Patti Waldmeir in The FT
“Better be safe than sorry.” I have never believed that.
I have lived my first 65 years often turning a blind eye to risk. I lived in China for eight years, enduring some of the worst industrial pollution on earth, despite having asthma. I risked damaging the lungs of my then small children by raising them in a place where their school often locked them in air-purified classrooms to protect them from the smog.
Before that, I lived for 20 years in Africa, refusing to boil water in areas where it needed boiling, eating bushmeat at roadside stalls — not to mention the escapades that I got up to as a young woman in the pre-Aids era.
But now, as I peer over the precipice into life as a senior citizen, coronavirus has finally introduced me to the concept of risk. Part of it is the whole “60 is the new 80” paradigm that the pandemic has forced on us — but most of it is that, whether I like it or not, I fit squarely in the category of “at risk” for severe illness or death if I catch Covid-19.
I have diabetes, asthma and am finishing my 65th year. I don’t live in a nursing home, a jail, a monastery or a convent (as does one close friend with Covid-19), but according to the US Centers for Disease Control and Prevention (CDC), I still qualify as high risk because of my underlying conditions and age.
So what do I — and people like me, I am far from alone — do now that the world is reopening without us? I’ve got some big decisions to make in the next few days. My youngest child is moving back to our flat outside Chicago after a month living elsewhere: does one of us need to be locked in the bedroom? Do I have to eat on the balcony for two weeks?
There is no shortage of people, not least President Donald Trump, telling me that all this is simple: vulnerable people should just stay home. But what if they live with other people? What if those people have jobs? And what about our dogs? Our two old mutts are overdue for a rabies shot because the vet was only seeing emergencies. Is it safe for me to take them in now? Can my kids go to the dentist, and then come home to live at close quarters with me?
I asked several medical experts these questions, and they all offered versions of “we haven’t got a clue”. Robert Gabbay, incoming chief scientific and medical officer of the American Diabetes Association, was the most helpful: “Individuals with diabetes are all in the higher-risk category but even within that category, those who are older and with co-morbidities are at more risk — and control of blood glucose seems to matter.
“You are probably somewhere in the middle” of the high-risk category, he decided. My diabetes is well controlled and I don’t have many other illnesses. “But your age is a factor,” he added. Up to now, I’ve thought I was in the “60 is the new 40 crowd”: now I know there is no such crowd.
The head of the Illinois Department of Public Health underlined this at the weekend when she gave her personal list of Covid dos and don’ts, including don’t visit a parent who is over 65 with pre-existing conditions for at least a year, or until there is a cure. Dr Ngozi Ezike also said she would not attend a wedding or a dinner party for a year and would avoid indoor restaurants for three months to a year — despite the fact that Chicago’s indoor restaurants reopen on Friday.
I turned to the CDC, which initially said it would issue new guidance for “at risk” people last week, but didn’t. This would be the same CDC that I trusted when it said not to wear a mask — though 1.3 billion people in China were masking up. Today China, which is 100 times larger by population than my home state of Illinois, has less than three-quarters as many total pandemic deaths. (Yes, I know China has been accused of undercounting cases, but so has the US.) Masks aren’t the only reason; but they are enough of a reason to erode my trust in what the CDC thinks I should do now.
It doesn’t help that the CDC website lists “moderate to severe asthma” as one of the primary risk factors for poor coronavirus outcomes — while the American Academy of Allergy Asthma and Immunology says “there are no published data to support this determination”, adding that there is “no evidence” that those with asthma are more at risk. Who’s right?
I need to know: this weekend is the one-year anniversary of the death of my eldest sibling. I’ve chosen not to make the trip to visit his grave in Michigan. Next month, I turn 65, and I want to spend that day with my 89-year-old father: should we rent a camper van, so we don’t infect his household? I thought about a porta potty for the journey, since public toilets are apparently a coronavirus hotspot. When I started searching for “female urination devices” online, I knew it was time to ditch this new “better safe than sorry” persona I’ve assumed under lockdown.
Maybe it’s time to remind myself of a fact that I once knew: that life is a risky business, and there is only so much I can do about that. I’ll die when it’s my time — probably not a day before or after, coronavirus or no coronavirus.
Showing posts with label diabetes. Show all posts
Showing posts with label diabetes. Show all posts
Thursday, 25 June 2020
Thursday, 4 June 2020
Genetics is not why more BAME people die of coronavirus: structural racism is
Yes, more people of black, Latin and south Asian origin are dying, but there is no genetic ‘susceptibility’ behind it writes Winston Morgan in The Guardian
Indeed, race is a social construct with no scientific basis. However, there are clear links between people’s racial groups, their socioeconomic status, what happens to them once they are infected, and the outcome of their infection. And focusing on the idea of a genetic link merely serves to distract from this.
You only have to look at how the statistics are gathered to understand how these issues are confused. Data from the UK’s Office for National Statistics that has been used to highlight the disparate death rates separates Indians from Pakistanis and Bangladeshis, and yet groups together all Africans (including black Caribbeans). This makes no sense in terms of race, ethnicity or genetics.
The data shows that those males categorised as black are more than 4.6 times more likely to die than their white counterparts from the virus. They are followed by Pakistanis/Bangladeshis (just over four times more likely to die), and then Chinese and Indians (just over 2.5 times).
