Only local studies will make ministers move


Global figures and studies argue that diabetes is a growing problem for the developing world, and that it needs to be tackled urgently or expensive complications will follow. But what about the local story? New studies in Africa, China and the rest of the world will soon show the real national costs of diabetes. And researchers in Kenya are revealing prevalence rates higher than HIV/AIDS – even in rural areas where diets are ‘healthy’.

Some 80% of cases of diabetes can now be found in the developing world, according to an Economist Intelligence Unit (EIU) study of the global issue.

In China, the total costs of diabetes are rising rapidly from US$12.4 billion in 2004 to US$20.5 billion in 2007, says the EIU, with lost productivity costs alone equivalent to 0.6% of GDP. Between 2007 and 2025, India and China will see a staggering increase of an additional 48.5m people with diabetes, the EIU reports, drawing data from the International Diabetes Federation’s world Diabetes Atlas. Over the same period, South and Central America will see 102% growth in the diabetes population, while Africa will witness an 80% increase, says the EIU.

But diabetes, like other non-communicable diseases, are still woefully neglected, and it seems that only a strong economic case for prevention and early care – to stop expensive complications like blindness and amputation of limbs – will make governments and donors sit up and take notice.

Yet diabetes is neglected in research too, so many of the figures being quoted are speculative, being based essentially on projections from studies in the developed world – giving politicians with tight budgets an easy way to escape from the claims.

With this in mind, Jonathan Brown, Senior Investigator at the Kaiser

Permanente Center for Health Research in Portland, Oregon, USA, is preparing country-by-country studies of the economic impact of diabetes in the developing world, and Kitirda Acharya of the Kenya Diabetes Management and Information Centre is making studies specifically in Kenya .

RealHealthNews talked to them at a Diabetes Summit in Nairobi this Summer.

>RHN: Developing countries need good global studies on diabetes, but they also need local studies, don’t they Jonathan – they need to know the situation – the numbers and the economics – in their country.

JB: That’s exactly right. In fact, that’s my main activity with the International Diabetes Federation. I chair an economics task force for them, and we’ve turned our attention to doing those local studies. We are finding the money to do them, and developing the methods, and then working with people in countries.

We are going to start up in Kenya and in Tanzania, Uganda, Rwanda, Cameroon, and several others.

>RHN: And you’re going to do this with local researchers?

JB: Yes, absolutely. Actually the point of our activities is to get the money to local researchers and the tools that they need. The rest of us work as volunteers and there’s no reason to pay us money to do this.

The people on the ground are incredibly capable. But they are very busy, and they need some funds to do it.

>RHN: In outline, what studies does a country need to do?

JB: Basically no one knows in each country how much is spent on diabetes, how much could be saved from treating it, or what is the impact on families.

Families are where diabetes actually translates into the impact on economies: people not being able to go to school because they have to care for their parents, or families breaking up and then women going into prostitution to make a living; people losing their land and animals.

Those are the sorts of things that happen when a chronic disease takes hold in a developing country – and that’s what stalls economies.

So we need to quantify that, see if it’s true that those impacts occur, how frequently do they occur, and detail what’s involved. And then there’s also finding out what treatments people get.

We need these figures because in many countries it’s finance ministers as well as health ministers that need to see the stakes for the country in diabetes and other chronic diseases, if anything is to be done.

So getting those data, which have really never been gotten, is part of our objective. And then people need local data because local problems are solved locally, and it’s always compelling to be able to know your own situation and not just be speculating.

>RHN: It’s politically more compelling, and it’s evidentially more compelling.

JB: It is. And the decision makers can be involved in the design of the study. I mean we shouldn’t just put the results on their desks as a surprise later, but get them interested in the studies at the beginning.

>RHN: And are you doing that in this research you’re doing in Africa?

JB: Yes, it’s actually one of the selection criteria we use.

>RHN: On what kind of scale do you need to do these studies? What kind of populations?

JB: We’re thinking 500 people with diabetes and then 500 controls who are matched for age and sex, and maybe where they live, to make the comparison.

Because it turns out, in any country, from the United States to Burundi, you can’t look into medical records or interview responses and see what was caused by diabetes and what wasn’t.

It turns out that diabetes is a disease that causes all kinds of problems besides the recognised complications, from infections to mental health issues to just seeing the doctor more frequently, even accidents related to dementia and other things, so the costs are spread out through the healthcare system and the only way to really see them is to compare people with the disease and those without.

>RHN: So you’ll be looking at a whole range of factors in each group. They’ll be structured interviews, essentially?

JB: Oh, yes, they’re basically questions and answers with specific coded responses and so forth, so the data can be collected and compared.

