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  • Diabetes Treatment

    Diabetes, with its attendant acute and long term complications, and the myriad of disorders associated with it, is a major health hazard. In keeping with the scenario of most developing countries, India has long passed the stage of a diabetes epidemic. The problem has now reached, in scientific language, "pandemic" proportions. To put it simply, it has crossed the dividing line in which it is a problem associated with individuals, no matter how large this number may be, and is now a very large public health problem, growing astronomically year after year. More than a matter of individual health and well being, the pandemic calls for an effort in which attention must be paid not only to treating a patient with diabetes. It involves a collective response which includes the setting up of a complete infrastructure which involves attention to prevention as well as making diabetes care "Available, Accessible and Affordable" to all persons with diabetes.

    Diabetes care should be "available", not only in terms of equipment, but, more importantly in terms of expertise. It should be "accessible" to the people without their having to travel long distances to avail of it. Importantly, such services must take into consideration the economic realities and be "affordable".

    This concept of "available, accessible and affordable" is central to the successful implementation of any planned program.

    The 1997 WHO report has shown that there is a marked increase in the number of people affected with diabetes and this trend is scheduled to grow in geometric proportions in the next couple of decades.
    YEAR
    NO OF PEOPLE AFFECTED
    (in millions)
    1995 124.7
    2000 153.9
    2025 299.1

    We, In India know this to be true from personal experience.

    The crude prevalence rate of diabetes in urban areas is about 9% and that the prevalence in rural areas has also increased to around 3% of the total population. If one takes into consideration that the total population of India is more than 1000 million then one can understand the sheer numbers involved. Taking a urban-rural population distribution of 70:30 and an overall crude prevalence rate of around 4%, at a conservative estimate, India is home to around 40 million diabetics and this number is thought to give India the dubious distinction of being home to the largest number of diabetics in any one country.

    Surveys have also shown that the prevalence of Impaired Glucose Tolerance (IGT) is also high. It has been reported that the prevalence of IGT is around 8.7% in urban and 7.9% in rural areas. Recently, another study has shown that the prevalence rates for urban areas is around 6%, whilst the figures in the rural areas was found to be around 5%. Given the observation that around 35% of those with IGT will develop full blown diabetes within five years, the sheer numbers of those with diabetes seems overwhelming.

    Screening has also shown that the unknown to known diabetes ratio is about 1.8:1 in urban areas, whilst it is as high as 3.3:1 in rural places.

    Moreover, the type of diabetes which we see in India is considerably different from that described in the western literature. Although the estimate of Type 1 is around 1% of the total diabetics, the vast majority of the so-called Type Iis differ significantly from their western counterparts. Only about one third of these would be considered obese. 10-15% would be underweight and the rest would be of normal weight or just slightly over the acceptable weight range.

    What is of considerable interest is not only that the numbers are increasing in leaps and bounds, but it appears earlier in life (with many Type IIs being diagnosed at the age of 20-30 years), but the chronic long term complications are occurring earlier, progressing more rapidly and reaching the hard end points in diabetics who are relatively younger as compared to the picture seen in the past.

    Whilst the high rates of prevalence of complications is disturbing, the picture is rendered all the more gloomy with reports that many patients already show the presence of these complications at the time of diagnosis. It is a widely accepted fact that more than 35-40% of people show the presence of some diabetes related complications at the time of diagnosis.

    It is widely accepted that the health, socio-economic and personal costs of diabetes and its attendant complications is unacceptably high, not only to the individual, but also to the nation as a whole when one considers the sheer number of people who are already known to be diabetic. This burden can only increase with the projected increase in the numbers of people with diabetes.

    It is therefore, a major concern to those involved in diabetes care that India has no major initiative available, or even planned, to try and face this problem.

