The global diabetes epidemic is continuing to grow, especially in developing countries. According to the data provided by the International Diabetes Federation (IDF) and World Health Organization (WHO), there are over 400 million diabetics worldwide, including over 77% in low- and middle-income countries.
By 2030, there will be 600 million of them, including over 42 million in Africa. In Sub-Saharan Africa, in addition to the explosive growth in the number of patients, the disease already accounts for some 9% of deaths, with a number of disabling complications: cardiovascular diseases, kidney failure, diabetic coma. The disease is the main cause of blindness and accounts for over 50% of non-traumatic amputations.
Diabetes has become a global scourge
Although diabetes used to be considered as a disease affecting rich countries, it has now become a global scourge.
This epidemiological transition has been caused by profound changes in lifestyles around the world, with rampant urbanization, a rapid nutritional transition, as well as the increase in sedentary behavior. These changes foster the increase in a number of risk factors for diabetes, high blood pressure and certain types of cancer.
In West Africa, it is estimated that more than 21% of the over 20s are overweight or obese and that a fifth of the over 15s in the subregion are sedentary. Comparable data has been collected in East Africa, the Indian Ocean and the Union of the Comoros.
These figures contrast sharply with the persistent image of an undernourished continent. Indeed, while undernutrition continues to be a major problem in Africa, undernutrition (malnutrition and deficiencies) now coexists there with overnutrition (overweight and obesity). This “dual nutritional burden” is still too often overlooked by international aid actors and is taken into account very little within national health systems.
Epidemic holds back development
The financial cost of the care related to diabetes management for individuals and States, combined with the high level of mortality from diabetes in Africa, is a clear obstacle to the achievement of the new Sustainable Development Goals (SDGs). This especially holds true because the link between chronic disease and economic growth has now been proven.
Some studies even agree that a 10% increase in the prevalence of chronic diseases leads to a 0.5% decline in the annual growth rate. In addition to this, and unlike what is seen in developed countries, in Africa diabetes primarily affects working-age people.
A study conducted in Benin in 2012 shows that 80% of people with diabetes in the country are part of the age group of active workers. The deaths and disabilities that the disease causes among working-age patients have devastating consequences, not only for households, but also for the country’s economy, and therefore on the development capacity of States.
Cost of chronic diseases
Health financing is one of the major challenges faced with the emergence of Non-Communicable Diseases (NCDs). The effectiveness of cost-recovery policies in Africa is gradually being called into question via several studies, which highlight that totally free access to healthcare, unlike recovery, would increase attendance and quality for healthcare.
Yet a number of these studies are based on models which use acute diseases requiring an inexpensive treatment, like malaria (for which the treatment is often less than EUR 3 per attack).
These economic models of free care financed by one or several donors do not stand up when the economy of chronic diseases is introduced. Their costs, and particularly for diabetes, require devising health financing policies in a completely different way.
In this context, the development of integrated social protection systems, such as the one set up in Mali with compulsory medical assistance, appears as an alternative for financing due to their capacity to bear 75 to 80% of the costs associated with both the chronic disease and its complications. This is an alternative which could be extended to non-salaried people in Mali via Universal Health Cover (UHC).
Diabetes and cardiovascular diseases kill more than AIDS
In Africa, diabetes and cardiovascular diseases cause more deaths than HIV/AIDS. While billions of dollars have been invested in the fight against HIV/AIDs over the past 15 years, these massive and targeted investments have only strengthened certain health sector systems, when they have not further destabilised them.
By comparison, even today, very few technical and financial partners of international aid have a real strategy to support NCD prevention and management programmes.
AFD is working towards this in the Comoros, Burkina Faso, Mali and Senegal, in collaboration with the national authorities, in particular thanks to the support from the NGO Santé Diabète.
In this respect, the emergence of diabetes provides an opportunity to rethink an inclusive organization of more horizontal care, as it is necessarily multisectoral. A diabetic does not only need care just to manage his diabetes, but he also needs it for all the complications of the disease, which are very frequent, or to manage the related diseases.
For example, high blood pressure affects 60% of diabetic patients, neuropathy 40% and nephropathy 15% of patients. Care must therefore be integrated throughout the health pyramid in order to ensure there is an optimal management between the different specialties. Consequently, through a concerted and ambitious policy to fight against diabetes, the entire health system is strengthened at all levels and not just one part.
Scourge of gestational diabetes
The alarming increase in diabetes is gradually calling into question the indicators related to maternal and child health in the specific, yet frequent, case of gestational diabetes. Today, it affects one pregnancy in 25, but is constantly increasing.
If it is not diagnosed and controlled, it can lead to risks of fatal complications for the woman and child. Women with gestational diabetes in particular have a high risk of developing type 2 diabetes in the years following the pregnancy.
It should also be noted that children born to mothers who have developed gestational diabetes have a higher prevalence of obesity during their first years.
The Lancet series “Women and Health: the key for sustainable development” stresses that in Africa, very few bilateral or multilateral maternal health programmes include gestational diabetes screening and management, despite its consequences on the health of the mother and child.
Between undernutrition and overnutrition
Finally, in Africa we are seeing an extremely rapid nutritional transition, which is often combined with a sharp decline in physical activity.
These changes in lifestyles have led to a radical alteration to the landscape of malnutrition in developing countries. With undernutrition still sometimes endemic, many countries must today address the increasingly problematic issue of overnutrition.
This phenomenon primarily affects cities, where one woman in four and one man in six are overweight or obese, irrespective of social class. Yet the national nutrition policies of Sub-Saharan African countries and strategies of international donors all too often only focus on undernutrition and very little on these new overnutrition issues.
Children the first victims
In addition to this dual nutritional burden, there is the now proven “Barker” hypothesis, which highlights the weight of the neonatal nutritional environment (and during early childhood) on a child’s propensity to develop non-communicable diseases in adulthood. Indeed, depending on its plasticity, the human body adapts to its environment during growth.
Consequently, a baby exposed to malnutrition, even moderate, during its intrauterine life or early childhood, will tend to adapt to this shortage, but at the expense of a greater vulnerability to NCDs in the longer term, especially if the environment is conducive to a diet and lifestyle that foster overweight and obesity.
Lack of awareness of this biological phenomenon means there is a real time bomb, especially in Africa.
Need for an ambitious and innovative international response
Despite small signs of renewed awareness among the international community on the issue of NCDs, such as several resolutions and positions taken by the United Nations and the new post-2015 development plan in which a Development Goal is specifically devoted to it, diabetes often continues to be overlooked by development assistance actors in the health sector.
The fight against diabetes in developing countries is today insufficient in view of the disastrous consequences of the disease for populations, health systems, States and their development.
The pressing need to take diabetes into account and build an effective international response is especially important since the issue is complex and raises a number of critical challenges, both for international development policies and for the health systems which are directly affected.
Faced with the increasing incidence of diabetes in Africa, there is an urgent need to build a considered and ambitious response, including and mobilising numerous technical and financial partners and public authorities in the countries that are directly concerned. Otherwise, diabetes and all the NCDs will place an ever-greater strain on the living conditions of the populations of the most fragile States and on their capacity to build a quality health system.