Most genome-wide association studies group all south Asians. Yet, at least in the UK, Covid-19 can apparently separate Indians and Pakistanis, suggesting genetics have little to do with it. The categories used to collect government data for the pandemic are far more suited to social outcomes such as employment or education.
This problem arises even with a recent analysis that purportedly shows people from ethnic minorities are no more likely to die, once you take into account the effects of other illnesses and deprivation. The main analysis only compares whites to everybody else, masking the data for specific groups, while the headline of the newspaper article about the study refers only to black people.
Meanwhile, in the US the groups most disproportionately affected are African Americans and Hispanics/Latinos. All these groups come from very different population groups. We’ve also seen high death rates in Brazil, China and Italy, all of which have very different populations using the classical definition of race.
The idea that Covid-19 discriminates along traditional racial lines is created by these statistics and fails to adequately portray what’s really going on. These kinds of assumptions ignore the fact that there is as much genetic variation within racialised groups as there is between the whole human population.
There are some medical conditions with a higher prevalence in some racialised groups, such as sickle cell anaemia, and differences in how some groups respond to certain drugs. But these are traits linked to single genes and all transcend the traditional definitions of race. Such “monogenic” traits affect a very small subset of many populations, such as some southern Europeans and south Asians who also have a predisposition to sickle cell anaemia.
Death from Covid-19 is also linked to pre-existing conditions that appear in higher levels in black and south Asian groups, such as diabetes. The argument that this may provide a genetic underpinning is only partly supported by the limited evidence that links genetics to diabetes.
However, the ONS figures confirm that genes predisposing people to diabetes cannot be the same as those that predispose to Covid-19. Otherwise, Indians would be affected as much as Pakistanis and Bangladeshis, who belong to the same genome-wide association group.
Any genetic differences that may predispose you to diabetes are heavily influenced by environmental factors. There isn’t a “diabetes gene” linking the varying groups that are affected by Covid-19. But the prevalence of these so-called “lifestyle” diseases in racialised groups is strongly linked to social factors.
Another target that has come in for speculation is vitamin D deficiency. People with darker skin who do not get enough exposure to direct sunlight may produce less vitamin D, which is essential for many bodily functions, including the immune system. In terms of a link to susceptibility to Covid-19, this has not been proven. But very little work on this has been done and the pandemic should prompt more research on the medical consequences of vitamin D deficiency generally.
Other evidence suggests higher death rates from Covid-19 including among racialised groups might be linked to higher levels of a cell surface receptor molecule known as ACE2. But this can result from taking drugs for diabetes and hypertension, which takes us back to the point about the social causes of such diseases.
In the absence of any genetic link between racial groups and susceptibility to the virus, we are left with the reality, which seems more difficult to accept: that these groups are suffering more from how our societies are organised. There is no clear evidence that higher levels of conditions such as type-2 diabetes, cardiovascular disease and weakened immune systems in disadvantaged communities are because of inherent genetic predispositions.
But there is evidence they are the result of structural racism. All these underlying problems can be directly connected to the food and exercise you have access to, the level of education, employment, housing, healthcare, economic and political power within these communities.
The evidence suggests that this coronavirus does not discriminate, but highlights existing discriminations. The continued prevalence of ideas about race today – despite the lack of any scientific basis – shows how these ideas can mutate to provide justification for the power structures that have ordered our society since the 18th century.
A TfL worker sprays antiviral solution inside a tube train. Photograph: Kirsty O’Connor/PA
From the start of the coronavirus pandemic, there has been an attempt to use science to explain the disproportionate impact of Covid-19 on different groups through the prism of race. Data from the UK and the US suggests that people categorised as black, Hispanic (Latino) and south Asian are more likely to die from the disease.
The way this issue is often discussed, but also the response of some scientists, would suggest that there might be some biological reason for the higher death rates based on genetic differences between these groups and their white counterparts. But the reality is there is no evidence that the genes used to divide people into races are linked to how our immune system responds to viral infections.
There are certain genetic mutations that can be found among specific ethnic groups that can play a role in the body’s immune response. But because of the loose definition of race (primarily based on genes for skin colour) and recent population movements, these should be seen as unreliable indicators when it comes to susceptibility to viral infections.
From the start of the coronavirus pandemic, there has been an attempt to use science to explain the disproportionate impact of Covid-19 on different groups through the prism of race. Data from the UK and the US suggests that people categorised as black, Hispanic (Latino) and south Asian are more likely to die from the disease.
The way this issue is often discussed, but also the response of some scientists, would suggest that there might be some biological reason for the higher death rates based on genetic differences between these groups and their white counterparts. But the reality is there is no evidence that the genes used to divide people into races are linked to how our immune system responds to viral infections.
There are certain genetic mutations that can be found among specific ethnic groups that can play a role in the body’s immune response. But because of the loose definition of race (primarily based on genes for skin colour) and recent population movements, these should be seen as unreliable indicators when it comes to susceptibility to viral infections.
Indeed, race is a social construct with no scientific basis. However, there are clear links between people’s racial groups, their socioeconomic status, what happens to them once they are infected, and the outcome of their infection. And focusing on the idea of a genetic link merely serves to distract from this.
You only have to look at how the statistics are gathered to understand how these issues are confused. Data from the UK’s Office for National Statistics that has been used to highlight the disparate death rates separates Indians from Pakistanis and Bangladeshis, and yet groups together all Africans (including black Caribbeans). This makes no sense in terms of race, ethnicity or genetics.
