Diabetes in India: A Sleeping Giant

Project HOPE India is located just a few minutes from the Rashtrapati Bhavan (President’s Palace) in New Delhi. The Program Manager for India, Dr. Sonia Kakar, has been working with the India team here to setup a capacity-building approach to help patients with diabetes across multiple cities in India. Their India Diabetes Educator Project (IDEP) started in 2008 as a four-year multi-partner collaborative initiative to combat the rapidly growing threat of diabetes in India. The 6 month course for experienced healthcare professionals (nurses, nutritionists, physical therapists, psychiatrists) is recognized by the International Diabetes Federation (IDF) and is the first large scale initiative to train and educate allied healthcare professionals in India on diabetes education, care and management (supported by BD, Lilly, and Bayer)¹.

India has about 40.9 million people living with diabetes, over 65% of which are not aware of their condition^2,3. By 2025, this is expected to nearly double to 69.9 million, representing the highest burden of diabetes in the world². This prevalence is concentrated in the wealthier socioeconomic groups and cities, with a 12% prevalence rate in urban areas. The shocking difference about diabetes prevalence in India is that the population has a higher propensity for the disease at a lower BMI and age-range than seen in the US. Of all Type 2 patients (99% of cases), only one third would be considered obese, 52-57% are in the normal weight range, and 10-15% would be considered underweight. In addition the average age for diagnosis is 20-30 years old (35-40% of which already have complications)³.

Why doesn’t India have a diabetes care program? The Indian Government still does not consider diabetes and other non communicable diseases as a priority area. India still has large public health needs related to infectious diseases and clean water / sanitation. These priorities are ultimately limited by India’s relatively narrow national budget for healthcare: 4.9% of GDP (0.9% of the government's budget) or the equivalent of about US$39 per person per year⁴. This is a very large contrast to the budgets seen in Brazil and Mexico where 7.5% and 6.2% of GDP are allocated to health, respectively. Additionally, an estimated 45% of India lives below the poverty line (US$1 per day) with the estimated average income around $42,000 rupees (around US$1016)^5,6.

Additionally 70% of people in India live in rural areas and there is an ongoing rural to urban shift in the population (if these statistics are right then that means 97% of all diabetes cases are in urban areas). The significant diversity among people living in rural, semi-urban and urban areas must be taken into account when designing a diabetes prevention and treatment program³. From a prevention standpoint, it’s important to think about where the future patients with diabetes will emerge. If they will grow mostly in urban areas as a result of the rural-urban shift, then a diabetes program in urban areas might be the best investment. On the contrary, if lifestyle habits from the cities start replicating themselves in more semi-urban and rural areas, a much larger comprehensive prevention program is needed to reach the mass population.

Cheena Malhotra, Program Associate for Project HOPE India, took me to visit several of Project HOPE’s eleven IDEP centers where they train healthcare professionals to diagnose and treat patients with diabetes. The 6 month course is very rigorous and is mostly a distance learning course with three in-person meetings (Induction, Workshop 1, and Workshop 2 & Final Exam). The program aims to train 3,000 diabetes educators by 2011 and generates awareness activities in the health facilities such as continuing education for General Practitioners.

It’s important to keep in mind that culturally, India is very “medically” oriented and prefers physicians to other healthcare workers or peer educators. This can make peer-education (or perhaps even just education) models slightly more challenging as it is usually the word of the physician that is respected at the end of the day. Traveling doctors are also very common in semi-rural and rural areas to help reach more patients where the needs are high, but infrastructure/funding is low; could these be a target for effective diabetes prevention programs? Communities here are also very family-based, and therefore working with family doctors may be another approach for reaching patients with preventive and screening efforts.

Project HOPE Diabetes Master Trainers, me and Cheena at Sitaram Bhartia in Delhi.

Next week we will be completing a number of site visits and interviews in Delhi and Bangalore! More exciting India findings to come soon…

Sources:

1. Project HOPE India Diabetes Educator Project

2. Diabetes Atlas 2007, WHO

3. National Diabetic Association of India http://www.diabetesindia.com/diabetes/itfdci.htm

4. World Health Organization (WHOSIS)

5. IMF 2008

6. India Survey for BPL Families http://www.pbplanning.gov.in/pdf/BPL16-3-07.pdf