The global diabetes epidemic 3: access to essential medicine
In the third part of our series on the global burden of diabetes, Joshua Schulman-Marcus discusses availability of drug treatment
The rising prevalence of Type 2 diabetes mellitus in developing countries presents a global health challenge that is now garnering attention. With researchers projecting at least a 31% increase in diabetes prevalence in working age adults (1), there is concern for the potential effects on health, household income, and macroeconomics. (2) Current trends in nutrition, obesity, urbanization, and economic development in developing countries suggest that societal risk factors for diabetes will increase in the near future (2,3). Wrongly considered a “disease of affluence,” increasing obesity and other risk factors amongst the poor in developing countries suggest that the burden of disease will fall most heavily on their shoulders. (3,4)
The mainstay of Type 2 diabetes treatment is control of blood glucose (”glycemic control”), either through diet or pharmacological means. Glycemic control is commonly determined through the monitoring of fasting blood glucose levels or glycosylated hemoglobin A1c (HgA1c) (1). The UK Prospective Diabetes Study (UKPDS) was one of the largest trials supporting this treatment hypothesis. The trial demonstrated that a 10% reduction in HgA1c over ten years led to a 25% reduction in microvascular endpoints (eye, kidney, and peripheral nerve diseases) and a trend towards reduced myocardial infarction. However, the UKPDS found that more intensive control of blood glucose had no significant effect on overall mortality. (5)
Current International Diabetes Federation (IDF) guidelines suggest a target HgA1c of 6.5% for those with diabetes, which should be attained through a combination of lifestyle modification and pharmacological management. (6) This target has been difficult to attain even in highly developed countries, and a recent study has suggested it may even be detrimental. (7) Still, glycemic control in patients with an HgA1c over 9% remains an uncontested standard of care, and such elevated levels are commonly found in developing world patients (1,8,9). The Disease Control Priorities Project has found glycemic control in such patients cost-saving in all developing countries. (1)
Generally, oral agents are first-line agents in the pharmacological treatment of diabetes, though many people with Type 2 diabetes eventually need insulin therapy as well. (6) Consequently, the World Health Organization (WHO) has designated three glucose-modifying medications to be essential: insulin, sulfonylureas, and metformin. (10)
However, despite their designation, insulin and oral diabetes medications are often unavailable in developing countries. A 2006 IDF survey of ten African countries found that in 30% of sites surveyed insulin was available less than 25% of the time. (11) A collaborative study between the WHO and Health Action International in six developing countries found access to insulin in public facilities to be uniformly poor. (12) Availability at private clinics and pharmacies was better but significantly more expensive. Only one of six hospitals surveyed in Mozambique had insulin despite it being on formulary, and it was available at none of six clinics. (13) Access problems are consistently worse in rural areas as compared to cities. (12,13)
When available, insulin and other medications may be prohibitively expensive, especially for poor patients. A recent national study of Indians with diabetes found patients paying between 4-7% of household income on medications alone, with 86-97% paying all costs directly out-of-pocket. (14) The poorest patients paid the highest percentage of household income and experienced the greatest rise in costs over seven years. The six-country WHO study found that monthly insulin alone cost the equivalent of three days’ salary in Brazil and nearly twenty days’ salary in Malawi, (12) while the median price for a single vial of insulin in ten African countries was US$10. (11) These prices are far higher than what can be afforded by most citizens or health services. (15)
Furthermore, effective insulin therapy requires costly ancillary equipment. Syringes, testing strips, and glucometers may be unavailable in public facilities and expensive in private ones. (15) Only the wealthiest people with diabetes in Mozambique could afford to buy a glucometer, (13) while in Mexico the expense causes people to wait to buy until the disease is symptomatically severe and complications irreversible (16). Such barriers to care make it exceedingly difficult to achieve IDF guidelines for glucose self-monitoring, (6) and make it more difficult for patients to take an active role in their own care. (1,15)
Some recent efforts have been made to reduce the price of essential diabetes medicines, especially insulin, using mechanisms analogous to those employed to procure medications for HIV/AIDS. (12,15) Even so, decreased prices alone do not ensure access to essential medicines. Systemic problems such as fragmented distribution systems, limited population awareness of diabetes, fraudulent medications, and health care worker shortages present additional barriers. (1,3,12,15) As insulin needs to be refrigerated, non-electrified rural households may be unable to adequately store insulin at home. A recent article contained anecdotes of Indian villagers storing their insulin in clay pots. (17)
Furthermore, access to essential diabetes medications is impeded by health systems that are set up to respond to acute and infectious diseases, which reflects the historical disease burden and popular conceptions of illness. Conversely, the effective use of and adherence to diabetes medications are contingent on consistent patient-health worker collaboration and longitudinal care coordination. This can facilitate patient self-management by providing personal and culturally acceptable care. Present health systems in many developing countries, though, are unable to nurture patient motivation to self-manage disease. This presents an important psychological barrier to access. (1,3,18,19)
The three articles in this series on the global epidemic of diabetes have tried to make the case that this is a serious, complex, and growing problem throughout the developing world. Diabetes results in enormous and unnecessary premature disability and death in developing countries. Worldwide trends indicate that it will increasingly affect the world’s poorest and most vulnerable citizens. Many of the health systems where those people live are not currently prepared to manage diabetes or other chronic noncommunicable diseases.
