The real face of lack of access to health care

.

I have often written about the fact that lack of health insurance is a major source of cost for the health system. People without insurance often cannot afford to pay doctors or buy medications, and so do not seek care for treatable illnesses until they are so far gone that they can no longer be ignored, and then show up in the Emergency Room and require admission and treatment for advanced disease (for example, in Does the nation need a clear policy on a right to basic health care?, April 10, 2009). The cost is not only enormous in human terms -- treatable diseases converted into much more serious conditions because they haven’t been treated -- although this is the most important. It is also much more costly in terms of actual health care dollars, as these advanced conditions are much more difficult and expensive to treat.

However, as in every area, what affects us most are not the data or the statistics, but the individual stories of individual people.  These are the stories that touch our hearts because they we can identify with them – they could be our stories, or those of our friends or neighbors or relatives. These are the stories that make the evening news, the stories that might persuade a legislator to become interested in a problem, the stories that motivate us to send a donation to a worthy cause.

This was brought home to me very starkly when I recently served as the attending physician on our inpatient service in the hospital. We take care of a lot of patients, and they are very sick. Their medical diagnoses varied: kidney failure, diabetic ketoacidosis, malignant hypertension, severe asthma exacerbation, infections in a variety of places, etc. But, really, the most common diagnosis was lack of access to health care, mainly because of lack of health insurance. While not all these people are poor, they, like most people, have limited incomes, and have many other basic needs (rent, food, caring for their children) that compete with health care for the dollars available. Asymptomatic diseases (or conditions with “tolerable” symptoms) often seem to be a lower priority.

I’d like to share some of their stories, although obviously I cannot share their names or present too many actual details about them; I’ll make up initials and change some details that do not affect the essential issues. These are real people, with real names and real problems.

·     AG has diabetes and high blood pressure. (These two conditions, diabetes and high blood pressure, are going to be a recurrent theme; they are the mainstay, most-common, diseases of any general adult medicine practice. They are treatable, but when not well controlled their complications -- strokes or kidney failure or heart attacks or amputations – are also major contributors to the work of many subspecialists: cardiologists and endocrinologists and nephrologists and neurologists and surgeons and orthopedists, just to name a few.) AG had lost his job, and while unemployed and without health insurance he hadn’t been going to the doctor. Luckily, his chronic diseases weren’t bothering him much, except for a small sore on the bottom of his foot. High blood pressure often causes no symptoms, until the stroke or heart attack; foot sores in diabetes are a big threat, because the disease both diminishes the sensation of pain, so it doesn’t hurt much, and the circulation of blood so it doesn’t heal well, but the lack of pain makes it seem not so bad. He finally found a job, a reasonably good job with the promise of health insurance after a while. Unfortunately, it involved walking almost 20 miles per day, not a good thing for his foot. The foot developed a severe infection, requiring expensive hospitalization for intravenous antibiotics, and might still need to be amputated.

·     PS also has diabetes, which, especially when untreated, makes one susceptible to infections, and he has had several of them. Now, in late middle age, he presents with a very serious infection, requiring not only intravenous antibiotics, but surgery to clean out the pus, resulting in an open wound. A machine attached to drain out the residual infection and keep it clean will need to be regularly replaced, for many weeks as he continues the intravenous antibiotics. Fortunately (should you ever be in a similar situation), home health can be arranged to provide these services. Provided you have health insurance coverage. Oh yes, and a home. PS has neither. Makes follow-up care a little more difficult.

·    DR is a good deal younger but also had a severe infection requiring long-term antibiotics for a foot infection, after an unsuccessful attempt at outpatient treatment. And, yes, his diabetes is uncontrolled because he hasn’t had insurance and so hasn’t gone to the doctor or taken his medicine in quite a while. He also had lost over 80% of his kidney function, so he’ll be on dialysis soon. There is a “silver lining” (!); thanks to a law passed early in the 1970s, anyone with end-stage kidney disease requiring dialysis is eligible for Medicare, so he will be insured. Of course, the cost to Medicare will be far, far more than would have been the treatment of his diabetes, had he had coverage before the “end stage”.

·     MT will also become insured through this wonderful program, although her kidney failure is due mainly to untreated high blood pressure rather than diabetes. As I noted above, high blood pressure is often asymptomatic (thus the sobriquet “silent killer”); she didn’t have insurance or money so didn’t go to the doctor to find out how uncontrolled it was, as it slowly destroyed her kidneys.

Not all of our patients’ problems came from diabetes or infections, and not everyone who is uninsured is poor.

