“Tip of the iceberg”

Diabetes is spreading in many parts of the developing world. In Malawi and other sub-Saharan countries, patients have to cope in difficult circumstances. Diabetes often goes undiagnosed, which raises patients’ risks of growing blind or losing a limb – if they survive at all. Theresa Allain of the College of Medicine and the Queen Elizabeth Central Hospital (QECH) in Blantyre, Malawi, discussed the issues with Eleonore von Bothmer.

How many people in Malawi are suffering from diabetes?
We only have a rough idea. The WHO conducted the “STEPS-survey for Malawi”. They went out into the communities and took blood-sugar levels of 5,206 adults aged from 25 to 64. The result was that 5.6 % had raised blood glucose levels. That doesn’t prove they have diabetes, but it is very likely. These results are consistent with results found in other countries. Five per cent is a huge number! It means that in the Greater Blantyre area with one million inhabitants, half of whom are adults, there must be around 25,000 diabetics. At the moment, only around 2,000 patients are registered at our clinic, so we are only seeing a tiny tip of the iceberg.

What about the other patients?
Most of them haven’t been diagnosed yet. The symptoms of diabetes can be quite subtle – people, for example, may just feel tired, without realising that there is something very much wrong with them. When the blood-sugar level rises, people start to have more obvious symptoms like frequent urination and thirst. This is when they come and seek medical help. A rough estimate is that patients who are diagnosed with type 2 diabetes had high sugar levels for four years before the diagnosis was made. This is nothing particular to Malawi, things are similar in other countries. We see patients who are already suffering from serious complications like retinopathy when they are first diagnosed. So they must have had high sugar levels for at least four or five years.

Is there any difference between rural and urban people?
One should think diabetes would be more common in urban areas because this is where people are getting fatter and doing less exercise. But the STEPS-survey showed that there is no difference. I guess that, if you take equivalent countries of the region with similar health issues – excluding South Africa –, this situation is the same.

What is the life expectancy of a diabetic in Malawi?
I don’t have exact figures. But for sure it will reduce your life expectancy because of the complications. Most diabetics should be able to lead a normal life once the sugar is under control – which means taking proper medication. The better the sugar and hypertension control, the fewer the complications.

Some figures imply that a child diagnosed with type 1 diabetes in Africa has a life-expectancy of a few months to seven years.
Children are less likely to go undiagnosed because the symptoms of their diabetes are very obvious. So children with diabetes usually come for medical treatment quickly. These days, with adequate insulin treatment we would hope that our children with diabetes will live much longer than you suggest.

Why are diabetes rates rising in Malawi?
There are two main factors:
– First, the so called life-style-transition; the transition from subsistence farming to urban dwelling and change of habits, particularly associated with obesity.
– Second, the population of Malawi is ageing and most diabetes starts in the middle age.
In countries like Malawi, our main health challenge has been to control HIV/AIDS, TB, malaria and malnutrition. But those battles are being won and those adults that neither have HIV nor suffer from malnutrition are living longer thanks to better health care. Most of our patients are type 2 diabetics. The average age of the patients at our clinic is 55 years, and more and more people survive beyond that age. Again, this probably reflects international trends.

What is special about developing countries?
There is one very serious concern. The epidemic is likely to become worse in Africa than it is in Europe and America. If you are born with a low birth-weight, you are at a higher risk of becoming a diabetic later in life. In Malawi, a lot of children are born with low birth-weights, and this may well be the reason why rural areas are just as affected as urban areas.

When did people get aware of the fact that diabetes is such a big issue?
The diabetes clinic in Blantyre has been here for more than ten years. I only joined the college of medicine and began working at QECH in 2007; from then on we started to improve diabetes care at QECH and hopefully diabetes care will improve in the whole country.

How do you do to improve things?
We applied to the World Diabetes Foundation (WDF) for grants in 2008, which we received at the end of 2008. They also support the district hospitals, so there was training for their staff too. We cooperate very well with the WDF.

How many diabetes-patients are attending the QECH?
We only started to register in 2008. Some of them are not with us any more – some might have died or moved away – but we have 2,000 plus registered patients. We are registering around 20 new people a week. This huge increase is really shocking for us. Also, these people stay as our patients for a long time. Diabetes is not a disease which can be cured, they keep coming back.

How do hospitals in the rural districts get along?
The district hospitals in the region are in different stages of development. Some are running a diabetes clinic, some are tackling diabetes and hypertension, and some are just general clinics. We are trying to improve the situation, so that they will offer a diabetes clinic at least once a month, so all patients could come at the same time, which makes it easier for the staff to deal with their problems.

What are the main challenges?
Medical staff have to be very systematic with diabetes. A lot is about screening for foot or eye diseases, for example. And that will only work effectively if things are well organised.

How much does the treatment cost?
It varies. There is an ideal medication, which would be very expensive and would include pharmaceuticals to lower cholesterol levels, for example. Our patients are not on an ideal cocktail. We rely on a second best, compromise cocktail that we can afford. We would like to improve it, of course. There is a drug called Metformin, which is excellent for type 2 diabetes but its availability is very limited.

The government never anticipated the extent of the diabetes epidemic, so the procurement price is lagging behind. I really do hope that in the next two years, Metformin will be much more available to many more patients. The irony is that the prices come down when a drug is used more often. At the moment Metformin is still very expensive because it is not being used widely.

Who pays for medication?
The Ministry of Health does. All these clinics – QECH and the district hospitals – are government-run. All medical care in Malawi is free, except for the tiny private sector. The WDF is putting in some funds to help to get us organised and more systematic. But the drugs are being paid for by the ministry.

Why wasn’t the spread of diabetes anticipated – was there no awareness of the issue?
Well, yes, there is more awareness now. But it depends. I was in Zimbabwe from 1994 to 1996. We found more or less the same trends there as in the Malawi STEPS-survey, except that the rural rate was very low – two per cent or even less – and the urban was about eight per cent. But that was 15 years ago. So the information was out there. Some people would say that Zimbabwe was more developed than Malawi – certainly so, at that time – so they were ahead of us in the epidemic. I think, what we are seeing here was predictable. However, while many diseases have to be recorded and reported to the Ministry of Health – which is extremely necessary for HIV/AIDS and TB – diabetes was never reported separately. So even though this epidemic was creeping on it did not get much attention.

What does the WDF do?
They have a huge interest to ensure that all diabetics receive the best care possible, and complications are prevented. The priorities of the WDF match our own priorities.
– One is to prevent blindness by putting in place systems for diabetic patients to have regular eye checks, so they’ll get early treatment. The earlier the treatment starts, the easier it is to save their eyesight.
– Another is to try to improve the treatment of diabetes patients’ foot-care. Diabetes can lead to amputations because of foot sores, which is largely preventable by early screening for neuropathy cases, and also by the proper management of sores if they develop. This is the same worldwide: Even in England, diabetics come far too late with foot problems.
– A third priority is to try to identify gestational diabetes. If a woman develops gestational diabetes or if she already has diabetes and doesn’t know about it while she is pregnant, there is a worse outcome to the mother and the baby, they might even die. If gestational diabetes is diagnosed and treated, this can prevent maternal and neonatal mortality, thus helping Malawi come closer to achieving the UN Millennium Development Goals (MDGs).

Questions by Eleonore von Bothmer.

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