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When Elliott P. Joslin, M.D. 1895, S.D. '40, first opened his clinic at 81 Bay State Road in Boston a century ago, diabetes was a particularly pernicious and lethal disease. Even with the best treatment available at the time, physicians knew that most of their patients would die within two and a half years of diagnosis.
Like several other diabetes-treatment innovators of his day, Joslin observed that an extremely low calorie diet that provided all the basic nutrients could extend patients' lives a few months or years. After following Joslin's regimen for five years, for example, a nurse named Elizabeth Mudge starved herself down to 69 pounds, "just about the weight of human bones and a soul," Joslin observed. Patients dwindled, but Joslin kept them and their hopes alive. Hang on, he said, and soon we may have something for you.
Miraculously, Joslin's prediction proved correct. In 1921, when Frederick Banting and Charles Best discovered insulin, the pancreas's vital secretion, it was considered one of the most astonishing accomplishments of modern medicine. As Joslin himself was about to administer to Mudge the first shot of the drug Banting and Best called "Isletin," he reportedly was so overcome by emotion that he passed the syringe from his own shaking hand to that of his assistant, Howard Root '13, M.D. '19. Such were the feelings that ushered in a new era.
Unfortunately, it was not to be the "post-diabetes" era. Insulin was a miracle, but only a few years after Joslin and his colleagues began using it, they knew that it was not the cure for the disease. Although insulin, diet, and exercise together could keep patients' blood sugar from entering a lethal range, the chronic, long-term effects of diabetes continued. Joslin, meanwhile, continued to rally his patients' hopes for a cure. "Diabetics!" he wrote. "Take this lesson to heart! Keep your blood sugar normal and your diabetes controlled...and thereby keep alive to profit by some new discovery!"
As it has since the dawn of recorded history, diabetes today continues to take a significant toll in lives and health. The disease affects at least 16 million Americans, including an estimated 5.4 million who don't know they have it. Most Americans suffer from the Type 2 form that was not even recognized until 50 years ago. Although the disease is not as rapidly fatal as it was before insulin, our improved understanding of diabetes has left patients with the daily toil of testing and self-treatment with injections or anti-diabetic drugs. Even the best-treated diabetes still carries some risk of causing heart, eye, kidney, nerve, or vascular disease. Nationally, an estimated $92 billion is spent annually on diabetes and its complications.
"There are a number of reasons why diabetes is on the rise," explains Kenneth Quickel, M.D., lecturer on medicine and president of what is now the Harvard-affiliated Joslin Diabetes Center. "First of all, people with diabetes used to die quickly; now they live for many years after diagnosis. Before the discovery of insulin, people with the disease seldom had children. Today, because of improved treatment, people with diabetes have children all the time, and their genes are kept in the population. Second, African Americans, American Indians, Hispanics, Asian Americans, and Pacific Islanders are more vulnerable to the disease, and as those groups' proportional numbers rise in the population, so does diabetes. Lastly, large numbers of diabetes cases are developing here and overseas, in areas where high-calorie 'Western' diets and sedentary lifestyles have been adopted."
No cure appears imminent. We have realized since Joslin's time that diabetes is really more like a loose coalition of diseases than a single entity. In Type 1 diabetes, an autoimmune attack on the pancreas destroys the body's ability to make insulin, the hormone that ushers sugar out of the bloodstream and into fat and muscle. Type 2 diabetes, on the other hand, probably results from the body's resistance to insulin; people with this form of the disease may make a lot of insulin, but their cells respond insufficiently. Curing two such distinct diseases in one fell swoop would be extremely unlikely. So far, unfortunately, we're 0 for 2.
Eleven years ago, my wife, Judi, was diagnosed with Type 1 diabetes. Although she was a nurse and familiar with caring for the disease, she refused to believe she had it until she was admitted to her own hospital with diabetic ketoacidosis, a potentially lethal condition that results from acutely high blood-sugar levels.
"In my first few days, I heard a lot about advances in treatment," she recalls. "It sounded like there would be some breakthrough in the next few years that would make my injections a thing of the past. But my hopes have been frustrated. Now, when I see an article in the newspaper about a potential cure for diabetes, I'm very skeptical."
This is not to say that science has not yielded many important advances in diabetes treatment; it has. Before insulin, Joslin had only the crude tool of diet to control blood-sugar levels. Insulin was a huge step forward. Today, we have home glucose monitoring that enables patients to determine at almost any time whether or not they need more sugar or insulin. We have insulin pumps that allow patients to finely adjust their insulin dose. We have a bounty of new drugs to deal with the particular problems of people with Type 2 diabetes, and it appears that more formulations are on the way.
Our improved ability to control the blood-sugar levels of those with diabetes has prevented medical complications in thousands of people. The Diabetes Control and Complications Trial, completed in 1993, showed that tight blood-sugar control could at least halve the rate of eye, kidney, and neurological complications among people with Type 1 diabetes. Additional studies in Type 2 patients echo these findings.
Why, then, aren't people with diabetes and their families rejoicing? Because those with Type 1 diabetes still have to watch their diets carefully, prick their fingers four times a day, and give themselves insulin. Because, even though it's suspected that nine out of 10 people with Type 2 diabetes could control their blood sugar by losing weight, they have tremendous difficulty doing so. And because, even if we were perfectly able to control the blood sugar of all people with diabetes using the available means--which we can't--there's no guarantee that it would mean the end of diabetes' lethal complications. Until we fully understand diabetes, we just won't know.
"We've come a long way just over the last few years in treating diabetes and preventing complications," says David M. Nathan, M.D., associate professor of medicine and director of the Diabetes Center at Massachusetts General Hospital. "But I still hear frustration from patients, and particularly the parents of young patients. 'Where are you? Do more! Go faster!' And I fully understand and sympathize with their complaints."
Elliott Joslin's clinic has grown into a treatment and research facility dedicated solely to diabetes. Despite the work done there and elsewhere throughout the world, however, diabetes research has lagged behind more visible diseases in public support. Quickel often calls diabetes the "Rodney Dangerfield" of diseases, because it just doesn't get "respect." "AIDS, prostate cancer, breast cancer, heart disease," he says, "they all get a lot of funding because they frighten people--and they should. Diabetes does not strike fear into people's hearts, probably because it is seldom reported as a cause of death. The Grateful Dead's Jerry Garcia died of a heart attack that was probably brought on by diabetes. Most people who die of kidney disease got it as a result of having diabetes. And diabetes is still the number-one cause of blindness in America."
This year a convergence of forces on Capitol Hill led to President Clinton's dedication of $300 million for diabetes research over the next five years. Half the money will go to research on Type 1 diabetes, the other half to addressing the problems of Native Americans, who suffer from the highest rate of Type 2 diabetes in the country. Some Native American communities report rates as high as 50 percent among people over age 35. The new funding may lead to the development of new insulin pumps, transplant procedures, or perhaps gene therapy that will lead to even better control of diabetes, and perhaps--dare we speak it?--a cure.
In addition, Congress has mandated that Medicare pay for the machines and test strips that allow people with diabetes to monitor their blood-sugar levels, as well as for patient training in how to manage diabetes. Coverage for these services is expected to cost $2.1 billion over the next five years.
It has been a hundred years since Joslin opened his practice on Bay State Road. In 1998, diabetes may finally begin receiving the respect it deserves.
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