·     KF has asthma, pretty severe asthma, for which he was taking an inhaler to be able to breathe. It is a bronchodilator (airway-opener), the right drug for an acute attack, but KF’s attack never went away and he was taking far more of it than was safe. And spending an awful lot of money on it. It is available for a much lower cost at some pharmacies that provide certain generic medications for $4, but he didn’t know that. He does now, after being in the hospital for a week getting expensive breathing treatments. It’s a good thing, too, because the other inhalers that he needs to prevent (or at least decrease the frequency and severity of) these attacks, steroids and sustained-release bronchodilators, cost a lot, well over $100 per inhaler. They have been around for a long time, so one would expect that by now at least some of them would be available generically and cheaper. But there’s a great story here. The propellant in these inhalers used to be fluorocarbons, but these, as we know, destroy the ozone layer and contribute to a lot of bad environmental effects. So they were made illegal, and the pharmaceutical manufacturers had to replace them with environmentally safe propellants. Good for the environment. Unfortunately, bad for KF and millions of other people with asthma; using a different propellant meant that the drug was a “new formulation”, which allowed the drug makers to extend their patents for many years. So low-cost inhaled steroids are still not available. This is a cruel joke, but it is not a joke. The pharmaceutical companies will not suffer; only patients will.

AG, PS, DR, MT, and KF were all people we cared for in one week, and they were not the only ones with a primary diagnosis of lack of health insurance coverage. Of course, we also took care of lots of sick people with health insurance; I don’t work in a “safety net” hospital. People with insurance, even with good insurance (and certainly not all insurance is “good”, not all insurance covers necessary medications and tests) also get serious diseases and need to be hospitalized. But the people whose stories I have told, and others I have not discussed, stand out because they didn’t have to be as sick as they were and require the costly services that they did. That they were, and did, is not only immoral and bad medicine, it is bad economics. It is inexcusable.

Maybe DR and MT would not have had kidney failure and need dialysis if they had Medicare or any other kind of coverage before needing it. Maybe everybody should have Medicare. In a future blog, I’ll discuss the proposals to “save Medicare” that are currently being floated, but now I’d just like to have some thought given to saving these actual people. Got any ideas?

.

The Sharp End of Ideology

.
This powerful piece was written by Robert Ferrer, MD, MPH, who has previously written guest blogs. It is too bad that the pundits and policy wonks will not see it.

On any given day there are five to ten of them on our hospital service. In the room that our clinical team uses to discuss patients we reserve one of our two white boards just for them. As a group they are defined by three characteristics: they have suffered from diabetes for many years, they have lacked steady health insurance and medical care, and they are in various stages of dismemberment. Uncontrolled diabetes has damaged their blood vessels, and the ensuing gangrene or bone infections brings them to our hospital, where we care for their medical problems while the surgeons amputate toes, feet, or lower legs. The patients often lose these parts in sequential episodes as their circulation worsens and the complications progress.

Most are men, and many of them are younger than you would expect, in their late thirties or early forties. Almost all have been recently working, though the operation they now require will usually end their employability in the blue collar jobs they occupy. When we ask when they last received regular care for their diabetes, the only mystery is where they*ll fall in the range from "a year ago" to "never". And therein lies what makes these complications especially sad, because with patient education and periodic low-tech evaluations, most of the amputations could have been prevented.

The fact that they are so often not prevented emerges from an unhappy synergy between two epidemics: diabetes and uninsurance. Among large American cities, San Antonio ranks near the top for both; a quarter of its residents lack health insurance and about 1 in 10 have diabetes, though in the less affluent parts of town the diabetes statistic is closer to 1 in 4. Being poor puts one at risk for both diabetes and being uninsured, but being poor in particular locales is especially risky. What those locales share is stingy public insurance programs, (for example, the earnings ceiling above which adults with children no longer qualify for Texas Medicaid just 26% of the federal poverty level -- about $5200 for a family of four -- and, as in most states, childless adults without disabilities don*t qualify at all), and many jobs that don*t come with health insurance. In many cities, as in ours, a large number of undocumented immigrants also add to the number of uninsured.

So there are three of the big conundrums of national heath care reform: the scope of public insurance, expanding coverage under private sector insurance, and what should be done about non-citizens. (A fourth, costs, will come up later). Framed in this way, as bloodless policy questions far removed from the daily realities of the ward, the urgency is drained out of them. Raised yet another level of abstraction higher -- Socialism! -- the debate becomes an absurd joke, the cruelty of which will be felt by those who will needlessly lose limbs in the coming years if reform fails yet again.