And once we have data from many countries, for instance in Africa, then we can answer more detailed questions about the specific impacts of amputations, for example, which are a hugely frequent complication in the developing world but are very rare in developed countries.

>RHN: You’re working in several countries in Africa, but what about the rest of the world, in Latin America and Asia?

JB: Well, in fact we began working WHO in Shanghai, China. We finished a study there [as yet unpublished] in an urban population. We are about to begin in seven countries in Central America, working with the Pan American Health Organisation. And it looks like we will do more studies in China and now we’re branching out to other Asian countries and the former Soviet Republics, and Eastern Europe.

>RHN: What were your results in China?

JB: In that case it was a population in a particular neighbourhood in Shanghai, which is probably the wealthiest city in China. So they don’t represent the entire country. Now we’re meeting with the Chinese Centres for Disease Control and then also the National Diabetes Association about a national population based study where they will screen to find people with diabetes, and then we will work with them to add an economic component to the study at the same time, so they can see the economic impact.

China has a much bigger diabetes problem than is appreciated. In the cities, the prevalence of diabetes among adults is now greater than 10%, which is a huge number, and they’re still at a relatively early phase in their development of obesity and so forth.

>RHN: Is it due to change in diet?

JB: Diet, lack of physical activity, and genetic issues. Diabetes has many different genetic forms, and populations like the Han Chinese and South Asians and others have a very high susceptibility to diabetes; so once the process begins, of indolence and getting plenty to eat, or actually being poor and having to buy the cheapest calories you can, which tend to be obesogenic calories, diabetes appears very quickly.

>RHN: So with the kind of research you are planning you will get the details.

JB: But on the other hand, the big picture in countries is quite compelling. We don’t need two decimal points to understand that, for instance, in Russia, if you make a very conservative estimate of the cost of a life lost, and use the average national income per person, they lose 25 times that every year in deaths from diabetes and disability from diabetes than they spend to treat the disease, as far as we know. And they lose five times as much economic growth as they spend to treat the disease.

So with numbers like that, you know, what happens to the right of the decimal point is not going to change the conclusion.

>RHN: If I could turn to you now, Kitirda Acharya – you are Vice-Chair of the Kenya Diabetes Management and Information Centre. Yesterday William Mania, Head of the Department of Non-Communicable Diseases at the Ministry of Health, stressed that in order to make a political case he needs the national figures. He can get all these global studies, but where are the national figures? What’s the answer for Kenya?

KA: We have started collecting data. We’re probably ten years behind, but it’s better late than never, and we’re actually working closely with the Ministry. A lot of the data is still in raw form and we need to process it, but basically we are coming out with prevalence rates of diabetes nationally and it’s an alarming figure, it’s higher than HIV/AIDS. We’re picking up prevalence rates of 11%.

We go out a lot on epidemiological projects, screening projects round the country. Also we are at the university, which is a major diabetes referral clinic for the whole country, so we get the patients coming to us with all the complications. So we have a bit both of the patient load, and the public.

When we go out in communities we go screening adults, people over the age of 30. We have done surveys in rural Kenya as well as urban Kenya, and we find that the prevalence rates are almost equal. So there is a lot of diabetes out in the rural areas – where they have healthy lifestyles, they walk long distances, and they have healthy diets – because a traditional African diet is an extremely healthy diet, very low in sugar and fats.

>RHN: So that’s very extraordinary. That goes counter to the normal assumption that it’s urbanization that causes it.

KA: That’s right, that’s right. Of course in the urbanized areas we get higher prevalence, but it’s not that wide a difference. So we’re looking into all the other environmental factors. Is there something in the soil, the pesticides? Again, we are finding certain communities there are much higher prevalence rates, even if they follow all the steps to prevent diabetes. So we believe there is a genetic and ethnic component as well.

Now Kenya is quite cosmopolitan, especially in the urban areas, and we have a big influx especially of Asian communities living in Kenya, of which I am one. And I find again in my private practice it’s extremely, extremely prevalent. In every family there are two or three people with type two diabetes over the age of 30 years.

>RHN: Among the Asians?

KA: Among the Asians. And also there’s a lot of impaired glucose tolerance. I’ve personally been collecting data and carrying out oral glucose tolerance tests (OGTTs) on families of patients with diabetes. And as we tracing diabetes down generations, we find a lot of impaired glucose tolerance as well.

Now that is something we’re very excited about, because we can actually prevent it coming early. The son who sees his father going in for an amputation or for laser therapy wants to take all the actions to prevent the same happening to him. So we are actually able to get across the message of prevention much louder.

>RHN: So you’re talking about genetic susceptibility to type two diabetes?

