The New York Times has done a several part story on the diabetes epidemic. I know the snips are long, but I urge you to read them anyway, even if you do not click the whole article. The chances are good that if neither diabetes nor health care crime kills you, it will kill someone you love. And soon.

Begin on the sixth floor, third room from the end, swathed in
fluorescence: a 60-year-old woman was having two toes sawed off. One floor up,
corner room: a middle-aged man sprawled, recuperating from a kidney
transplant. Next door: nerve damage. Eighth floor, first room to the left:
stroke. Two doors down: more toes being removed. Next room: a flawed

As always, the beds at Montefiore Medical Center in the Bronx were
filled with a universe of afflictions. In truth, these assorted burdens
were all the work of a single illness: diabetes. Room after room, floor
after floor, diabetes. On any given day, hospital officials say, nearly
half the patients are there for some trouble precipitated by the

An estimated 800,000 adult New Yorkers – more than one in every eight –
now have diabetes, and city health officials describe the problem as a
bona fide epidemic. Diabetes is the only major disease in the city that
is growing, both in the number of new cases and the number of people it
kills. And it is growing quickly, even as other scourges like heart
disease and cancers are stable or in decline.

Already, diabetes has swept through families, entire neighborhoods in
the Bronx and broad slices of Brooklyn, where it is such a fact of life
that people describe it casually, almost comfortably, as “getting the
sugar” or having “the sweet blood.”…

There are two predominant types of diabetes. In Type 1, the immune
system destroys the cells in the pancreas that make insulin. In Type 2,
which accounts for an estimated 90 percent to 95 percent of all cases, the
body’s cells are not sufficiently receptive to insulin, or the pancreas
makes too little of it, or both.

Type 1 used to be called “juvenile diabetes” and Type 2 “adult-onset
diabetes.” By 1997, so many children had developed Type 2 that the
Diabetes Association changed the names.

What is especially disturbing about the rise of Type 2 is that it can
be delayed and perhaps prevented with changes in diet and exercise. For
although both types are believed to stem in part from genetic factors,
Type 2 is also spurred by obesity and inactivity. This is particularly
true in those prone to the illness. Plenty of fat, slothful people do
not get diabetes. And some thin, vigorous people do.

The health care system is good at dispensing pills and opening up
bodies, and with diabetes it had better be, because it has proved
ineffectual at stopping the disease. People typically have it for 7 to 10 years
before it is even diagnosed, and by that time it will often have begun
to set off grievous consequences. …

But as alarmed as health officials are about the present, they worry
more about what is to come.

Within a generation or so, doctors fear, a huge wave of new cases could
overwhelm the public health system and engulf growing numbers of the
young, creating a city where hospitals are swamped by the disease’s
handiwork, schools scramble for resources as they accommodate diabetic
children, and the work force abounds with the blind and the halt.

The prospect is frightening, but it has gone largely unnoticed outside
public health circles….

One in three children born in the United States five years ago are
expected to become diabetic in their lifetimes, according to a projection
by the Centers for Disease Control and Prevention. The forecast is even
bleaker for Latinos: one in every two….

Diabetes has no cure. It is progressive and often fatal, and while the
patient lives, the welter of medical complications it sets off can
attack every major organ. As many war veterans lost lower limbs last year
to the disease as American soldiers did to combat injuries in the entire
Vietnam War. Diabetes is the principal reason adults go blind…

So-called Type 2 diabetes, the predominant form and the focus of this
series, is creeping into children, something almost unheard of two
decades ago. The American Diabetes Association says the disease could
actually lower the average life expectancy of Americans for the first time in
more than a century….

“Either we fall apart or we stop this,” said Dr. Thomas R. Frieden,
commissioner of the New York City Department of Health and Mental Hygiene…

Yet for years, public health authorities around the country have all
but ignored chronic illnesses like diabetes, focusing instead on
communicable diseases, which kill far fewer people. New York, with its
ambitious and highly praised public health system, has just three people and a
$950,000 budget to outwit diabetes, a disease soon expected to afflict
more than a million people in the city.

Tuberculosis, which infected about 1,000 New Yorkers last year, gets
$27 million and a staff of almost 400.