    India has a distinct need for a comprehensive diabetes care program. This should not only confined to report on the standards of diabetes care which are prevalent here, but needs to be more wide ranging. It has to be a continuos ongoing process, which approaches the problem from an all encompassing primordial, primary, secondary and tertiary approaches. At the same time, it should be workable and have short and long term aims and objectives in the quest to improve diabetes care in India. It needs to continuously examined and reevaluated so that one is sure that the objectives are being achieved. Without such an objective evaluation, there is always a possibility that such programs will be high on "percept" and abysmal in "practice". For any such program to succeed, it must be rooted in ground realities as present in India. The program should have an infrastructure that makes it "AVAILABLE", both in terms of technology and expertise, "ACCESSIBLE", even to the common man with diabetes, and should be "AFFORDABLE"!

    Why is it that India does not have a diabetes care program? The Indian Government still does not consider diabetes and other non communicable diseases as a priority area. The feeling is that we still have a long way to go in dealing with communicable diseases which are again seeing a rise in numbers, immunisation, providing clean drinking water and sanitation to the majority of the people. With a health budget which comprises just 1.2% of the total outlay ( this comes to less than half a rupee per person! ) and its given priorities, the government does not seem to have the finances to undertake any major program for non communicable diseases in general, and diabetes in particular.

    Moreover, the diabetes associations in India have done little, if anything, to bring to focus the need for any such program, or even tried to evolve any such program. This is extremely unfortunate, as a good program can go a long way to improving the state of diabetes care in India. Not only can it act as a pressure point, but it can bring into focus the terrible long term consequences of doing nothing, vis a vis the health , socio-economic and personal costs which we shall soon be faced with.

    In the absence of any diabetes care program available in India, the question is often asked that if India does not have it’s own home grown program, why then does it not "import" a program from abroad? There are many countries and regions which have good diabetes related programs and one of these should be used in India. Such imported diabetes care programs will rarely succeed in India. Programs based on the St. Vincent Declaration or the Declaration of the Americas, though excellent in themselves, can only act as beacons and not as the ultimate goals. We must evolve our own program based on ground realities. Based on this and the perceived needs and lacunae in diabetes care, we can then draw up plans for improving the lot of our people with diabetes. Only such a plan will be workable. Else, we will be left with high sounding charters and programs which look impressive on paper, but achieve little, if anything.

    India is a vast and diverse country. This is something which is often forgotten. Not only is India a vast and heavily populated country, but the people who live here are ethnically heterogenous. This heterogeneity is manifested in significantly different religions, communities, castes, cultures, languages ( 18 major languages and more than 200 dialects!), food habits, life styles and in their genetic endowment. It would be true to say that India has more diversity than the whole of Europe and this diversity must be taken into account when planning any program for diabetes care in India. Moreover, the rural-urban divide between the people must also be taken into account. Around 70% of the people live in rural areas and 30% in urban surroundings. There is an ongoing rural to urban shift in the population. Even in the so-called urban milieu, one must consider the differences between those living in major cities and those living in smaller towns. It is rarely appreciated that there is a significant diversity amongst people living in rural, semi-urban and urban areas. Whilst the ultimate goals of a diabetes care program may be the same, the differences and diversity must be taken into account when drawing up specific plans and guidelines, which will be put into effect in order to achieve the objectives of the diabetes care program.

    Economic realities have to be taken into consideration. This includes, both, the finances to make comprehensive and acceptable diabetes care services available to the people, and more importantly, the capacity of the people to afford these services. The Indian government spends around 1.2% of its annual budget on health and as communicable disease prevention and management is still an important aspect of health in India, the money routinely allocated to non communicable diseases, and especially diabetes, is sparse.

    Even if the finances necessary for providing the basic modicum of services is made available, can the average person afford it? To modify what the 1998 Nobel Prize winner in Economics Amartya Sen has said in the context of famines, " the root cause of starvation in famines is not the lack of food, but the capacity of the average person to buy the food", it can be said that the root cause of a failure of a diabetes program is not only the availability of services, but the capacity of the average person to afford these services.

     


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