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 kod lekara i to činimo sa poverenjem i slepom verom da su testovi koje oni naručuju i lekovi koje prepisuju zasnovani na dokazima - dokazima koji su predviđeni da nam pomognu. Međutim, u stvarnosti, to nije uvek bio slučaj za svakog. Šta ako vam kažem da je ono što je medicinska nauka otkrila tokom proteklog veka zasnovano na svega polovini 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 doktor urgentne medicine. Obučena sam da budem pripremljena u slučaju medicinske hitnosti. Radi se o spašavanju života. Zar to nije kul? Okej, ima mnogo kijavica i ozleda na nožnim prstima, ali bez obzira na to ko ušeta kroz vrata hitne službe, zatražimo iste testove, prepisujemo iste lekove, a da nikada ne razmišljamo o polu ili rodu naših pacijenata. Zašto bismo? Nikada 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A recent Government Accountability study revealed that 80 percent of the drugs withdrawn from the market are due to side effects on women.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?
Nedavna studija odgovornosti vlade je pokazala da je 80 odsto lekova povučeno sa tržišta zbog neželjenih dejstava na žene. Hajde da razmislimo o tome na minut. Zašto otkrivamo neželjena dejstva na žene tek nakon što je lek pušten na tržište? Da li znate da su potrebne godine da bi lek prešao put od ideje do testiranja na ćelijama u laboratoriji, do studija na životinjama, do kliničkih ispitivanja na ljudima, da bi konačno prošao kroz regulacioni proces odobravanja, da bi bio na raspolaganju doktoru da vam ga prepiše? Da ne pominjemo finansiranje od miliona i milijardi dolara koje je potrebno da prođe kroz taj proces. Pa zašto otkrivamo neprihvatljive nuspojave kod polovine populacije nakon što se prošlo kroz sve to? Šta se dešava?
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.
Pa, ispostavilo se da su ćelije koje su korišćene u toj laboratoriji muške ćelije, a životinje korišćene u životinjskim studijama su mužjaci, a klinička ispitivanja se sprovode skoro 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 je muški model postao naš okvir za medicinska istraživanja? Hajde da pogledamo primer koji je popularizovan u medijima, a radi se o Ambienu, pomoćnom sredstvu za uspavljivanje. Ambien je pušten na tržište pre više od 20 godina i od tada su napisane stotine miliona recepata, naročito ženama, jer žene više pate od poremećaja sna nego muškarci. Međutim, prošle godine, Uprava za hranu i lekove je preporučila smanjivanje doze upola samo za žene, jer su upravo shvatili da žene metabolišu lek sporije od muškaraca, što uzrokuje da se probude ujutru sa više aktivnog leka u svom sistemu. Tada su pospane, a sednu da voze i u riziku su od saobraćajnih nesreća. Ne mogu da ne pomislim, kao lekar za hitne slučajeve, koliko je mojih pacijenata o kojima sam brinula svih ovih godina bilo u nesrećama u motornom vozilu koje su mogle biti sprečene da je ovakva analiza sprovedena i da se postupalo u skladu sa njom pre 20 godina, kada je lek pušten u prodaju. Koliko još stvari treba analizirati kroz polne razlike? Šta još propuštamo?
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 svetski rat je promenio mnogo toga, a doneo je i potrebu da se ljudi zaštite da ne bi postali žrtve medicinskih istraživanja bez davanja informacija i saglasnosti. Stoga su preko potrebne smernice ili pravila postavljeni na svoje mesto, a deo toga je bila želja da se zaštite žene u plodnim godinama od uključivanja u bilo kakve studije medicinskih ispitivanja. Postojao je strah: šta ako se nešto dogodi fetusu za vreme studije? Ko bi bio odgovoran? Tako su naučnici u tom trenutku pomislili da je ovo bila sreća u nesreći, jer, budimo realni - tela muškaraca su prilično homogena. Kod njih ne postoji stalno fluktuiranje nivoa hormona, koje može da poremeti čiste podatke koje mogu da dobiju ako imaju samo muškarce. Bilo je lakše. Bilo je jeftinije. Da ne napominjem da je u ovo vreme postojala opšta pretpostavka da su muškarci i žene jednaki u svakom pogledu, izuzev njihovih reproduktivnih organa i polnih hormona. Tako je odlučeno: medicinska istraživanja su sprovođena na muškarcima, a rezultati su kasnije primenjivani na ženama.
