wrote above about zero zone epicenter of endocrine-metabolic and cardiovascular devastation - under which you find a non-modifiable structure of poverty and underdevelopment -. Nevertheless, one's responsibility puts you as a senior specialist in diabetes and obesity, both diseases consequences of genetics - that did not change to a great deal -, environment - that change a lot in the wrong way -, and social and economic deprivation. I could gain some insight in the analysis, but it exceeds the proposal of the post.

Maybe it’s better to take again the main story: it’s a well-known issue the fact that Big Pharma is marketing promising new drugs for obesity complicated with type 2 diabetes mellitus. With the old drugs, it was frequent to experience some mild hypo reactions and to gain some weight. The new ones lead you to some weight loss and avoid those inconvenient hypo reactions. You just need to substitute a new expensive drug (some twenty times more expensive) for a much cheaper, well known drug that has been decades in the community. For millions of patients. Every day. In a relentless progression. You just need to make the calculations.

Next problem: bariatric surgery, I beg you pardon: surgery for the very obese. “Making your stomach smaller”, as many patients usually call the procedure. Well, it works. It is by no means an experimental procedure. Perioperative mortality has attained a reasonable figure (1/200 to 1/300) in experienced centers, taking into account clear-cut benefits. ¿What are the benefits? I could say something about them just underlining something that would have sounded bizarre some fifteen years ago: significantly obese patients (BMI>35) having Type 2 diabetes and submitted to bariatric surgery have an elevated chance to get rid from diabetes after the procedure. As you read it. And, should the condition remain, it is much more easily treatable, insulin doses are tapered or insulin can be withdrawn at all. One of my colleagues currently following up postsurgical patients told me some years ago: “Federico… ¡Blood sugar simply melts away!” Just imagine the army of candidates to these procedures if you simply apply the well-examined cost-efficacy criteria of the British NICE about the issue.

Third: let’s talk about the progression of the problem. Almost everywhere in the world, but specially here in Southwestern Spain, in zone zero epicenter, figures depict a gloomy landscape. Population as a whole is progressively obese. Type 2 diabetes presents a debut at an age progressively more precocious. So, progressively we find more candidates for the medical or surgical treatments described above. You just need to place this in an aging society installed in a difficult-to-solve economic depression, holding chronic unemployment and a particularly fragile pension system whose future seems threatened by the weakness of its young base, that its scarcely populated and has very low wages.

Keeping a close relationship with the issue, some days ago I had the chance to have a look upon the famous Spanish cardiologist Valentin Fuster’s book “La Ciencia de la Salud” (The Health Science). I underline some words: page 307, under the epigraph “medicine will change society”, almost at the end of the page:
But unless we find a solution for people to keep contributing for the community – he writes about retired people – while they are in good health conditions, and I hope that we find them, we will find us in a dramatic situation: we’ll have treatment modalities to save ill people, but we’ll have no money to pay for them.”

It’s been some time now that I’ve been maintaining such an idea. Recently, in an intervention that I had the chance to have with common citizens in a rural area, I insisted about the use of life-style modifications as the most important mean to prevent disease or to stop its course once it has begun.

Because, otherwise, maybe that the gloomy- but sound - Fuster’s prophecy could come true very soon. And, knowing the behavior of Health Systems managers, both in my country and abroad, it could well be that people in charge of taking decisions could avoid any responsibility and put the pressure down, just saying: “money is limited; it’s you to decide how to spend…” And so, it is conceivable that somebody well placed in the power system could find it comfortable that health professionals began playing head or tails and making a painful Schindler’s list to select who is going to be treated, and who is not. Who is going to be treated today, who is going to be treated tomorrow and who can wait until next year. “Budget restrictions made money fly for the present year. There’s no more. Try your best in the selection.”

But that’s not by job, sorry to say. I refuse to be Oskar Schindler and to compose a therapeutic list. It’s you to assume your responsibility and make figures clear. See what it is affordable and what it is not. And speak frankly to people: “there is a wonderful treatment for your problem, but the Country Health System cannot pay for it.” Some other health issues are not currently being covered, isn’t it?


Some old youth memories come to my mind. That John Lennon of my early years with that (ingenuous?) “Power to the People”. Now, what I call the “health sugar candy tweet world” is always speaking about concepts that are actually frightening, like patient empowerment o information sharing. Patient empowerment means sharing all available information. That means transparence. That is to say: the basis for real freedom and democracy. What we can pay and what we cannot. What things are useful for and what they are not. And up to what point. And to set up real mechanisms to allow common people – who suffer and pay everything – to have concrete pieces of truth in order to make informed bets. Holding every card in hand.

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