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World Diabetes Day 2006 - Diabetes and the economically disadvantaged

The most significant contributor to disadvantage and vulnerability is economic status. Article 25 of the Declaration of Human Rights states that: ‘everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including medical care.’ This basic right is a luxury that many cannot afford. More than 2.5 billion people in the world have to survive on less than two dollars a day; over a billion on less than one dollar a day. A quarter (a staggering 320 million) of the poorest people in the world live in Sub-Saharan Africa (World Bank 2001 figures).

IDF estimates that the number of people with diabetes will increase to over 350 million within a generation (2025). Of this total, 80% will live in low- and medium-income countries. In many of these countries there is little or no access to life-saving and disability-preventing diabetes treatments. The growing burden of diabetes is going to fall hardest on those who are at the greatest economic disadvantage. The twin burdens of absolute poverty and ill-health leave many people with few options.

Absolute poverty is not the only issue. Socio-economic factors are highly influential in deciding what people can eat, whether or not they get enough physical activity and access to care. Consequently, people who are relatively poor in affluent countries such as those located in Western Europe, North America and Australasia are at greater risk of type 2 diabetes than those who are wealthier. In the USA, for example, households with the lowest incomes have been shown to have the highest incidence of diabetes.

The recent WHO publication Preventing Chronic Diseases: a vital investment explains how a combination of higher levels of risk behavior, unhealthy living conditions, material deprivation, psychosocial stress and limited access to optimal care are leading to increasing incidence of diabetes and worse outcomes among the economically disadvantaged. Unfortunately, there is evidence that the gap between the rich and the poor is widening in many countries, for example in India, China and the USA.

Quite contrary then to the widely held misconception that diabetes is a disease of the affluent, it is impoverished communities that are most vulnerable to diabetes and least equipped to seek care and prevent the onset of diabetes complications. On the other side of the vicious circle is the impact of diabetes on a family’s economy. The enormous direct and indirect economic burden that diabetes inflicts pushes many people and their families further into poverty. From a wider perspective, diabetes can impact negatively on economic growth, particularly in developing countries. Without action the increase in numbers seeking care will far outstrip the global healthcare resources available to provide that care.

Diabetes and ethnic minorities

Ethnic minorities can be defined as groups within communities that have different national or cultural traditions from the main population. In many countries, both developed and developing, people from ethnic minorities are more likely than the general population to be disadvantaged in terms of access to essential services such as education, employment, housing, and healthcare. For members of first-generation migrant groups, language barriers can present an obvious problem to full integration into a host community. For members of subsequent generations, discrimination and cultural bias often prevent or discourage access to available healthcare services.

People from ethnic minorities are in many cases more prone to disease and disability than the general population.

They are at an increased risk of developing chronic diseases such as diabetes and are disproportionately affected by the rising global diabetes epidemic. Ethnic differences in diabetes outcomes can mainly be explained by differences in socio-economic status, possibilities provided by the living environment (in particular those of dietary choice and exercise), and access to services. These differences are exacerbated by an increased genetic susceptibility to diabetes among many minority ethnic groups. Members of these groups can have a two to six-fold greater risk of developing diabetes than the general population and are more likely to develop the condition at a younger age. In the United States, for example, it is estimated that one in two people from minorities born in the year 2000 will develop diabetes during their lifetime. Furthermore, because people from ethnic minorities are more likely to be economically disadvantaged, they are more likely to live in deprived areas, be unemployed, and have less access to a healthy diet. These factors present a formidable barrier to adopting a lifestyle conducive to preventing a condition that, in the majority of cases, can be avoided.

The cultural, economic and social barriers that ethnic minorities face in accessing and receiving care and treatment can often have serious, life-threatening consequences. Among people with diabetes, those from ethnic minorities are often the least likely to receive clinical services that are important for monitoring and controlling their condition. Attitudes of healthcare professionals and services can constitute an obstacle to accessing and receiving healthcare for these groups. Healthcare services often take little or no account of the different cultural and communication requirements that members of these groups may have. Conventional diabetes education can often be culturally inappropriate and inaccessible to people with diabetes who do not speak the main language of a country. Furthermore, people from ethnic minorities are in many countries under-represented among healthcare professionals, a factor which can further restrict the willingness to seek care and treatment by groups that can feel misunderstood and overlooked. Diabetes is a silent and misunderstood disease within many communities and therefore it is vital for health professionals to adapt their prevention and awareness-raising strategies to ensure that they are culturally appropriate.

Effectively engaging with minority communities and adopting a patient-centred approach that recognizes cultural and language barriers has proven to be successful in improving diabetes outcomes among these high-risk groups. Involving community leaders in the promotion of health awareness campaigns has also helped to achieve successful results.

