Thursday, 5 April 2012


Dear Friends:
The Endocrine Society is objecting the fact that some of the anti diabetic medications would be sold over the counter, insisting that the diabetes care has to be under SUPERVISION of a medical doctor who would coordinate the other activities. Ever since I have begun working with the Indians, I have known that model to be faulty, the only way we can improve the health of the Indians, is work together, not in a hierarchical fashion but in a circular fashion and make the patient feel and understand that it is possible to take care of their health. I have always joked to Michele, My aim is to make my self Unemployed! Indian Health Services and the Tribal Programmes are leading the way and showing the light on how to better look after an indian patient with Diabetes: cooperation and consensus. I am becoming more and more an ornament, I happily admit!
Best wishes
I am enlosing a letter I wrote to Maurits Van Pelt who runs a diabetes are programme in Cambodia ( in which people from the community are taught to take care of people with diabetes , the so called Peer to Peer Education Programme. I know you have thousands of emails to read, but read my letter to him if you have a minute to spare.
Dear Maurits,
Recently I heard a comment, I am not sure where in Asia, that the doctor said: I am against medications being freely made available to the patient. Current studies show that up to 80 per cent of the patients (abstract presented at ADA last year) do not follow the regimen prescribed. Among my own patients I can be sure that they take the morning dosage and often do not take the afternoon dosage because of their social life balanced towards evenings and nights.
FDA in the USA, not always a user friendly organization seems to have decided to make available without prescription commonly used drugs. But Endocrine Society vehemently protests that Diabetes medications be excluded from this benevolence.
Just look at the tone of the letter from Endo Society, a little bit condescending and arrogant. We in the field recognize that the days of Doctor directed or supervised Diabetes Care is going to be history and that innovation is coming in from empowerment is given to the patient and not provide more authority to the Doctor.
My role in the team in our clinic, is to see the patient last, rather than first and organize their therapeutic regimen, but after they have been seen by: optometrist, podiatrist, diabetes nutritionist and diabetes educator, I am given time to counsel and talk about spiritual matters (this being possible among the Native American Indians). The Diabetes Educators would have already begun the change in treatment regimen if they thought so, I agree with them almost always. I do keep an eye on prevention factors on complications,especially nephropathy, again following very local criteria, such as
our patients normal BP is around 110-120/60-70.
There is unexplained haematuria with or without diabetes, possibility of IgA nephropathy.
Protein is always measured in the urine and followed. (this is also being automated without my participation) and i check that.
So the time given to me, which is about 45 min to 1 hour per patient: 25 % on medically related matters and 75% on non medical non pharmaceutical matters.
Our patients have easy access to medications and strips to measure blood sugars.
So our system is much closer to MOPOTSYO model than the model espoused by Endocrine society and here is their note:
Society Recommends Exclusion of Diabetes Medications from Nonprescription Drug Expansion

Endocrine Insider
April 4, 2012

To increase patients’ access to safe treatments for certain conditions, the U.S. Food and Drug Administration (FDA) is considering making some commonly used prescription drugs available without a prescription. FDA held a hearing on March 22-23 to receive public feedback on the expansion, which is proposed to provide more ready access for medications for highly prevalent diseases that can be self-diagnosed and treated. As examples of such diseases, FDA listed hyperlipidemia, hypertension, migraine headaches, and asthma in a February 28 request for comments. The Society is concerned that FDA might also include medications for diabetes under this expansion due to the high prevalence of the disease.

As a result of its concerns, the Society submitted a comment letterurging the FDA to exclude diabetes medications from this expansion due to the complexity of treating and managing diabetes. The Society recommends that diabetes medications continue to be prescribed by a physician and that allied health professionals should continue to provide education and assistance to patients in coordination with a supervising physician. The FDA is currently considering comments on the proposed expansion and the Society will inform its members once a determination has been made. Additional information can be accessed here.

as an anthropologist I have to question the motive of the society, which is primarily to protect the endocrinologists rather than the welfare of the patient? Medications are freely available in most parts of the world and in many countries patients never get to see a doctor but a pharmacist is the one that gives the advice.

Quantitatively speaking, the results of National Studies in the USA, does not show that the measurements are any better than poor, developing countries of the world. and of course if you compare, the results among the Mexican Americans in Texas or Blacks in Georgia or American Indians in South Dakota, most of the developing countries have similar or better quantitative profiles . In Basra, Iraq a war zone the average A1C is very similar to the above groups mentioned.

What Endocrine Society need to understand is that Diabetes as we see it (excluding type 1) is a social disease and the answers are going to be social in nature, with a good contribution from medications. In a study published in the last couple of days they wanted to show that injectable Exanetide was better than Metformin, but it turned out to be not superior to any of the medications we commonly use except Sitagliptin, another newer medication.

Today I will start reading about Outcome Measurements and also i was happy to see that the World Diabetes Foundation has taken an interest in the Diabetes among Indigenous peoples of the world! I will be in touch with you regarding how to approach them.

Enjoy your holidays. You deserve it. It is a beautiful day in Paris. I will be leaving for the Indians (Nebraska and South Dakota) on April 16th.