Receipt or Change

Receipt or Change

There was an agreement made, but no one affected by the decision was involved in making it.  Basically, there wasn’t much discussion.  It seemed a simple enough remedy to a rapidly evolving global health economic problem.

For years and years, actually decades, the government had been trying to get control of the diabetes epidemic.  They had tried the approach of telling people they were too fat and encouraging weight loss by traipsing skinny little waifs across all the magazine covers, but just when it looked like it was beginning to work, they suddenly discovered that bulimia and anorexia caused diabetes too.  And since it was just too difficult to get people to have a normal weight, something else had to be done before the epidemic of diabetes bankrupted the world.

After their first couple of attempts failed, they next chose to try and control the cost of insulin, but that didn’t work.  The drug companies sued and the Supreme Court agreed with them that it was illegal for the government to fix prices, even if the government thought they had a good cause.  Capitalism demanded that governments bow to profitability; otherwise nothing would ever be made or produced again.  At least, that was the idly mentioned threat.

The next step was to force better glucose control.  The thinking was that better glucose control would lead to fewer problems with diabetes, such as heart disease and kidney failure.  The best way proven to repair glucose control was to do pancreatic cell transplants, but they couldn’t find enough pancreas cells and no one, not even with inducements, was anxious to give up a few pancreas cells when the risk was that they would become diabetic and suffer the wrath of the government as well, or worse yet blindness, heart attacks, or strokes.  Then when some bright-eyed economist crunched the numbers, the cost of pancreatic islet cell transplants was prohibitive, and that was just a subtotal, without factoring the cost of life-long immunosuppressive therapy.

Somewhere during the debate, someone suggested maybe they should just stop supplying insulin at government cost.  The civil libertarians sued over the concept and it never did manage to gain much support.  Nobody could quite grasp the idea of pushing grandma off a porch in her wheelchair, just because her pancreas didn’t work any longer and her feeble brain couldn’t remember her injections, nor could her feeble eyesight guide her feeble shaky hands to draw up the right amount of insulin and jab it into her emaciated abdomen.  Once that ad hit the airwaves, all the old people; the only ones known to vote their own self-interests, took to the streets in droves.  Unfortunately, it was during the middle of a drought and a humid heat wave in Las Vegas, and some of them keeled over and died right there on television, during primetime news, while crossing the street in front of Caesar’s Palace.

For a couple of years, it seemed everything had died down.  It appeared the different governments had acquiesced and decided to just go bankrupt figuring, what was the worst that could happen?  It wasn’t until the prospect of all those third world countries, without demoralizing diabetes, arising into the post-capitalist vacuum and wagging their dirty unmanicured fingers over the nuclear wand of all humanity took hold, did the conclusive option materialize. 

It was conceived and initiated at a penal colony in an unnamed country with an unbelievably high rate of non-governmentally created adult-onset diabetes.  They promised the local peasant government some kind of loan forgiveness as well as absolute secrecy and plausible deniability for their unconscionable complicity.  In all likelihood, they probably didn’t need to offer them as much as they did, but they were in a hurry and wanted to guarantee a grateful gullible ally.

None of the prisoners knew they were part of an experiment and since the local government considered it a national emergency, they had no intention of asking for consent.  None of the nurses or doctors initially on-site was ever aware of their participation in an unauthorized study.  They were just grateful for all the new help that arrived with the bright shiny new computers and the curvaceous diabetes nurses.  The insulin arrived on time for once.  It was given per routine orders and lo and behold, suddenly they had one hundred percent compliance.  The doctors thought it was secondary to the curvaceous nurses with their really light touch with the lancet. 

The local health department got wind of their unheard-of successful compliance and decided to do a prospective study on the outcomes as far as decreased heart attacks, blindness, strokes, and kidney disease.  They would have probably attained good results, but they had an inordinate number of easily explainable deaths, namely, the death penalty case losers.  For whatever reasons, most of the inmates with diabetes were on death row and all of their appeals first ground to a halt and then suddenly expired.  The health department did release the results, but they focused on the high rate of violent crime activity and its high concordance rate with diabetes.  The compliance rate was mentioned as an aside on the bottom corner of one of the tables.  Everyone figured it was just a fluke and didn’t bother trying to explain it.  Who could really believe 100% compliance?

