We all go to doctors. And we do so with trust and blind faith that the test they are ordering and the medications they're prescribing are based upon evidence -- evidence that's designed to help us. However, the reality is that that hasn't always been the case for everyone. What if I told you that the medical science discovered over the past century has been based on only half the population?
Svi mi idemo doktorima, i to s povjerenjem i slijepo vjerujući da su pretrage na koje nas šalju i lijekovi koje nam prepisuju utemeljeni na dokazima - dokazima koji su zamišljeni s ciljem da nam pomognu. No, to nije uvijek bilo tako za sve. Što kad bih vam rekla da je zdravstvena znanost otkrivena tijekom prošlog stoljeća temeljena na samo polovici populacije?
I'm an emergency medicine doctor. I was trained to be prepared in a medical emergency. It's about saving lives. How cool is that? OK, there's a lot of runny noses and stubbed toes, but no matter who walks through the door to the ER, we order the same tests, we prescribe the same medication, without ever thinking about the sex or gender of our patients. Why would we? We were never taught that there were any differences between men and women.
Ja sam liječnik hitne pomoći. Obučena sam za nošenje s hitnim slučajevima. Spašavanje života je najvažnije. Nije li to cool? Dobro, ima tu i puno prehlada i udarenih nožnih prstiju, ali bez obzira na to tko prolazi kroz vrata do sobe za pružanje hitne pomoći, pošaljemo ih na iste pretrage, prepišemo im iste lijekove ne razmišljajući o spolu i rodu naših pacijenata. Zašto bismo? Nikad nas nisu učili da postoje ikakve razlike između muškaraca i žena.
A recent Government Accountability study revealed that 80 percent of the drugs withdrawn from the market are due to side effects on women. So let's think about that for a minute. Why are we discovering side effects on women only after a drug has been released to the market? Do you know that it takes years for a drug to go from an idea to being tested on cells in a laboratory, to animal studies, to then clinical trials on humans, finally to go through a regulatory approval process, to be available for your doctor to prescribe to you? Not to mention the millions and billions of dollars of funding it takes to go through that process. So why are we discovering unacceptable side effects on half the population after that has gone through? What's happening?
Nedavno istraživanje o odgovornosti Vlade otkrilo je da je 80 % lijekova maknuto s tržišta jer je izazivalo određene nuspojave kod žena. Razmislimo o tome na trenutak. Zašto nuspojave kod žena otkrivamo tek nakon što je lijek pušten u prodaju? Znate li da su potrebne godine da se lijek pretvori iz ideje u nešto što se testira na stanicama u laboratoriju, kasnije na životinjama, pa se rade klinička ispitivanja na ljudima sve dok se ne dođe do postupka odobravanja kako bi vam ga vaš liječnik mogao prepisati? A da ne spominjemo milijune i milijarde dolara uloženih u sam proces. Zašto onda neželjene nuspojave otkrivamo na polovici populacije nakon što je lijek prošao sve to? Što se događa?
Well, it turns out that those cells used in that laboratory, they're male cells, and the animals used in the animal studies were male animals, and the clinical trials have been performed almost exclusively on men.
Ispostavilo se da su stanice korištene u laboratoriju zapravo muške stanice, a životinje na kojima se lijek testirao također su mužjaci, a klinička ispitivanja provode se gotovo isključivo na muškarcima.
How is it that the male model became our framework for medical research? Let's look at an example that has been popularized in the media, and it has to do with the sleep aid Ambien. Ambien was released on the market over 20 years ago, and since then, hundreds of millions of prescriptions have been written, primarily to women, because women suffer more sleep disorders than men. But just this past year, the Food and Drug Administration recommended cutting the dose in half for women only, because they just realized that women metabolize the drug at a slower rate than men, causing them to wake up in the morning with more of the active drug in their system. And then they're drowsy and they're getting behind the wheel of the car, and they're at risk for motor vehicle accidents. And I can't help but think, as an emergency physician, how many of my patients that I've cared for over the years were involved in a motor vehicle accident that possibly could have been prevented if this type of analysis was performed and acted upon 20 years ago when this drug was first released. How many other things need to be analyzed by gender? What else are we missing?
