Endocrine Ethics Blog

On the 12^th anniversary of Hurricane Katrina, another devastating hurricane and flooding situation is ongoing with Hurricane Harvey in the Houston area. But there are some new lessons learned from Katrina when it comes to the impact of hurricanes on people with diabetes: preventative ethics.

On the 10^th anniversary of Katrina, I wrote this, which largely reminded us about the terrible health disparities in plain view among a largely African American population of hurricane victims: http://endocrineethicsblog.org/2015/08/

Since Katrina, the endocrine community has become much more aware of the impact of natural disasters when it comes to diabetes care. Here are some “real time” postings in anticipation of Hurricane Harvey, and the large diabetic population that is being affected.

Several diabetes organizations and drug companies are now offering targeted help to people with diabetes, on display here:

https://www.diabetesdaily.com/blog/helping-hurricane-harvey-victims-with-diabetes-477597/

https://diatribe.org/hurricane-harvey-diabetes

http://www.jdrf.org/press-releases/american-diabetes-association-jdrf-insulin-life-respond-catastrophic-flooding-due-hurricane-harvey-texas/

With more hurricanes to come in 2017, diabetes disaster planning, at least, has gotten a little better from the painful lessons of Katrina. But how many hurricanes will it take for there to be recognition that climate change is a public health menace, requiring major reform in carbon emissions policy? “The answer, my friend, is blowin’ in the wind…”

This has not been a good month for anyone in the world. But there has been some especially bad news about diabetes this month, too.

On Veteran’s Day, the International Diabetes Federation called upon the G20 world leaders — who were about to meet in Turkey Nov 15-16 — to discuss a sugar tax to help reduce, and pay for the global disease burden of both obesity and diabetes.

Diabetes has now emerged as the biggest “killer disease” globally, surpassing HIV, tuberculosis and malaria combined. (See: http://www.reuters.com/article/2015/11/12/us-health-diabetes-sugar-idUSKCN0T100K20151112#C30Xvj0aGKKIX2MZ.97 and http://www.huffingtonpost.com/entry/diabetes-deaths_5643e784e4b08cda348777bf).

The IDF compared the crisis in diabetes to the global financial crisis of 2008, and pointed out that the global economy is at stake if we cannot get the epidemic under control. Currently 415 million adults globally have diabetes (the largest number of cases are in China), and we spend $673 billion in diabetes care. By 2040, one in every 10 adults in the world are expected to be diabetic, with cases projected to reach 642 million with healthcare spending on diabetes to reach $802 billion.

Then the Paris attacks of 11/13 happened, and no one in Turkey talked about diabetes. And fewer Americans talked about turkey. Instead, the global response to the Paris ISIS attacks dominated all discussions. Once again, the U.S. is faced with debating sending ground troops to fight a war – perhaps even a world war. This time, we’re going to need a lot of troops, and resource allocation is a problem. Our strained, all-volunteer military is exhausted after multiple tours in Iraq and Afghanistan.

Here’s where all this connects.

In the U.S., we don’t have enough fit people to even recruit into the volunteer military because of obesity issues. See: http://www.motherjones.com/mojo/2012/12/most-americans-are-still-too-fat-defend-america

In fact, my first blog was about this problem. See: http://endocrineethicsblog.org/childhood-obesity-and-national-security-widespread-consequences/

The number of ground troops needed from the U.S. to fight ISIS is estimated to be around 50,000 (see: http://philadelphia.cbslocal.com/2015/11/18/former-military-strategist-significant-ground-troops-needed-to-defeat-isis/).

If we need that many, we’re going to have to bring back the draft. (In fact, Russia just did that last month).  It may be that bringing back a draft, along with a sugar tax, would also solve the “diabesity” problem. Our young adults would be forced to get fit. Our older adults would consume less sugary foods, and would even help pay for the war.

Is it ethical to have a draft? At times, it is ethically justified to have a military draft; WWII met that criteria. And maybe, in the face of this heinous threat, now would be a good time to bring it back. Making our young adults fit could not only combat the obesity threat at the same time, but may prolong more lives, even when weighing the risks of putting them in harm’s way.

Not quite the usual Turkey talk in November, but that’s how Diabetes Awareness Month went down in 2015.

Today marks the 10^th Anniversary of Hurricane Katrina, which revealed alarming data from an “accidental” 2005 diabetes care study funded by “Mother Nature” in a state that ranked at the time 48th in levels of health insurance, 45th in public health, and 50th in overall health (See: http://www.ncbi.nlm.nih.gov/pubmed/16239669).

This event revealed clear health disparities to the average television viewer. The incidence and co-morbidity of diabetes and/or diabetes complications in the population that stayed behind — the lower income and largely African-American community — overwhelmed the ability of public health agencies to respond in this national emergency (See also: http://www.ncbi.nlm.nih.gov/pubmed/16373918 and http://www.ncbi.nlm.nih.gov/pubmed/16221772 )

Diabetes complications interfered with evacuation, rescue for those who survived, and appropriate resources for evacuees with limited supplies. Some authors liken Katrina to the infamous distributive justice tale of the Titanic, in that there were clearly “not enough lifeboats” for diabetes patients in “steerage class”.