Diabetes is “the Rodney Dangerfield of diseases,” said Dr. James L.
Rosenzweig, the director of disease management at the Joslin Diabetes
Center in Boston. As fresh cases and their medical complications pile up,
the health care system tinkers with new models of dispensing care and
then forsakes them, unable to wring out profits. Insurers shun diabetics
as too expensive. In Albany, bills aimed at the problem go nowhere.

“I will go out on a limb,” said Dr. Frieden, the health commissioner,
“and say, 20 years from now people will look back and say: ‘What were
they thinking? They’re in the middle of an epidemic and kids are watching
20,000 hours of commercials for junk food.’….

Santos Alicea tottered haltingly over to the art shop in East Harlem,
his legs screaming. The regulars knew what he was going through. They
always did – the diabetes was speaking. He confirmed this with numerical
rigor: 228, his nasty blood-sugar reading this morning. Nods all
around. They had ugly numbers, too.

James De La Vega owned the art shop on Lexington Avenue, near 104th
Street, and regarded the sidewalk out front as his living room. There,
with his friends and family, he shared a lot over the years: Latino art
and culture, the slow cadences of East Harlem life, runs of hard luck.
And diabetes.

Indeed, in East Harlem, it is possible to take any simple nexus of
people – the line at an A.T.M., a portion of a postal route, the members of
a church choir – and trace an invisible web of diabetes that stretches
through the group and out into the neighborhood, touching nearly every
life with its menace.

Mr. De La Vega, a 33-year-old self-styled “sidewalk philosopher” whose
murals and sidewalk chalk drawings are familiar neighborhood ornaments,
has a mother with diabetes. His stepfather’s case was confirmed in
March. And a number of Mr. De La Vega’s friends who occupied his chairs or
sat in the bordering garden, well, they had it. Mr. De La Vega said he
would probably get it, too.

In East Harlem, in fact, it seems peculiar if you don’t have it.

Months spent in the easy company of the shop’s dozen or so regulars
reveal something more than just the insidiousness of Type 2 diabetes, the
disease’s most common form. Those months, and conversations, disclose
with relentless consistency the human behavior that makes dealing with
Type 2 often feel so futile – the force of habit, the failure of will,
the shrugging defeatism, the urge to salve a hard life by surrendering
to small comforts: a piece of cake, a couple of beers, a day off from
sticking oneself with needles….

Elsie Matos, Mr. De La Vega’s mother,
sat out front, her dark hair in a ponytail. The two of them still lived
together. She was 56 and worked in the office at a local public school.

She discovered her diabetes coincidentally, as many do, nine years ago.
A boil on her left thigh refused to heal. A blood test told her what
she didn’t want to know. Her fasting blood-sugar reading was nearly
triple the 126 milligrams per deciliter that defines the illness….

When she got the diagnosis, the doctor told her to shed 100 pounds.
With a crash diet she did just that, slimming down to 150. She stayed
thinner for a year.

“Then I started cheating,” she said. “Sandwiches. Frankfurters. I
didn’t care. I didn’t think it would matter.”

She was put on pills. Those who have diabetes usually suffer from
related conditions, especially high blood pressure and high cholesterol, and
often swallow 8 to 10 pills a day. Ms. Matos had high cholesterol and

She was warned that she had to control her lust for calorie-rich food,
that taking pills was not enough. Doctors like to say that patients can
eat their way through the pills. And a cruel truth of diabetes care is
that many oral medications prompt weight gain. Oral diabetes drugs also
tend to lose effectiveness. They sometimes work for a few years, then
have to be teamed with other drugs. Anyone who has diabetes long enough
is likely to find herself on insulin.

Ms. Matos frowned at her stomach. She said she was 165 or 170 pounds,
still too much. “The doctor said if I didn’t diet, I’d have to take the
insulin,” she said. “I don’t want the needle.”…

For many Type 2 diabetics, doctors say, a half-hour of daily exercise
and the loss of as little as 10 to 15 pounds can make a big difference
in their health. Still, that can be a formidable challenge.

Understandably, people talk about wanting to take a vacation from
diabetes, but it grants no time off.

Ms. Matos often found herself succumbing to a lifestyle guaranteed to
make her sicker. Until it has been in the system for a long time,
diabetes doesn’t hurt. In East Harlem, what doesn’t hurt is often ignored.

