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?
Vsi obiskujemo zdravnike. In slepo verjamemo da preiskave, ki jih opravijo in zdravila, ki jih predpišejo temeljijo na znanstvenih dokazih -- dokazih, ki naj bi nam pomagali. V resnici pa to ne drži za vsakogar. Kaj pa, če vam povem, da so medicinski izsledki iz zadnjih nekaj stoletij, zasnovani le na 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.
Sem specialistka urgentne medicine. Izurjena sem bila za ukrepanje v nujnih medicinskih primerih. Rešujem življenja. Ni to super?! Ja, res je veliko prehladov in udarjenih nožnih prstov, ampak vsem, ki pridejo v urgentno ambulanto, opravimo enake preiskave, predpišemo enaka zdravila, brez da bi pomislili na spol svojih pacientov. Zakaj le? Nikoli nas niso učili, da obstajajo razlike med moškimi in ženskami.
A recent Government Accountability study revealed that 80 percent of the drugs withdrawn from the market are due to side effects on women.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?
Nedavna študija vladne odgovornosti je pokazala, da je 80 % zdravil s trga odstranjenih zaradi stranskih učinkov pri ženskah. Razmislimo o tem. Zakaj ugotavljamo stranske učinke pri ženskah šele po tem, ko je zdravilo že na trgu? Veste, da so potrebna leta, da iz ideje razvijemo zdravilo, ki ga testiramo sprva na celicah v laboratoriju, nato na živalih, potem na ljudeh, in nato sledi še proces nadzora pred odobritvijo. Šele nato je zdravilo na voljo zdravnikom za predpisovanje. Da sploh ne omenjam milijonov in milijard dolarjev, ki so potrebni za financiranje takšnega procesa. Zakaj torej odkrivamo nesprejemljive stranske učinke pri polovici populacije po tem, ko smo opravili ta celoten proces? Kaj se dogaja?
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.
Izkaže se, da so tiste celice, ki jih uporabljamo v laboratoriju, moške celice, da so živali, ki jih uporabljamo v živalskih študijah, samci in da so tudi klinične študije opravljene skoraj izključno na moških pacientih.
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?
Zakaj pa so moški postali modeli za naše medicinske raziskave? Oglejmo si en medijsko razvpit primer. Gre za sedativ z imenom Ambien. Ambien je na tržišče prišel pred več kot dvajsetimi leti in je bil od tedaj predpisan na stotinam milijonov pacientov, predvsem pa ženskam, saj imajo ženske pogosteje motnje spanja. V zadnjem letu pa je Agencija za hrano in zdravila priporočila prepolovitev doze, vendar le pri ženskah. Saj so ugotovili, da ženske zdravilo presnavljajo počasneje kot moški. Zato se zjutraj zbudijo z več aktivnega zdravila v telesu, so še omotične, ko se usedejo za volan avtomobila in zato tudi bolj ogrožene za prometne nesreče. Ne morem si pomagati, da ne bi pomislila, koliko mojih pacientov, za katere sem skrbela v preteklih letih, je bilo udeleženih v prometnih nesrečah, ki bi se jih dalo preprečiti, če bi to analizo zdravila naredili in primerno ukrepali pred dvajsetimi leti, ko je zdravilo prišlo na tržišče. Kaj vse še moramo analizirati po spolu? Česa vsega še ne vemo?
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.
Druga svetovna vojna je prinesla veliko sprememb in ena izmed njih je bila potreba po zaščiti ljudi pred sodelovanjem v medicinskih raziskavah brez pristanka. Zato so določili nekatere nujno potrebne smernice oziroma pravila. Med drugim so želeli zaščititi ženske v rodni dobi pred sodelovanjem v medicinskih študijah. Bali so se, da se bo med študijo kaj pripetilo zarodku. Kdo bi bil odgovoren za to? Takrat so znanstveniki pravzaprav menili, da je ta uredba pravi blagoslov, kajti moška telesa so precej homogena. Pri moških ni stalno spreminjajočih-se ravni hormonov, ki bi motile jasne podatke, pridobljene le od moških. Tako je bilo preprosteje. In ceneje. Da sploh ne omenjam, da so takrat mislili, da so si moški in ženske enaki v vseh pogledih, razen v spolnih organih in hormonih. Padla je odločitev: medicinske raziskave so opravljali na moških, rezultate pa kasneje uporabljali na ženskah.