Hurricane Katrina put the health effects of poverty and race in plain view, although the health disparities in the incidence and management of Type 2 diabetes had long been documented at the time of the storm (See: http://www.ncbi.nlm.nih.gov/pubmed/15983347):

• African-Americans are twice as likely as Caucasians to have diabetes.
• African-Americans suffer greater diabetes-related complications.
• Uninsured diabetes patients in 2005 had a 25% greater risk of premature death.
• The percentage of uninsured African-Americans in 2005 was 73% greater than in the Caucasian community.
• African-American diabetes patients in 2005 were less likely to have their A1C measured.
• Usual care for African-American diabetes patients in 2005 failed to meet published diabetes care guidelines.

Hurricane Katrina taught us that chronic disease management is a critical public health need in a disaster — on par with infection control. Stockpiling supplies for diabetes care should now be part of Disaster Planning.

In 2012, diabetes patients with end-stage renal disease caught in Hurricane Sandy were at risk again. (See: http://www.nj.com/healthfit/index.ssf/2015/08/hurricane_sandy_diabetics.html).

How many hurricanes does it take to get disaster diabetes care planning right? We’re not there yet, but we do know that diabetes and poverty always spell disaster for stranded vulnerable populations.

If you’re an endocrinologist who takes care of seniors with diabetes, you should say “Thank You!” to Lyndon B. Johnson.

Yesterday marked the 50^th anniversary of Medicare (see: https://www.medicare.gov/anniversary/index.html). And while the politics and questions about this program continue (see: http://www.huffingtonpost.com/entry/medicare-was-born-50-years-ago-today-and-its-still-under-attack_55b93d85e4b095423d0db7f9?), it marked a healthcare ethics milestone in the United States.

Medicare has had an especially profound impact on ethical care for people with diabetes, and end-stage-renal disease (see: https://www.annanurse.org/download/reference/health/esrdReimbursementFactSheet.pdf)

But Oh — The Times They Are A-Changin’…

When Medicare was signed into law on July 30, 1965, just 1.2% of the population had diabetes, which translated then into 2.39 million Americans. In 2014, the CDC reported that 29.1 million Americans (9.3% of the population) have diabetes, but of those, 8.1 million remain undiagnosed (see: http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html). You can view the growth in diabetes prevalence from 1958-2013 here: http://www.cdc.gov/diabetes/statistics/slides/long_term_trends.pdf

The sharp increase in diabetes was likely never foreseen, but we now know how much this is tied to obesity and our toxic diet, particularly the aggressive marketing of sugary drinks. (http://endocrineethicsblog.org/mad-men-finale-and-type-2-diabetes-what-happened-when-we-bought-the-world-a-coke/)

Countless people with diabetes may not be diagnosed until they have access to primary care and health coverage, which is why last month’s SCOTUS ruling on the Affordable Care Act is so important. (http://endocrineethicsblog.org/bench-to-bedside-how-the-supreme-court-decisions-this-week-affect-endocrinologists/)

It was also reported yesterday that only 1 in 3 seniors are actually well controlled http://consumer.healthday.com/diabetes-information-10/demographic-diabetes-news-177/seniors-diabetes-control-diabetes-care-jhbsph-release-batch-1857-701577.html), and some of these reasons may have to do with continuing health disparities.

One thing is certain: LBJ did the right thing 50 years ago. And your patients are still benefiting.

As all Mad Men fans now know, the main character, Don Draper, “found” himself at a wellness retreat — and presumably “taught the world to sing” by creating that iconic “Hilltop” Coca-Cola ad from 1971, which established Coca-Cola as a global brand: https://www.youtube.com/watch?v=2msbfN81Gm0 .

See the New York Times review of the finale here:
http://artsbeat.blogs.nytimes.com/2015/05/18/mad-men-series-finale-recap/?_r=0

A few things happened when we bought the world a Coke.

In 2005, the Liquid Candy report was released, which tracked soaring obesity rates directly to the marketing of soft drinks: http://www.cspinet.org/sodapop/liquid_candy.htm

In 2010, a paper in Diabetes published a direct link to type 2 diabetes: people who consume sugary drinks regularly—1 to 2 cans a day or more—have a 26% greater risk of developing type 2 diabetes than people who rarely have such drinks: http://www.ncbi.nlm.nih.gov/pubmed/20693348

What are the ethics of allowing soft drink companies to continue to promote their products to children, or at sporting events? Should we impose similar advertising bans as we did with Big Tobacco? When the Mayor of New York City tried to impose a ban on Big Soda (as in jumbo size containers), it didn’t go very well:
http://www.nytimes.com/2014/06/27/nyregion/city-loses-final-appeal-on-limiting-sales-of-large-sodas.html?_r=0

In 2011, Coca-Cola began its own wellness campaign to offset public opinion:
http://www.coca-colacompany.com/sustainabilityreport/me/active-healthy-living.html#section-the-global-problem-of-obesity

Unlike Big Tobacco, which is an addictive carcinogen with a direct causal link to lung cancer (as we see in the fate of the character, Betty), Big Soda is not in the same category. It is only one of many factors in the type 2 diabetes delivery system.