For the patients who occupy the beds on our wards -- high-risk people in low-benefits occupations living in a low-services state -- the list of responsive policy options seems very narrow. The realistic options are heavily regulated public or private plans based on large risk pools and with adequate subsidies to ensure that cost is not a barrier to regular care. Less important than the exact mechanism, however, is that there be a path to coverage short of losing a leg, becoming disabled, and qualifying for coverage through disability benefits. As for the non-citizens, our county decided in 1997 to respond to the compelling local needs by creating a publicly funded plan that allows the working poor to access full-spectrum health care on a sliding repayment scale. Hard-liners may balk at reform that even considers these types of arrangements, but what is the alternative? Deporting people with gangrenous limbs or failing kidneys? Continuing to provide only expensive, last-minute rescue care?

Although we have much yet to learn about controlling health care costs, one clear message is that preventing complications among high-risk patients with chronic disease will yield important savings. A typical hospital bill for a diabetic patient having an amputation runs to $10,000 or $20,000 or more, not because of the surgeon*s fee, but because the patients* other diagnoses, often including antibiotic-resistant infections and failing kidneys, complicate their treatment. Investing in access and regular care before a crisis occurs saves money - as well as limbs, kidneys, and hearts.

Meaningful reform cannot be postponed any longer. George Orwell wrote that in political discourse, *words fall upon the facts like soft snow blurring the outline and covering up all the detail.* Through the seasons of debate, the the urgent needs of those suffering for lack of care have been buried beneath the snow of words. But those needs are still there, regardless of the political calculations. To pretend that there is not a way forward to a workable conclusion coldly discards the opportunity to ease the suffering for millions of our people. If that happens, many will feel the metaphorical phantom pain of another lost opportunity for reform. And a smaller subset of the vulnerable among us will experience the real thing.
.

Penyebab dan Tipe Diabetes Mellitus

Diabetes terjadi jika tubuh tidak menghasilkan insulin yang cukup untuk mempertahankan kadar gula darah yang normal atau jika sel tidak memberikan respons yang tepat terhadap insulin. Ada 2 tipe Diabetes Mellitus, yaitu:
1. Diabetes Mellitus tipe 1 (diabetes yang tergantung kepada insulin)
2. Diabettes Mellitus tipe 2 (diabetes yang tidak tergantung kepada insulin, NIDDM)
Penyebab diabetres lainnya
• Kadar kortikosteroid yang tinggi
• Kehamilan diabetes gestasional), akan hilang setelah melahirkan.
• Obat-obatan yang dapat merusak pankreas.
• Racun yang mempengaruhi pembentukan atau efek dari insulin.
Sulit Terbaca
Gejala awalnya berhubungan dengan efek langsung dari kadar gula darah yang tinggi. Jika kadar gula darah sampai diatas 160-180 mg/dL, maka glukosa akan dikeluarkan melalui air kemih.
Jika kadarnya lebih tinggi lagi, ginjal akan membuang air tambahan untuk mengencerkan sejumlah besar glukosa yang hilang. Karena ginjal menghasilkan air kemih dalam jumlah yang berlebihan, maka penderita sering berkemih dalam jumlah yang banyak (poliuri). Akibatnya, maka penderita merasakan haus yang berlebihan sehingga banyak minum (polidipsi).
Sejumlah besar kalori hilang ke dalam air kemih, sehingga penderita mengalami penurunan berat badan. Untuk mengkompensasikan hal ini penderita seringkali merasakan lapar yang luar biasa sehingga banyak makan (polifagi).
Gejala lainnya adalah pandangan kabur, pusing, mual dan berkurangnya ketahanan tubuh selama melakukan olah raga. Penderita diabetes yang gula darahnya kurang terkontrol lebih peka terhadap infeksi.
Pada penderita diabetes tipe 1, terjadi suatu keadaan yang disebut dengan ketoasidosis diabetikum. Meskipun kadar gula di dalam darah tinggi tetapi sebagian besar sel tidak dapat menggunakan gula tanpa insulin, sehingga sel-sel ini mengambil energi dari sumber yang lain.
Sumber untuk energi dapat berasal dari lemak tubuh. Sel lemak dipecah dan menghasilkan keton, yang merupakan senyawa kimia beracun yang bisa menyebabkan darah menjadi asam (ketoasidosis).
Gejala awal dari ketoasidosis diabetikum adalah rasa haus dan berkemih yang berlebihan, mual, muntah, lelah dan nyeri perut (terutama pada anak-anak). Pernafasan menjadi dalam dan cepat karena tubuh berusaha untuk memperbaiki keasaman darah.
Bau nafas penderita tercium seperti bau aseton. Tanpa pengobatan, ketoasidosis diabetikum bisa berkembang menjadi koma, kadang dalam waktu hanya beberapa jam.
Bahkan setelah mulai menjalani terapi insulin, penderita diabetes tipe 1 bisa mengalami ketoasidosis jika mereka melewatkan satu kali penyuntikan insulin atau mengalami stres akibat infeksi, kecelakaan atau penyakit yang serius.
Penderita diabetes tipe 2 bisa tidak menunjukkan gejala-gejala selama beberapa tahun. Jika kekurangan insulin semakin parah, maka timbullah gejala yang berupa sering berkemih dan sering merasa haus. Jarang terjadi ketoasidosis.
Jika kadar gula darah sangat tinggi (sampai lebih dari 1.000 mg/dL, biasanya terjadi akibat infeksi atau obat-obatan), maka penderita akan mengalami dehidrasi berat, yang bisa menyebabkan kebingungan mental, pusing, kejang dan suatu keadaan yang disebut koma hiperglike mik-hiperosmolar non-ketotik.

