Insulin and Eugenics... I am upset. This is a rant.

As a type 1 diabetic, I am often very angry. Usually this is secondary to hypoglycemia or an ability to eat something because I inadvertently left my insulin at home.

But today I am upset because I am running out of insulin and I only have $600 left in student loans until late February. Why is this a problem? Because as someone with good medical insurance, my doctors have always prescribed me humalog and lantus, which are bloody expensive without a prescription (and are actually still really expensive with a prescription and insurance: $50 each for what I need in a month). But as a medical student I don't have time to go see a doctor to get a prescription to get my bloody f***ing insulin. I am really upset because as I speak I have about enough humalog (lispro, short-acting insulin) to get me through to Monday, after which I guess I'll start employing a poor man's metformin: large amounts of acetaminophen and straight hard liquor. Your liver transaminases skyrocket, but you've effectively bludgeoned your body's best organ so badly that it stops going through with gluconeogenesis. Oh, and a ton of aerobic exercise makes your body more sensitive to the effects of lantus (glargine, long-acting insulin), so I guess I can look forward to dropping a few pant sizes and... cirrhosis. Lots of preventable, freaking cirrhosis.

I don't know what I'm supposed to do. There must be type 1's who are busier than me and have less time to see doctors. And I know there are type 1's who don't have health insurance because this country is absolutely terrible. So how can I get insulin at a reasonable price without having to see a doctor? Because, honestly, I've had diabetes for over ten years and I know my body's personalized ways of dealing with this disease in a way that literally no other health professional could understand. I know the tricks. I know the secrets of my metabolism. My A1c is always under 7.0 and my hypoglycemic events are now well controlled. I know what I'm doing.

SIDENOTE... no wait, MAIN POINT: I think it is absolute bullshit that people need prescriptions for something that their body erroneously stopped producing. Almost everyone else around me is making insulin, but just because my body f***ed up when I was thirteen, I have to spend thousands of dollars on a month's worth of high quality insulin? What kind of justice is that? Answer: it's not. It's wrong. It's condemning people to a constant economical disadvantage on top of the disease they've contracted who's co-morbidities will likely kill them if they don't control the aforementioned disease. In a country where medications aren't regulated to make them fairly priced (hell, I think they should be bloody f***ing free but I realize I'm incredibly biased) and health insurance is severely limited, we are essentially killing off diabetics. I realize that many type 1 diabetics can make it to reproductive age without dying first, but I've seen a 24 year old diabetic with f***ing gastroparesis--that's really severe neuropathy. And now that I've gone through OB-GYN, it becomes apparent that type 1 diabetics with A1c's of 13.6, like this 24 year old, would never be able to carry a healthy child to term. She will likely never produce any children because why? Because our health system is unjust? What sick kind of world is this?

And you know what's worse? The type 1 diabetic population that is under insured and hurting the most is minorities, specifically blacks. And you know what's f***ing insane about that? DIABETES IN AFRICAN POPULATIONS HAS NO DISCERNABLE GENETIC COMPONENT. Whereas caucasian type 1 diabetics usually have some weird HLA inherited predisposition sh*t. And yet, at least in Chicago, those people will be preferentially allowed to live with a disease that could be greatly reduced within the human population if only they were put to the slow and painful death that awaits most uninsured type 1 diabetics.



[edit]: Okay. So I calmed down a little bit. Let me just say that I recognize that a lot of white people don't have health insurance either. But at least in Chicago, economics and race are obnoxiously linked in a way that has already started to upset my psyche. So I'm sorry about that. The truth is, all type 1 diabetics are in an equally unfortunate place in a society where close health maintenance is ludicrously expensive.

And also, I don't think I do a good job of separating my emotion's from the job. Especially other type 1 diabetics so far along. Seeing another black, 24-year-old, type 1 diabetic, laying on a bed in the emergency department, clutching at her stomach and moaning for morphine, secondary to gastroparesis and then her resultant addiction to painkillers, really upset me I guess. I want to help them but I know that it's literally too late because you don't recover from severe autonomic neuropathy. You just suffer until you die. From something completely preventable.

I guess this whole thing bothers me, not just because on the whole diabetics are treated very poorly, but because I'm now a healthcare professional, and I am surrounded by physicians every day, but I don't think I can just ask them to write me a prescription for insulin because I'd rather go to work than call the doctor's office to set up an appointment, then call the dean of student affairs (another physician), and then the clerkship director (also a physician), and then drive to god knows where for a fifteen minute conversation with the doctor to write me a prescription so I can save $350 for something that almost everyone in the world doesn't think about.

It's upsetting. If I had my way, everyone with a type of medical/biochemical deficiency would be able to get whatever they need for next to nothing because that's what equality is. Hypothyroid? You get thyroxine, no problem. Chronically depressed? We'll get you an SSRI or maybe even some SNRI's if you're lucky and need more norepinephrine. Diabetic? We'll get you all the insulin you want. Because giving you anything less than that is a crime.