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.
Šta je ovo učinilo sa poimanjem zdravlja žena? Zdravlje žena je postalo sinonim za reprodukciju: grudi, jajnici, materica, trudnoća. To je termin o kome sada govorimo kao o „bikini medicini“. To je ostalo tako otprilike do '80-ih, kada je ovaj koncept dovela u pitanje medicinska zajednica i donosioci odluka u javnom zdravstvu kada su shvatili da smo ženama, isključujući ih iz svih medicinskih istraživanja, učinili medveđu uslugu, time da se osim reproduktivnih problema praktično ništa nije znalo o jedinstvenim potrebama ženskih pacijenata.
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 tada, ogroman broj dokaza je izašao na videlo koji nam pokazuju koliko su muškarci i žene različiti u svakom pogledu. Znate, imamo ovu izreku u medicini: deca nisu samo mali odrasli. To kažemo da bismo se podsetili da deca zapravo imaju različitu fiziologiju od normalnih odraslih osoba. Zbog toga je medicinska specijalizacija pedijatrije izašla na svetlost dana i sada sprovodimo istraživanja na deci kako bismo poboljšali njihove živote. Znam da isto to može da se kaže za žene. Žene nisu samo muškarci sa grudima i jajovodima, već imaju i sopstvenu anatomiju i fiziologiju koja zaslužuje da se izučava 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.
Uzmimo kardiovaskularni sistem, na primer. Ova oblast medicine je najviše uradila pokušavajući da otkrije zašto se čini da muškarci i žene imaju potpuno različite srčane udare. Srčana oboljenja su ubica broj jedan i za muškarce i za žene, ali više žena nego muškaraca umire u toku prve godine od dobijanja srčanog udara. Muškarci se žale na pritiskajući bol u grudima, kao da im slon sedi na grudima, a to nazivamo tipičnim. Žene takođe imaju bolove u grudima. Međutim, više žena nego muškaraca požaliće se da se „ne osećaju baš najbolje“, da „ne mogu da uhvate dovoljno vazduha“, da su „baš umorne u poslednje vreme“. Iz nekog razloga to nazivamo atipičnim, iako, kao što sam pomenula, žene sačinjavaju polovinu 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?
Dakle, koji su dokazi koji mogu poslužiti u objašnjenju nekih od ovih razlika? Ako pogledamo anatomiju, krvni sudovi koji okružuju srce su manji kod žena u poređenju sa muškarcima, a način na koji ti krvni sudovi razvijaju oboljenje se razlikuje kod žena u poređenju sa muškarcima. A testovi koje koristimo da bismo ustanovili da li je neko pod rizikom od srčanog udara, pa, oni su prvobitno osmišljeni, testirani i usavršeni na muškarcima, tako da nisu toliko dobri u utvrđivanju toga kod žena. Zatim, ako razmišljamo o lekovima - uobičajenim lekovima koje koristimo, kao što je aspirin. Dajemo aspirin zdravim muškarcima da bismo im pomogli u sprečavanju da dobiju srčani udar, ali da li ste znali da je, ako date aspirin zdravoj ženi, to zapravo 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?
Ovo nam naprosto govori da smo tek zagrebali površinu. Urgentna medicina je posao koji se radi brzim tempom. U koliko oblasti medicine od životnog značaja, kao što su rak i šlog, postoje značajne razlike između muškaraca i žena koje možemo iskoristiti? Ili čak, zašto neki ljudi dobijaju kijavicu češće od drugih, ili zašto lekovi za bolove koje dajemo za ozleđene prste na nogama deluju kod nekih, a kod drugih 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.