Kako to da nam je muškarac postao okvir rada za medicinska istraživanja? Proučimo primjer populariziran u medijima. a vezan je uz Ambien, lijek za spavanje. Ambien se na tržištu pojavio prije više od 20 godina, a otada je pacijentima prepisan stotine milijuna puta, najčešće ženama jer žene češće pate od poremećaja spavanja od muškaraca. No, prošle godine FDA je preporučila da se njegovo doziranje prepolovi samo za žene jer su shvatili da žene sporije probavljaju lijek od muškaraca, zbog čega se one ujutro probude s više aktivne droge u organizmu pa postanu pospane, sjednu za volan i riskiraju izazivanje prometnih nesreća. Kao liječnica prve pomoći, ne mogu ne pomisliti koliko je mojih pacijenata koje sam liječila tijekom godina sudjelovalo u automobilskoj nesreći koja se mogla spriječiti da se ovakva analiza provela i da su se ti zaključci primijenili prije 20 godina kad se ovaj lijek tek pojavio na tržištu. Koje se još stvari trebaju analizirati po spolovima? Što nam je još promaklo?
World War II changed a lot of things, and one of them was this need to protect people from becoming victims of medical research without informed consent. So some much-needed guidelines or rules were set into place, and part of that was this desire to protect women of childbearing age from entering into any medical research studies. There was fear: what if something happened to the fetus during the study? Who would be responsible? And so the scientists at this time actually thought this was a blessing in disguise, because let's face it -- men's bodies are pretty homogeneous. They don't have the constantly fluctuating levels of hormones that could disrupt clean data they could get if they had only men. It was easier. It was cheaper. Not to mention, at this time, there was a general assumption that men and women were alike in every way, apart from their reproductive organs and sex hormones. So it was decided: medical research was performed on men, and the results were later applied to women.
Drugi svjetski rat promijenio je puno toga, a jedna od tih stvari bila je potreba za zaštitom ljudi od toga da budu žrtve medicinskih istraživanja bez informiranog pristanka. Postavljene su neke nužne smjernice i pravila, a dio toga bila je ta želja da se zaštiti žene koje su u reprodukcijskoj dobi od sudjelovanja u bilo kakvim medicinskim istraživanjima. Strahovalo se od toga da se fetusu nešto ne dogodi tijekom istraživanja. Tko bi bio odgovoran? Znanstvenici su u to vrijeme zaista mislili da je to bila sreća u nesreći jer su tijela muškaraca prilično homogena. Nemaju stalne promjene u razinama hormona koje bi ometale čiste podatke koje su dobivali istraživanjima s muškarcima. Bilo je lakše, jeftinije, a da ni ne pričamo o tome kako se vjerovalo da su muškarci i žene potpuno isti u svakom pogledu, osim njihovih reproduktivnih organa i spolnih hormona. Donesena je odluka: medicinska istraživanja provodila su se na muškarcima, a njihovi rezultati kasnije su primijenjeni na žene.
What did this do to the notion of women's health? Women's health became synonymous with reproduction: breasts, ovaries, uterus, pregnancy. It's this term we now refer to as "bikini medicine." And this stayed this way until about the 1980s, when this concept was challenged by the medical community and by the public health policymakers when they realized that by excluding women from all medical research studies we actually did them a disservice, in that apart from reproductive issues, virtually nothing was known about the unique needs of the female patient.