The data shows that those males categorised as black are more than 4.6 times more likely to die than their white counterparts from the virus. They are followed by Pakistanis/Bangladeshis (just over four times more likely to die), and then Chinese and Indians (just over 2.5 times).
Most genome-wide association studies group all south Asians. Yet, at least in the UK, Covid-19 can apparently separate Indians and Pakistanis, suggesting genetics have little to do with it. The categories used to collect government data for the pandemic are far more suited to social outcomes such as employment or education.
This problem arises even with a recent analysis that purportedly shows people from ethnic minorities are no more likely to die, once you take into account the effects of other illnesses and deprivation. The main analysis only compares whites to everybody else, masking the data for specific groups, while the headline of the newspaper article about the study refers only to black people.
Meanwhile, in the US the groups most disproportionately affected are African Americans and Hispanics/Latinos. All these groups come from very different population groups. We’ve also seen high death rates in Brazil, China and Italy, all of which have very different populations using the classical definition of race.
The idea that Covid-19 discriminates along traditional racial lines is created by these statistics and fails to adequately portray what’s really going on. These kinds of assumptions ignore the fact that there is as much genetic variation within racialised groups as there is between the whole human population.
There are some medical conditions with a higher prevalence in some racialised groups, such as sickle cell anaemia, and differences in how some groups respond to certain drugs. But these are traits linked to single genes and all transcend the traditional definitions of race. Such “monogenic” traits affect a very small subset of many populations, such as some southern Europeans and south Asians who also have a predisposition to sickle cell anaemia.
Death from Covid-19 is also linked to pre-existing conditions that appear in higher levels in black and south Asian groups, such as diabetes. The argument that this may provide a genetic underpinning is only partly supported by the limited evidence that links genetics to diabetes.
However, the ONS figures confirm that genes predisposing people to diabetes cannot be the same as those that predispose to Covid-19. Otherwise, Indians would be affected as much as Pakistanis and Bangladeshis, who belong to the same genome-wide association group.
Any genetic differences that may predispose you to diabetes are heavily influenced by environmental factors. There isn’t a “diabetes gene” linking the varying groups that are affected by Covid-19. But the prevalence of these so-called “lifestyle” diseases in racialised groups is strongly linked to social factors.
Another target that has come in for speculation is vitamin D deficiency. People with darker skin who do not get enough exposure to direct sunlight may produce less vitamin D, which is essential for many bodily functions, including the immune system. In terms of a link to susceptibility to Covid-19, this has not been proven. But very little work on this has been done and the pandemic should prompt more research on the medical consequences of vitamin D deficiency generally.
Other evidence suggests higher death rates from Covid-19 including among racialised groups might be linked to higher levels of a cell surface receptor molecule known as ACE2. But this can result from taking drugs for diabetes and hypertension, which takes us back to the point about the social causes of such diseases.
In the absence of any genetic link between racial groups and susceptibility to the virus, we are left with the reality, which seems more difficult to accept: that these groups are suffering more from how our societies are organised. There is no clear evidence that higher levels of conditions such as type-2 diabetes, cardiovascular disease and weakened immune systems in disadvantaged communities are because of inherent genetic predispositions.
But there is evidence they are the result of structural racism. All these underlying problems can be directly connected to the food and exercise you have access to, the level of education, employment, housing, healthcare, economic and political power within these communities.
The evidence suggests that this coronavirus does not discriminate, but highlights existing discriminations. The continued prevalence of ideas about race today – despite the lack of any scientific basis – shows how these ideas can mutate to provide justification for the power structures that have ordered our society since the 18th century.
Tuesday, 28 May 2019
A sweet tale: the son who reinvented sugar to help diabetic dad
The natural substitute helps diabetics, combats obesity and tackles climate change writes Senay Boztas in The Guardian
Javier Larragoiti (centre) and his Xilinat team in the lab in Mexico City. Photograph: Courtesy Xilinat
Javier Larragoiti was 18 when his father was diagnosed with diabetes. The teenager had just started a degree in chemical engineering in Mexico City. So he dedicated his studies to a side project: creating an acceptable alternative to help his father and millions of Mexicans like him avoid sugar.
“It’s only when you know someone with this sickness that you realise how common it is and how sugar intake plays a huge role,” he says. “My dad tried to use stevia and sucralose, just hated the taste, and kept cheating on his diet.”
The young chemist started dabbling with xylitol, a sweet-tasting alcohol commonly extracted from birch wood and used in products such as chewing gum.
“It has so many good properties for human health, and the same flavour as sugar, but the problem was that producing it was so expensive,” he says. “So I decided to start working on a cheaper process to make it accessible to everyone.”Quick guide
What is the Upside?ShowSign up here for a weekly roundup from this series emailed to your inbox every Friday
Ten years later, Larragoiti has patented a fermentation-based process to turn wasted corn cobs from Mexico’s 27.5m-tonne annual crop into xylitol. It is thereby solving a second problem: what to do with all that agricultural waste that otherwise might be burned, adding greenhouse gases to the overladen atmosphere.
His business, Xilinat (pronounced Hill-Ee-Natt), buys waste from 13 local farmers, producing 1 tonne of the product a year. This month his invention was awarded a prestigious $310,000 Chivas Venture prize award, which will enable him to industrialise production and scale up production tenfold.
