diabetes as a disease of technology - who | world health ... · technology is the usage and...
TRANSCRIPT
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DiabetesAs a Diseaseof Technology
Chris Feudtner, MD PhD MPHThe Children’s Hospital of Philadelphia
The University of Pennsylvania
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What Stories We Choose to Tell
about Diabetes ...
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The stories we tell
shape the questions we pose
and the answers we create
Broad Thesis
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Diabetes is a Disease
Profoundly Shaped
By Technology
Specific Thesis
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Technology is the usage and knowledge of tools, techniques, crafts, systems or methods of organization. (Wikipedia, accessed 24 August 2010)
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• Enthusiastic regard of technology as a solution to our problems
• Framing bias: constricted view of what matters
• Examples of over-enthusiasm abound
• Yet, technology can be marvelous
• How, then, do we assess ‘miracles’?
• Diabetes as a paradigmatic case
Technology Ethos
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Two Quotations
• The best treatment for diabetes is to “eat as little as possible.”
• “The remedy for diabetes is not in the drugstore but in the kitchen.”
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Story 1
- Unambiguous ProgressThough Technology -
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Frederick Banting
JJR MacLeod
Charlie Best
JB Collip
Wonderful Technology:Insulin’s Discovery & Development, 1921 - 1922
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11 January 1922
Toronto General Hospital
Insulin first used in a human, Leonard Thompson, then 12
years old
Only a modest reduction in blood glucose
Discovery & Development of Insulin
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• Reliable industrial supply by late 1922
• Nobel Prize in 1923
Discovery & Development of Insulin
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Billy Leroy,before the onset of
diabetes
Stunning photographs …
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Joslin Clinic Staff, circa 1950
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Survival After Onset of Diabetes:JDC Pre & Post Insulin Cohorts
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Story II
- Type 2 Diabetes as a Genetic Disease -
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Genome Wide Association Studies
• Type 2 Diabetes is associated with TCF7L2, FTO, and other genes
• Risk may be due to altered energy metabolism, insulin resistance, insulin secretion
• Much media coverage of these associations
• Known genetic associations still explain only a small portion of why people develop diabetes
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Story III
- Disease Change withGreat yet Ironic Consequences -
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2 Mechanisms
TransmutationPhysical Disease Change
TransformationIllness Experience Change
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2. Disease Transmutation: How Do Diseases Change?
Patterns
Eradicated or Diminished
Substituted for Infections
Relocated or Exported
Emerged De Novo
Re-emerged
Transmuted
Examples
Smallpox, Typhoid, Measles
CVD, cancer
Cholera, tobacco-related illness
HIV, SARS
TB, gonorrhea
...
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Survivors with long-term sequelae
• Childhood cancers, prematurity, transplantation
Dependent upon intensive regimens
• Cystic fibrosis, HIV-related illnesses
Dependent upon machines
• Chronic renal dialysis, ventilators
Dependent upon medications
• Asthma, hemophilia, arrhythmias, diabetes ...
Transmuted Diseases: Examples
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‘Natural’ Disease Course
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Transmuted Disease Course
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Cycles of Disease Transmutation
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• Children with diabetes, some of whom are female & who become
• Young women who
• Sometimes become pregnant &
• Have babies
Priscilla White, MD (1900-1989)
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Transformation of Illness
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3 Themes
Getting the Point Self-care work
The Want of ControlAlluring, elusive
Regulating ResponsibilityPraise and blame
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• Less stigma
• Summer camps and sports
• Not advised against marriage or child bearing
• Less employment discriminated
• Health insurance made care more affordable
• Struggles still with
• Managing daily work
• Striving for control
• Apportioning responsibility
Transformation of Diabetic Illness
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• Master clinician
• Pioneered diabetes care
• Diet and insulin therapy
• “Manuals” for patients
• Standardized records
• Special visiting nurses
• Public health visionary
• Diabetes screening
• Blended medicine & moralism
• The Want of Control
Elliott P. Joslin, MD (1869-1962)
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Life Span Medal
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Life Span Medal
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InjectingInsulin
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The First Jab
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7 AMand allO.K.
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Givingthe
S.O.S.at 7 AM
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• Nearly 90 years after insulin’s discovery, diabetes continues to put people at risk of
• Blindness
• Amputations
• Kidney failure
• Heart attacks
I don’t want this to happen
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Story IV
- Diabetes as a Disease Created & Shaped by Technology -
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... crisis
UN Resolution (2006): “Diabetes is a global pandemic”, “a silent killer that kills one person every 10 seconds”
Diabetes (Type 2) is a ...
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Focus of Public Awareness Campaign:
World Diabetes DayNovember 14th
Diabetes (Type 2) is the ...
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Diabetes (Type 2) is a ...
“A disease of civilization”
• Apollinaire Bouchardat (1806 - 1886)
• 1871 siege of Paris - food scarce - patients with diabetes faired better
• “Eat as little as possible” – mangez le moins possible
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1994
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2 Quotations
• The best treatment for diabetes is to “eat as little as possible.” Apollinaire Bouchardat (1806-1886)
• “The remedy for diabetes is not in the drugstore but in the kitchen.” Arnoldo Cantani (1837-1893)
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Diabetes (Type 2) is ...
An epidemic
• ... due to metabolic aberration
• ... due to human energy imbalance
• ... due to technology
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Diabetes (Type 2) is ...
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Diabetes (Type 2) is ...
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Technology Dimensions
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Technology Dimensions
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Technology Dimensions
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Types of Technologies1. Small-Intimate-Pleasant/Unpleasant
• Applied at n = 1 level
• Deployed in personal space
• Adherence
2. Large-Vast-Pleasant/Benign
• Applied at population level
• Deployed at far remove from person
• Acquiescence
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Let’s put our thoughts in order
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Order …
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… versus a different sort of order …
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... and another sort of order ...
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… versus yet a different sort of order
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Conclusions
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There is not only an artistic style,
there is also a style of thinking.
Owsei Temkin
“Historiography of ideas in medicine”
The History of Depicting Diabetes
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• “Give me a place to stand, and I shall move the world.”
Archimedes
287 - 212 BCE
A question of leverage
• Where should we stand to do the work of improving health?
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1. What story -- or stories -- should we tell about diabetes?
If diabetes is a disease of technology ...
2. Is more technology the answer to technology?
3. What products, programs, and policies are needed to compete with small-scale pleasant or large-scale pleasant/benign technologies that cause energy imbalance?
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The stories we tell
shape the questions we pose
and the answers we create
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• ... for your time and attention
Thank you ...