Institut za medicinu kaže da svaka ćeija ima pol. Šta to znači? Pol je DNK. Rod je kako se neko predstavlja u društvu, a ta dva se ne poklapaju uvek, kao što možemo videti kod transrodne populacije. Ipak, važno je shvatiti da, od trenutka začeća, svaka ćelija u našem telu - koža, kosa, srce i pluća - sadrži našu sopstvenu jedinstvenu DNK, a ta DNK sadrži hromozome koji određuju da li ćemo 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.
Nekada je smatrano da ti hromozomi koji određuju pol prikazani na slici ovde - XY ako ste muško, XX ako ste žensko - određuju samo da li ćete biti rođeni sa jajnicima ili testisima i da su polni hormoni koje ti organi proizvode odgovorni za razlike koje vidimo kod suprotnog pola. Sada znamo da je ta teorija pogrešna - ili makar da je nepotpuna. Na sreću, naučnici poput dr Pejdža sa Vajthed Instituta, koji radi sa Y hromozomom, i dr Janga sa Univerziteta Kalifornije, Los Anđeles, pronašli su dokaz koji nam govori da ti hromozomi koji određuju pol koji postoje u svakoj ćeliji u našem telu ostaju aktivni celog našeg života i moguće je da su odgovorni za razlike koje vidimo u doziranju lekova, ili za to što postoje razlike između muškaraca i žena u pogledu podložnosti bolestima i težini bolesti. Ovo novo saznanje preokreće stvari, i na tim naučnicima je da nastave da pronalaze te dokaze, ali je na kliničarima da počnu sa prenošenjem tih podataka na bolničku postelju, danas. Upravo sada. Da bih pomogla u tome, ja sam suosnivač nacionalne organizacije pod nazivom Polna i rodna saradnja za zdravlje žena, i mi prikupljamo sve te podatke tako da budu dostupni za podučavanje i za negu pacijenata. I radimo na tome da okupimo medicinske edukatore za jednim stolom. To je veliki posao. Ovo menja način na koji se sprovodi medicinska obuka još od njenog početka.
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.
Ipak, ja verujem u njih. Znam da će videti vrednost uključivanja rodne perspektive u aktuelni nastavni program. Radi se o ispravnoj obuci budućih zdravstvenih radnika. A regionalno, ja sam suosnivač jedinice u okviru Odeljenja urgentne medicine ovde na Univerzitetu Braun, pod imenom Pol i rod u urgentnoj medicini, i mi sprovodimo istraživanja da bismo ustanovili razlike između muškaraca i žena u hitnim situacijama, kao što su srčana oboljenja, šlog, sepsa, zloupotreba supstanci, ali takođe verujemo da je obrazovanje od najvećeg značaja.
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.
Napravili smo model obrazovanja od 360 stepeni. Imamo programe za doktore, bolničare, studente i pacijente. Jer ovo ne može samo da se prepusti liderima zdravstvene zaštite. Svi imamo ulogu u donošenju promena. Ipak, moram da vas upozorim: ovo nije lako. U stvari, teško je. To je u suštini menjanje načina na koji razmišljamo o medicini, zdravlju i istraživanju. To je promena našeg odnosa sa sistemom zdravstvene zaštite. No, nema povratka. Sada znamo tek toliko da znamo da nismo radili kako treba.
Martin Luther King, Jr. has said, "Change does not roll in on the wheels of inevitability, but comes through continuous struggle."
Martin Luter King mlađi je rekao: „Promena se neće dokotrljati na točkovima neizbežnosti, već kroz neprekidnu 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.
A prvi korak ka promeni je svesnost. Ovde se ne radi samo o poboljšanju medicinske nege za žene. Radi se o personalizovanoj, individualizovanoj zdravstvenoj zaštiti za sve. Ova svest ima moć da transformiše medicinsku negu za muškarce i žene i hoću da od sada pitate svoje lekare da li je lečenje koje dobijate specifično namenjeno vašem polu i rodu. Možda ne znaju odgovor - još. No, razgovori su otpočeli i zajedno možemo da učimo. Upamtite, za mene i moje kolege u ovom polju, vaš pol i rod su bitni.
Thank you.
Hvala.
(Applause)
(Aplauz)