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.
Kaj pa je to pomenilo za koncept ženskega zdravja? Zdravstvena oskrba žensk, je postala sinonimna z reprodukcijo: prsmi, jajčniki, maternico in nosečnostjo. Temu danes rečemo "bikini medicina." In tako je ostalo do osemdesetih let 20. stoletja, ko so medicinska skupnost in javnozdravstveni zakonodajalci spoznali, da so ženskam z izključitvijo iz medicinskih raziskav, povzročili škodo. Saj z izjemo reprodukcije, ni bilo nič znanega o edinstvenih potrebah ženskih pacientk.
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.
Od tedaj smo odkrili ogromno dokazov, ki kažejo številne razlike med moškimi in ženskami na vseh področjih. Veste, v medicini imamo izrek: "Otroci niso le pomanjšani odrasli." Ta izrek nam služi v opomin, da imajo otroci dejansko drugačno fiziologijo kot normalni odrasli. Zaradi tega je tudi nastala medicinska specializacija pediatrija. Sedaj na otrocih tudi izvajamo raziskave, da bi izboljšali njihova življenja. Vem, da enako lahko rečemo tudi za ženske. Ženske niso le moški s prsmi in jajčniki, pač pa imajo lastno anatomijo in fiziologijo, ki sta vredni enako intenzivnega preučevanja.
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.
Vzemimo na primer srčnožilni sistem. Na tem področju si zelo močno prizadevajo odkriti zakaj imajo moški in ženske drugačne oblike srčnih kapi. Bolezni srca so najpogostejši vzrok smrti tako pri moških kot pri ženskah, vendar, v primerjavi z moškimi, več žensk umre v prvem letu po srčni kapi. Moški bodo potožili, da imajo tiščočo bolečino v prsih... kot bi jim slon sedel na prsih. In mi rečemo, da je to tipično. Tudi ženske občutijo bolečino v prsih. A ženske pogosteje kot moški potožijo, da se "enostavno ne počutijo dobro," "ne morejo zajeti dovolj sape," "so zadnje čase zelo utrujene." In iz nekega razloga mi to označimo za atipično, čeprav, kot sem že omenila, ženske predstavljajo polovico 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?
Kateri dokazi nam torej pomagajo pojasniti te razlike? Če si ogledamo anatomijo vidimo, da so krvne žile okoli srca pri ženskah manjše kot pri moških in razvoj bolezni v teh žilah je drugačen pri ženskah v primerjavi z moškimi. Tudi testi, ki jih uporabljamo za določanje ogroženosti za srčno kap, so bili prvotno zasnovani, preizkušeni in izpopolnjeni za moške in posledično pri ženskah ne delujejo enako dobro. In če si sedaj ogledamo še zdravila... pogosto uporabljena zdravila, na primer Aspirin. Aspirin dajemo zdravim moškim, da preprečimo srčno kap. Ampak ali veste, da je predpisovanje Aspirina zdravim ženskam v resnici škodljivo?
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?
Kar nam ta primer pove, je, da je to le vrh ledene gore. Urgentna medicina je naglo razvijajoče-se področje. Na koliko življenjsko pomembnih področjih medicine, na primer rakavih boleznih in infarktih, obstajajo pomembne razlike med spoloma, ki bi jih lahko s pridom uporabljali? Celo pri vprašanju zakaj so nekateri pogosteje prehlajeni kot ostali. Ali zakaj protibolečinska zdravila pri tistih udarninah prstov nekaterim pomagajo, drugim pa ne.
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.
Inštitut za Medicino pravi, da ima vsaka celica spol. Kaj to pomeni? Spol je DNA. Spol v socialnem smislu, pa označuje kako se človek predstavlja v družbi. Ta dva koncepta se ne ujemata vedno, kar opazimo pri transseksualni populaciji. Pomembno pa se je zavedati, da od trenutka spočetja vsaka celica v našem telesu, kožna, srčna, pljučna ali celica las, vsebuje našo edinstveno DNA in ta DNA vključuje kromosome, ki določajo ali bomo postali moški ali ženska.