She pointed out that many people in her world were stressed out and
depressed. There are other serious health issues, like asthma and H.I.V.,
the signposts of many poor neighborhoods. Their cobbled-together lives
drain residents of their resolve. And so they cede diabetes the upper
hand and eat what tastes good to them to counteract the gravity of

“Listen, if I want to eat a piece of cake, I’m going to eat it,” she
said. “No doctor can tell me what to eat. I’m going to eat it, because
I’m hungry. We got too much to worry about. We got to worry about
tomorrow. We got to worry about the rent. We got to worry about our jobs. I’m
not going to worry about a piece of cake.”

Ms. Matos gave a feeble glance at a shopper mulling the mugs and
T-shirts. She carried her glucose meter around, but didn’t like to use it
regularly, especially when she was with friends, a vanity of hers. “It’s
embarrassing to check your blood in front of people,” she said. It irked
her, this machine laying a claim on her.

Diabetes, then, had worn her out. She was quite direct about that. “I
hate it,” she said. “I hate diabetes. I’m tired of checking my blood
three times a day.”…

He was 50 and lived with his mother. She was 66, and after more than a
dozen years with diabetes had been hit by its full-court press. Kidney
dialysis three times a week. Open-heart surgery. Dependent on a
wheelchair. Legally blind. It was Mr. Rivera who had to inject her with
insulin twice a day. “She’s black and blue from all the needles,” he said.
Lately, she had been in the hospital more than out.

Mr. Rivera, after a back injury, quit his job as a parking attendant 15
years ago. He had no income or insurance. He had not been to a doctor
in several years. Last time he saw one, he was told he had high
cholesterol and given medication. He didn’t take it. He didn’t like pills.
“That’s me,” he said.

Juan Concepcion, 57, Mr. De La Vega’s stepfather, materialized. He had
been a truck mechanic, until he became disabled by rheumatoid
arthritis. In March, he spent 12 days in the hospital after nearly passing out,
and his diabetes became bleakly clear. Ten years ago, his father died
of diabetes. “He kept taking sugar,” Mr. Concepcion said. “He kept
drinking beer. He was a stubborn guy. They cut one leg at the ankle. Then
they took the other above the knee.”

He stared unblinkingly into the distance. “I felt I was too strong for
it,” he said.

He drew on a cigarette, ashes fluttering in the air. He knew he should
quit. Smoking is especially bad for diabetics. “I check my blood every
morning and every night,” he said. “I’m supposed to do it four times,
but sometimes my fingers hurt and I don’t do it as often.” He was trying
to lose weight. “I loved my coffee with three sugars. My Pepsi, Coke,
beer.” He was given a book about diabetes by a doctor. “But I didn’t go
deep into the book, because it makes me lose my mind,” he said. “I’m
going to do it slowly. But I know, this is a killing machine.”

He shook his head. “Everywhere you go here, someone tells me they have
diabetes. I’ll go into a store and ask for coffee, no sugar. They say,
‘Oh, you have diabetes?’ “…

Doctors say the will to fight the
disease is often eroded by its psychological toll.

Sitting with these men and women whose lives were pervaded by diabetes,
one couldn’t escape feeling that they shared a dark cosmic joke – that
diabetes was too much to master at the individual level in a world that
had become so hospitable to it.

Mr. Concepcion said: “Everything about this neighborhood, the pollution
in the air, it all makes you sick. Don’t get me wrong, we love this
place, we love Spanish Harlem. But it does stuff to us. Now it’s giving us
all diabetes.”

Mr. De La Vega nodded. “We love eating trash,” he said. “We grew up
eating McDonald’s, and I still find myself eating candy and chocolate

People got huffy about their doctors. “Mine tells me, ‘Lose weight,
exercise more,’ ” Ms. Matos said. “Let him live my life and see.”

Mr. Rivera said: “You know what I think? I think there’s a cure. We’re
the poor, so they don’t want to give it to us.”…

Mr. Rivera bathed Mr. De La Vega with an odd look: “Did Mike have
diabetes? The guy who passed away?”

Mr. De La Vega said, “Yeah, he had it.”

“He was, like, 300 pounds.”

“He would brag about eating a pint of ice cream every night.”

“He used to eat six pork chops in one sitting. Then he would drown them
down with a quart of Budweiser. What was he when he died?”


Bigwig pulled up a chair beneath a thicket of light. The streets were
puddled from morning rain. His real name was Luis Hernandez. His job was
route supervisor for a produce company. He was a veteran member of the
art-shop crowd, and now a new admission to its diabetic subset.

