15 May 2008, 08:37
by Robert Walgate
Developing countries tell EAGLES, the European Action on Global Life Sciences, and RealHealthNews, the research that’s really needed.
Eighty per cent of people with diabetes in the world live in developing countries, where the number of people with diabetes is predicted to increase by 150% in the next 25 years, according to the World Health Organization (WHO). Even in the next ten years, diabetes deaths will increase 50% without urgent action. And the International Diabetes Federation (IDF) estimates that 3.8 million people died as a result of diabetes in 2007. This is more than deaths from HIV/AIDS and nearly four times the deaths from malaria.
So in this context, what research should be underway, to help developing countries face the scourge of diabetes? Surely the best way to find out is to ask the countries themselves. So the European Action for Global Life Sciences – EAGLES – commissioned the Editor of RealHealthNews, Robert Walgate, to talk to leading diabetes researchers and practitioners in countries in Asia and Africa and ask exactly that question, reporting his conclusions back to the Commission of the European Union (EU) in Brussels and the European Parliament. Here is a brief summary of what we heard. Key recommendations are marked by bullets.
Jean Claude Mbanya, President-Elect of the International Diabetes Federation, spoke to us from the low-middle-income country Cameroon – one of the few well-studied developing countries thanks to a European Union research programme comparing diabetes in Africans in Cameroon, the Caribbean and the UK in 1994.
READ ON: EAGLES
“In 1998, the prevalence of diabetes was about 2%,” said Mbanya. “In 2003 it was already 5%, and 2007 it is going to be about 6.5%”. It’s a dramatic rate of increase, and it extends to the rural areas, “where you get so many people now with impaired glucose tolerance, and impaired fasting glycaemia” – precursors of diabetes.
READ ON: International Diabetes Federation
“If you look at obesity, which is one of the major risk factors for diabetes in Cameroon – it’s about 16% in the rural areas. And nearly 30% in the urban areas” said Mbanya.
“I don’t think it’s mostly nutrition, I think it’s mostly a more sedentary lifestyle – a change of physical activity. It’s the Chinese phenomenon of having motorbikes everywhere. Where they used to walk to places, now they have a bike.”
So what research would be useful?
- “I think first of all you need to produce data to convince the government. I think it also helps very much when you have a local champion – because he or she at least can work towards the achievement of certain goals. And also you need a team, like mine, to carry out the surveys and assist the government.”
“Some data, no matter how it is collected, is better than no data!”
JEAN CLAUDE MBANYA
Economic studies are also crucial:
- “Some data, no matter how it is collected, is better than no data!” said Mbanya. “You can do hospital analysis of admissions, bed occupancy and deaths, for chronic diseases and the rest. Over a period of time you would see that the greatest burden is maybe diabetic foot – the foot ulcer; they stay in hospital for three months, or the foot is amputated. If you look at the economic burden imposed by diabetic foot on the hospital, you’ll see that it chops off a whole chunk of the budget! It’s more than malaria, tuberculosis, AIDS and the rest!” It can become a priority therefore to deal with that.
In urban Sri Lanka one person in six has diabetes – “And the figures might double by the year 2025”
Mahen Wijesuriya, Chair of the IDF South East Asian Region, speaking from Rajagiriya, Sri Lanka, told us that two million people had diabetes in his country, out of a population of 20 million – a rate of 10%. In the urban population 16% – one person in six – has diabetes, and in the rural areas it is about 8%. “And the figures might double by the year 2025” said Wijesuriya.
There is a similar pattern in India and Bangladesh, he says – “All of us are running around 16-20% in the urban population – we are the double-digit boys.” And in Sri Lanka “we have care in quality but not in quantity” said Wijesuriya.
- Wijesuriya emphasised the value of “translation research” – where investigation is made of how to translate academic research into practical action. So with IDF support Sri Lanka is investigating the development of proven life-style risk factors – such as poor nutrition and little exercise – in children, “where we have committed ourselves to intervene in life-style changes, over three years”.
- “We want to use these [risk] factors to see if we can bring down the incidence and prevalence of diabetes in our community” said Wijesuriya. “We hope to make this a landmark study where others could follow.”
- These studies to create positive interventions could be made on the basis of the “four agreed major causes of diabetes: genetic factors, intrauterine nutrition [principally poor nutrition of the pregnant mother], life-style after birth – and mental stress”.
What about research to bring down the cost of treatments (primarily drugs for late onset type 2 diabetes, and insulin injections for childhood type 1), we asked?
“Now you’ve hit upon the sensitive point. When they got human [cloned] insulin, we all thought it was a bonanza and we were going to get enough cheap insulin. But the price never came down, and it is now going up again, away from the poor man’s pocket.”
- “That is where something can be done from the richer part of the world, with equitable distribution of production, and cost-factor analysis…. We don’t want the insulin producing companies to go broke. But we want good insulin, cheap.”
Li Liu, a paediatric diabetes physician at Guangzhou Children’s’ Hospital, China – told us: “95% of the diabetes at this hospital is of course [childhood] type 1. It’s easy to diagnose here, but it’s often misdiagnosed in the countryside, if they aren’t aware of it, for things like nausea and abdominal pain.” This is a consequence of the ketoacidosis that follows a diabetic child’s lack of natural insulin.