Obesity is one of the fastest-growing global health problems. One in seven people are obese and about 10% have type 2 diabetes. Since 1980 the rate of obesity has doubled in more than 70 countries.
Larragoiti says that sugary diets are a real problem in Coca-Cola-lovingMexico, which has the world’s second-highest rate of obesity and has successfully taxed sugary drinks to try to combat a main source of the issue.
Paradoxically, another corn byproduct – fructose – is part of the problem, used to make corn syrup that has been linked to increasing obesity in the US.
“It’s kind of ironic,” Larragoiti says. “High fructose corn syrup is just a bomb of carbs and concentrated sugar that makes a high peak of insulin. It’s many times sweeter than regular glucose. Companies use and pay less and that’s the issue.”
Reusing agricultural waste is rapidly emerging as a promising sector for social entrepreneurs keen to tackle global heating and make useful things at the same time.
“One corn stalk has 70% to 80% waste by weight when you get down to it,” says Stefan Mühlbauer, the chief executive of the Sustainable Projects Group Inc. His company has a pilot plant in Alsace, France, and is building another in Indiana, US, to turn corn waste into a peat moss substitute and a super-absorbent foam for filters or soil. “Farmers are excited as it gives them something that extends their harvest season and they see another source of revenue,” he adds.
In Mexico, agricultural waste is often burned, releasing greenhouse gasesand creating one of the country’s highest sources of dioxin emissions. “Burning the residue is cheap and quick and may suppress pests and diseases,” says Dr Wolter Elbersen, a crop production expert at Wageningen University & Research. “The disadvantages such as air pollution, loss of organic matter and nutrients are less appreciated apparently. Removing the material for feed or compost, or added value products such as paper pulp or fuels is often not cost-effective, or no labour is available to do all the work in a short window of time.”
But thinking in a different way about “waste products” is essential if we are going to conserve scarce resources and feed a growing population, according to the Ellen MacArthur Foundation. “We need to think about the principles in the past, where we had to do much with little, and at the same time apply the technology we have at hand nowadays to succeed in the challenge of feeding the world,” says Clementine Schouteden, who leads the global initiative on the circular economy for food at the campaigning organisation.
“There’s definitely a sense of urgency in making sure that we farm in a way that is regenerative, preventing waste but also [creating value from] the waste that is currently not edible, with a food industry making the right options for consumers and for the planet.”
Xilinat’s idea has huge potential, according to Sonal Shah, the founding executive director of the Beeck Center for Social Impact + Innovation at Georgetown University, and a Chivas Venture judge. “It’s not just that he’s building a sugar substitute that tastes like sugar but that it’s going to become scalable so every company that uses sugar in its food has the opportunity to rethink what kind of substitute they use,” she said.
Ebersen added, though, that “you do, however, need a solution for using the leftovers after the xylose has been extracted and the demand for xylitol is small [currently] compared with the amount of residue”.
Meanwhile, what about Javier’s father? “My dad is super-happy,” Larragoiti says. “He uses my product every day and he’s willing not to cheat on his diet any more!”
Javier Larragoiti was 18 when his father was diagnosed with diabetes. The teenager had just started a degree in chemical engineering in Mexico City. So he dedicated his studies to a side project: creating an acceptable alternative to help his father and millions of Mexicans like him avoid sugar.
“It’s only when you know someone with this sickness that you realise how common it is and how sugar intake plays a huge role,” he says. “My dad tried to use stevia and sucralose, just hated the taste, and kept cheating on his diet.”
The young chemist started dabbling with xylitol, a sweet-tasting alcohol commonly extracted from birch wood and used in products such as chewing gum.
“It has so many good properties for human health, and the same flavour as sugar, but the problem was that producing it was so expensive,” he says. “So I decided to start working on a cheaper process to make it accessible to everyone.”Quick guide
What is the Upside?ShowSign up here for a weekly roundup from this series emailed to your inbox every Friday
Ten years later, Larragoiti has patented a fermentation-based process to turn wasted corn cobs from Mexico’s 27.5m-tonne annual crop into xylitol. It is thereby solving a second problem: what to do with all that agricultural waste that otherwise might be burned, adding greenhouse gases to the overladen atmosphere.
His business, Xilinat (pronounced Hill-Ee-Natt), buys waste from 13 local farmers, producing 1 tonne of the product a year. This month his invention was awarded a prestigious $310,000 Chivas Venture prize award, which will enable him to industrialise production and scale up production tenfold.
Obesity is one of the fastest-growing global health problems. One in seven people are obese and about 10% have type 2 diabetes. Since 1980 the rate of obesity has doubled in more than 70 countries.
Larragoiti says that sugary diets are a real problem in Coca-Cola-lovingMexico, which has the world’s second-highest rate of obesity and has successfully taxed sugary drinks to try to combat a main source of the issue.
Paradoxically, another corn byproduct – fructose – is part of the problem, used to make corn syrup that has been linked to increasing obesity in the US.
“It’s kind of ironic,” Larragoiti says. “High fructose corn syrup is just a bomb of carbs and concentrated sugar that makes a high peak of insulin. It’s many times sweeter than regular glucose. Companies use and pay less and that’s the issue.”
Reusing agricultural waste is rapidly emerging as a promising sector for social entrepreneurs keen to tackle global heating and make useful things at the same time.