His vision had been getting a little blurred – he’d look at a paper and
it was like 3-D vision; one morning he woke up and one eye wouldn’t
focus – and a physical found the source. “When they told me, it was like
somebody punched me in the gut,” he said.

His diabetic mother died in 2004, at 59. She had done little to address
her condition. She continued to smoke and eat generously.

He was confused. He said his doctor put him on pills and suggested
avoiding juice or sweets, but didn’t tell him much more.

He weighed 252 when he got the news. He had cut it to 245. He knew it
should be lower. But he found it excruciatingly hard to adopt a new
rhythm of life, particularly since it was less appealing than the one he

Bigwig had to go. Maria Calderon stopped by to visit Elsie Matos. Give
her a moment. Ms. Matos was waiting on a young woman torn between two

Yes, Ms. Calderon had it, too. Seven years since the diagnosis. She was
69. She was 210 pounds, and had been told to lose weight. “I didn’t
think it was important,” she said….

“How can you worry about your health when you don’t know where you’re
going to live next week?” …

She said to Ms. Matos: “I have a friend, she’s diabetic and everything
else. She takes 52 pills a day. She has everything in the book. When
she calls, she wants to talk for 99 hours. I say: ‘My sister’s calling.
I’ve got to get off.’ “

Ms. Matos said: “What, 52 pills? She’s nuts.”

On Third Avenue, around the corner from the art
shop, a banner outside McDonald’s proclaimed, “$1 Menu.” Down the way,
plastered on Burger King, “New Enormous Omelet Sandwich. It’s Huge.” At
KFC, a sign boasted, “Feed Your Family for Under $4 each.”…

In East Harlem, people sometimes have to choose between getting their
diabetes medication and eating. They sometimes share their pills, cut
them in half and take half-dosages. They improvise. Everywhere blare the
signals that the best meal is the biggest meal.

Nutritious food exists, but it isn’t easy to find. Dr. Carol R.
Horowitz, an assistant professor at Mount Sinai School of Medicine, heads an
East Harlem coalition trying to improve diabetes care. She oversaw a
study several years ago that tracked the availability of diet soda,
low-fat or fat-free milk, high-fiber bread, fresh fruit and fresh vegetables
in food stores in East Harlem and the Upper East Side.

Stores on the Upper East Side were more than three times more likely
than those in East Harlem to stock all five items. It did not seem to
matter that East Harlem has more than twice as many food stores per capita
as its wealthier neighbor to the south….

James De La Vega laughed. “We’ve got cultural differences,” he said.
“Here, for a guy to eat a salad, he’s a wimp. He’ll eat a big portion of
rice and beans and chicken. The women can’t be chumps, either. A woman
can eat a salad but has to eat it on the low. She has to do it quiet.
They make fun of you: What are you, a rabbit?”

What’s wrong with an orange?

Mr. De La Vega said: “Oranges are messy. You dirty your teeth.”

Uncontrolled diabetes is a forced death march. Literature handed out in
the community underscores this.

Knowledge alone, though, is never enough to change behavior,
particularly in an overwhelmed neighborhood. Chocolate cake may be a risk, but it
tastes so good on a bleak day. What stops that?

Mr. De La Vega said: “People ultimately feel powerless about a lot of
things. People think about bigger things. They think about survival.
Kids grow up fighting in the streets, so you want to raise big, strong
kids. So you give them three pork chops, a nice tall glass of soda to make
them strong. You realize, some of these people go to prison, and they
have to be strong. They eat and they eat. Nobody teaches them about

“I have two nieces,” Ms. Matos said. “They’re 24. I call them the sumo
wrestlers. They eat everything.”…

His mother said, “If you drink a diet soda and a man is watching, he’ll
say, ‘Why you drinking that?’ “

Mr. De La Vega said: “Nobody here goes out and gets an apple. They get
cake. People here associate diet as unhealthy. If you’re dieting, then
you’re sick. You look at the people on the streets, they’re heavy.
That’s the way we grow up here.”

Mr. De La Vega was silent, listening to the boom box. He said: “Around
here, if you make it to 40, you think, hey, I’m lucky, I made it to 40.
You have to understand, the philosophy out here is we’re going to die
from something.”…

Xiomariz didn’t mind her weight. “I feel my weight makes me look like
me,” she said. “So I don’t have to look like those skinny people.”

