EDITORIALS
this group the best approach is the admittedly tedious and difficult regimen of caloric reduction and physical exercise. It would appear that as much research effort as possible should now be directed to the attempts at successful islet transplantation or the provision of a continuous regulated insulin supply, or both, for patients with severe diabetes. Only then will we be in a position to take a definitive stand towards the issue of strict control and its benefits. RACHMIEL LEVINE, MD Director Department of Metabolism and Endocrinology City of Hope National Medical Centter Duarte, California REFERENCES 1. Naunyn B: Der Diabetes Mellitus. Vienna, Deuticke, 1896 2. Kimmelstiel P, Wilson C: Intercapillary lesions in the glomeruli of the kidney. Am J Path 12:83-98, 1936 3. Siperstein MD, Colwell AR Sr, Meyer K (Eds): Small Blood Vessel Involvement in Diabetes Mellitus. Washington, DC, American Institute of Biological Sciences, 1964 4. Cogan DG, Toussaint D, Kuwabara T: RetinaL vascular patterns-1V. Diabetic retinopathy. Arch Ophthal (Chicago) 66: 366-378, 1961 5. Farquhar MG, Palade GE: Functional evidence for the existence of a third cell type in the renal glomerulus-Phagocytosis of filtration residues by a distinctive "third" cell. J Cell Biol 13:
55-87, 1962 6. Pirart J: Diabetic neuropathy: A metabolic or a vascular disease? Diabetes 14:1-9, 1965 7. Field RA: Altered nerve metabolism in diabetes. Diabetes 15:696-698, 1966 8. Gabbay KH, Merola LO, Field RA: Sorbitol pathway: Presence in nerve and cord with substrate accumulation in diabetes. Science 151:209-210, 1966 9. LeCompte PM: Vascular lesions in diabetes mellitus. J Chronic Dis 2:178-185, 1955 10. Woolf N: Diabetes and atherosclerosis. Acta Diab Lat 8 (Suppi 1):14-39, 1971 11. Bornstein J, Lawrence RD: Two types of diabetes mellitus, with and without available plasma insulin. Br Med J 1:732-733, 1951 12. Bornstein J, Lawrence RD: Plasma-insulin in human diabetes meilitus. Br Med J 2:1541-1544, 1951 13. Yalow RS, Berson SA: Immunoassay of endogenous plasma insulin in man. J Clin Invest 39:1157-1175, 1960 14. Reaven GM, Olefsky JM: Role of insulin resistance in the pathogenesis of hyperglycemia, In Katzen and Mahler (Eds): Diabetes, Obesity and Vascular Disease. New York, Wiley and Sons, 1978, pp 229-266 15. Knowles HC: Diabetic vascular disease: Relation to blood sugar. Trans Am Clin Climatol Assoc 76:142-151, 1964 16. Knowles HC Jr, Guest GM, Lampe J, et al: The course of juvenile diabetes treated with unmeasured diet. Diabetes 14:239273, 1965 17. Colwell JA: Effect of diabetic control on retinopathy. Diabetes 15:497-499, 1966 18. Johansen K, Hansen AP: High 24-hour level of serum growth hormone in juvenile diabetics. Br Med J 2:356-357, 1969 19. Rifkin H, Solomon S, Lieberman S: Role of the adrenal cortex in diabetic retinopathy and nephropathy. Diabetes 7:9-14, 1958 20. Blumenthal HT, Berns AW, Owens CT, et al: The pathogenesis of diabetic glomerulosclerosis-I. The significance of various histopathological components of the disease. Diabetes 11: 296-307, 1962 21. Job D, Eschwege E, Tchobroutsky G, et al: Effect of multiple daily insulin injections on the course of diabetic retinopathy. Diabetes 25:463-469, 1976 22. Mahler R: The effect of diabetes and insulin on biochemical reactions of the arterial wall. Acta Diab Lat 8 (Suppl 1) :68-83, 1971 23. Stout RW: Development of vascular lesions in insulintreated animals fed a normal diet. Br Med J 3:685-687, 1970 24. Stout RW: Insulin-stimulated lipogenesis in arterial tissue in relation to diabetes and atheroma. Lancet 2:702-703, 1968 25. Duff GL, Macmillan GC: The effect of alloxan diabetes on experimental cholesterol atherosclerosis in the rabbit. J Exp Med 89:611-630, 1949 26. Cruz AB, Amatuzio DS, Grande F, et al: Effect of intraarterial insulin on tissue cholesterol and fatty acids in alloxandiabetic dogs. Circul Res 9:39-43, 1961
A Perspective on Health Care Costs IN ALL THE HUE AND CRY about health care costs it is often overlooked that these costs actually reflect a remarkable degree of success in achieving a national goal. Some will remember that shortly after World War II there was a definite determination to invest more of the nation's resources in health and health care for our citizens. With the use of unlimited dollars impressive technology had been developed for destructive war purposes, and when the war was won it seemed reasonable and desirable to turn this capability to a constructive purpose which would benefit people. Better health and health care became a national goal. What has been accomplished is one of the great success stories of our times. At first substantial public and private resources were allocated to medical research and the development of new technology. Subsequently, the health care that was developed with this new knowledge and new technology was declared to be a right to which all citizens should have equal access. New and sophisticated diagnostic and therapeutic procedures have been developed which allow for greatly improved management of such conditions as heart disease and many forms of