Introduction Diabetes mellitus (DM) is a disorder

 

Introduction

Diabetes mellitus (DM) is a disorder of the endocrine
system, occurring as a result of the pancreas’ inability to produce insulin
(Type 1), or the body’s capability to respond to insulin and/or impaired
insulin production (Type 2). Poor regulation of blood glucose levels can lead
to hyperglycaemia (high blood glucose), with early symptoms commonly presenting
as increased thirst, hunger, urination, as well as blurred vision. Long term
complications may manifest through vascular disease, impaired kidney function, optic
and nerve damage, limb amputations as well as an increased susceptibility to
infection.  Heart disease remains to be
the leading cause of mortality in DM1.

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TIDM is caused by autoimmune destruction of pancreatic beta
cells responsible for insulin secretion, whereas TIIDM is thought to have a
number of risk factors, such as age, obesity, lack of exercise, as well as
genetic predisposition.

There is currently no known cure for DM, and so management
of the condition normally consists of a lifelong combination of dietary
measures, exercise, as well as drugs which help to regulate blood glucose
levels. This includes the injectable administration of insulin, and/or the use
of oral medication which help to improve blood glucose regulation.

Diabetes was once thought of as a condition which only
afflicted the affluent; however an increasing body of literature seems to suggest
that this is no longer the case35.

 

 

Global Burden

It is estimated that in 2014, there were around 422 million
people living with diabetes, with 1.5 million deaths occurring in 2012 as a
result of diabetes. An additional 2.2 million deaths have been attributed
cardiovascular disease, chronic kidney disease and tuberculosis related
higher-than optimal blood glucose levels. Over the past decade, diabetes prevalence has risen
faster in low- and middle-income countries than in high-income countries, with
no less than three-quarters of diabetics now living in these regions26.
The WHO’s Eastern Mediterranean region currently bears the greatest prevalence
of diabetes2.

 

 

 

 

 

 

 

 

 

 

 

 

 

This essay hopes to evaluate how factors such as access to
quality health care, socio-economic development, as well as migration affect
the burden of type 2 diabetes mellitus (as this type accounts for around 90-95%
of diabetic cases globally40), using research already undertaken in
regions with relatively high prevalence rates, so as to inform policy making
for nations where the burden is increasing, such as in Africa.

The infrastructure of healthcare systems across Africa
varies substantially, with many countries lacking adequate structural
capability to effectively respond to the increasing burden of non-communicable
diseases. This is resulting from a combination of vertical and/or ear-marked
funding for certain diseases by external donors, as well as decisions to allocate
funding and recourses already available towards the management of acute
conditions and infections.

With vascular disease already being a leading cause of
mortality worldwide31, it would be useful to take into consideration
management strategies for diabetes, which could help to also reduce the global
burden cardiovascular disease.

A number of studies have also identified diabetes as
increasing the risk of developing active tuberculososis30. The
global burden of diabetes is also important to consider then in the global
fight against tuberculosis.

Diabetes can also present a heavy burden economically, via direct costs to service users’ pockets, to health
systems and society, in addition to indirect costs attributable to premature
mortality, temporary disability and permanent disability attributable to
secondary complications arising from the condition39.

Access to Quality Healthcare

Definitions of ‘access to
health services’ are variable ranging from the narrow focus approach of service
entry to the multidimensional approach, which includes: availability,
acceptability, affordability, and accommodation4. The
delivery of effective therapy in relation to diabetes management requires
several components; continuity of care, uninterrupted access to medicines and syringes, tools for diagnosis and follow-up,
availability of trained healthcare workers, government policies and the role of
diabetes associations10.

Limited access to healthcare can present a number of
challenges to the management of diabetes, such as case detection and treatment
delivery. Early case detection, for example can help to prevent the onset of
long term complications arising from diabetes. Individuals with undiagnosed
TIIDM can remain so for years, and are considered be at significantly higher
risk of cardiovascular disease than individuals without; failure then in making
a diagnosis could restrict one’s access to treatment potentially resulting in
death3. It is estimated that globally, around 45.8% of all diabetes cases in adults are
estimated to be undiagnosed11.

More than 80% of deaths from diabetes are currently
occurring in developing countries, where access to proper healthcare and
financial means are an implicating factor9.