“One corn stalk has 70% to 80% waste by weight when you get down to it,” says Stefan Mühlbauer, the chief executive of the Sustainable Projects Group Inc. His company has a pilot plant in Alsace, France, and is building another in Indiana, US, to turn corn waste into a peat moss substitute and a super-absorbent foam for filters or soil. “Farmers are excited as it gives them something that extends their harvest season and they see another source of revenue,” he adds.
In Mexico, agricultural waste is often burned, releasing greenhouse gasesand creating one of the country’s highest sources of dioxin emissions. “Burning the residue is cheap and quick and may suppress pests and diseases,” says Dr Wolter Elbersen, a crop production expert at Wageningen University & Research. “The disadvantages such as air pollution, loss of organic matter and nutrients are less appreciated apparently. Removing the material for feed or compost, or added value products such as paper pulp or fuels is often not cost-effective, or no labour is available to do all the work in a short window of time.”
But thinking in a different way about “waste products” is essential if we are going to conserve scarce resources and feed a growing population, according to the Ellen MacArthur Foundation. “We need to think about the principles in the past, where we had to do much with little, and at the same time apply the technology we have at hand nowadays to succeed in the challenge of feeding the world,” says Clementine Schouteden, who leads the global initiative on the circular economy for food at the campaigning organisation.
“There’s definitely a sense of urgency in making sure that we farm in a way that is regenerative, preventing waste but also [creating value from] the waste that is currently not edible, with a food industry making the right options for consumers and for the planet.”
Xilinat’s idea has huge potential, according to Sonal Shah, the founding executive director of the Beeck Center for Social Impact + Innovation at Georgetown University, and a Chivas Venture judge. “It’s not just that he’s building a sugar substitute that tastes like sugar but that it’s going to become scalable so every company that uses sugar in its food has the opportunity to rethink what kind of substitute they use,” she said.
Ebersen added, though, that “you do, however, need a solution for using the leftovers after the xylose has been extracted and the demand for xylitol is small [currently] compared with the amount of residue”.
Meanwhile, what about Javier’s father? “My dad is super-happy,” Larragoiti says. “He uses my product every day and he’s willing not to cheat on his diet any more!”
Wednesday, 17 August 2016
Feet first, our NHS is limping towards privatisation
Polly Toynbee in The Guardian
A fish rots from the head, but the NHS may be rotting from the feet. Podiatry is not up there in the headlines, yet what’s going on in that unglamorous zone is an alarming microcosm of the downward path of the health service. This is a story of the NHS in England in retreat and the private sector filling the vacuum.
You know the big picture from the ever-worsening monthly figures: deteriorating A&E, ambulance and operation waiting times, and a steep rise in bed-blocking. As debts pass £2.5bn, the NHS feels the tightening financial tourniquet.
Now look at it through the prism of just one small corner, as seen from the feet up. Every week 135 people have amputations because diabetes has caused their feet to rot: their circulation goes and then the sensation in their feet, so they don’t notice damage done by rubbing shoes, stubbed toes or stepping on nails. Minor injuries turn into ulcers that if left untreated turn gangrenous, and so the toes, then the foot, then the leg are lost – horrific life-changing damage. Numbers are rising fast, with nearly three million diabetics. The scandal is that 80% of these amputations are preventable – if there were the podiatrists to treat the first signs of foot ulcers. But the numbers employed and in training are falling.
In his surgery, the head of podiatry for Solent NHS Trust, Graham Bowen, is unwrapping the foot of a lifelong diabetic to reveal a large missing chunk of heel, a great red hole nearly through to the bone. This man has already had some toes amputated. He has been having treatment with maggots, bandaged into his wound to eat the dead skin and help healing – and he is slowly improving. Everyone Bowen sees now is at similarly high risk. Small ulcers, incipient ulcers, the ones that need to be caught early (and cheaply) no longer get NHS treatment. “On the NHS we’re essentially firefighting the worst cases now,” says Bowen. “We are going through our lists and discharging all the rest of our patients.”
FacebookTwitterPinterest ‘On a 15-minute visit carers can’t check feet.’ Photograph: Andrew Bret Wallis/Getty Images
But not even all these acute patients get the same optimal treatments, due to the vagaries of the 2012 NHS Act. Solent, a community trust that covers mental health and a host of other services, is used by five different clinical commissioning groups (CCGs), including Southampton, Portsmouth and West Hampshire. Each has its own criteria for what it will pay for, and each is toughening those criteria. Depending on their address, some patients get the very best, others only get what their cash-strapped CCG pays for.
You need to know about diabetic feet to understand the difference in treatments: the conventional and cheapest treatment is a dressing and a removable plastic boot, and telling patients to keep their foot up for months. But patients who can’t feel their feet tend to take off the boot and hobble to make a quick cup of tea. “Ten minutes of putting pressure on the ulcer undoes 23 hours of resting it,” Bowen says, so it takes 52 weeks on average to heal ulcers that way. For £500 extra, a new instant fibreglass cast saves any pressure on ulcers and cures them within eight weeks.
Although the National Institute for Health and Care Excellence says this total-contact cast is the gold standard, most of Bowen’s CCGs won’t pay for it. I watched him putting one on a patient in under half an hour: after nine weekly replacements, that ulcer would be completely healed. For every 10 of the new casts, one amputation is prevented – and each amputation costs the NHS £65,000. Such is the madness of NHS fragmentation, divided between multiple commissioners and providers, all in serious financial trouble, that no one spends a bit more now for others to save later, even when the payback is so quick.