Što je to učinilo za žensko zdravlje? Žensko zdravlje postalo je sinonim za reprodukciju: grudi, jajnici, maternica, trudnoća. To je pojam koji sada nazivamo medicinom bikini-zone, a tako je i ostalo do 1980-ih kad je taj koncept pokušalo osporiti medicinsko društvo i tvorci zdravstvene politike kad su shvatili da smo ženama, isključivši ih iz formalnih medicinskih istraživanjima, učinili medvjeđu uslugu jer se osim reproduktivnih pitanja gotovo ništa nije znalo o jedinstvenim potrebama pacijentica.
Since that time, an overwhelming amount of evidence has come to light that shows us just how different men and women are in every way. You know, we have this saying in medicine: children are not just little adults. And we say that to remind ourselves that children actually have a different physiology than normal adults. And it's because of this that the medical specialty of pediatrics came to light. And we now conduct research on children in order to improve their lives. And I know the same thing can be said about women. Women are not just men with boobs and tubes. But they have their own anatomy and physiology that deserves to be studied with the same intensity.
Otada je ogromna količina dokaza izašla na vidjelo koji pokazuju kako su muškarci i žene potpuno drugačiji. U medicini koristimo ovu izreku: djeca nisu samo odrasli u malom. To si govorimo da se podsjetimo da djeca zapravo imaju drugačiju fiziologiju od normalnih odraslih ljudi. Zbog toga se rodila pedijatrija. Sad možemo provoditi istraživanja na djeci kako bismo im poboljšali živote. Isto se može reći i za žene. Žene nisu samo muškarci s grudima i jajovodom - one imaju vlastitu anatomiju i fiziologiju koja zaslužuje biti proučavana istim intenzitetom.
Let's take the cardiovascular system, for example. This area in medicine has done the most to try to figure out why it seems men and women have completely different heart attacks. Heart disease is the number one killer for both men and women, but more women die within the first year of having a heart attack than men. Men will complain of crushing chest pain -- an elephant is sitting on their chest. And we call this typical. Women have chest pain, too. But more women than men will complain of "just not feeling right," "can't seem to get enough air in," "just so tired lately." And for some reason we call this atypical, even though, as I mentioned, women do make up half the population.
Npr. promotrimo kardiovaskularni sustav. Ovo područje medicine potrudilo se saznati zašto muškarci i žene doživljavaju potpuno različite srčane udare. Bolesti srca vodeći su uzročnik smrti i muškaraca i žena, ali više žena umire tijekom godine dana nakon doživljenog srčanog udara. Muškarci se žale na teške bolove u prsima - kao da im slon sjedi na prsima. To je za njih tipično. I žene pate od bolova u prsima, ali žene se žale na to da se "jednostavno ne osjećaju dobro", "nemaju dovoljno zraka u plućima", "u zadnje vrijeme su umorne". Iz nekog razloga to je netipično iako, kao što već spomenuh, žene čine polovicu populacije.
And so what is some of the evidence to help explain some of these differences? If we look at the anatomy, the blood vessels that surround the heart are smaller in women compared to men, and the way that those blood vessels develop disease is different in women compared to men. And the test that we use to determine if someone is at risk for a heart attack, well, they were initially designed and tested and perfected in men, and so aren't as good at determining that in women. And then if we think about the medications -- common medications that we use, like aspirin. We give aspirin to healthy men to help prevent them from having a heart attack, but do you know that if you give aspirin to a healthy woman, it's actually harmful?
Kojim dokazima možemo objasniti neke od ovih razlika? Promotrimo anatomiju: krvne žile koje okružuju srce kod žena su manje nego kod muškaraca, a drugačiji je i način na koji te krvne žile razvijaju bolesti kod žena i muškaraca. Test kojim ispitujemo prijeti li nekome opasnost od srčanog udara osmišljen je, ispitan i usavršen na muškarcima, stoga nije toliko dobar u utvrđivanju opasnosti kod žena. Zatim lijekovi - uobičajeni lijekovi koje koristimo, lijekovi poput aspirina. Aspirin dajemo zdravim muškarcima u svrhu prevencije srčanog udara, ali jeste li znali da ukoliko aspirin date zdravoj ženi, to zapravo može biti štetno?