Not long after starting, in fact, she quit the gym – too much time and
too much money.

She didn’t comprehend the terror of the disease. “I know you can’t pass
it like kissing someone or something,” she said.

Some mornings, rushing, she neglected to take her pills. She had
stopped checking her sugar. She said she had lost the meter.

Was she worried about her diabetes?

She moved her head from side to side. “Sometimes I forget I have it,”
she said. “It’s not that big a deal.”

What other disease would she compare diabetes to? She thought a moment,
and found the answer. She said, “A cold.” …

He was talking to Jose Castro, 52, a squat man with a grizzled face,
worlds of feeling in his eyes. “I got it, too,” he said. “Yeah, I got the

The diagnosis came six years ago. Was he monitoring his sugar?

“I check once a day or every two days.”

How was it?

He laughed. “Been a little high,” he said. “I started eating Frosted
Flakes. What can I say? I like them. You can’t always be eating things
without sugar. Sometimes, you have to take a chance.”…

“The other day, I took my blood count and it was 40,” he added. “My son
took me to the hospital. They said I may have forgotten to take my
insulin. I don’t know. I don’t remember.”

He used to keep a log of his readings, but quit. Why?

“I don’t know,” he said. “So many things you have to do. It gets

Mr. Alicea tired, his
eyelids sailing down, and he returned to his two-room apartment across
the street. His furniture was plain. Bare bulbs protruded from the
ceiling. Mr. Alicea shared the place with his older brother, Pedro.

He, too, had diabetes. His vision was poor, his circulation was not
good, he had asthma, he had a weak heart. A while ago, he had fallen and
broken his arm and hit his head, and had not been himself since. “He’s
like a baby,” Mr. Alicea said. “He’s supposed to use insulin, but he
doesn’t like the needle.”

He didn’t like to prick his finger to check his sugar level, so he had
no idea what it was….

When he had the amputations, Mr. Salicrup was in the hospital a month
and a half, amassing medical bills he put at more than $300,000. It was
an amount in some ways laughable to him, because he expected never to
pay it off in this lifetime, but at the same time he knew it was a
serious matter. He gave something each month, and it constricted his life,
hanging over him like a sentence. He had since acquired insurance, for
which he paid stiff premiums.

“You make choices,” he said. “Instead of buying sneakers, you stay with
what you’re wearing. I’ve got to stay ahead of the blade.”…

Five toes gone, Mr. Salicrup didn’t want to lose more. He did his best,
he said, to tame his illness. He never cut the toenails on his left
foot. He paid a podiatrist. He still had a hard time wrapping his mind
around that: Here he was, a grown man, paying somebody else to clip his

Many affluent Americans will read this part of the series and aghast, raise horror-stricken palms. “How stupid!” They will say, as they go off to the pharmacy to purchase their medications with their well-stocked bank cards, on their way to the endocrinologist, no wait, it’s the dietician this week.

Intellectually, most of us know that we are all mortal, but to suggest that the immediacy, the emotional proximity of mortality is no different for rich and poor in America is to ignore reality.

Within the context of the ghetto, the barrio, the projects, death is not a thing of hushed tones and carnations, gold-edged sympathy cards and phone calls to Tele-Florist for something really nice, or when it hits closer to home, not a thing of catered wakes and readings of the will and long discussions round the big oak table in the stainless steel professional kitchen over expresso on the weighty subject of whether to sell or keep the lake house, that land down south.

Death is the special quality after the scream that follows the pop of a cap, gunfire itself is elevator music. Death is blood and brains all over the stoop, your clothes, right there. Wet and warm and nasty. Death from disease is one day you come home and there they are. And the first thing that comes to mind is not oh no granny’s gone, but how the hell are we going to pay to bury her because she cashed in that little policy she had, remember, when the rent went up the last time, isn’t there some thing at the city, some program, yeah I think so, when Sophia’s daddy died they called somewhere and they sent a truck. There are not many people in the projects who have not seen at least one somebody die before they get to high school. If they get to high school.

Death is not only something that is going to happen to you, death is something that is pretty certain to happen to you sooner rather than later. There are more aspects of life that are going to kill you than ones that are not, and within that context, diabetes care must take its place. And it’s not a very high one.