This clinic lost four podiatry posts to save money: though diabetic numbers soar, its budget has been static for five years. “Doing more for less,” he says with the same weary sigh you hear echoing through the NHS. As Bowen goes through the clinic’s books removing all but the most acute cases, he turns away diabetics whose problems should be caught early. He turns away others he used to treat: the old and frail who have become immobile due to foot problems; the partially sighted or people with dementia who have poor home care. On a 15-minute visit carers can’t check feet and find out if they are the reason someone doesn’t get out of bed, toes buckled in, leaving them needlessly incapacitated and heading for residential care sooner than necessary.
What happens to those he takes off his books? “They have to go private, if they can afford it. If not, then nothing.” He used to send them to Age UK, but lack of funds shut that service. Only 5% of podiatry is now done by the NHS so Bowen has set up TipToe, a private practice attached to his NHS clinic. It’s not what he wants, but it keeps prices low and all proceeds go to the NHS.
Alarm bells should ring here: how silently the NHS slides into the private sector. Labour leadership contender Owen Smith has flagged up his team’s research showing private practice has doubled since 2010. Now that many CCGs only pay for one cataract, how many go private for the second eye? As the Guardian’s health policy editor, Denis Campbell, has asked, how many more vital treatments will go this way?
Podiatry is the ground floor of the NHS hierarchy. The profession reckons the NHS in England needs 12,000 practitioners but only has about 3,000 – and that’s falling, despite so many high-risk diabetics needing weekly appointments. Next year podiatry trainees, like nurses, will no longer receive state bursaries, so fewer will apply. They tend to be older, with families, unable to take on a £45,000 debt for a job paying around £35,000 per year. Already student places have been cut by nearly a quarter in five years. Most of the 7,000 amputations a year are preventable. A shocking statistic: half of those who undergo amputations will die within two years.
Only in the details of what’s happening on the frontline can we understand the daily reality of Britain’s shrinking state. Step back and ask how it can be that a country still growing richer can afford less quality care than when it was poorer? Is that the country’s choice? As the NHS slides into the private sector, here is yet another public service in retreat.
A fish rots from the head, but the NHS may be rotting from the feet. Podiatry is not up there in the headlines, yet what’s going on in that unglamorous zone is an alarming microcosm of the downward path of the health service. This is a story of the NHS in England in retreat and the private sector filling the vacuum.
You know the big picture from the ever-worsening monthly figures: deteriorating A&E, ambulance and operation waiting times, and a steep rise in bed-blocking. As debts pass £2.5bn, the NHS feels the tightening financial tourniquet.
Now look at it through the prism of just one small corner, as seen from the feet up. Every week 135 people have amputations because diabetes has caused their feet to rot: their circulation goes and then the sensation in their feet, so they don’t notice damage done by rubbing shoes, stubbed toes or stepping on nails. Minor injuries turn into ulcers that if left untreated turn gangrenous, and so the toes, then the foot, then the leg are lost – horrific life-changing damage. Numbers are rising fast, with nearly three million diabetics. The scandal is that 80% of these amputations are preventable – if there were the podiatrists to treat the first signs of foot ulcers. But the numbers employed and in training are falling.
In his surgery, the head of podiatry for Solent NHS Trust, Graham Bowen, is unwrapping the foot of a lifelong diabetic to reveal a large missing chunk of heel, a great red hole nearly through to the bone. This man has already had some toes amputated. He has been having treatment with maggots, bandaged into his wound to eat the dead skin and help healing – and he is slowly improving. Everyone Bowen sees now is at similarly high risk. Small ulcers, incipient ulcers, the ones that need to be caught early (and cheaply) no longer get NHS treatment. “On the NHS we’re essentially firefighting the worst cases now,” says Bowen. “We are going through our lists and discharging all the rest of our patients.”
FacebookTwitterPinterest ‘On a 15-minute visit carers can’t check feet.’ Photograph: Andrew Bret Wallis/Getty Images
But not even all these acute patients get the same optimal treatments, due to the vagaries of the 2012 NHS Act. Solent, a community trust that covers mental health and a host of other services, is used by five different clinical commissioning groups (CCGs), including Southampton, Portsmouth and West Hampshire. Each has its own criteria for what it will pay for, and each is toughening those criteria. Depending on their address, some patients get the very best, others only get what their cash-strapped CCG pays for.
You need to know about diabetic feet to understand the difference in treatments: the conventional and cheapest treatment is a dressing and a removable plastic boot, and telling patients to keep their foot up for months. But patients who can’t feel their feet tend to take off the boot and hobble to make a quick cup of tea. “Ten minutes of putting pressure on the ulcer undoes 23 hours of resting it,” Bowen says, so it takes 52 weeks on average to heal ulcers that way. For £500 extra, a new instant fibreglass cast saves any pressure on ulcers and cures them within eight weeks.
Although the National Institute for Health and Care Excellence says this total-contact cast is the gold standard, most of Bowen’s CCGs won’t pay for it. I watched him putting one on a patient in under half an hour: after nine weekly replacements, that ulcer would be completely healed. For every 10 of the new casts, one amputation is prevented – and each amputation costs the NHS £65,000. Such is the madness of NHS fragmentation, divided between multiple commissioners and providers, all in serious financial trouble, that no one spends a bit more now for others to save later, even when the payback is so quick.