What this is doing is merely telling us that we are scratching the surface. Emergency medicine is a fast-paced business. In how many life-saving areas of medicine, like cancer and stroke, are there important differences between men and women that we could be utilizing? Or even, why is it that some people get those runny noses more than others, or why the pain medication that we give to those stubbed toes work in some and not in others?
To nam govori da smo tek zagrebali ispod površine. Medicina prve pomoći ubrzan je posao. U koliko područja medicine koji se bave spašavanjem života, poput raka i moždanog udara, postoje važne razlike između muškaraca i žena koje bismo mogli koristiti? Ili zašto nekim ljudima curi nos više nego drugima ili zašto lijekovi protiv bolova koje dajemo za udarene nožne prste na neke djeluje, a na druge ne djeluju?
The Institute of Medicine has said every cell has a sex. What does this mean? Sex is DNA. Gender is how someone presents themselves in society. And these two may not always match up, as we can see with our transgendered population. But it's important to realize that from the moment of conception, every cell in our bodies -- skin, hair, heart and lungs -- contains our own unique DNA, and that DNA contains the chromosomes that determine whether we become male or female, man or woman.
Institut medicine tvrdi da svaka stanica ima spol. Što to znači? Spol je DNK. Rod je način na koji se netko predstavlja u društvu, a to dvoje ne podudara se baš uvijek, kao što možemo primijetiti kod transrodnih pojedinaca. Kako bilo, važno je shvatiti da od trenutka začeća svaka stanica u našim tijelima - koža, kosa, srce i pluća - sadrži naš jedinstveni DNK, a taj DNK sadrži kromosome koji određuju hoćemo li postati muško ili žensko, muškarac ili žena.
It used to be thought that those sex-determining chromosomes pictured here -- XY if you're male, XX if you're female -- merely determined whether you would be born with ovaries or testes, and it was the sex hormones that those organs produced that were responsible for the differences we see in the opposite sex. But we now know that that theory was wrong -- or it's at least a little incomplete. And thankfully, scientists like Dr. Page from the Whitehead Institute, who works on the Y chromosome, and Doctor Yang from UCLA, they have found evidence that tells us that those sex-determining chromosomes that are in every cell in our bodies continue to remain active for our entire lives and could be what's responsible for the differences we see in the dosing of drugs, or why there are differences between men and women in the susceptibility and severity of diseases. This new knowledge is the game-changer, and it's up to those scientists that continue to find that evidence, but it's up to the clinicians to start translating this data at the bedside, today. Right now. And to help do this, I'm a co-founder of a national organization called Sex and Gender Women's Health Collaborative, and we collect all of this data so that it's available for teaching and for patient care. And we're working to bring together the medical educators to the table. That's a big job. It's changing the way medical training has been done since its inception.
Nekoć se smatralo da ti kromosomi koji određuju spol i koji su prikazani ovdje - XY za muškarca, XX za ženu - samo određuju hoćete li se roditi s jajnicima ili s testisima, a spolni hormoni koje su ti organi proizvodili odgovorni su za razlike koje vidimo na suprotnom spolu. Sad znamo da je ta teorija bila pogrešna - ili barem da je bila nepotpuna. Srećom, znanstvenici poput dr. Pagea s Instituta Whitehead koji radi na kromosomu Y i dr. Yang sa Sveučilišta u Kaliforniji pronašli su dokaze koji nam pokazuju da ti kromosomi koji određuju spol, a koji se nalaze u svakoj stanici našeg tijela, ostaju aktivni tijekom cijelih naših života i mogli bi biti odgovorni za razlike koje vidimo kod doziranja lijekova ili zašto postoje razlike između muškaraca i žena u podložnosti i ozbiljnosti pojedine bolesti. To novostečeno znanje mijenja sve, a na znanstvenicima, koji još uvijek pronalaze takve dokaze, ali i na liječnicima je da počnu proučavati te podatke prije spavanja - još danas. Odmah. Kako bih im u tome pomogla, suosnovala sam državnu organizaciju "Spol i rod - suradnja za žensko zdravlje" i prikupljamo sve te podatke kako bi bilo dostupno za poučavanje i brigu o pacijentima. Radimo na tome da okupimo profesore medicine. Velik je to posao koji mijenja način na koji se provodi medicinska obuka još od njezinih začetaka.
