And now what? Time for daring innovation
Clicerio González Villalpando, MD, MACP; Ruy López Ridaura, MD, DSc; Eduardo Lazcano Ponce, MC, Dr en Sc; Ma Elena González Villalpando, MD
Instituto Nacional de Salud Pública, Cuernavaca, Morelos, México
The results presented in this issue of Salud Pública de México are without any doubt, a clear description of a daunting panorama for our country. The most important resource for us, our people, is suffering severe consequences in their health (during their prime and subsequently vulnerable years of their lives). Most likely, the scenario will only get worse if we continue to do what we are currently doing. This means, doing the same, will produce not the same, but worst results.
Thinking as physicians, are we facing a situation that is, in itself the diagnoses? Or are we identifying the signs and symptoms of a systemic illness, that is more profound and encompasses all of these elements plus others?
In medicine, this is a crucial question, since it will direct the therapeutic strategies (therapy based in etiology). Our current model of action is directed towards the implementation of primary, secondary and even tertiary preventive and therapeutic measures (usually very costly), geared to these specific disorders as if we were sure, that these are the diagnoses. We focus our actions on these illnesses. But, we need to ask ourselves: are we directing our efforts to the correct target (the etiology)? What is the main force driving the obesity-diabetes-hypertension-dyslipidemia epidemic?
This question is the crux of the matter. Can we group along with these conditions, other dysfunctional aspects present in our society? Can we identify elements that could link tobacco and alcohol consumption, gambling, illicit drug abuse among others to the so called cardiovascular risk factors? The answer is probably yes. We can recognize that the motor driving these, self destructive behaviors is consumption. Literally, all of these maladaptive circumstances share the force of consumption. Eat!, drink!, inhale!, inoculate!, apply!, purchase!, but do it! and do it as much as you can! This is the message society hears repeatedly, loud and clear reiterated via all the possible channels.The situation could be named as the "essence deficit-hiperconsumption syndrome". For he past generations, we have left, at the mercy of the market forces, our population's education (even though we have spent significant and precious resources, mainly time, in an effort to develop public education). Naturally, society has responded and in many ways, at an outstanding level. Our society is recognized as a leader in consumption (sadly, in many aspects, quite the opposite in production). We are seen as a good "market", avid, uninformed, malleable, growing, mostly unregulated. An ideal situation for good sound marketing.
We need to question our current paradigm and accept that in chronic conditions (this is 85% of the entire monetary resources dedicated to health), we are not performing as we need nor as we think we are doing. In fact, the current paradigm (the one in operation now) is also a self perpetuation of the consumption model. More medicines, more costly, more laboratory studies, more modern (and expensive) hospitals (with costly technologies), more of anything that can be consumed. Butâ¦ for what? To provide "better" care? The definition of this goal requires clarification. What does not need a clearer definition, is the expense of this model and the ultimate outcomes we can obtain and measure. In this respect, our country is facing a situation similar to the one seen in many parts of the world. Incremental costs with systems unable to sustain the expense. The current political crisis affecting the United States resides precisely in this grounds. The uncontrolled costs have imposed a toll that has bankrupted the system. Since in many ways, the United States exerts strong influence in the Mexican system, we are seeing now a replication in Mexico, of many costly, inefficient, perverse, profit-centered health care models prevalent in the United States. We as a society have a heterogeneous level of awareness, the majority has almost no knowledge of these circumstances, consequently are not empowered to have an informed decision. The pro-choice argument is simply not applicable. We are in fact dealing with a vulnerable society regardless of its income, age, race, language or gender. This is the most compelling issue for systematic questioning, innovation, evaluation and rectification or ratification. We, the professionals are obliged to lead.
Recognizing this almost quixotic aim and responding to the challenge within the realm of our institutions, we moved forward with an initiative that pretends to be a seminal force within our minds first, subsequently our actions. We named this Proclama para la Prevención y Control de la Diabetes en México (Proclamation for the Prevention and Control of Diabetes in Mexico). This initiative signed by our Institute in conjunction with the Sociedad Mexicana de Nutrición y Endocrinología, the Fundación Mexicana para la Salud and the Centro de Estudios en Diabetes, was presented to the Ministries of Health that attended the National Congress of Public Health held on March 2009. It was a meeting during which all attendees expressed their support and coincided with the need for systematic actions. The consensus was that the declaration would be presented at the National Health Council at their next meeting, which was done. Subsequently the declaration was taken to the National State Governors (Conferencia Nacional de Gobernadores, Conago). We were told that in all of these instances, there was support and agreement with the need for action. However, there has been a lag time that we are sure we do not have. The future is here, the impact of these phenomena is rapidly expanding the costs and challenges.This is the time for daring innovation.
Proclamation for the Prevention and Control of Diabetes in Mexico
1. Data from the latest Mexican Health and Nutrition Survey 2006 confirmed a national prevalence of diabetes of 14.4% in the adult population aged 20 and over, representing more than 7 million Mexicans with diabetes. Almost half of them were unaware of their diagnosis.
2. Diabetes is the leading cause of death in Mexican population.
3. The combination of a high incidence with high mortality reflects the enormity of this growing epidemic.
4. The impact of diabetes on the health of Mexican population is ubiquitous, affecting urban and rural population, particularly vulnerable groups such as older adults of lower socioeconomic status.
