Can the United Nations Help Fashion a Global Response to Diabetes?
By S. M. Sadikot
Declaring 14 November as World Diabetes Day is a significant first step taken by the United Nations in recognizing diabetes. However, the annual observance of the Day would be meaningless if concrete programmes for people with diabetes, especially the most vulnerable, are not launched and monitored, and if funding to help them is not provided. Thus, it is imperative that this recognition does not end with a simple commemoration.
UN staff members, joined by outside supporters, form the campaigns "blue circle" logo on the North Lawn of the UN Headquarters during the observance of World Diabetes Day. (Photo: UN Photo/ Mark Garten)
It should be clear that we do not need just a one-time involvement by the United Nations, but a continuing long-term association, so that this health problem, which has already reached frightening proportions, and is on the increase, can be adequately dealt with by treatment focused on the targeted populations. Moreover, the UN recognition must be universal and not exclusive to any particular entities, all of whom should be seen as important and equal partners in a larger, global cause.
The United Nations should act as a forum to coordinate interactions between various “stakeholder” groups, so that it can facilitate and oversee widely agreed and properly targeted initiatives and programmes to stem the spread of diabetes. It should also set up a global fund, which would help in the implementation of these programmes, as those most affected are the most vulnerable populations in poor and developing countries. Furthermore, the programmes would definitely have the impact of making non-communicable diseases an integral part of health policies worldwide.
There is no doubt that diabetes—with its attendant complications and related diseases, such as high blood pressure, lipid abnormalities and obesity, especially visceral obesity, leading to a significant increase in the number of people with the early onset of cardiovascular disease and death—has reached pandemic proportions. In fact, diabetes is a global killer, rivalling HIV/AIDS in its deadly reach and causing some 3.8 million deaths a year. By the time you have read this, one person would have died of diabetes-related causes and two would have been diagnosed with the disease!
Today, 246 million people are affected, the vast majority of them having type 2 diabetes (T2DM), which represents about 6 per cent of the adult population in the world. There is also a misconception that diabetes is a sickness of the rich and wealthy; however, more than 70 to 80 per cent of diabetics live in poor and developing countries. With seven out of the ten developing countries harbouring the highest number of diabetics, the consequences of the disease and its related complications are a tremendous burden to the health economics of many countries, as well as to the socio-economic fallout among its citizens. In other words, it is not a question of whether the United Nations can do anything to fashion a response to the problem—as it must—but when? The answer must be “now”!
So what can the United Nations do about this rising tide that is threatening to engulf us? It should initiate a platform for intensive and continuing interaction among various medical and lay “stakeholder” federations, organizations and societies, that address concerns such as renal, ophthalmic, lipid, nutrition, hypertension, obesity, atherosclerotic and metabolic—their complications and the components of the metabolic syndrome.
Diabetes is not just about simply controlling blood glucose levels. It is responsible for over 1 million amputations each year. People with diabetes are 15 to 40 times more likely to require limb amputations compared to the general population. In most countries, diabetes is the second biggest cause of lower-limb amputations, after accidents. It is estimated that more than 2.5 million people worldwide are affected by diabetic retinopathy (eye disease), the leading cause of legal blindness. Diabetes is also the most common cause of kidney failure, which is responsible for huge dialysis costs; about 10 to 20 per cent of those affected die of renal failure. In India, it has been estimated that 1 out of 3 to 4 patients undergoing dialysis or renal transplants had kidney problems resulting from diabetes. Cardiovascular disease, arising from diabetes, is the major cause of disability and death, accounting for some 50 per cent of all diabetic fatalities. On average, people with T2DM will die 5 to 10 years ahead of those without diabetes—the major cause of this mortality is cardiovascular disease.
The coming together of many organizations as a loose “confederation”, under the coordination and umbrella of the United Nations and its agencies, would give them strength and authority. It would be a neutral platform for coordination among main organizations to come up with clear-cut, time-bound initiatives and projects that would have a direct positive impact on people with diabetes where ever they may live. Initiatives must have inbuilt validation measures and changes that could be made even in the midst of such schemes. One key area of action should be to raise awareness and increase knowledge about diabetes among the medical fraternity, especially family practitioners, those with diabetes and the general population. Educational programmes should be adapted to local environments.
