Difficulties in diabetes care in Africa

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Chronicity of the disease

In general, the problems of the fight against diabetes in Africa are the same as those faced by doctors and health authorities concerning infectious, parasitic or chronic diseases (AIDS, malaria, tuberculosis, etc.) The difficulties include getting an early diagnosis and access to care, the problem of abandonment of the treatment because of the cost of transport and medicines, the lack of qualified personnel and structures, and the often detrimental competition with traditional healers.

To these must be added the chronic nature of the disease, which further complicates the problem, because as Professor Sidibé Assa Traore, an endocrinologist of Bamako, reminds us, “In Africa, we believe that if a disease is treatable, it can be cured. It is very difficult for a patient to accept that he must live with the disease for the rest of his life.”That is why we see many patients stopping their treatment as soon as they feel an improvement in their condition; and we find them again in consultation a few months later with severe complications. The disease’s chronic nature requires lifelong treatment, which creates an ongoing expense for the patient and his family. This makes treatment compliance very difficult in countries where resources are very limited.

Limited diabetes education

Fully understanding what prevention is all about and finding the means to stay healthy at the least possible cost are the fundamental issues for a real diabetes education policy in Africa. But in a context of limited human and financial resources, dominated by infectious diseases, health systems in African countries often put specific investments for non-infectious diseases like cancer or diabetes on the back burner. The lack of resources dedicated to training, the shortage of health professionals, the cost of treatment and appropriate diet and their limited availability, are all major obstacles to effective education in the long term.

The difficulties of a suitable diet

In most African countries, establishing a suitable diet can run into many snags due to the cost of food and its seasonal availability. Some social particularisms can also add to these difficulties. For instance, “large family” meals eaten by hand from a common dish means it is difficult to control the amount of food eaten and for the patient to personalise his diet and food intake. Furthermore, not taking part in the family meal is often seen as social exclusion and is quickly abandoned.

The prestige associated with overweight and obesity, which symbolise social success and good health, is an additional challenge that doctors have to face.

The meal is a crucial moment of the day and people must leave the table feeling satiated to feel satisfied. This often leads to consuming far more food than is needed and people are therefore in a state of overnutrition.   The amount of ingredients that make up the dish highlights the prosperity of the family but also the supposedly modern methods of preparation are another sign of prestige. Thus oil, a major provider of fats, stock cubes and tomato concentrate, major suppliers of salt and sugar, are added to sauces, mashes and drinks in large quantities. These massive additions of oil, salt and sugar, which amounts to over-consumption, are extremely harmful for the population as a whole and all the more so for diabetic patients and people at risk.

Eating habits are directly related to socio-economic status and ethnic and geographical origins. So it is very difficult for a patient to follow a diet that includes food he is not used to eating. This difficulty is accentuated again by the frequent lack of support from family and friends.

Inadequate health systems

Having insulin, syringes and testing equipment is vital, but it is not enough. It must go hand in hand with a health system with trained personnel and adequate facilities. Health systems in sub-Saharan Africa focus predominantly on the treatment of acute diseases and suffer from a serious lack of nearby health stuctures. Patients often have to travel on long distances with a prohibitive cost of transport to get tested and seek treatment. This context of scarcity, combined with the influence of some traditional healers who divert their customers of modern medicine, is the cause of delays or lack of access to diagnosis and treatment and this is very disadvantageous in the case of patients with diabetes.

In Mali, a country with 12 million inhabitants, in 2004, there were only 2 doctors specialized in the management of diabetes, with 2 or 3 health workers who had received a little additional training. This specialized staff only worked in the 3 specialized care units of the country located in the capital. Patients, some living over 500 miles away, had to travel to Bamako and many of them were limited to one annual consultation because of the cost and difficulty of the trip. Moreover, the vast amount of patients for only 3 doctors, resulting in crowded consultations meant that the quality of medical care was not the best. This situation, with a high number of complications and a very high death rate, is not exclusive to Mali. It is the same in most African countries.

Drugs: scarce and too expensive

The absence of health cost reimbursement in African countries and the high cost of drugs (oral diabetes pills and insulin) make it very difficult for patients to get them. For example, in Mali, in 2004, a vial of insulin was worth about 10 Euros in a country where the average monthly wage is around 50 Euros. It is estimated that one year’s supply of insulin for a patient represented nearly 40% of the family’s annual income. Oral diabetes pills, rarely available in their generic form, remained unaffordable for most patients.

In addition to financial difficulties to access treatment and care, there are problems of geographic access. In most African countries, cheap generic drugs are ordered by the central pharmacy and then distributed throughout the territory by decentralized offices.   However, the absence or the small number of diabetes clinics outside large cities makes it extremely difficult to know how many drugs are actually needed. Hence, the underestimated orders and the need to turn to the private sector, which sells these drugs at far higher prices. The supply difficulties outside the specialized structures of the capital also explain the frequently tragic interruptions in patients’ treatment.

Shortage of monitoring equipment needed for diabetes care

Drugs alone are not sufficient. Diabetes requires very regular monitoring. Patients need to regularly monitor their blood pressure, their blood sugar level, but also other biological constants such as their blood lipid level (fat) and the state of their kidneys to follow the evolution of their disease. There again, these tests requiring a blood pressure monitor, a glucometer or laboratory tests means that the equipment should be available but also that patients can afford the tests.