In addition to poor access to affordable insulin, diabetics
in low and middle income countries can face wide price variations resulting
from the complexity of supply chains, location of purchase, as well as the
manner by which it is purchased. For example, the price of insulin from a
single producer can vary from US$9 in Zimbabwe to over US$44 in the Congo 9.
Affordable access to measurement tools which can be used in assessing long term
glycaemic control, such as glycosylated haemoglobin concentrations (Hb1Ac)
may also affect the quality of care that can be delivered by healthcare
professionals32.

The undersupply, as well as oversupply of medication can
also be associated with poor outcomes in health. In a study conducted by Chen
and colleagues12, only around 50% of diabetes patients followed up
post-initial diagnosis, were receiving an appropriate supply of medication. The
same study also identified that oversupply of medication could result in
increased disease-related hospitalisations and emergency department visits, as
well as an increased burden of cost. Undersupply of medication was also found
to increase disease related hospitalisation but for different reasons.

 Even when governments
provide anti-diabetic medication free of charge for economically disadvantaged
groups, in practice, many eligible patients do not have access to these schemes19.

A systematic review by Paduch et al.20 identified
a number of pyscho-social barriers to healthcare use for individuals suffering
from diabetes. These ranged from cultural beliefs that men should not care
about their health, a preference for traditional healers21, and
religious beliefs which may predispose individuals to fatalistic attitudes. The
decision to not pursue treatment, or opt for a therapy which may not provide
adequate glycaemic control could then lead to deterioration in health.

One may initially consider the lack of refrigeration
facilities to affect access to insulin which has not been affected by
temperature (as this is normally kept in refrigeration). However, recent
discussions have identified solutions to overcome this potential obstacle to
delivering quality care41.

Migration

Migration may occur for
various reasons: For voluntary migrants the desire or need to leave the country
of origin may be stronger than the desire to stay, and/or the receiving country
is in need of the type and class of labor that the migrants have to offer29,
whereas involuntary migration can occur due to displacement resulting from war,
persecution, or natural disasters.

Globally, the total number of
migrants in 2015 exceeded 244 million and is not expected to reduce5,
with healthcare systems in upper-middle and high income countries facing
significant challenges in providing equitable, accessible and culturally
competent healthcare for growing ethnic minority groups4.

The
relation between migration status and disease pattern is complex due to
potential underlying factors related to their country of origin, their new host
country, and possibly also by the migration process itself6.

 

Figure
X highlights the various factors which may act as determinants towards
developing TIIDM17, as a result of migration.

The World Health Organisation
has identified migrant and refugee populations with non-communicable diseases
to be at greater vulnerability of adverse events related to their condition.
Forced displacement could result in disruption to the continuity of access to
health and medication, loss of prescriptions, as well as irregular food
supplies. Such circumstances could help to deteriorate the condition of
individuals already suffering from diabetes.

The legal, or documented status of a migrant, is one of
the most important determinants of the access of migrants to health services in
a country16, where non-documented
status may also result in the underutilisation of healthcare services33.

A number of studies have
identified migrant populations to have a greater prevalence of TIIDM in
comparison to their host populations22, 23. Migrants may also be at
greater risk of developing TIIDM in relation to their native counterparts; migrant Asian Indians living in the UK were
found to be more obese, to have higher blood pressure, total cholesterol, and
blood glucose levels, and to be more insulin-resistant than their non-migrant
siblings living in India31.

Cultural and language
barriers may also impair the capabilities of migrant populations to seek
healthcare, or effectively utilise services where and when accessed. Lack of
education regarding diabetes, poor understanding of host population health
systems, and well as mistrust of healthcare professionals may also have a
negative impact on undertaking preventative measures, service access, and
treatment adherence18.

The process of acculturation,
which often occurs alongside migration, can result in changes to dietary habits
of migrants which may increase their risk of developing TIIDM. One trend which
has been observed is an increased fat and overall energy intake, with a
reduction in carbohydrates, as well as a switch from whole grains and pulses to
more refined forms of carbohydrates27, 28.

Migration may also occur
domestically from rural to urban environments; the changes in lifestyle that
this may bring may also be associated with an increased prevalence in TIIDM34.
Rural migrants may also be less likely to access healthcare services (or
experience greater difficulty in doing so) compared to their urban counterparts36.