Ternyata Kafein Tingkatkan Level Gula Penderita Diabetes

Beberapa peneliti Duke University Medical Center, North Carolina, AS, menemukan kafein mampu meningkatkan level gula darah penderita diabetes.

Karena itu, penderita diabetes harus mengurangi konsumsi kafein agar mampu mengendalikan lebih baik level gula darah mereka. "Ketika seorang penderita diabetes mengonsumsi sedikit saja kafein, terutama sesudah makan, maka glukosa gula darah meningkat di sepanjang hari," ujar ahli psikologi medis Duke University Medical Center James Lane.

Lane memaparkan, kafein berbahaya bagi penderita diabetes karena kafein mengganggu metabolisme glukosa. Kafein ditemukan pada kopi, teh, dan banyak minuman ringan. Diabetes adalah kondisi ketika seseorang memiliki level gula darah terlalu tinggi. Ketika seseorang memiliki level gula darah terlalu tinggi, dia terancam risiko kerusakan mata, ginjal, dan syaraf.

Diabetes juga dinilai dapat menyebabkan penyakit jantung, stroke, dan amputasi. Diabetes memiliki kaitan erat dengan obesitas (kelebihan berat badan). Penemuan terbaru ini berlawanan dengan penelitian sebelumnya yang berupaya mencari kaitan diabetes dengan kafein. Penelitian sebelumnya berpendapat, konsumsi kafein dapat mengurangi risiko diabetes dan orang yang mengonsumsi kafein paling banyak memiliki risiko diabetes paling kecil.

Namun, penelitian terbaru ini dinilai lebih akurat karena para ilmuwan menggunakan teknologi baru, yaitu alat pemantau level glukosa yang ditanam di bawah kulit perut. Alat itu ditanam pada sepuluh orang yang berusia rata-rata 63 tahun.

Ketika para relawan diberi empat tablet berisi kafein setara empat cangkir kopi, padahari tersebut level gula darah mereka meningkat 8 persen lebih tinggi daripada hari ketika mereka tidak mengonsumsi kafein

Meniran berkhasiat obati diabetes dan diare

Luar biasa! Suatu tumbuhan yang tumbuh secara liar, biasanya dapat ditemui di daerah seperti di tepi sungai atau bahkan pekarangan rumah (daerah lembab dan berbatu), ternyata memiliki khasiat sebagai tanaman obat. Sekarang ini, bahkan sudah ada (dijual) produk obat dalam bentuk sirup ataupun kapsul yang terbuat dari tumbuhan ini! Meniran (Phyllanthus niruri) nama tumbuhan berkhasiat obat ini.

Meniran tersebut, diantaranya, memiliki khasiat untuk menurunkan kadar gula darah dan antidiare. Namun, selain khasiat ini, berdasarkan hasil dari berbagai penelitian yang telah dilakukan, masih banyak lagi khasiat yang telah diklaim dimiliki oleh meniran. Wow!

Kandungan

Lantas, apa sebenarnya kandungan yang dimiliki meniran? Berdasarkan penelitian yang telah dilakukan di berbagai negara, berikut adalah kandungan yang dimiliki meniran:

a. Lignan (filabnerntin, hipofilantin, filtetralin, nirantin, nirtetralin, nirfilin, nirurin, niruriside, filtetralin, lintetralin, isotetralin dan filnirurin)

b. Terpen (cymene, limonene, lupeol dan lupeol acetate)

c. Flavonoid (quercetin, quercitrin, isoquercitin, astragalin, rutine dan physetinglucoside)

d. Benzenoid (methylsalicilate)

e. Lipid (ricinoleic acid, dotriancontanoic acid, linoleic acid dan linolenic acid)

f. Alkaloid (norsecurinine, 4-metoxy-norsecurinine, entnorsecurinina dan phyllochrysine)

g. Alkanes (triacontanal dan triacontanol)

h. Steroid (beta-sitosterol)

i. Vitamin C dan K.

dari: myhealthblogging.com