This clinic lost four podiatry posts to save money: though diabetic numbers soar, its budget has been static for five years. “Doing more for less,” he says with the same weary sigh you hear echoing through the NHS. As Bowen goes through the clinic’s books removing all but the most acute cases, he turns away diabetics whose problems should be caught early. He turns away others he used to treat: the old and frail who have become immobile due to foot problems; the partially sighted or people with dementia who have poor home care. On a 15-minute visit carers can’t check feet and find out if they are the reason someone doesn’t get out of bed, toes buckled in, leaving them needlessly incapacitated and heading for residential care sooner than necessary.
What happens to those he takes off his books? “They have to go private, if they can afford it. If not, then nothing.” He used to send them to Age UK, but lack of funds shut that service. Only 5% of podiatry is now done by the NHS so Bowen has set up TipToe, a private practice attached to his NHS clinic. It’s not what he wants, but it keeps prices low and all proceeds go to the NHS.
Alarm bells should ring here: how silently the NHS slides into the private sector. Labour leadership contender Owen Smith has flagged up his team’s research showing private practice has doubled since 2010. Now that many CCGs only pay for one cataract, how many go private for the second eye? As the Guardian’s health policy editor, Denis Campbell, has asked, how many more vital treatments will go this way?
Podiatry is the ground floor of the NHS hierarchy. The profession reckons the NHS in England needs 12,000 practitioners but only has about 3,000 – and that’s falling, despite so many high-risk diabetics needing weekly appointments. Next year podiatry trainees, like nurses, will no longer receive state bursaries, so fewer will apply. They tend to be older, with families, unable to take on a £45,000 debt for a job paying around £35,000 per year. Already student places have been cut by nearly a quarter in five years. Most of the 7,000 amputations a year are preventable. A shocking statistic: half of those who undergo amputations will die within two years.
Only in the details of what’s happening on the frontline can we understand the daily reality of Britain’s shrinking state. Step back and ask how it can be that a country still growing richer can afford less quality care than when it was poorer? Is that the country’s choice? As the NHS slides into the private sector, here is yet another public service in retreat.
Saturday, 16 March 2013
Metformin can help reduce cancer prospects!
Diabetes pill beats cancer...and costs just 2p a day
A DIABETES pill that costs just 2p a day could prevent thousands dying from Britain’s biggest cancer killers every year.
Wednesday, 30 January 2013
Families face battle with GSK over dangerous diabetes drug
Exclusive: Pharmaceutical giant resists claims despite settlement with victims in US
GlaxoSmithKline has agreed to payouts in US lawsuits alleging Avandia pills could cause heart attacks. Photograph: Bloomberg/Getty Images
Thousands of families in the UK could be deprived of compensation for the death or harm of a relative caused by the diabetes drug Avandia, even though the British maker has agreed to pay billions of dollars to settle similar claims in the US.
The licence for Avandia was revoked in Europe, in September 2010, because of evidence that it could cause heart failure and heart attacks. The drug can still be prescribed in the US, but not to patients at risk of heart problems.
A scientist with the Food and Drug Administration estimated that Avandia could have been responsible for 100,000 heart attacks in the US.
The manufacturer, GlaxoSmithKline, has admitted concealing data about the damaging side-effects of the drug, and there is evidence of the drug's harmful effects. But, despite this, GSK is not prepared to settle claims in the UK without a court fight.
The history of drug litigation in the UK suggests that families might not easily get compensation.
Daniel Slade, with the Express company of solicitors in Manchester, has 19 cases on his books and has begun proceedings against GSK in four of them.
The pharmaceutical firm has told the solicitors that it will contest the cases. In just one of the cases it has indicated a willingness to spend £600,000 on its defence, which, the solicitor says, would be a fraction of what the claim is worth.
"It is very disappointing," said Slade. "We anticipate that these claims do have a good prospect of success, but they still have to prove their case in the UK with suitable evidence. They are tasked with having to produce that evidence, including medical expert opinion. It is a burden one would have thought they might not have to go through."
He expected that, if GSK fought in the courts rather than settled outside, as it had done in the US, it would take years for bereaved relatives, or those who have been harmed, to get any sort of payment.
A spokesman for GSK said: "We have every sympathy for people with complications associated with diabetes and those who care for them, but unfortunately we are unable to comment on individual legal cases. We continue to believe that the company acted appropriately and responsibly in its management of Avandia."
Liz Thomas, policy manager at the patient safety charity Action against Medical Accidents, said it had "become increasingly difficult in the UK to challenge large corporations such as pharmaceutical companies, an incredibly expensive form of litigation".
Corporations have a vast amount of money at their disposal to contest legal cases, butlegal aid is about to cease for medical negligence cases.
The Avandia cases in Manchester will be fought on a "no win, no fee" basis by Express solicitors.
The cases in the US were settled by GSK extremely quickly, said Thomas. "I would hope they would not take advantage [in Britain] of the inequality of arms."
Avandia was first introduced in the NHS in July 2000. It was given to people with type 2 diabetes whose glucose levels were no longer being properly controlled by the standard drugs – metformin and a sulphonylurea drug. Avandia could be prescribed with those drugs or on its own.
