Diabetes in the third world / by Thomas Oshotayo Johnson

Diabetes in the Third World by Thomas Oshotayo Johnson H ealth in the Third World is a difficult commodity to safe-guard in the economically dis- advantaged environment of those countries. The disease scene is domi- nated by acute infections, communic- able diseases, malnutrition, problems of mother and child health, and soar- ing population. In such a milieu, life expectancy at birth is short and until recently the chronic noncommunicable diseases were not seen as a problem. OJer the last three decades, these circumstances have been changing and Third World communities are now experiencing the additional burden of diseases like diabetes mellitus and high blood pressure. In some cases, change is occurring at an alarming rate. In two separate reports, WHO noted the increasing occurrence of diabetes in the developing world and gave recognition to a type of diabetes which affects large numbers of young people in poor communities in tropical developing countries. In 1989, the World Health Assembly noted the growing burden that diabetes imposes on public health services, especially in developing countries. It invited member nations to assess the national importance of diabetes and to carry out population-based measures, appropriate to the local situation, to prevent and control diabetes. Through WHO's initiatives, together with the unflagging activities of the International Diabetes Federation (IDF), more attention is being directed to the problem of diabetes globally and not just as a problem of the developed world. The current world population of people with diabetes is estimated to be over 50 million. About one half of them live in the developing world. Precise occurrence rates for many developing countries are not available, and in general the quality and quantity of disease reporting are weak. Eye examination in India. Diabetes can result in partial or complete blindness, yet in the Third World only one diabetes case in four is diagnosed. 8 Many reports on the frequency of occurrence of diabetes and the extent to which it causes premature death or severe long-term disability have come from hospital-based information. These reports have pointed out the emergence of the disease in the popu- lation and have been used to describe the evolution of the disease over time. Community-derived information on occurrence rates has made something of a breakthrough in the last 20 years. Agreement on the criteria for diag- nosing the disease has made compari- . sons possible among different populations and ethnic groups, and has highlighted the need for more studies to define the national impor- tance of diabetes. In developed coun- tries, for every person known to have the disease there is at least one other who has the disease and is not known. The situation in developing coun- . tries is vastly different. For every known diabetic there may be up to four others yet undiagnosed. Diabetes now affects a higher proportion of persons in many developing countries than it does in Western countries, where two or three per cent of the population are affected. This trend has been linked with increasing life expectancy, rural- urban shifts, moves from traditional to modem life-styles, changes in diet, and physical inactivity and obesity. The situation of diabetes in developing countries is providing newer and further insight into the role of genetic and environmental factors in the development of the disease. Latin America. In the Americas, south of latitude 30.N, diabetes has been recognized as a public health challenge affecting between one in 40 and one in 20 of the adult population. The area 1 vi i comprises a mix of developed and developing countries. Africa. Diabetes is less common among black Africans than among Caucasians and black Americans, but reliable population-based studies are scarce. In the United Republic of Tanzania, where an integrated approach to non- communicable diseases (NCO), includ- ing diabetes, was initiated some years ago, and in Nigeria, where a nation- wide NCO survey is going on, an Inter-Health approach is being tested to evaluate the real magnitude of certain chronic diseases and imple- ment appropriate strategies for control and prevention. Diabetes is far. from being a problem of minor public health importance, and is commoner in Afri- can countries north of the Sahara than in those to the south. The Middle East In the Arab countries, diabetes rates in the large communities are now level with or slightly higher than the Western rates. The situation in Malta is interesting: one in 12 of the adult population has diabetes and a national diabetes programme is in place to learn more about the natural history and care aspects of the disease. South-East Asia. The frequency of occurrence of diabetes in the Asian region varies between countries and ethnic groups. In all groups it is at least 2% and may be as high as 5% in some countries. The disease affects Indians more commonly than Malays and Indonesians, and much more so than the Chinese in the same communities. Oceania. Diabetes has recently emerged as a serious health problem in the Pacific region. The Micronesian papulation of Nauru has one of the highest rates for diabetes yet recorded: every other adult person (one in two) in this population has diabetes. Although diabetes was known in China more than 2000 years ago, a nation- wide survey in the early 1980s showed that it is relatively uncommon among the Chinese compared with Western countries, Japan and other Asian countries. The acute onset and often severe type of diabetes which affects young people and requires life-long admin- istration of insulin to maintain life (lOOM) appears to be relatively rare in most developing countries. It is prob- able that many children who develop it die undiagnosed, especially if they live in isolated areas with poor medical care. Noninsulin-dependent diabetes (NIOOM) constitutes the great majority of cases of diabetes