One of the basic problems is that knowledge about managing diabetes and its complications, including its attendant co-morbidities, is very limited among family physicians and even internists in most countries. Also in many vulnerable countries, 95 to 99 per cent of patients are seen only by family physicians, many of whom, although trained in the allopathic branch of medicine, have poor knowledge of diabetes management.
In recent years, there seems to be a plethora of clinical guidelines on practically every aspect of disease states and their management, including diabetes and the metabolic syndrome. The creation of evidence-based and highly academic guidelines is necessary, but it is imperative that steps are taken to “translate” such guidelines into practical means and methods, which would provide good care to diabetic patients on the ground.
Another important development would be to draft a “Clinical Pointers” handbook, which would be much more definitive and inclusive, with inputs from experts in all fields related to the disease. The draft handbook should be distributed among various stakeholders in different countries and regions for their inputs— initially via e-mail as a cost-effective measure. Finance permitting, the draft should be finalized by an international group of experts and stakeholders. The handbook would be extremely practical for family practitioners and other physicians.
The general feeling is that such a UN-facilitated and coordinated effort would be one of the most important steps in ameliorating the ravages of diabetes, by empowering doctors to manage their patients in an optimal manner. After all, what is the use of high-sounding initiatives which really do not help the vast majority of the medical fraternity, especially family physicians, to better treat and manage patients?
Importantly, what is the use of “available” knowledge if it is not accessible to many people, especially in poor and developing countries. In 2007, the world will spend an estimated $215 billion to $375 billion to care for patients with diabetes and its complications. Of this, only 9.2 per cent of global spending will be divided among South East Asia, the Eastern Mediterranean and the Middle East, South and Central America, Africa and parts of North America, where 70 to 80 per cent of diabetics live. India, the country with the largest population of persons with diabetes, will spend an estimated $2 billion, while the 47 countries in the African region will spend a total of $0.7 billion. The World Health Organization (WHO) estimates that 80 per cent of people in developing countries pay for some or all of their own medicine. In Latin America, families pay 40 to 60 per cent of the costs of diabetes care out of their own pockets. In India, a low-income family with a diabetic adult member could spend as much as 25 per cent of the family income on care. And if one considers the health costs of other illnesses that may affect the family, the figures become prohibitive especially in rural regions, where the problem receives inadequate attention.
In view of this, it is also imperative that the United Nations, in consultation with many stakeholders, draws up a list of the basic drugs needed to prevent or treat diabetes and its complications, and insists that countries not levy any tax on such drugs to keep their prices under control. It must also consider setting up a global fund that would act as a one-point source for sponsoring initiatives, which would be meticulously and independently validated and monitored in a transparent manner.
There is no doubt that prevention or early diagnosis and optimal management of diabetes may limit the occurrence of complications. However, even with increasing awareness about foot care, for example, and the prevention of complications to avoid severe foot problems requiring major amputation, data show that more than a million people with diabetes undergo lower-limb amputations every year. Are we then to leave these people aside to act as a burden to their family, society and national economies? And what happens to a family if the affected person is the sole breadwinner?
Western-style, lower-limb prostheses are very expensive, at about $8,000. However, good and relatively cheaper prostheses are available in many countries. A collaboration of stakeholders would allow many countries to have access to cheaper and cost-effective alternatives. For example, many people are unaware of the Jaipur foot or its various cheap modifications; the cost of a below-the-knee Jaipur Foot replacement is only $70 and an above-the-knee replacement is $140 to $150.
While there is no dispute that much needs to be done about diabetes, one also needs to look to the future. T2DM prevalence is rising at alarming rates. The increasing burden will be felt in developing countries, which will see a 170-per-cent rise in the number of people with diabetes, compared to a 40-per-cent increase in the developed world. In 2025, some 80 per cent of all cases of diabetes will be in low- and middle-income countries that are possibly ill-equipped to cope with this epidemic. Again, the United Nations can play an important role. by helping many poor and transitional countries to focus on chronic metabolic disorders, such as diabetes, high blood pressure, overweight and obesity in their health policies.
Biography
S. M. Sadikot is Vice President of the International Diabetes Federation and President of DiabetesIndia.