Diabetes and the elderly

The world’s population is ageing. There are around 600 million people over the age of 60 in the world today, and it is estimated that this total will reach almost 2 billion by 20501. Half of these people will be located in low-income countries. In comparison to the general population, elderly people are more likely to be affected by illness and disability. People over the age of 65 are almost 10 times more likely to develop diabetes than people in the 20-40 year age group and are also significantly more likely to develop complications of diabetes requiring hospitalization such as those affecting the eyes, feet, heart and kidneys2.

This higher susceptibility to illness and disease is exacerbated by the fact that elderly people are more likely than other age groups to have low incomes and live in poverty. In developing countries, some 80% of older people have no regular income3, which seriously affects their ability to access and receive the healthcare that they require. In the case of a chronic disease like diabetes, this economic barrier results in serious and life-threatening consequences.

The rising prevalence of chronic diseases like diabetes is placing a huge strain on national healthcare systems. The control and management of diabetes that is required to avoid or delay complications and live a healthy life requires daily treatment and monitoring that place a significant economic burden on people with diabetes and their families. The global epidemic of type 2 diabetes is predominantly affecting adults, and in developed countries, adults of retirement age. This means that the inability of many national health systems to provide the necessary services impacts highly on the elderly, a group that is more likely to be both economically disadvantaged and in need of care and treatment.

Other barriers that elderly people face in accessing and receiving diabetes care include:

– many elderly people, particularly in the developing world, live in rural areas where healthcare is often inaccessible, very limited, or inadequate.

Limited mobility – elderly people are more likely to suffer from a disability that often prevents or hampers them from accessing healthcare services. A further restriction in many countries is the lack of affordable public transport that discourages people from seeking care and treatment.

Stigma – negative attitudes from health staff towards the treatment of elderly people can often constitute an obstacle to seeking care and treatment.

Lack of information – elderly people often lacks reliable information about the services and benefits that they are entitled. This often results in unnecessary hospitalization. Access to information can also be reduced by physical isolation and limited mobility.

Diabetes and indigenous communities

An estimated 150 million people from approximately 5000 different indigenous peoples are found in more than 70 countries (Some place the figure as high as 375 million1). They share the following characteristics:

•  They are native to the area or country
They descend from groups that pre-date the arrival of colonizers
They identify themselves and are seen by others as a distinct cultural group
They seek to maintain their historical, cultural and social identity
They illustrate a unique attachment to traditional habitats and ancestral territories
The impact of Western intrusion on the health of indigenous communities can be seen across the globe.

Indigenous people are marginalized wherever they live and for the most part are generally unable to influence their overall economic situation, education or healthcare. This marginalization, coupled with the alarming rise in rates of non-communicable diseases such as diabetes, places the very existence of these groups at risk. This would ultimately result in the loss of invaluable cultural heritage and diversity.

Indigenous communities are particularly vulnerable to diabetes. It is common to see high rates of diabetes and earlier onset of the disease than in the general population. For example, some 40% of Pima Indians in the USA have type 2 diabetes. In Australia, the estimated number of indigenous adults with type 2 diabetes is up to four times higher than that of Australians of European descent (10 times higher than the national prevalence in 25- to 50-year-olds). Similarly, in Canada the prevalence of diabetes is two to three times higher among First Nation populations than for the general population.

Diabetes in indigenous people is often detected late, making the condition more serious as complications may already be present. The prevalence of diabetes and its complications is predicted to increase and will place a huge burden on health resources if nothing is done. Driving the rapid increase in diabetes among indigenous communities are two powerful forces: rapid cultural transition to Western lifestyles and a genetic pre-disposition to diabetes. Indigenous peoples have, in many cases, lost much of their traditional culture due to the intrusion of colonizers. Westernization has brought with it high unemployment and poverty, which in turn has brought dramatic changes in diet and lifestyle. Furthermore, the evolutionary selection of genes that may have been advantageous when food was scarce and had to be won through hard physical effort, places indigenous peoples at high risk of diabetes − the rapid change to an energy-rich diet and low levels of physical activity means that the genes now confer disadvantage by leading to high levels of obesity and type 2 diabetes.

Indigenous peoples often suffer comparatively higher rates of complications and are more likely to lack access to adequate health services. The severe complications of diabetes, such as those affecting circulation, the eyes, the kidneys and the nerves can lead to a greatly reduced quality of life and an early death. A study undertaken among Manitoba3 First Nations predicted a 10-fold increase in the rate of cardiovascular disease; a 5-fold increase in strokes, a 10-fold increase in kidney failure; a 10-fold increase in amputations and a 5-fold increase in blindness in 20 years (up to 2016). This increased risk and subsequent need for healthcare is often not addressed by health services, which fail to take into account the unique history and needs of indigenous people.

It is of vital importance that the right of these high-risk groups to access appropriate healthcare be recognized and respected, and that measures be put in place to prevent the increase in death and disability that will result if nothing is done to address the diabetes and obesity epidemics currently affecting indigenous people worldwide.
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