So this is where I read that Diabetes in blacks and asians is often idiopathic: http://www.aafp.org/afp/1998/1015/p1355.html
Although since I am both caucasian and african, I won't know if I have the idiopathic form until either A) my entire genome gets sequenced (I hear it's only $1000 now!) or B) they look for islet cell antibodies in my serum.

Hassling with the "Need" to Medicate Mental Conditions

I think I'd be a great psychiatrist:

1. I like sitting.

2. Physical exams are my worst competency in clinicals.

3. I have several mental conditions (possibly), but I most definitely have one.

4. I treat people with mental conditions like people.

5. I see people with mental conditions as people.

Now let me elaborate:

In clinical neuroscience we end up watching a lot of patient interviews. One day we saw one with a schizophrenic. Later, me and a group of people got into a discussion, and I was the only one on my side of the argument, which was basically, the person seemed fine and functional enough, and why should we deem him “flawed”?

Yes, he had once been an irritable and a frequent assaulter. But on medication, he seemed talkative—enough, he had moods—enough of them, and he seemed normal—enough.

[One small point, shouldn’t normal be set by the patient? For example, when I was depressed, I knew I didn’t want to be depressed, and I considered the feeling abnormal and I wanted it corrected. But if I have occasional hallucinations that I enjoy, why change that? Or if I have synesthesia? That’s enjoyable. Right? And like, all famous actors have dyslexia. And they talk openly about it and it seems normal now, although you could easily argue it’s not.]

No one agreed with me. "Here," they said, "is a deeply troubled man. He assaulted over 100 patients, nurses, and doctors at his first hospital—etcetera etcetera. He was barely lucid. He wasn’t making sense. He wasn’t talkative."

But these things seemed normal to me. The great variance of human personalities also includes medically treated schizophrenics.

And why are we so eager to eliminate imperfections? Even the term imperfections makes it sound like there’s a one true normal (there isn’t) or that there’s only so many ways a person can be functional (there aren’t). I don’t want to sound like the preachy 2^nd grade teacher you were scared of because they loved diversity thiiiiiiiiiiiiiiiiiiis much, but in all honesty, I hate the idea that mental illness has to always be treated and that we all automatically look down on people with mental illness because society has trained us to fear the abnormal, especially the mentally so. I’m not just saying this because I have a mental illness, but as a person who has known, talked to, interacted with, and dated people with mental illnesses, I say we should all work on the way we see others with DSM-logged disorders.

If you’re born with something, you shouldn’t have to awkwardly try to hide it constantly. And while most mental illnesses aren’t entirely genetic, many of them have a strong genetic component. Even more importantly, if you don’t want to hide it, you shouldn’t be forced to.

Schizophrenia an interesting mental illness. While I haven’t yet studied the topic enough to know if most schizophrenics are violent, I do know that public perception of schizophrenics paints them as violent.

[Side note: There was a great episode of Law & Order: SVU that involved a schizophrenic who appeared to have killed the woman who was in charge of his group home. No one trusted him and he was in a panic for the entire episode. Until the person who murdered the woman murdered him. I rarely cry watching law shows. I bawled.]

Most schizophrenics probably don't want schizophrenia. But what if they don't mind it? Similarly, most people with bipolar disorder I don't want it, but what if they don't mind it? Should we medicate people? And when we do, are we actually doing it to protect others? Or are we just doing it to quiet an imperfection, an imperfection we are holding on with us and projecting onto the larger world? I think this is especially a problem for doctors, who control so much power to change a person's life. Wouldn't it be best to understand what quality of life such a person wants first?

Gotta Catch 'Em All

I only have to collect heart, kidney, liver, and lung disease before I win something!

Got my flu shot today. It was actually awesome for two reasons: 1) it was the first time I ever got to check yes to the question: "Are you a healthcare worker?" and 2) needles just keep getting smaller! It was literally painless.

It was also, somehow, free. So thanks America, for always having my back (it's the least you could do after you presumably gave me asthma.... we need cleaner air damn it!!!) But still, Walgreens' Pharmacy, specifically at my Walgreens, is always a pleasure and has re-instilled my faith in  health care.

Now I just need to find a family physician... to deal with my multitude of health problems (see above).

Drug Surplus

I am perusing the notes for tomorrow's clinical biochemistry lecture. We are going to be discussing high cholesterol and how to properly assess risk for the condition. I love cholesterol.

Let me tell you why:

High cholesterol runs in my family, on my mother's side (German). My great-grandmother, who passed away recently at the age of 101, lived most of her life with a total cholesterol level greater than 200 mg/dL. The healthy average is around 160 mg/dL. Hypertension runs on my dad's side of the family (Nigerian). His blood pressure was 200/140mm Hg (normal 120/80), before he cut salt out of his diet and it fell back to normal. My generation, a chimeric mix of German and Nigerian traits, is now at a high risk of getting both conditions, which is a well studied recipe for early death.