In consequence, a lot of her patients arrive late – and unconscious, in a coma, says Li. The first need of all her patients is medical insulin, she says. But they must pay – and a lot of them have to have insurance cover. “It’s very expensive compared to their income,” she said. “So some of them give up the treatment.” And the child dies.
It costs US$700 for the first visit, and then US$40-70 for a period of treatment – usually about a month – until they become stable, using insulin injections and blood sugar tests, said Li. “Then they go home, and then they have to continue the treatment, injecting at least twice a day for life, and testing their blood sugar” said Li, at a cost of around US$40-70 per month.
“I met a nine-year old patient, a girl, and her parents were very poor and they said she would cost us a lot of money… we will raise another child, and not continue treatment.”
“We have many neonatal cases, and sometimes the parents give up” she said. “They think the children will face education problems, marriage problems, and employment problems… You know in China parents prefer sons. I met a nine-year old patient, a girl, and her parents were very poor and they said she would cost us a lot of money… we will raise another child, and not continue treatment.” Also, universities and employers are obliged to pay their students’ or employee’s medical costs. So although it’s illegal they find reasons to exclude diabetic patients. “Some diabetics, when they reach puberty, want to commit suicide,” said Li.
Kaushik Ramaiya, a physician and researcher in Tanzania, stressed the need for:
- Research in population-based epidemiology of diabetes. “We have nothing significant outside South Africa, Tanzania and Cameroon,” he told us. “We need help to get these basic epidemiological studies done, to identify the state of the problem… Then we need to get the risk factor profiles.”
“We also need to strengthen the healthcare system itself – infrastructure, tools to make the diagnosis, like a basic ophthalmoscope for eye problems. You need tools to identify and diagnose the complications.” But totally new tools aren’t needed – just the availability of the one we’ve already got. “And then you need the training how to use them.”
- “Health systems research could identify the gaps within the resources, in the training, in the equipment, and find ways to fill up those gaps” he said. “We also need to improve the supply and logistics systems, especially for life-saving drugs like insulin. We need insulin at an affordable cost, but them we need to get it from urban right out to rural areas.”
READ ON: Diabetes India
Shaukat Sadikot, President, Diabetes India, told us: “Everyone will tell you the problem is prevention; it’s important, but quite frankly the problem in India right now is that a lot of people who have diabetes don’t even know they’ve got it. So they present with complications.”
“In the rural areas, four out of five people with diabetes didn’t know it. Even in the major cities, it was one out of two. So one of the main things is to inform people.”
Also “98% of patients are treated only by family physicians, and that doesn’t mean physicians who studied allopathic [modern] medicine. It might be someone who’s done ayurvedic or homeopathic medicine and so on…. So the basic problem is creating awareness – amongst the doctors and amongst the public.”
There are very simple diagnostics that can be done, said Sadikot – like checking for maculopathy (macular decay, a diabetic complication which leads to blindness in the central part of the eye) with a simple eye test card.
- “And we have the Jaipur foot, for amputees. A good foot costs US$8 000. But a modified Jaipur foot costs US$25-30. Why can’t India establish 20 centres to provide them across India?” Sadikot asked.
But these things are not being implemented “because chronic diseases have not come into the focus of the ministry… India spends 0.9% of its expenditure on health. Less even than Mali. For a country like ours it’s absurd”.
As for research, “We keep doing these studies, and after that no-one takes it on”, Sadikot told EAGLES. “And imagine I’m the minister. Even if I want to take on diabetes management and prevention, the effects won’t show for 10-15 years, and I know I’m not going to be in still the job. If I were the health minister – or the finance minister – I know I’m going to face an election in five years, so I’m going to do something that gives me mileage right now, like being seen giving polio drops to people and all those things.”
“70-80% of the cost is born by the patients themselves. And 40% of our population earns less than US$1 a day… I’m on the Insulin Task Force, and we still have insulin available, with one vial containing 400 units. It’s cheap because two or three Indian companies began making it and the prices definitely fell. It’s not cheap enough for a very poor person, but in the type of society that we have, Diabetes India is able to give free insulin to poor children.”
“We have enough studies now! When are we going to get out of that academic loop?”
- Thus India’s prime need, according to Sadikot, is to identify what communication campaigns would be effective. “Absolutely. And for the doctors. I’m a physician. We don’t want complex information – we want to know simple things. A patient walks into my clinic with high blood sugar. What do I do? How do I adjust doses? What do I look out for? We have enough studies now! When are we going to get out of that academic loop?”
Diabetes physicians and NGOs in developing countries also come up with many, simple proposals for practical products that if they were available to them, would make a great difference. All that’s needed is to ask. Here are just two more recommendations that were proposed during our investigation:
- Develop, produce, and make available low cost strips for blood glucose testing.
- Develop, produce, and make available low cost safety devices for the ‘sharps’ used in blood tests and insulin injection.
And existing cheap technologies need to be shared globally, such as:
READ ON: EAGLES report on diabetes
- Ceramic pots, with water, underground in a very cool place, can be used to store insulin safely. [It must be kept below 30ºC to remain active.] A two-skin pot has been developed by diabetes NGO, the DREAM Trust, in India. Similar pots are used in Tanzania.
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