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.
Včasih so mislili, da spolni kromosomi na sliki, XY za moške, XX za ženske, določajo le, ali se bo človek rodil z jajčniki ali testisi. Spolni hormoni, ki jih ta organa izdelujeta, pa naj bi bili odgovorni za ostale razlike med spoloma. Danes pa vemo, da je ta teorija napačna, oziroma vsaj nepopolna. Na srečo so znanstveniki kot dr. Page iz Inštituta Whitehead, ki raziskuje kromosom Y in doktor Yang iz UCLA, odkrili dokaze, da spolni kromosomi, ki se nahajajo v vseh telesnih celicah, ostanejo aktivni skozi celotno življenje in bi lahko bili odgovorni za razlike pri doziranju zdravil ali za razlike med moškimi in ženskami pri dovzetnosti za bolezni in resnosti bolezni. Ta nova spoznanja spremenijo vse in naloga znanstvenikov je, da nadaljujejo z odkrivanjem novih dokazov, vendar pa je tudi naloga zdravnikov, da pričnejo uporabljati te podatke ob bolnikovi postelji, še danes. Takoj zdaj. Da bi pomagala pri tem, sem soustanoviteljica nacionalne zveze imenovane Spol: Skupnost za zdravje žensk, kjer zbiramo vse te podatke, zato da so dostopni za poučevanje in skrb za paciente. Trudimo se vključiti tudi medicinske izobraževalne ustanove. To je pomembno delo. Spreminjmo način poučevanja medicine, ki je bil uveljavljen od samega začetka.
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.
Vendar jaz verjamem vanje. Vem, da bodo sprevideli koristnost vključitve razlik med spoloma v sedanji učni načrt. Gre se za to, da pravilno izučimo bodoče izvajalce zdravstvenih storitev. Regionalno pa sem soustanoviteljica divizije znotraj oddelka za urgentno medicino tu na Univerzi Brown, ki se imenuje Spol v urgentni medicini. Tu izvajamo raziskave s katerimi ugotavljamo razlike med spoloma v urgentnih stanjih, na primer srčnih boleznih in kapi, sepsi in zlorabi prepovedanih drog. Hkrati pa verjamemo, da je izobraževanje ključno.
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.
Razvili smo vse-vključujoč model izobrazbe. Imamo izobraževalne programe za zdravnike, medicinske tehnike, študente in za paciente. Kajti tega problema ne moremo prepustiti le izvajalcem zdravstvenih storitev. Vsi imamo vlogo pri spreminjanju sedanjega stanja. Moram pa vas posvariti, da to ni preprosto. Pravzaprav je težko. V bistvu želimo spremeniti način, kako razmišljamo o medicini, zdravju in raziskovanju. Spreminjamo naš odnos do zdravstvenega sistema. A ni poti nazaj. Vemo ravno dovolj, da se zavedamo, da smo se prej motili.
Martin Luther King, Jr. has said, "Change does not roll in on the wheels of inevitability, but comes through continuous struggle."
Martin Luther King mlajši je rekel: "Spremembe niso neizbežne, zanje je potreben neprestan trud."
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 proti spremembi pa je zavedanje. Ne gre se samo za izboljšanje zdravstvene oskrbe za ženske. Gre za personalizirano, individualizirano zdravstveno oskrbo za vse. Zavedanje tega lahko spremeni medicinsko oskrbo tako za moške kot za ženske. Želim si, da od sedaj naprej vprašate svojega zdravnika ali je terapija, ki jo prejemate, namenjena prav vašemu spolu. Mogoče vam ne bodo znali odgovoriti... še. Ampak ta pogovor se je že začel in skupaj se lahko vsi učimo. Zapomnite si, da je zame in moje kolege na tem področju vaš spol pomemben.
Thank you.
Hvala vam.
(Applause)
(Aplavz)