This fatalism, this meekness, is at once both infuriating and understandable. Infuriating for those who naturally, looking at history, and to an extent, even toward more contemporary events, cherish some sort of expectation that the Revolution is going to spring up from this teeming, burgeoning underclass, that at some point, somebody is going to stand up and say, “Oh no you DON’T!! I am every bit as valuable as the rich lady up on Park Avenue who gets all the test strips she needs, and who doesn’t have to split her tablets in half and share them with her sister!”

And understandable for those reality-based enough to know that anyone who did such a thing would be hauled off by “security” and most likely imprisoned, where her chances of receiving adequate care for her diabetes would hardly improve, or the chances that her cause of death would involve a bullet from the gun of the popo today would outweigh the chances that her diabetes will kill her in a year.

For those with even an inkling of awareness or familiarity with the real world effects of the feudalism, racism, the whole slimy tangle of nasty little isms that make up life in the US for the bottom 75 or so percent of its inhabitants, most of the revelations in this part of the series may cause sadness, but little surprise.

But some of what we hear from the East Harlem residents could just as easily come from the minds, if not the mouths, of people anywhere. Who among us does not know smokers, for example, whose denial and magical thinking, avoidance and resignation are every bit as evident in their behavior, if not their words, as anything told to the NYT reporter?

And is there a diabetic, or person suffering from any chronic illness, anywhere on earth, in any economic situation, who cannot relate to the desire to “have a vacation” from the disease? Even the wealthy, who can afford the best of medicine and medical treatment, cannot buy their way out of diabetes, or lupus, or heart disease, or cancer, even for a single day.

How many times have you heard someone say, “I don’t want to go to the doctor because they might tell me something is wrong?” And this is not something heard only in ghettos and barrios, but in the suburbs and the McMansions and the penthouses.

Thus while some of the East Harlemites’ attitudes and behaviors regarding their illness may have roots in the culture of poverty and despair, we also see many emotions that are quite universal, even among people with access to exemplary and state of the art medical treatment.

Which is something that the poor, whether in East Harlem or East Atlanta or East LA do not have. Even their slightly more fortunate brothers on the economic scale, those of the HMOs and group plans grudgingly “provided” by their employers fare little better, even as their co-pays and deductibles go up, their level of care does not.

In the next part of the series, we learn about why.

With much optimism, Beth Israel Medical Center in Manhattan opened its
new diabetes center in March 1999….

But seven years later, even as the number of New Yorkers with Type 2
diabetes has nearly doubled, three of the four centers, including Beth
Israel’s, have closed.

They did not shut down because they had failed their patients. They
closed because they had failed to make money. They were victims of the
byzantine world of American health care, in which the real profit is made
not by controlling chronic diseases like diabetes but by treating their
many complications.

Insurers, for example, will often refuse to pay $150 for a diabetic to
see a podiatrist, who can help prevent foot ailments associated with
the disease. Nearly all of them, though, cover amputations, which
typically cost more than $30,000.

Patients have trouble securing a reimbursement for a $75 visit to the
nutritionist who counsels them on controlling their diabetes. Insurers
do not balk, however, at paying $315 for a single session of dialysis,
which treats one of the disease’s serious complications.

Not surprising, as the epidemic of Type 2 diabetes has grown, more than
100 dialysis centers have opened in the city.

“It’s almost as though the system encourages people to get sick and
then people get paid to treat them,” said Dr. Matthew E. Fink, a former
president of Beth Israel….

“If a hospital charges, and can get reimbursed by insurance, $50,000
for a bariatric surgery that takes just 40 minutes,” she said, “or it can
get reimbursed $20 for the same amount of time spent with a
nutritionist, where do you think priorities will be?”…

One patient, Ella M. Hammond, a retired school administrator, recalled
standing up in the classroom one day in 1999.

“Has anyone noticed what’s different about me?” Ms. Hammond asked.

Blank stares.

“Now, come on,” she said, ruffling the fabric of a black gabardine
pantsuit she had not worn since slimmer days, years earlier.

“Don’t y’all notice 20 pounds when it goes away?” she asked…

“The center was a totally different experience,” Ms. Hammond said.
“What they did worked because they taught me how to deal with the disease,
and then they forced me to do it.”

Two hours a day, twice a week for five weeks, Ms. Hammond learned how
to manage her disease. How the pancreas works to create insulin, a
hormone needed to process sugar. Why it is important to leave four hours
between meals so insulin can finish breaking down the sugar. She counted
the grams of carbohydrates in a bag of Ruffles salt and vinegar potato
chips, her favorite, and traded vegetarian recipes.