worldwide. A slow, savage killer, its complications still W ORLD HEALTH, May-June 1991 WHO/P. Almasy constitute a major cause of early death among those who suffer from it in the developing world. In large areas of the tropics a rather rare form of the disease has been recognized ·as malnutrition-related dia- betes mellitus (MROM) . To many doctors in these areas, this type of diabetes is a real entity although it still needs clearer definition and its occur- rence rates in the community have yet to be described. Problems of diabetes care Regrettably, awareness of the burden of diabetes in the developing world is very low, and this causes serious social and cultural problems. The plight of the individual with dia- betes is often a sad one. Low literacy levels have worked against effective diabetes education of the patient and the family, and unfair discrimination in society at large may be serious enough to prevent him or her leading a full social life. Such people are often Adults learning to read and write in Mexico. Low literacy levels are a handi- cap for education programmes designed for diabetics, and leave the patients themselves at a disadvantage. ashamed to disclose their ailment because of the social stigma attached to it, and women have reduced pros- pects of acquiring a husband. It is in the . area of care and management that the sufferers are hardest hit. Developing countries have limited numbers of health workers and uneven distribution of the available manpower. Low per capita earnings and the competing claims of many sectors result in the annual expendi- ture on health falling below the recom- mended levels. It is against this background that competition for prio- rity attention among specific groups of health problems has to be seen. Since the Declaration of Alma-Ata, developing countries in particular have 9 Diabetes in the Third World adopted primary health care (PHC} as the essential element in their national health care systems, and it is within the framework of PHC that community care and control programmes for dia- betes are best applied. Such an approach should serve as a prototype for the other chronic diseases. Material resources for diabetes care are lacking and essential supplies (insulin, needles and syringes, oral anti-diabetic drugs, and materials for monitoring control} are scarce. Much of the insulin produced in the world is from animal sources. Technological advances have led to a theoretically limitless ability to produce insulin. Despite this, people still die from want of insulin in many developing countries. During a recent IDF /WHO leadership course on planning and delivery of diabetes health care, held in Louvain, Belgium, one of the 32 participants, all from the developing world, commen- ted: "If I see a child with diabetes today, I am almost certain that I will not see him again five years later because he will be dead by that time. The main cause of this tragic death is simply the non-availability of insulin". At the same course, participants were asked: "If you prescribe insulin for a patient, how many of you can guaran- tee that the insulin which is necessary to sustain life will be available and affordable that day?" A majority could not guarantee this essential drug for their patients. One of the recommendations of the Second WHO Expert Committee on Diabetes (1980} was that the adequate and continued availability of insulin to children and adults with diabetes everywhere must be assured by national guarantee. This recom- mendation has yet to be met by many governments in developing countries. For a start, customs duties and other tariffs could be reduced or abolished on these essential items, as has recently been the case in the Domini- can Republic and Paraguay. Many specialists believe that dia- betes rates in developing countries will inevitably reach or exceed the levels in developed countries, and that this is part of the unwelcome price to be paid for industrialization and socioecono- mic development. We should not wait until all the causative factors for diabetes have been unravelled before putting in place strategies for prevention and control. The potential for prevention exists now in developing countries. Those aspects 10 of traditional life-styles that are known or thought to be protective for the disease should be promoted. Preven- tive measures for other conditions may also protect against diabetes. More studies are needed of the possible causative roles of protein- deficiency malnutrition as well as environmental toxins in MRDM of the tropics. Prevention of childhood mal- nutrition is already a part of child survival strategies in developing countries. Provided countries have a correct appreciation of the problem and can obtain the political will and commit- ment and basic health administrative skills, much that is appropriate for diabetes and other chronic disease control and prevention can be effected by developing countries themselves within an efficient PHC structure. Intersectoral collaboration and par- ticipation of nongovemmental organi- zations like national diabetes associations, the pharmaceutical industry, and the private sector- galvanized if necessary by intergovern- A health worker in Nepal checks the growth progress of a small child. But if the child is diabetic, what will be its chances of swvival? mental support among developing nations and between developed and developing countries--can achieve these goals. Health education is a cornerstone of diabetes prevention, care and control. This should be targeted, using appro- priate technology, towards the individ- ual patient, the family, the community, health care personnel, health admini- strators, policy-makers and politicians in order to raise awareness for action now. This particular stitch in time will save nine in the future! • Professor Thomas Osho- tayo Johnson is with the Department of Medicine, Lagos University Teaching Hospital. PM B 12003, Lagos, Nigeria. WORLD HEALTH. May-June 1991