5. Diabetes and obesity are the main factors associated with the loss of healthy life years.
6. Diabetes is the leading cause of preventable blindness, chronic renal failure and non-traumatic amputation in Mexico.
7. Most patients with diabetes in Mexico are in poor metabolic control.
8. Diabetes is the most costly item for the country's health care system.
It is imperative to make a joint proclamation by integrating all stakeholders, where society participates synergistically in a creative response to this common challenge.
In this regard, the National Institute of Public Health, in carrying out its mission, invites all Ministries of Health of the States of the Republic to declare its support for a comprehensive, national, synergistic, efficient, focused on the patient and measurable strategy for the prevention and control of diabetes.
We define the following actions:
1. In coordination with the federal health sector, encourage the creation of a single strategy applicable across the country, aimed at the prevention and control of diabetes, obesity and cardiovascular risk.
2. The action plan will focus its assistance in promoting a healthy lifestyle, balanced diet and physical activity.
3. Encourage the state and federal legislature to generate initiatives that promote a healthy living environment and monitor the relevance and validity of consumer information in relation to food, food supplements and drugs.
4. Promote specific strategies to adapt the current care model to a context of shared responsibility between patient-family-health team-health system.
5. Promote the implementation, monitoring and adherence to the Norma Oficial Mexicana para la Prevención Diagnóstico y Tratamiento de la Diabetes (Mexican Official Standard for the Prevention, Diagnosis and Control of Diabetes).
6. Encourage and support the continuous training of health providers, including modification of undergraduate academic programs of schools of medicine, nutrition and nursing.
7. Promote accessibility to medicines, including insulin, laboratory tests for adequate surveillance and monitoring diabetic patients.
8. Encourage performance and evaluation of the program in terms of technical quality, cost-benefit, and also in terms of warmth of care.
9. Encourage the generation of state and national information for feedback on the results of evaluations.
Proclama para la Prevención y Control de la Diabetes en México
1. Datos de la Encuesta Nacional de Salud y Nutrición 2006 confirmaron una prevalencia nacional de diabetes de 14.4 % en la población adulta de 20 años y más. Esto significa que más de 7 millones de mexicanos padecen diabetes, y prácticamente la mitad de éstos desconocían su diagnóstico.
2. La diabetes es la primera causa de muerte en población mexicana.
3. La conjunción de una alta prevalencia con una alta mortalidad refleja la enorme complejidad y magnitud de esta creciente epidemia.
4. El impacto de la diabetes en la salud de la población mexicana es ubicuo pues afecta a población urbana y rural, particularmente a grupos vulnerables tales como adultos mayores, mujeres, indígenas y personas de menor nivel socioeconómico.
5. La diabetes, junto con la obesidad, son los principales factores asociados a la pérdida de años de vida saludables.
6. La diabetes es la primera causa de ceguera prevenible, de insuficiencia renal crónica terminal y de amputaciones no traumáticas en México.
7. La mayoría de los pacientes con diabetes en México se encuentran en descontrol metabólico grave, independientemente del acceso a servicio médico.
8. La diabetes es el rubro más costoso para el sistema de salud del país.
Es imperativo hacer una proclama conjunta integrando a todos los actores involucrados, en donde la sociedad en pleno participe de manera sinérgica en una respuesta creativa ante este reto común.
En este sentido, el Instituto Nacional de Salud Pública, en el ejercicio de su misión, invita a todos los Secretarios de Salud de los estados de la República a declarar su apoyo a una estrategia integral, nacional, sinérgica, eficiente, evaluable y centrada en el paciente para la prevención y control de la diabetes.
Para lo cual se definen las siguientes acciones:
1. En coordinación con el sector Salud a nivel federal, se fomentará la creación de una estrategia única aplicable en todo el país, dirigida a la prevención y control de diabetes, obesidad y riesgo cardiovascular.
2. El plan de acción centrará sus intervenciones en el fomento de un estilo de vida sano, alimentación balanceada y promoción de la actividad física.
3. Fomentar que el Poder Legislativo, tanto estatal como federal, genere iniciativas que promuevan un entorno de vida más saludable y vigile la pertinencia y validez de la información para el consumidor en relación con la alimentación, complementos alimenticios y fármacos.
4. Promover estrategias específicas que adapten el modelo de atención actual a un contexto de corresponsabilidad entre paciente, familia, equipo de salud, sistema de salud y sociedad en general.
5. Fomentar la implementación, apego y seguimiento de la Norma Oficial Mexicana para la Prevención, Diagnóstico y Tratamiento de la Diabetes.
6. Fomentar y apoyar la capacitación continua de los prestadores de servicios de salud, incluyendo la modificación de los programas académicos de pregrado de las escuelas de medicina, nutrición y enfermería.
7. Fomentar la accesibilidad a medicamentos, incluyendo insulina, y a exámenes de laboratorio y gabinete para la adecuada vigilancia y control del paciente con diabetes.
8. Fomentar la evaluación del desempeño del programa no sólo en términos de calidad técnica y costo/beneficio sino también en términos de calidez de la atención.
9. Fomentar la generación de información tanto estatal como nacional para la retroalimentación de los resultados de las evaluaciones.