After ignoring her condition for 20 years, Ms. Hammond, 63, began to
ride a bicycle twice a week and mastered a special sauce, “more garlic
than butter,” that made asparagus palatable…

To fix Type 2 diabetes, experts agree, you have to fix people. Change
lifestyles. Adjust thinking. Get diabetics to give up sweets and prick
their fingers to test their blood several times a day.

It is a tall order for the primary care doctors who are the sole health
care providers for 90 percent of diabetics.

Too tall, many doctors say. When office visits typically last as little
as eight minutes, doctors say there is no time to retool patients so
they can adopt an entirely new approach to food and life.

“Think of it this way,” said Dr. Berger. “An average person spends less
than .03 percent of their entire life meeting with a clinician…

As a result, primary care doctors often have a fatalistic attitude
about controlling the disease. They monitor patients less closely than
specialists, studies show….

Fewer than 40 percent of those with newly diagnosed diabetes receive
any follow-up, according to another study….

This grim reality persuaded hospital officials in the 1990’s to try
something different. The new centers would provide the tricks for changing
behavior and the methods of tracking complications that were lacking
from most care.

Instead of having rushed conversations with harried primary care
physicians, patients would discuss their weights and habits for months with a
team of diabetes educators, and have their conditions tracked by a
panel of endocrinologists, ophthalmologists and podiatrists….

By all apparent measures, the aggressive strategy worked. Five months
into the program, more than 60 percent of the center’s patients who were
tested had their blood sugar under control. Close to half the patients
who were measured had already lost weight. Competing hospitals directed
patients to the program….

Mount Sinai Hospital’s diabetes center hired an accounting firm to
calculate just how many bypass surgeries, kidney transplants and other
profitable procedures the center would have to send to the hospital to
offset the cost of keeping the center running, said Dr. Andrew Drexler, the
center’s director.

Nonetheless, both of these centers closed for financial reasons within
five years of opening.

In hindsight, the financial flaws were hardly mysterious, experts say.
Chronic care is simply not as profitable as acute care because
insurers, and consumers, do not want to pay as much for care that is not

Patients are also more inclined to pay high prices when severe health
consequences are imminent….

Indeed, former officials of the Beth Israel center said they
anticipated that operating costs would be underwritten by the amputations and
dialysis that some of their diabetic patients would end up needing anyway,
despite the center’s best efforts. “In other words, our financial
success in part depended on our medical failure,” Ms. Slavin said…

The center also lost money, its former staff members said, every time a
nurse called a patient at home to check on his diet or contacted a
physician to relate a patient’s progress. Both calls are considered
essential to getting people to change their habits. But medical professionals,
unlike lawyers and accountants, cannot bill for phone time, so more
money was lost.

And the insurance reimbursement for an hourlong diabetes class did not
come close to covering the cost. Most insurers paid less than $25 for a
class, said Denise Rivera, the secretary for the center.

“That wasn’t even enough to pay for what it cost to have me to do the
paperwork to get the reimbursement,” she said….

keeping customers who are diabetic is not the goal of
most health insurance companies, experts said. Avoiding diabetics is
actually more the point….

Some preventive measures would, at first glance, seem sure money savers
for health insurers since they might eliminate or forestall expensive
diabetes complications down the road. But many insurers do not think
that way. They figure that complications are often so far into the future,
insurance analysts say, that many people will have already switched
jobs or insurers, or have even died, by the time they hit…

With the center gone, Ms. Hammond said she has had to try to muddle
through. She goes to the podiatrist once a year, but she said she could
not remember the last time she visited an eye doctor. She has gained
about 40 pounds.

Some days she wakes up and her blood sugar is high. Other mornings she
doesn’t bother to check, she said.

“I couldn’t get to where I was before,” she said.

Two years ago, she said, she took a last look at that favorite
gabardine pantsuit she had once modeled for her class. Then, she said, she gave
it to her cousin….

 Of course, providing care to the “indigent,” those who have no money for either practitioners or insurance companies, is not profitable, but surely, one would suppose, those who pay insurance premiums every month will be getting their money’s worth?