But so far, at age twenty-two, I'm pretty healthy. My blood pressure has always been normal. I exercise a lot. I am slightly overweight, but that's just because BMI is useless for people afflicted with big bones. My diet is pretty healthy; I eat many more servings of fruits and vegetables than the average American my age. But I am at an "increased risk" for heart disease because I have diabetes mellitus. I still do not understand why I am at an increased risk if I am a type I diabetic. I don't think I've ever been told or have ever read that type I diabetes puts people at an increased risk for cardiovascular disease. So why do I have to worry about my cholesterol?

Well, first, my cholesterol actually was a little high. The first time I can recall being conscious about my cholesterol was when my lipid panel was reviewed by my adult endocrinologist. She immediately put me on Lipitor. At the time I thought whatever would make me healthier, I'd do. As a "lay person," I trusted my physician entirely. When I did my lipid panel screening again, about a half year later, my numbers were lower--they were better--and she kept me on Lipitor. I became suspicious. So I checked my numbers. The lab results always provide a normal range, so I reviewed it. Both times, my numbers were excellent. I mean, not excellent, but they were normal and I was healthy.

So why the Lipitor?

A risk assessment is used to judge whether or not a patient should consider changing their lifestyle (eating, exercising) habits or if they need to be more pro-active and be placed on a drug-enhancing regimen (Lipitor), Diabetes--but they never say which type--is considered a high risk factor. But that's the only risk factor I have. The risk assessment formula says that if I have 0-1 risk factors, my low density lipoprotein (LDL, the bad cholesterol) goal should be: <160 mg/dL. Guess what? It was! HIPPA be damned, I'll tell you what my LDL cholesterol was: 132 mg/dL. If it had been above 160 mg/dL, according to the assessment chart, a lifestyle change would have been recommended. Only at 190 would I need a more intensive pharmaceutical intervention. So why was I put on Lipitor?

Well, it helped. My total cholesterol was 190, my HDL was 43, and my Triglyceride was 77. A year later with Lipitor, my total cholesterol was 195, my triglyceride was 56, as was my HDL. And my LDL was a greatly reduced 128 (sarcasm).

But you know what made me even healthier according to the scale and charts and assessments? First, I gave up on Lipitor after my second lipid panel screening. Why? Because the pharmacy said I didn't have any more prescriptions and I didn't feel like calling my doctor to get me more. Second, I turned twenty-one. And around six months into being twenty-one, I realized that I loved red wine. I also started cooking more often and realized that olive oil is a good substitute for butter in almost everything. At age twenty-two I had another lipid panel screening. This time, my total cholesterol was 167, HDL 64, triglyceride 55, LDL 92.

Hmmm....

I know they're just numbers, but "statistically" I was much healthier.

What am I suggesting? That diabetics be given red wine earlier than age twenty-one? No. Never. Although...

In all seriousness, drugs are great. But they aren't a cure-all. Especially when it's something that can be heavily modulated by simple lifestyle choices. Look at America. There are serious health issues we need to address. But should we prescribe drugs after a problem arises? Or should we try to tell people what they can change in their kitchen and in their lives to make them healthier by their own volition? Drugs are great, and I don't want to argue against their over prescription in America, but when I'm placed on a drug to lower cholesterol, it would be great if I was told how this problem arose and what I can do, myself, to make it better.

Boiled down, what happened to me was simply a problem with patient empowerment. If you give your patients advice that is comprehensive but also understandable, their adherence should be higher, and as a result, they should be healthier. Doctors are important. We need more of them. But perhaps what's even more vital than quantity is quality, specifically as it deals to communication. A patient should know that sometimes, they are their own best medicine.

Drug Shortage

Perhaps a continuing theme of my writing's will be concerned with how few doctors there are. As previously noted, there is a shortage of primary care physicians in America. There is also a shortage of podiatrists. But did you know, that there is also, right now, a shortage of drugs in America?

I was just watching the national news last week when Diane Sawyer told me that the lack of prescription drugs in America was having real health consequences in America, with an estimated 15 deaths caused from drug shortages in the last year. Fifteen deaths. It doesn't sound that terrifying or even wrong if it's applied to something expected to be deadly in America, like Swine Flu or even just the regular type of influenza. But fifteen is a lot of lives lost if you consider that these afflictions were 100% treatable. I know morality and ethics tend to devolve into an annoying morass of public opinion sometimes, but if these people wanted to be alive yet couldn't make it because their health care providers couldn't provide the appropriate medicine, and then they died, that's wrong. Blatantly, offensively, inexcusably wrong. If I want to live, I should be afforded as much help as medically possible.

And do you know some of the theories behind why there are suddenly drug shortages in the nation that has the best health care in the world? Like everything else that's wrong with this country's politics, it's because of money. One of the suspected reasons drugs are suddenly hard to come by is because patents for some of the largest drugs have run out, which means they can start being manufactured and sold as cheaper generics from the non-original company. This means that the original company stops making as much of their product because they know they will lose profit as other pharmaceutical companies increase supply by mass producing generics. Except when they don't. And then, well, you know, people die.