But I believe in them. I know they're going to see the value of incorporating the gender lens into the current curriculum. It's about training the future health care providers correctly. And regionally, I'm a co-creator of a division within the Department of Emergency Medicine here at Brown University, called Sex and Gender in Emergency Medicine, and we conduct the research to determine the differences between men and women in emergent conditions, like heart disease and stroke and sepsis and substance abuse, but we also believe that education is paramount.
No, ja vjerujem u njih. Znam da će oni uvidjeti važnost uključivanja i uvažavanja spola u trenutni kurikulum. Radi se o pravilnom obučavanju budućih zdravstvenih djelatnika. Regionalno ja sam sukreatorica odsjeka unutar Odjela za prvu pomoć na Sveučilištu Brown pod nazivom "Spol i rod u medicini prve pomoći" i provodimo istraživanje kako bismo utvrdili razlike između muškaraca i žena u hitnim stanjima poput bolesti srca, moždanog udara, sepse i zlouporabe droga, ali također vjerujemo da su odgoj i obrazovanje najvažniji.
We've created a 360-degree model of education. We have programs for the doctors, for the nurses, for the students and for the patients. Because this cannot just be left up to the health care leaders. We all have a role in making a difference. But I must warn you: this is not easy. In fact, it's hard. It's essentially changing the way we think about medicine and health and research. It's changing our relationship to the health care system. But there's no going back. We now know just enough to know that we weren't doing it right.
Stvorili smo model odgoja i obrazovanja od 360 stupnjeva. Imamo programe za liječnike, za medicinske sestre, za studente i za pacijente jer ovo ne smije biti prepušteno samo zdravstvenim djelatnicima. Svi imamo ulogu u stvaranju promjena, ali moram vas upozoriti da nije lako. Štoviše, teško je. U biti se radi o mijenjanju načina na koji razmišljamo o medicini, zdravlju i istraživanjima. To će promijeniti naš odnos prema zdravstvenom sustavu, ali nema povratka. Znamo tek toliko da smo svjesni toga da smo nešto radili krivo.
Martin Luther King, Jr. has said, "Change does not roll in on the wheels of inevitability, but comes through continuous struggle."
Martin Luther King je rekao: "Promjena ne dolazi na krilima neizbježnosti, već kroz neprestanu borbu."
And the first step towards change is awareness. This is not just about improving medical care for women. This is about personalized, individualized health care for everyone. This awareness has the power to transform medical care for men and women. And from now on, I want you to ask your doctors whether the treatments you are receiving are specific to your sex and gender. They may not know the answer -- yet. But the conversation has begun, and together we can all learn. Remember, for me and my colleagues in this field, your sex and gender matter.
Prvi korak prema promjeni jest svijest koja se ne tiče samo poboljšavanja zdravstvene skrbi za žene, već se tiče i individualiziranije, osobnije zdravstvene skrbi za sve. Ta svijest može promijeniti zdravstvenu skrb za muškarce i žene. Odsada pa nadalje želim da pitate svoje liječnike je li terapija koju dobivate prilagođena vašem spolu i rodu. Možda vam neće znati odgovoriti na to pitanje - bar ne još. Dijalog je počeo, a zajedno svi možemo učiti. Zapamtite da je meni i mojim kolegama na ovom području vaš spol i rod važan.
Thank you.
Hvala vam.
(Applause)
(Pljesak)