cancer. Advanced life support systems have become available in general and community hospitals throughout the country. And life support for victims of end-stage renal disease has become possible and its very substantial cost has been assumed by the federal government. These are -only some of the scientific and technologic advances that have added to the cost of health care. Much has also been accomplished in implementing the right of equal access to health care and, as might have been expected, this has substantially increased the amount of care rendered and thus the total cost. Government programs such as Aid to Crippled Children, Medicare, Medicaid, and more recently special programs for handicapped people provide access to better and more costly care for many formerly relatively deprived segments of the population. Private health insurance has provided it for most of the rest. Charity has been almost completely eliminated from mainstream health care. It was considered demeaning. And the compensation of health workers throughout the system has been brought up to parity with workers in other fields THE WESTERN JOURNAL OF MEDICINE
233
EDITORIALS
in business and industry. Looked upon in this way, the health care enterprise is truly a success story. The costs which have risen faster than other segments of the economy are seen to be the costs of carrying out the mandates of a major national commitment, and the whole has been a combined, although not always a cooperative, effort of the public and private sectors. In this perspective it is seen that we have accomplished much of what we as a nation set out to do some 30 years ago. The increment of the costs that is rising faster than other indices in the economy represents the allocation of additional resources from both the public and private sectors to this purpose. But all of this is not to say
234
SEPTEMBER 1978 *
129 * 3
that the costs of health care should not now be contained. Rather it suggests that it may be time to review what has been accomplished, see where we should go from here, and perhaps most immediately identify and eliminate costs that do not produce a commensurate benefit, whether they be for procedures, services, facilities or administration, or are costs added by government regulation. This too will have to be a collaborative effort of the public and private sectors. Let us hope that the success story in health care will continue and that our national achievement will not be frittered away with crude and clumsy bureaucratic controls. This is a very present danger. -MSMW
this group the best approach is the admittedly tedious and difficult regimen of caloric reduction and physical exercise. It would appear that as much research effort as possible should now be directed to the attempts at successful islet transplantation or the provision of a continuous regulated insulin supply, or both, for patients with severe diabetes. Only then will we be in a position to take a definitive stand towards the issue of strict control and its benefits. RACHMIEL LEVINE, MD Director Department of Metabolism and Endocrinology City of Hope National Medical Centter Duarte, California REFERENCES 1. Naunyn B: Der Diabetes Mellitus. Vienna, Deuticke, 1896 2. Kimmelstiel P, Wilson C: Intercapillary lesions in the glomeruli of the kidney. Am J Path 12:83-98, 1936 3. Siperstein MD, Colwell AR Sr, Meyer K (Eds): Small Blood Vessel Involvement in Diabetes Mellitus. Washington, DC, American Institute of Biological Sciences, 1964 4. Cogan DG, Toussaint D, Kuwabara T: RetinaL vascular patterns-1V. Diabetic retinopathy. Arch Ophthal (Chicago) 66: 366-378, 1961 5. Farquhar MG, Palade GE: Functional evidence for the existence of a third cell type in the renal glomerulus-Phagocytosis of filtration residues by a distinctive "third" cell. J Cell Biol 13:
55-87, 1962 6. Pirart J: Diabetic neuropathy: A metabolic or a vascular disease? Diabetes 14:1-9, 1965 7. Field RA: Altered nerve metabolism in diabetes. Diabetes 15:696-698, 1966 8. Gabbay KH, Merola LO, Field RA: Sorbitol pathway: Presence in nerve and cord with substrate accumulation in diabetes. Science 151:209-210, 1966 9. LeCompte PM: Vascular lesions in diabetes mellitus. J Chronic Dis 2:178-185, 1955 10. Woolf N: Diabetes and atherosclerosis. Acta Diab Lat 8 (Suppi 1):14-39, 1971 11. Bornstein J, Lawrence RD: Two types of diabetes mellitus, with and without available plasma insulin. Br Med J 1:732-733, 1951 12. Bornstein J, Lawrence RD: Plasma-insulin in human diabetes meilitus. Br Med J 2:1541-1544, 1951 13. Yalow RS, Berson SA: Immunoassay of endogenous plasma insulin in man. J Clin Invest 39:1157-1175, 1960 14. Reaven GM, Olefsky JM: Role of insulin resistance in the pathogenesis of hyperglycemia, In Katzen and Mahler (Eds): Diabetes, Obesity and Vascular Disease. New York, Wiley and Sons, 1978, pp 229-266 15. Knowles HC: Diabetic vascular disease: Relation to blood sugar. Trans Am Clin Climatol Assoc 76:142-151, 1964 16. Knowles HC Jr, Guest GM, Lampe J, et al: The course of juvenile diabetes treated with unmeasured diet. Diabetes 14:239273, 1965 17. Colwell JA: Effect of diabetic control on retinopathy. Diabetes 15:497-499, 1966 18. Johansen K, Hansen AP: High 24-hour level of serum growth hormone in juvenile diabetics. Br Med J 2:356-357, 1969 19. Rifkin H, Solomon S, Lieberman S: Role of the adrenal cortex in diabetic retinopathy and nephropathy. Diabetes 7:9-14, 1958 20. Blumenthal HT, Berns AW, Owens CT, et al: The pathogenesis of diabetic glomerulosclerosis-I. The significance of various histopathological components of the disease. Diabetes 11: 296-307, 1962 21. Job D, Eschwege E, Tchobroutsky G, et al: Effect of multiple daily insulin injections on the course of diabetic retinopathy. Diabetes 25:463-469, 1976 22. Mahler R: The effect of diabetes and insulin on biochemical reactions of the arterial wall. Acta Diab Lat 8 (Suppl 1) :68-83, 1971 23. Stout RW: Development of vascular lesions in insulintreated animals fed a normal diet. Br Med J 3:685-687, 1970 24. Stout RW: Insulin-stimulated lipogenesis in arterial tissue in relation to diabetes and atheroma. Lancet 2:702-703, 1968 25. Duff GL, Macmillan GC: The effect of alloxan diabetes on experimental cholesterol atherosclerosis in the rabbit. J Exp Med 89:611-630, 1949 26. Cruz AB, Amatuzio DS, Grande F, et al: Effect of intraarterial insulin on tissue cholesterol and fatty acids in alloxandiabetic dogs. Circul Res 9:39-43, 1961
A Perspective on Health Care Costs IN ALL THE HUE AND CRY about health care costs it is often overlooked that these costs actually reflect a remarkable degree of success in achieving a national goal. Some will remember that shortly after World War II there was a definite determination to invest more of the nation's resources in health and health care for our citizens. With the use of unlimited dollars impressive technology had been developed for destructive war purposes, and when the war was won it seemed reasonable and desirable to turn this capability to a constructive purpose which would benefit people. Better health and health care became a national goal. What has been accomplished is one of the great success stories of our times. At first substantial public and private resources were allocated to medical research and the development of new technology. Subsequently, the health care that was developed with this new knowledge and new technology was declared to be a right to which all citizens should have equal access. New and sophisticated diagnostic and therapeutic procedures have been developed which allow for greatly improved management of such conditions as heart disease and many forms of cancer. Advanced life support systems have become available in general and community hospitals throughout the country. And life support for victims of end-stage renal disease has become possible and its very substantial cost has been assumed by the federal government. These are -only some of the scientific and technologic advances that have added to the cost of health care. Much has also been accomplished in implementing the right of equal access to health care and, as might have been expected, this has substantially increased the amount of care rendered and thus the total cost. Government programs such as Aid to Crippled Children, Medicare, Medicaid, and more recently special programs for handicapped people provide access to better and more costly care for many formerly relatively deprived segments of the population. Private health insurance has provided it for most of the rest. Charity has been almost completely eliminated from mainstream health care. It was considered demeaning. And the compensation of health workers throughout the system has been brought up to parity with workers in other fields THE WESTERN JOURNAL OF MEDICINE
233
EDITORIALS
in business and industry. Looked upon in this way, the health care enterprise is truly a success story. The costs which have risen faster than other segments of the economy are seen to be the costs of carrying out the mandates of a major national commitment, and the whole has been a combined, although not always a cooperative, effort of the public and private sectors. In this perspective it is seen that we have accomplished much of what we as a nation set out to do some 30 years ago. The increment of the costs that is rising faster than other indices in the economy represents the allocation of additional resources from both the public and private sectors to this purpose. But all of this is not to say
234
SEPTEMBER 1978 *
129 * 3
that the costs of health care should not now be contained. Rather it suggests that it may be time to review what has been accomplished, see where we should go from here, and perhaps most immediately identify and eliminate costs that do not produce a commensurate benefit, whether they be for procedures, services, facilities or administration, or are costs added by government regulation. This too will have to be a collaborative effort of the public and private sectors. Let us hope that the success story in health care will continue and that our national achievement will not be frittered away with crude and clumsy bureaucratic controls. This is a very present danger. -MSMW