With the success of their study, the number of countries salivating over extending the study to their population grew at an alarming rate.  Soon, every single industrialized country had at least one penal site participating in the secret study.  The correctional advocates just thought they were finally making some headway to improve ethical and moral healthcare within prisons.  They were positively giddy with delight over the added personnel and expertise.

Things would have continued merrily on had it not been for a couple of foreign sites that had abolished the death penalty.  Soon enough, another group of university public health wannabes made note of the high compliance rates and wanted to measure their outcomes.  They were denied at every turn; so of course, they went to court and sued to do the study, arguing its international medical and geopolitical significance.  They won in one country where all of the justices on the court had diabetes and a couple of them had had strokes and heart attacks.  No one mentioned that one or two were demented from their cerebral accidents or repeated episodes of hypoglycemia.  Somehow it wouldn’t have been kind.  Besides, the ones who hadn’t had strokes merely had to glance down the bench a ways to see their futures in uncharacteristic stark relief on the distorted faces of a couple of their drooling, blathering, colleagues.  Their decision was unanimous.  The study was ordered.  It was even expedited.

One site studied the results by chart review, but the other decided they needed to determine the behavioral components of their outrageous measures of adherence.  Their questions weren’t answered by studying the charts, so they did interviews of the inmates, the nurses, and the doctors.  They became suspicious when some of the staff refused interviews and then disappeared.  They became even more suspicious when the inmates told of initially getting a buzz on their insulin and later had withdrawal symptoms when they were more than ten minutes late for their injections.  It didn’t seem to matter if they were on once, twice, or thrice daily injections.  They had to be punctual.  The need for their insulin also convinced them they couldn’t do time in solitary confinement.  In solitary, they couldn’t guarantee the timeliness of their injections; consequently all the diabetics were model prisoners.  All of them had episodes of low blood sugar and each could relate the death of someone in their midst who had gotten their insulin but had been deprived of food for some inordinate reason.  All of them were afraid it would happen to them; another good reason to be obedient and kind.  They also all told their friends when they got in that maybe they shouldn’t take insulin while they were there.  They mentioned the oral medications as reasonable options until friends were released.  None of them could recall hearing about a released diabetic who was out more than a day or so before violating parole and trying to get back to their original prison or some jail site that was a part of the study.  No one ever came back though.  It was really odd.  As they spoke about it, they realized no one ever left anymore.  No one seemed to want to go.  They all managed to convince the low level officers to advocate for increasing their time; often through bribery.  It was too odd. 

One particular warden was becoming concerned that his prison was being filled with diabetics who never left.  He was really freaked out about it.  It was eating up his medical budget.  He barely made mention of it, but the next day he had a heart attack and died.  His replacement interestingly wasn’t concerned at all.

When the news finally hit the airwaves that the inmates were achieving better outcomes with their diabetes control, there were riots in the streets and demands for non-convicted people to get equal, if not better, care than the inmates.  It probably would have happened had the poorer communities wanted to participate.  Their concerns were dismissed as further conspiracy theories, but they still didn’t participate.  None of the doctors could get them to agree, not even at the university hospitals, so only the rich and the incarcerated were involved in the studies.  And just as in the prisons, the wealthy were having great outcomes with their diabetic management.  The stroke rates, heart attacks, and kidney failure rates plummeted.  The only problems seemed to be social issues.  They had high rates of failed marriages, unwarranted pregnancies, and lapses in employment.  So, of course, someone wanted to do a study of why.  They concluded that since it was equally affecting women, men, and all minority groups, then it must be related to some effect of diabetes on the brain, so some government whiz kids decided that they should recommend sterilization in diabetic families.  No one thought it would pass, but it did. Then no one thought it would be generally accepted, but it was.  It was seen as a protective measure for future children and an end to the scourge of diabetes.  It had the unintended consequence of leading to a redistribution of wealth and prosperity as the wealthy, now not having children to support or leave their fortunes to, simply donated to charities or had their funds confiscated by the government.  The charities and the government then used the funds to support social structures in poor communities leading to improved nutrition, education, and healthcare.  It was a win-win situation all around.  The next disease on the list was high blood pressure.  Stay tuned.