The drug, which generically is known as rosiglitazone, was designed to lessen the body's resistance to insulin. It was available as a standalone drug – Avandia – or in a combination with metformin, and known as Avandamet.
When both drugs were withdrawn by the European Medicines Agency, there were about 90,000 people taking them in the UK.
The first warnings of trouble with Avandia came in 2007, when a prominent US scientist, Steve Nissen, published data from a review of 42 clinical trials which had been carried out on the drug. The trials involved 28,000 patients, and showed that Avandia could cause heart attacks. Further trials, the results of which were published in 2010, found people on Avandia were 27% more likely to have a stroke, 25% more likely to have heart failure, and 14% more likely to die, than patients on an alternative diabetes drug.
Potentially yet more damaging for GSK was its guilty plea to federal charges of concealing data about the drug's side effects. Most of the data on the drug comes from GSK's own trials. In November 2011 GSK agreed to pay $3bn to the US government over the Avandia issue and to end investigations into its marketing of the antidepressants Paxil (Seroxat in the UK) and Wellbutrin.
"This is a significant step toward resolving difficult, long-standing matters which do not reflect the company that we are today," Andrew Witty, chief executive of GlaxoSmithKline, said at the time.
GSK is also still defending cases in the UK from people who claim to have been badly affected by Seroxat. A group action, involving people who say they suffered severe withdrawal problems when they tried to stop the drug, has been going on for years though many claims have been settled in the US.
The same is true of Vioxx, made by Merck, the painkiller that was withdrawn after it emerged eight years ago that it doubled the risk of a heart attack.
Monday, 13 February 2012
Sugar: it's time to get real and regulate
The consumption of fructose and sucrose is on the increase – and so are preventable diseases such as Type 2 diabetes
Last week, a trio of American scientists led by Robert Lustig, professor of clinical paediatrics at the University of California, published an article in the journal Nature, outlining the toxic effects that sugar has on humans and arguing for governmental controls on its sale and distribution. While the authors come short of labelling sugar a "poison" outright, in a 2007 interview with ABC Radio about excess sugar consumption, Lustig said: "We're being poisoned to death. That's a very strong statement, but I think we can back it up with very clear scientific evidence."
That evidence has been growing – particularly in the western world, where consumption of sugar is increasing rapidly. Globally, sugar consumption has tripled in the past 50 years. But, it turns out, the greatest threat to human health is one type of sugar in particular: fructose.
In the US, per-capita consumption of fructose, a common food additive there – mainly in the form of high-fructose corn syrup – has increased more than 100-fold since 1970. Although fructose is not a common added sweetener in the UK and other countries, sucrose is; sucrose contains 50% fructose. Lustig and his co-authors note that last year, the United Nations announced that non-communicable diseases (NCDs) had, for the first time, overtaken infectious diseases in terms of the global health burden. Non-communicable diseases now account for 63% of all deaths, and that total is expected to increase by a further 17% over the next decade.
The scientists cite growing evidence that our increasing consumption of sugar is partly responsible for the growth of NCDs: diseases such as cardiovascular disease, cancer, diabetes and the suite of symptoms known as metabolic syndrome. And they argue that, as for substances known to cause NCDs such as tobacco and alcohol, sales and distribution of sugar should be controlled, and products with added sugar should be taxed.
I used to be a sugar addict. And yes, for those who haven't found out first-hand, sugar is addictive; perhaps not to the same degree as alcohol and tobacco, but a recent study has shown that sugary foods, or even just the expectation of eating sweets, can trick the brain into wanting more. When I decided to cut my sugar consumption 12 or so years ago, I had no idea of the serious health concerns that excess sugar consumption brings. I only wanted to avoid the so-called "empty calories" that sugar provides. I had noticed that eating cookies and desserts was making me feel lethargic.
Sugar, and in particular fructose, affects metabolism. Unlike glucose, fructose can only be metabolised in the liver. Some of its effects on the human body include increasing levels of uric acid, which raise blood pressure; increased fat deposition in the liver; and interference with the insulin receptor in the liver. This inhibits ability of the brain to detect the hormone leptin, which regulates appetite. So beyond the empty calories that fructose provides, eating it makes you want to eat more.
When I started reducing my sugar intake, I had no intention of cutting it out completely. Reducing my consumption was a gradual process, over many years. Sugar had been used as a reward when I was a child, and sweets were still a comfort food for me. But I found that the less of it I ate, the less I craved it. Today, I barely eat sweetened foods at all. If I were to eat what to most North Americans or Europeans is an "average" dessert serving, I would feel sick. Avoiding sugar is no longer an exercise in willpower; I have developed a revulsion for it. I feel that I have brought my body back to its original state. Sugar, in anything other than small quantities, feels like a poison to me.
Illnesses related to dietary choices do not affect only the individuals who become sick; they affect us all, as a society. The US alone spends $150bn on healthcare resources for illness related to metabolic syndrome. Of course, I would like to think that governmental regulation of a food-item such as sugar is not necessary. I do place value on an individual's right to choose, and on personal responsibility. But in the case of sugar, it's time to get real. The incidence of preventable diseases such as Type 2 diabetes is increasing and many health authorities have expressed concern that our current youth may be the first generation that does not live as long as their parents.
Most of us have known for some time that excess sugar is not good for us, but education and knowledge are clearly not enough. Regulation is required. This is no longer an issue of personal responsibility, but one of public expenditure and public health.
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