The inadequate access to essential diabetes medications reflects these shortcomings. Yet these medications are as essential as antibiotics and antiretrovirals, and are likely to become more so in coming years. It is time to start considering them as such, just as it is time to realize that diabetes is a growing global health priority that cannot be ignored.
Joshua Schulman-Marcus
4th year medical student
Mount Sinai School of Medicine
New York
USA
and
2007-08 Sarnoff Cardiovascular Foundation Fellow
Brigham and Women’s Hospital/Harvard School of Public Health
Boston
USA
jschumar@gmail.com
(1) ) Narayan KM, Zhang P, Kanaya AM et al. Diabetes: the pandemic and potential solutions. Disease Control Priorities in Developing Countries (2nd Edition),ed. , 591-604. New York: Oxford University Press, 2006
(2) Yach D, Stuckler D, Brownell KD. Epidemiologic and economic consequences of the global epidemic of obesity and diabetes. Nature Med 2006; 12:62-66.
(3) Preventing chronic diseases: a vital investment. Geneva: WHO, 2005
(4) Monteiro CA, Moura EC, Conde WL, Popkin BM. Socioeconomic status and obesity in adult populations of developing countries: a review. Bull World Health Organ 2004; 82:940-946.
(5) UK Prospective Diabetes Study (UKPDS) Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998; 352:837-853
(6) IDF Clinical guidelines task force. Global guidelines for type 2 diabetes: recommendations for standard, comprehensive, and minimal care. Diabet Med 2006; 23:579-593
(7) For Safety, NHLBI Changes Intensive Blood Sugar Treatment Strategy in Clinical Trial of Diabetes and Cardiovascular Disease. http://www.nhlbi.nih.gov/health/prof/heart/other/accord/
(8) Pradeepa R, Rema M, Vignesh J et al. Prevalence and risk factors for diabetic neuropathy in an urban south Indian population: the Chennai Urban Rural Epidemiology Study (CURES-55). Diabet Med 2008; 25:407-412
(9) Windus DW, Ladenson JH, Merrins CK et al. Impact of a multidisciplinary intervention for diabetes in Eritrea. Clin Chem 2007; 53:1954-1959.
(10) WHO Model Lists of Essential Medicines, 15th edition (2007). http://www.who.int/medicines/publications/essentialmedicines/
(11) Task Force on Insulin. Survey on access to insulin and diabetes supplies 2006. Brussels: International Diabetes Federation, 2006.
(12) Mendis S, Fukino K, Cameron A et al. The availability and affordability of selected essential medicines for chronic diseases in six low- and middle-income countries. Bull World Health Organ 2007; 85:279-88.
(13) Beran D, Yudkin JS, de Courten M. Access to care for patients with insulin-requiring diabetes in developing countries: case studies of Mozambique and Zambia. Diabetes Care 2005; 28:2136-2140.
(14) Ramachandran A, Ramachandran S, Snehalatha C et al. Increasing expenditure on health care incurred by diabetic subjects in a developing country. Diabetes Care 2007; 30:252-56.
(15) Beran D, Yudkin JS. Diabetes care in sub-Saharan Africa. Lancet 2006; 368:1689-95.
(16) Barclay E. In Mexico, diabetes strains lives and budgets. New York Times, 12 June 2007 http://www.nytimes.com
(17) Kleinfeld, NR. Modern ways open India’s doors to diabetes. New York Times, 13 September 2006, page 1A.
(18) Innovative care for chronic conditions: building blocks for action. Geneva: WHO, 2002
(19) Yach D, Hawkes C, Gould CL, Hofman K. The global burden of chronic diseases: overcoming impediments to prevention and control. JAMA 2004; 291:2616-2622.
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