KA: To type two diabetes, which is where most of the prevention in diabetes globally is focused. It’s very difficult to predict or prevent type one diabetes. Now though type one diabetes is supposed to be less than 10% of the total diabetes load, we are finding in Kenya again there is a rise in the number of new cases of type one diabetics. But that might be because we’re just screening more effectively, or because more people are coming forward for screening.

>RHN: Just to come back to the rural question – they are mostly Africans, are they not? Not Asians?

KA: They are. They’re all Africans, and they’re the poorer of the group.

>RHN: You said the studies are only just beginning, but there most be many different ethnic communities amongst the Africans themselves, with many different genetic patterns.

KA: There are. We’ve covered all the provinces. Kenya has eight provinces, so we’ve gone all over the provinces screening, and we do follow-up visits with the screening as well.

>RHN: But amongst the areas and the communities, amongst the Africans, do you find a genetic variation?

KA: We find diabetes is common in certain communities and certain families, so definitely there is a genetic susceptibility. In the urban areas, the diets are getting unhealthy, the lifestyle is becoming less active, more sedentary. But in the rural areas, really, the women work hard on the farms, and they are always on the go.

>RHN: They often have what used to be called the poorer diets.

KA: Yes. The poorer diets – which are actually the richer: less is more in this case.

Now one of the other explanations may be that there’s not good structured antenatal care in our country yet, and a lot of babies are born at low birth weight. Now low birth weight babies are at a higher chance of developing type two diabetes later on in life.

And we find the poorer communities are in the rural areas, so maybe we are condemning foetuses or babies before they’re born to diabetes because of poor nutrition during the mother’s pregnancy.

When we went to western Kenya, Kisumu, Kericho, Nyanza province we picked a lot of diabetes and we picked very poorly controlled diabetes.

>RHN: Can you give me some figures for variation among communities?

KA: We don’t have actual data, but all I can say is the central belt of Kenya, the highlands, there’s much more higher prevalence. if I were to tell you the hot spot areas for diabetes in Kenya we’ve picked very high prevalences in the central and the Rift Valley belt, and that tends to be slightly more affluent rural community, so we don’t know if it’s the affluence or epidemic.

And then we’ve picked a similar very high incidence amongst the coast where there’s a mixed population. It’s not pure African. They’re the Swahili, the Arabs, so there’s a mix of different ethnicities, and again the dietary habits are not the best, so we’re picking those hot spots in our country.

But remember the baby who’s born low birth weight is at higher risk, because the pancreas is not well developed, of getting type two diabetes later on, after they’re 30 years old. So that may explain why we’re getting this exponential rise.

A lot of traditional healers are also interfering with the work we do, so they are actually condemning people to these lives of misery and suffering with diabetes.

>RHN: In what way? How do they interfere?

KA: Well, they have a big influence on the local community, they speak the language, these are self-proclaimed leaders of some sort with these magical powers, and a lot of them have signs saying they can cure diabetes, they can cure HIV.

So they give these really horrible tasting concoctions of herbs and they do all these rituals, and when we’ve analysed some of the things that they’re giving out, sometimes we’ve found tablets of oral hypoglycaemic agents that have been mixed in with the herbs.

So the patient, if they are taking insulin and then go through the traditional healer, may collapse with hypoglycaemia.

Similarly for TB and HIV. They’re just crushing some antiretrovirals and put them in. Now this is going to lead to a lot of resistance to these drugs, so that in future coming up with new drugs that work is going to be a real economic challenge.

>RHN: I see. So they’re not providing simple herbal remedies, they’re actually using a little bit of the…

KA: They’re cheating as well.

>RHN: So you’re collecting lots of information, so why is the Ministry of Health saying, where is the information?

KA: Well, a lot of the information is still being analysed by our statisticians, and we don’t want to give half-baked figures to the Ministry.

>RHN: So you’re giving me provisional figures?

KA: They’re provisional. The Ministry has been actually very helpful in all fairness, because when we want to go out in the rural area, we want to go to a big hospital, the Ministry gives us permission to have access to that data.

>RHN: What are your needs to do this research? Do you need more finance?

KA: Funding is the biggest deterrent. Often we have some really good papers that are generated through the university, but they stop at being a pilot study or a paper, because we can’t push the study forward to follow patients over a longer period of time. Interventional research is very difficult because of the costs involved. We’re often doing research where we’re paying for all the tests that the patient needs, the transport fees for the patient to come up to see us, so there are a lot of financial restraints in already a poor resource setting.

Despite all this deterrence for the postgraduate students, they have to work on a thesis, so a lot of them have to find private funds to facilitate their research.

>RHN: What about publication?

KA: I’m encouraging a lot of my students to go abroad to international conferences. And of course we’ve been submitting our material for publication. The East African Medical Journal regularly publishes our work.