A mother and her infant, who was born by Caesarean section, died after the woman took a poisoned glucose supplement from a Cologne pharmacy. How the glucose solution was contaminated is still unclear - the investigators rule out neither negligence nor intent.
The solution with glucose (glucose) had been sold for a standard test for gestational diabetes. There has been criticism of this test method for quite some time - among others from Heinke Adamczewski, internist and diabetologist from Cologne. The 57-year-old sits on the board of the nationwide "Diabetes and Pregnancy Working Group" of the German Diabetes Association.
In the interview, Adamczewski talks about the weaknesses of the glucose preparation, the danger of false diagnoses and the austerity policies of the health insurance companies.
SPIEGEL: Ms. Adamczewski, experts like you publicly warned three years ago to use loosely packaged glucose powder for diabetes testing. Do you feel confirmed by the death in Cologne?
Heinke Adamczewski: At the time we did not think of a tragic death. But we had security concerns. The glucose powder is transferred in the pharmacies from large containers into small bags. We could not have thought of the fact that another substance could be put into it by carelessness or with criminal intent. Our central argument was and is different.
SPIEGEL: And which one?
Adamczewski: The decanting of the glucose powder is a multiple error-prone process. The powder must be weighed very carefully in the pharmacy, then we have to dissolve it completely in the practices in 300 milliliters of water; then the women drink the solution, after one and two hours we determine the blood sugar value. But even when stirred long and thoroughly, a sediment may remain in the vessel. Or there are still residues stuck to the film, if you pour the powder into the mixing bowl. We fear that such sources of error will falsify the test results and, in the end, unknowingly make false diagnoses.
SPIEGEL: What would be the consequences of such misdiagnoses?
Adamczewski: Overlooking gestational diabetes means significant risks for both mother and child. The likelihood that the child will develop diabetes later in life or have cardiovascular problems is increased. The mother also unknowingly carries a greater risk of developing life-long diabetes. The increased formation of insulin in the womb has the consequence that the fetus excessively increases in weight. The risk of a complicated birth increases, the risk of so-called pregnancy poisoning also. Because of these risks, the diabetes test must be offered according to the mandatory maternity guidelines of each pregnant woman. Then the basis may not be an error-prone test.
SPIEGEL: Which alternative do you see?
Adamczewski: There is a syrup that we have long used, a finished product. It causes side effects in a smaller number of women: they are less likely to vomit and have less circulatory problems than the glucose solution dissolved in practice. This finished solution is used worldwide, industrially produced and filled to a uniform standard. It is transported unopened until it is used in practice, and its manufacture is subject to quality control, such as a drug. This test costs just over five euros. But since 2016, it is part of the austerity policy of health insurance, only to refund the glucose powder. You pay to pharmacies per bag of € 1.21. The security and error rate would therefore be reduced if the health insurance companies would invest a good four euros more for each pregnant woman. With around 750,000 births a year, this amounts to about three million euros - apparently too much.
SPIEGEL: One could also argue differently: The health costs are exploding - so you have to contain them. And it is part of the job of the employees in medical practices and pharmacies to optimally process the glucose powder.
Adamczewski: That is correct as a principle, but it contradicts real life. Often, in a diabetic or obstetric practice, ten women are given the glucose solution in one day. The women are not allowed to eat anything and have not done much else that day, because all of that changes their metabolism. If, during this tight window of time, the dental staff have to mix a glucose powder in ten cups that dissolves anyway, precise working is not always possible.
SPIEGEL: In view of these disadvantages, are pregnant women unwilling to pay for the syrup test themselves?
Adamczewski: Many colleagues work in districts where more than half of the patients have a migrant background, often do not speak German and need a translator. These patients can not always explain the problem sufficiently well. Often money is tight, some have no wallet or without the consent of the husband spend money. Inviting women to pay for their own completion is, in my opinion, discriminatory and excludes the most vulnerable members of our society from optimal care.
SPIEGEL: And then you give them the powder test, even though you think that it is error-prone?
Adamczewski: Yes, that's the dilemma - what do you do? Doctors who use the ready-made solution must expect to receive reimbursement claims from health insurance companies for years to come. As far as I know, this issue is not treated equally strictly throughout Germany, but in the administrative district of North Rhine and in Bavaria, such recourse claims are piling up.
SPIEGEL: How do you and your colleagues react?
Adamczewski: We file an objection against these repayment claims every quarter. In addition, years ago and repeatedly, we formulated our concerns and presented them to the health insurance companies together with our specialist societies. We need legal certainty - not only because we may be left at extra cost. It is also about the question of who ultimately bears the responsibility when error-prone tests lead to a false diagnosis. We are concerned that we will be held liable.
SPIEGEL: Last week, it became known that the health insurances in North Rhine-Westphalia will pay for the syrup test from now until December, after the death in Cologne has raised so many questions.
Adamczewski: A first step - but this time limit is incomprehensible. This does not change the fundamental problem. After death in Cologne, the powder should no longer be used in any practice, regardless of how it came to the contamination of the glucose powder.
SPIEGEL: Do not you judge rashly? The investigation is still going on, and the deceased may as well have been the victim of a crime.
Adamczewski: The production of the glucose solution from powder contains many processing steps that could all be avoided and have opened up security gaps. Especially after this terrible death, the safety of the pregnant women entrusted to us and their children should be worth four euros more. For the health insurance companies, who have beaten the warnings and concerns of the professional societies for years, must now stand up for it.