 

 

Socio-economic development

 Certain
risk factors implicated in the development of diabetes are also known to be
associated with socioeconomic status (SES). Obesity, physical inactivity,
smoking, and low birth weight have all been described as risk factors for
TIIDM. In Western societies these factors have often been associated with low
socioeconomic status15. De
Silva and colleagues have also acknowledged that in high income
countries, prevalence, poor management and complications of diabetes exhibit a
social gradient, with higher proportions observed among lower socioeconomic
groups37.

 Interestingly, in many
developing and transitional countries, diabetes prevalence increases with SES
whereas the reverse is true in developed nations22.

Around
two thirds of diabetes patients live in urbanised areas, with those in the
lower socio-economic classes being disproportionally affected. The reasons for
this are still poorly understood, but unhealthier lifestyles may be considered
as a contributing factor7.

A
study conducted in Spain found that the prevalence of
TIIDM in individuals with lower SES was reported as 2.17 times as much as other
individuals, with the prevalence of obesity, sedentary lifestyle, and abnormal
blood lipid concentrations also being found to be higher in TIIDM patients of a
lower socio-economic status8.

The global rise in obesity has also been paralleled with an
increase in the prevalence of TIIDM14. With obesity often
disproportionately affecting lower socio-economic classes, it is also important
then to consider the impact of obesity and its role in the development of
TIIDM.  Obesity can be caused by a number
of factors, such as a high energy-dense diet, consuming highly processed foods
(often having high sugar and fat content), as well as lack of physical activity.
The SES of an individual may exert an influence in propagating these risk
factors. An individual of lower SES may have less income available in order to
source healthy foods at an affordable cost, or live in an area where there is a
high concentration of fast food outlets, where fiscally cheap, nutrient poor
foodstuffs are commonplace44. Living in such an environment could
incline the individual regularly consume such foods, thereby increasing their
risk of developing obesity, and potentially TIIDM as a consequence of such
lifestyle choices.

In many countries diabetes may demand a large financial
burden on the individual and their families, leading households into poverty.
For example in Sudan the total median cost for diabetes care was US$283, of
which one third was spent on insulin 13. 37.9% of Ugandan diabetes
patients also resorted to missing and omitting medication due to not being able
to afford it 19.

Increased SES may also help to improve access to medicines;
Christiani and colleagues19 found high income groups in a region of
rural southwestern China were more likely to be treated with any anti-diabetic
medication, than those of a lower income group. Tao and co-workers on the other
hand, found decreased SES being associated with poor metabolic control, as well
as a greater incidence of diabetes-related complications38.

 

 

 

Global Health Actors

There are a number of global
health actors currently working towards combatting the growing global diabetes
epidemic:

Pharmaceutical Industry

With medication being an
integral component to the management of diabetes post-onset, the diabetes
epidemic would naturally be of concern to the pharmaceutical industry for a
number of reasons.

Novo Nordisk is a pharmaceutical company
of Danish origins, having a historical base in insulin manufacture, and
currently provides around a half of the world’s insulin24. The
company currently outlines a number of commitments in their ‘Access to Health’
approach 25, with a focus on improving  accessibility, affordability, availability to
insulin therapy in resource poor settings, as well as advocating equal rights
and accessibility to healthcare.

Sanofi,
another leading pharmaceutical company in the field of diabetes, currently
supports a wide of programs globally which involve engaging with civil society
organisations26. The focus of these programs vary according to the
needs of the populations where they are being conducted, however the majority
of these initiatives place emphasis on education and promotion of prevention
strategies for the condition. It has also undertaken partnerships with other
pharmaceutical companies in order to further development of novel
oral-anti-diabetic agents.

 

World Health
Organisation

 The contributions of
WHO towards tackling the global diabetes epidemic is mainly focused on
advocacy, as well as the provision of technical guidance.

WHO published its very first report on the global burden of
diabetes in 20162, where it identified a number of measures which
can be implemented by governments in order to address the epidemic, calling on
other arms of governance such as trade and agriculture to consider the impact
their policies will have on health.

Access to essential medicines such as insulin, lipid
modifying, anti-hypertensive, and anti-diabetic medication have also been
recognised to not always be readily available in low and middle-income
countries, as well as the availability of basis diagnostic tools to facilitate
early case detection.

