III. A Half Century of Change

(and sometimes progress)

Part A of "Also Received Votes", not necessarily because of greater importance than those in Part B.

IDENTIFICATION AND MODIFICATION OF CAD RISK FACTORS

Fifty years ago, men in their 40s (sometimes younger) often died suddenly of cardiac arrest associated with coronary artery disease (CAD). Neither their doctors nor their young wives and families knew exactly why, even in those cases where such an event was a family curse. Then pathologists learned that the cheesy stuff clogging coronary arteries was cholesterol, and the link between that and diet was recognized. Some of us started eating more sensibly, others waited until medication was invented to lower cholesterol, thinking we could then safely consume large quantities of animal fat (that’s another story related to unrealistically hopeful human behavior.) Later, cigarette smoking, high blood pressure, and diabetes were added to the list of CAD-causing risks, and modification of them gained acceptance as preventive measures. Now, far fewer young people die of cardiac arrest and failure due to CAD.

ALZHEIMERS EXPLOSION

With all of the advances described above, we have a new problem; we’re all living longer and thus having more time to lose brain cells. The burden of having fewer functioning brain cells is outweighed only by the immense burden of care falling on families, health systems, and society. While there will never ever be a cure for dementia of aging, there will be reliable methods to slow its progress without causing uncomfortable side effects. At the moment, our skills in doing that are not classifiable as great. Vermont has started a novel and potentially lower cost plan to care for elderly victims of dementia, by paying family members to provide care in the patients’ homes. If successful, this plan will also prove to be more humane than the current process of dumping fragile, confused, old people into special care units far from their familiar surroundings.

HEALTH INSURANCE USE, ABUSE, AND LOSS

We have seen health insurance go from an emergency system helping pay hospital bills, to first-dollar coverage for all ailments large or small, to the concept of co-payments and increasing premiums, and then to a status of, “Available only to the affluent.” Application of expensive technologies to patient care is too frequently dependent on whether the person involved has insurance. The next step, to the dreaded (by many) and loved (by many others ) nationalization of healthcare may not be far off. If we expect our government to give all our citizens all the care they might want, at least comparable to that given those who now have adequate health insurance, we are going to see unbelievable and probably unsustainable numbers in the federal budget.

MANAGED CARE

The acronym HMO used to represent a good concept, Health Maintenance Organization. At first, HMOs were well accepted by patients whose health was indeed, as the name implied, well maintained. Unfortunately, the HMO explosion of the 1970s and 80s was driven by financial considerations, and the “M for maintenance” morphed into “M for management”. Since “care on the cheap with plenty left over for stockholders and CEOs” is synonymous with managed care, we’ve been on a downhill slide ever since. It isn’t possible to do away with HMOs, as suggested by many disgruntled users, and there may not be an effective alternative plan for a few decades. One such plan, a non-profit healthcare cooperative, has not gained appreciable attention from policy makers and politicians. For now, we’re stuck with the current models and their shortcomings.

HOME TESTING AND SELF CARE

The model for self-care and home monitoring of body function is diabetes. In 1960, the monitoring consisted of, “drop a tablet in a urine sample, wait until it stops bubbling, then read the sugar content by comparing the color of the fluid in the tube to the colors on a chart.” Not only was that imprecise, it also failed to reflect conditions actually going on inside the body. Fortunately for patients and those in charge of their care, we’ve moved well beyond urine testing. Accurate hand-held devices for testing blood sugar became available in the late 1970’s, coincident with the explosion in computer chip technology. From that time on, diabetics have had the ability to control their disease better, often testing themselves 4 or more times a day and adjusting insulin doses accordingly. This has resulted in far fewer long-term complications of their condition.

ANTIBIOTIC RESISTANCE

As soon as doctors began using penicillin they also began overusing and misusing penicillin, and bacterial resistance to that agent rapidly developed. Biochemists and pharmaceutical research teams steadily and reliably have produced new classes of antibiotics and newer agents within existing classes. The result? We are now faced with an explosion of bacterial resistance to what were thought to be our most formidable drugs and there is still no “gorilla-mycin” to rescue us. Observant and thoughtful clinicians concluded three or four decades ago that the only way out of the mess is with less (and more appropriate) antibiotic use rather than continued inappropriate use of new, different, and well-advertised drugs.

ALTERNATIVE / COMPLEMENTARY MEDICINE

At the same time as the patient revolution noted elsewhere in this booklet, there was a turn away from traditional medical care to alternatives usually considered quack remedies by the majority of us, physicians and patients alike. Thus we saw the rise of holistic practice, homeopathy, vitamins and supplements as therapy, meditation, various forms of massage and manipulation, acupuncture, acupressure, herbal medicine, and, last but certainly not least, the establishment in otherwise respectable colleges of medicine, departments of “complementary medicine”. Skeptics still say that anyone who responds favorably to any item in that list wasn’t really ill to begin with, and is merely one in the long line of those who think they’re ill and get well when someone pays them some attention. Right or wrong, the people who call the shots (meaning pay the bills) are accepting and paying for some forms of alternative care. It is a multi-billion dollar industry whose defenders believe traditional medical care is all about money and pills, and whose detractors believe it’s all about misspent money going into the wrong pockets. Some of us have become fence straddlers who partake of selected offerings from both camps. Even so, don’t expect a real truce to take place soon in this battle.

VACCINES FOR MANY DISEASES

Good pediatric care practiced in 1960 called for a series of three DPT (diphtheria, pertussis, tetanus) shots, the same series of polio shots, and a smallpox vaccination for all children by the time they were a year old. In the 1970s vaccines for measles, mumps and rubella became available and were added to the routine. In the 1980s, a pneumonia vaccine showed up, to be used primarily for adults with chronic lung disease. In subsequent decades, the pneumonia vaccine was adjusted for pediatric use, and given along with one for prevention of a serious infection due to hemophilus influenzae (HIB). Now we have methods for prevention of two forms of hepatitis (A and B) and a severe type of meningitis (meningococcal). These plus better influenza vaccine have resulted in many common diseases of childhood becoming rare, or almost non-existent. Smallpox is gone from the world and routine vaccination for it stopped a long time ago, polio is gone from the US, and frequently fatal, often disabling, meningitis due to pneumococcus or HIB is rare. Anyone, parent or physician, who lost a child due to one of those illnesses can only say, wistfully, “If only we’d had that vaccine back then----.“

ORAL HYPOGLYCEMICS

Type II diabetes is a condition in which a person has plenty of insulin in his body, but can’t make it work right to control blood sugar. Family inheritance, obesity, and inactivity are all causes of this condition, which can be prevented or delayed by proper diet and exercise, plus weight loss. The first oral drugs which lowered blood sugar came on the market in the 1960s. Their names were Orinase and Diabinase and they revolutionized type II diabetes management. Prior to their arrival, if weight loss, diet and exercise failed, insulin was the alternative. Now, with more oral agents available, working in several ways to control sugar, insulin therapy is a last resort for type II disease.