In developed countries, every 3 months patients do a specific measure of mean blood sugar level, called a “glycated haemoglobin” (HbA1c) test. This is the key test as regards diabetes monitoring. In parallel, patients carry out daily measurements of blood glucose thanks to devices that can be used at home. Unfortunately in Africa, we are very far from this ideal monitoring. In fact, laboratory test results are only available in one, perhaps two, private laboratories in the capital, at unaffordable prices for the vast majority of patients.

Fewer than 10% of African patients have the means to measure their blood glucose at home. A glucometer, a device used at home to measure glycaemia, costs over 100 € and the blood glucose test strips cost over 1 € each. Not being able to carry out their analysis at home prevents patients from keeping track of the evolution of their disease. This causes a great number of diabetes-related complications and potentially fatal accidents. Patients particularly at risk are those requiring insulin and who are not able to measure sugar levels in the blood before and after injections. Without this essential data, many African patients just inject an average dose hoping that there has been no significant change in their glucose level compared with their usual level. Finally, this lack of biological monitoring severely delays the detection of possible complications in patients.

High frequency of complications related to diabetes in Africa

In Africa, access to care is often difficult because of the limited public transport network, too expensive for most people, the lack of treatment outside big cities, and the lack of awareness and vigilance by communities and healthcare workers. So the majority of diabetic people only come to health centres when complications have already arisen.   In this context, while the prevalence of Type 2 diabetes is exploding all over Africa, the complications linked to the disease are shooting up as well. These are now the leading cause of blindness and dialysis treatment, and one of the major causes of heart attacks and strokes. They are responsible for 50 to 60% of non-traumatic amputations due to arteries and vessels being affected. These complications are a very heavy economic burden on health systems already hard hit by HIV / AIDS, Tuberculosis and Malaria.

Mortality associated with diabetes

Very few studies have followed diabetic patients from sub-Saharan Africa over a long period and in a structured way. What we see today is the high death rate among diabetics in this region, following chronic complications. The reported mortality rate associated with diabetic ketoacidosis is 25% in Tanzania and 33% in Kenya. A statistical study from 1995 in South Africa found a mortality rate of 44% following a hyperosmolar nonketotic coma. This complication affects primarily elderly patients, often suffering from other related conditions, which explains the very high mortality rate.

In Africa, insulin-dependent patients requiring vital and obligatory insulin treatment, including all Type 1 diabetic children, have a staggering mortality rate. This high death rate, especially among children, is often due to a lack of diagnosis or misdiagnosis, the non-availability of insulin or its prohibitive price. A study conducted at the University Hospital of Bamako, between 1990 and 1998, with 20 Type 1 diabetic children, showed that after 8 years, half of them had died. In Tanzania, a 5-year study of insulin-dependent diabetics showed a similar result with a mortality rate of 40%.

Specific problems of children with Type 1 diabetes

Type 1 diabetes is one of the most frequent chronic diseases affecting children and is a major public health challenge. In developing countries, the burden of the disease is very heavy but due to the lack of epidemiological data, its natural history and complications remain largely ignored.

The incidence of Type 1 diabetes is high in Africa and is constantly increasing. An incidence of 1.5 / 100,000 was found in Tanzania in 1993. In Sudan, it increased from 9.5 / 100,000 to 10.3 / 100,000 in the six years from 1991 to 1997, which means that the potential annual diagnostic of new cases, in this country, rose from 3,900 children to 4,350. Extrapolated to the situation in Mali, the annual diabetes incidence figures for Tanzania and Sudan indicate that there should be between 180 and 1200 cases of Type 1 diabetes diagnosed each year in Mali. It is easy to see the huge difference with the very low numbers of patients actually dealt with.

The explanation for this difference is as simple as it is tragic. The life expectancy of a child diagnosed with Type 1diabetes in most African countries is no longer than a year. This situation is due to a large number of interrelated factors. The shortage of health care personnel capable of diagnosing and treating diabetes increases the risk of misdiagnosis. Once the diagnosis confirmed, the problem is the lack of available monitoring equipment, the scarcity and high cost of insulin, the absence of refrigerators for storing insulin, and a health care system which is by and large deficient in managing chronic diseases.   In sub-Saharan Africa, most of the children who suffer from Type 1 diabetes are actually diagnosed when they go into a “ketoacidotic coma”. However, this can easily be confused with neuro-malaria, pneumocystis pneumonia, gastro-enteritis, denutrition or even meningitis. The risk of death through coma is all the greater as it occurs mostly in children under five years old.   All these factors, together with the competing demands on poor families in Africa who also have to pay for food, rent, and school fees etc., result in bleak chances of survival for a large majority of children with Type 1 diabetes.

In a family setting of perhaps 5 children, one of whom suffers from a costly, chronic and life-threatening condition, parents are faced with a very painful choice. To treat that one child would be at the expense of schooling for the rest of the children and perhaps even daily food for the entire family.

Role of traditional medicine

The World Health Organization (WHO) estimates that in Africa more than 80% of the population uses traditional medicine. Mali and Tanzania are no exception. This is why it is generally agreed that the development of modern medicine in Africa must take into account the presence of this traditional knowledge, which juxtaposes treatment with representations of misfortune and disease. We can make the distinction between methods of treatment stemming from family knowledge, handed down from generation to generation, and methods of treatment employed by traditional healers. Some traditional healers only use their knowledge of plants, others add witchcraft or geomancy, and others again use elements learned from modern medicine.

There are many problems linked with the use of traditional medicine in chronic diseases like diabetes. Certain traditional healers boldly claim to be specialists and promise patients that they can cure them. This has the dangerous and perverse effect of attracting a great number of patients who are put off by modern medicine declaring that the disease will stay with them for the rest of their lives.

Last update: 13/06/11