Well, yes, and no. Even with a prescription drug co-pay of $20 or $30 a pop, a low income worker taking several prescription medications daily can soon exceed in those costs alone, the cost of their monthly premium for a modest HMO. It may be, they think, an excellent value. Which in a way, it is, since the alternative would be to pay their entire salary for prescriptions alone, or go without. It is, you see, necessary to adjust one’s notions of “value” when discussing anything related to health care in the US.

But that low income worker who is managing to somehow come up with the co-pays for all that medicine, and is grateful to eat a little less to do it, is getting bit in the butt again by his HMO, who will deny him preventive or early stage care, betting that he will either get by without it, change jobs, or perish, before his condition requires them to fork over big bucks. The medical treatment industry itself is hoping the opposite, that the lack of that earlier care WILL result in the big bucks treatment, since it will be they who receive those big bucks. Whether he changes jobs or not, the only way they lose is when he becomes uninsured, at which point, depending on a variety of factors, they may have to admit him, stabilize him and send him back onto the street, or in some cases, actually treat him, and pass the big bucks he is unable to pay along to someone who is.

The reporter gives eight minutes as the average visit length accorded a patient visiting his primary care physician (or increasingly, his primary care nurse practioner or physician’s assistant), however in doing  my own anecdotal research I discovered  that people found this figure extremely comical. “More like eight seconds,” one Blue Cross HMO patient told me when she stopped laughing. “OK,” she admitted, “it is not that bad. But it is usually under a minute, maybe a little over a minute sometimes, of the time I am actually with her.” She has learned, she says, to write down her symptoms and concerns, and read them off when the practitioner enters the room, so that she will not get distracted in detailing the first one and forget other questions.

That particular lady is quite healthy, and did not really feel her care had suffered from this “speed treatment,” since she only went to see the doctor a couple of times a year, and that for a pap test and maybe a stubborn cough or sinus infection. Her neighbor, however, an older lady with diabetes, reported a similar lightning round experience with her primary care provider, and though a member of a group health plan supposedly a step up from an HMO, reported experiences similar to those recounted by the East Harlem patients, in terms of time spent and education provided. She was diagnosed, she told me, with the 3 words, “you have diabetes,” advised to “cut down on sweets” and given prescriptions to lower blood sugar. No nutritional counselling, no endocrinologist, no classes not even a book or pamphlet!

I have also spoken to other diabetics who told me that even when they developed complications, they were not referred to specialists, but treated perfunctorily by the same physicians’ assistant/nurse practitioner model. No one I spoke to, even a couple of people who paid for doctor visits out of their own pockets, were advised to consult an opthalmologist to check for damage to their retinas! (It has since been suggested to me that perhaps some of these patients’ primary care providers did not have referral arrangements with the corresponding specialists, so since no referral fees would be involved, or loss of reciprocal ones, there was no benefit seen in making the referral).

This custom of negligence is not confined to diabetics, if my own (again, anecdotal) research is any indication. I spoke with several overweight middle aged (over 50) smokers, both male and female, whose payment status ranged from HMO to self-insured, who reported making initial as well as follow-up visits to primary physicians for everything from a “checkup” to complaints of abdominal pain and assorted routine upper respiratory and musculo-skeletal injuries, and not one was given, or even recommended, either  an EKG or an X-Ray, even though their patient histories indicated they had never had one!

In fairness, the out of pocket payers in this category were visiting “urgent care clinics,” or “McDoctors.” I have been informed by a number of knowledgeable sources that had these individuals been affluent enough to pay for a consultation with a regular private practice physician, they would have been urged to have not only Chest X Rays and EKGS, but as many diagnostic tests as they were able to pay for at time of service.

As the recent Georgetown study found, uninsured individuals face more than substandard care, when they are able to obtain any at all:

A group of Georgetown medical students recently posed as either low-income, uninsured adults or as the parents of low-income uninsured children who needed a wellness exam. The students visited 311 clinics, doctors’ offices and community health centers in the District.

Nearly half of these pretend patients were unable to get an appointment; those who were able to get one usually had to wait 2 1/2 weeks to see a doctor.

Providers also asked the students for a pre-visit deposit averaging $190 — a quarter of the gross monthly income of a minimum-wage worker. Only one in 40 sites was willing to see an uninsured patient without payment at time of service, and four out of five required payment in full at the time of the visit. The students further reported that more than one in five of the personnel with whom they interacted were rude or very rude….

Next: The Deadly Melting Pot

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