The WHO also operates a program specifically dedicated to the
promotion of health of migrant populations42. A resolution was
passed on the 29th May 2017, urging member states to consider the
promotion of a framework containing priorities and guiding principles in order
to promote the health of refugees and migrants.

The WHO Essential Medicines and
Health Products (EMP) Department works with countries to promote affordable
access to quality, safe and effective medicines, vaccines, diagnostics and
other medical devices. Built on three main pillars – access, innovation and
regulation – EMP promotes policies and technical capacities in low-resourced
health systems, develops international standards for the manufacturing and
regulation of health products and provides guidance for health systems
everywhere to deliver them safely and cost-effectively45.

 

Non-State Actors

There are also a number of non-state actors which are
involved in dealing with diabetes.

The International
Diabetes Federation (IDF) is an umbrella organization of over 230 national
diabetes associations in 170 countries and territories27. Much of
their work involves advocacy, as well as conducting research, the compilation
of evidence based guidelines and epidemiological studies (allowing for the
publication of resources such as the IDF Diabetes Atlas), with an aim to
facilitate policy making and care delivery. 
The IDF also conducted a report in 2016 on the perspective of people and
healthcare professionals on the access to medicines and supplies for people
with diabetes.

The International
Insulin Foundation (IFF) is an organisation which conducts activities which
are specific to improving access to insulin for populations that require
it.  The IIF has developed tools to
assess access, such as the RAPIA (Rapid Assessment Protocol for Insulin Access)
46, as well as undertake research collaborations with other
organisations so as to inform key-stakeholders in low and middle-income
countries.

The World Diabetes
Foundation is an organisation whose work focuses on reach the poorest
populations suffering from diabetes globally. Their activities can be divided
into three main categories; improving access to diabetes care, promoting
primary prevention and awareness, as well as advocacy. Projects are undertaken
around the world in under a ‘focus area’, of which include tackling TIIDM
through various measure such as improving care access, as well as the double
burden of diabetes and tuberculosis47

 

National Governments

Governments around the world have undertaken a wide range of
approaches to contributory social security schemes, employer-based health
insurance and tax-based schemes to improve migrants’ health and access to
health services. For example, some countries of migrant origin that heavily
rely on remittances, such as Sri Lanka and the Philippines, put in place
insurance schemes for their overseas migrant workers. Countries of migrant
destination, including Thailand, offer health services to certain categories of
registered migrants and their families through a compulsory migrant health
scheme. Brazil, Spain and Portugal are examples of countries that have adopted
a policy of equal access to coverage for all migrants irrespective of their
legal status. Other initiatives are led by trade unions and employees. For
instance, in Argentina, employers of rural migrant workers contribute a
percentage of their workers’ salaries towards a special fund that covers social
benefits, including health insurance43.

Although these interventions may not be inherently directed
towards tackling diabetes, measures such as what has been outlined above would
help to improve access to health services in general.

Some governments have
taken an approach to policy making which considers its impact on health, such
as in Australia. South
Australia has implemented a health-in-all-policies approach, which emphasises
that government objectives for a healthy population are best achieved when all
sectors include health and wellbeing as a key component of policy development44.

 

 

 

 

Conclusion and
Recommendations

 

The increasing global burden of diabetes is something which has
only been recently acknowledged by the World Health Organisation. However, due
to the numerous long term complications that can arise from poor diabetes
management, both in terms of financial cost and health, diabetes is a condition
which should be taken with serious consideration.

 

Much work is being done to improve access to diabetes care
around the world, especially by non-state actors, but national governments must
also take responsibility in ensuring that adequate care can reach populations
in need. National governments can also play an important role in shaping policy
in such a way that always prioritises the health of its population, as well as
improve the socio-economic status of its citizens. Addressing other health
epidemics such as obesity through the use of frameworks such as the World
Cancer Research Fund International’s NOURISHING framework44 may help
to alleviate the future burden of diabetes

 

The delivery care of migrant populations may prove to be a
challenge for several reasons, be that due to language or cultural barriers, of
their temporary status, but one may consider from an ethical perspective that
quality care should be provided as a moral duty, especially if the same level
can be easily delivered to its own citizens.