Starvation in the midst of Plenty: The Cost of Diabetes (II)

A few years ago, a young boy was rushed into the emergency room unconscious. He had been complaining about feeling weak a few days prior to his collapse. The parents were very worried as he was their only child. Emergency room staff immediately followed protocol and checked his vital signs along with preliminary investigations. Only one […]

A few years ago, a young boy was rushed into the emergency room unconscious. He had been complaining about feeling weak a few days prior to his collapse. The parents were very worried as he was their only child. Emergency room staff immediately followed protocol and checked his vital signs along with preliminary investigations. Only one thing stood out: His random blood glucose levels was 24.6mmol/l.

We immediately started hydration and insulin and before long the ten-year-old had regained consciousness. His mother cried from relief and refused to leave her son’s side. Over the next few days and after many tests, the parents were counselled about his diagnosis: Type 1 diabetes mellitus. The parents appeared to be very accommodating of their son’s condition, that is, until they were told that he would be on Insulin for life. This time it was the father who broke down crying. The idea that his son would be taught to inject himself on his abdomen or thigh was too much for him to handle.

To calm him down and to let him know how far we have come, I told him a story.

Before insulin was discovered in 1921, people with diabetes didn’t live long as there wasn’t much doctors could do for them. The most effective treatment was to put patients with diabetes on very strict diets with minimal carbohydrate intake. This could buy patients a few extra years but ultimately couldn’t save them. Harsh diets (some prescribed as little as 450 calories a day!) sometimes even caused patients to die of starvation.

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In 1889, two German researchers, Oskar Minkowski and Joseph von Mering, found that when the pancreas gland was removed from dogs, the animals developed symptoms of diabetes and died soon afterward. This led to the idea that the pancreas was the site where “pancreatic substances” (insulin) were produced.

Later experimenters narrowed this search to the islets of Langerhans (a fancy name for clusters of specialized cells in the pancreas). In 1910, Sir Edward Albert Sharpey-Shafer suggested only one chemical was missing from the pancreas in people with diabetes. He decided to call this chemical insulin, which comes for the Latin word insula, meaning “island.”

What happened next? Something truly miraculous. In 1921, a young surgeon named Frederick Banting and his assistant Charles Best figured out how to remove insulin from a dog’s pancreas. Skeptical colleagues said the stuff looked like “thick brown muck,” but little did they know this would lead to life and hope for millions of people with diabetes.

With this murky concoction, Banting and Best kept another dog with severe diabetes alive for 70 days—the dog died only when there was no more extract. With this success, the researchers, along with the help of colleagues J.B. Collip and John Macleod, went a step further. A more refined and pure form of insulin was developed, this time from the pancreases of cattle.

In January 1922, Leonard Thompson, a 14-year-old boy dying from diabetes in a Toronto hospital, became the first person to receive an injection of insulin. Within 24 hours, Leonard’s dangerously high blood glucose levels dropped to near-normal levels.

The news about insulin spread around the world like wildfire. In 1923, Banting and Macleod received the Nobel Prize in Medicine, which they shared with Best and Collip. Thank you, diabetes researchers!

Soon after, the medical firm Eli Lilly started large-scale production of insulin. It wasn’t long before there was enough insulin to supply the entire North American continent. In the decades to follow, manufacturers developed a variety of slower-acting insulins, the first introduced by Novo Nordisk Pharmaceuticals, Inc., in 1936.

Insulin from cattle and pigs was used for many years to treat diabetes and saved millions of lives, but it wasn’t perfect, as it caused allergic reactions in many patients. The first genetically engineered, synthetic “human” insulin was produced in 1978 using E. coli bacteria to produce the insulin. Eli Lilly went on in 1982 to sell the first commercially available biosynthetic human insulin under the brand name Humulin.

Insulin now comes in many forms, from regular human insulin identical to what the body produces on its own, to ultra-rapid and ultra-long-acting insulins. Thanks to decades of research, people with diabetes can choose from a variety of formulas and ways to take their insulin based on their personal needs and lifestyles. From Humalog to Novolog and insulin pens to pumps, insulin has come a long way. It may not be a cure for diabetes, but it’s literally a life saver.

It may be a lifesaver, but it is also a financial heavy weight. Let me explain.

Treatment of diabetes per person rose from an average cost of N60,000 in 2011 to N300,000 in 2021, and is expected rise above N500,000 in 2030 and over N1.0 million by 2045 according to the IDF. In addition, the total diabetes related health expenditure in the country is expected to gross N745 billion in 2024.  This would shoot up to over N1.07 trillion in 2030 and reach N1.59 trillion by 2045 according to the IDF.

The outlook for Nigeria is particularly grim. More than 1 in 3 people with diabetes will develop a complication of the eyes known as diabetic retinopathy while those that develop diabetic foot risk suffering nerve damage and end up losing their limbs to amputation.

With the majority of patients financing their medical bills out of pocket, several diabetic patients fail to adhere to their medications and tests. Only 1 in 5 of the patients perform self–blood glucose monitoring among other tests.  Several patients resort to unorthodox treatment as a result.

Patients on Insulin can use N3,000 to N10,000 worth of medication per week. There are different types of insulin and they all have different prices. The minimum amount a patient can require a month is therefore between N12,000 to N40,000 for adult patients.

Drug companies making insulin for domestic use exist in India, China, Poland, Ukraine, United Arab Emirates, Brazil, Mexico, and Russia. Several have already expressed interest in entering the global market if they can win WHO-approval.

In a recent WHO survey of 24 countries, most of which were poor or middle-income, 40 percent of health care facilities had no insulin on hand. In some countries, the price of a vial in private pharmacies was 15 to 20 percent of a typical worker’s take-home pay.

According to a new modelling study published in The Lancet Diabetes & Endocrinology journal, the amount of insulin needed to effectively treat type 2 diabetes will rise by more than 20 per cent worldwide over the next 12 years, but without major improvements in access, insulin will be beyond the reach of around half of the 79 million adults with type 2 diabetes who will need it in 2030.

The findings are of particular concern for the African, Asian, and Oceania regions which the study predicts will have the largest unmet insulin need in 2030 if access remains at current levels. This analysis underscores the importance of tackling barriers to the insulin market, particularly in Africa. Experts warn that strategies to make insulin more widely available and affordable will be critical to ensure that demand is met.

Now let us return to the boy and his parents.

Fortunately, both his parents were working and doing well; but most importantly, had insurance coverage; therefore, their child’s medication would be obtained at only 10% of the cost until he turned 18. Examples of people who have lived many years on Insulin helped to calm down his parents.

A diagnosis of diabetes is not the end of the world, however, we still have a long way to go in Africa.