South Africa hosts a number of Africa’s leading experts on diabetes care in Cape Town, Johannesburg, and many dispersed in the less-urban centers of the country. Compared to Kenya, South Africa has far more resources for diabetes patients including more health coverage, system infrastructure, academic research, and a very established national Diabetes Association South Africa (Diabetes ZA). What I would learn is that my first stop, Johannesburg, would soon be the diabetes focus point for the African region with an upcoming IDF/WDF supported Africa Diabetes Leadership Forum in September 2010.
The Diabetes ZA Executive Manager, Leigh-Ann Bailie, cites that diabetes kills as many people annually as HIV/AIDS in South Africa. A country with eleven national languages and even more used in practice creates challenges for national efforts. With only about 2 physicians per 10,000 patients, resource constraints are a large concern. Additionally, the dichotomy of the “have” and “have-nots” in South Africa create two sub-groups of communities with diabetes. The programs and mechanisms used to reach, educate, and treat them maybe dramatically different. Despite considerable changes in the South African society over the past 20 years, racial tension and segregation must still be considered delicately.
Stefan Lawson, Project HOPE’s country lead in South Africa, took some time to update me on their efforts more broadly and current concepts in diabetes. Establishing a community-based clinic or hub for various activities – education, detection, treatment, etc. would be a potential program to get started. Similar to Kenya, many low-income families believe vegetables or fruits are out of reach. A garden or cooking classes could help empower women in the communities to change the way they think about providing affordable meals for their families. Stefan also cited the need for fitness opportunities in urban areas – where safety is largely a concern and gyms are reserved for the middle/upper classes.
Diet Remains a Challenge
Professor Rheeder of the University of Pretoria took some time with Stefan and I to lay out a number of issues, the first and foremost – diet. Similar to Kenya, the traditional low-income diet in South Africa is porridge or cornmeal “pop”. Dietary awareness programs are few and with even fewer examples of success to replicate more broadly. However, he notes, general awareness about diabetes and the link to obesity is “ok”. The growth of fastfood chains like KFC and others have been steady in the past 10 years. Still, the choices are limited and many lack access to patient education programs to help them make healthy decisions.
Access to Detection & Treatment Limited
In the short-term, curative medicine is the single greatest need for patients with or at risk of developing diabetes. Most patients also pay out of pocket and cannot afford either medication, glucose monitoring or both. Prof. Rheeder emphasized the importance of focusing on the curative capability with respect to the peripheral areas (i.e. complications) associated with longer-term cases.
However, in order to address the right population further programs need to be established to detect those with and at high risk for diabetes. The University of Pretoria, under Prof. Rheeder’s leadership, has established a mobile diabetes diagnostic bus to “share” resources and medical expertise across regions. This is very similar to Project HOPE’s partnership with United Healthcare in New Mexico. The South African bus spends about 3 weeks in a given location, either hospital parking lot or corporate area) to increase access and awareness for diabetes diagnosis.
Diabetes ZA is also heavily involved in doing discounted testing for patients in need. However, they don’t get enough donations to do free testing for low-income or unmotivated individuals. Some corporate efforts will sponsor nurses for a few hours a day, but these barely make enough money to cover the cost of strips – about 300 Rand (US $43) per 50 pack.
One of my favorite tools that they are testing, however, is the “patient passport.” Assuming the patient is literate, the patient passport could be a powerful mechanism to empower patients and promote them to take charge of their diabetes. Each passport has educational pieces up front (e.g. two pages on physiology), information on short-term and long-term complications, a checklist of what you should have performed in a clinic, and custom pages dedicated to “my story”. Similar to Mexico, these personalized pages document progress using the stop-light red, yellow, green methodology.
Healthcare Expertise & Capacity Issues
Healthcare expertise and capacity to treat populations with diabetes is undoubtedly better than most regions of Africa. However, South Africa has significant potential to develop and demonstrate success with capacity expansion efforts that could be translated to the rest of the region.
Professor Willie Mollentze of the University Free Sate in Bloemfontein, ZA describes his experience working in the second poorest province in the country. With a population of 2.6 million, Bloemfontein has about 98,000 people with diabetes, 48,000 of which were registered just this past year. In addition to this surprising growth, clinics dedicated for diabetes patients are overwhelmed with workload. He sees 80-100 patients a day and has been working to creatively identify ways to reach more patients with even the fewest resources (people, medications, and diagnostic/monitoring technologies) available.
Dr. Francois Bonnici has been a driving force behind capacity expansion efforts focusing on children with Type 1 diabetes at the Red Cross Children’s Hospital in Cape Town. As one of the most eminent global leaders in diabetes, Dr. Bonnici has also worked to establish a number of the diabetes associations and national programs and policies all over Africa.
Serving now as the only wholly dedicated children’s diabetes center in the southern hemisphere, the Red Cross Children’s Hospital treats about 750 active patients under the leadership of Lyn Starck, a diabetes educator and pediatric nurse. Over the years she notes an increase in children with Type 2 diabetes and the sentiment that the onset of Type 1 diabetes is occurring younger and younger in their community. Lyn reflects on a number of familiar challenges: glucose monitoring strips are too expensive, nurses “waste” time spent on admin responsibilities and paperwork, language barriers for patients in various regions, and lack of skilled healthcare professionals. She also mentioned a number of national efforts to improve healthcare infrastructure in South Africa – primary care rebuilt only at the expense of tertiary care. These shortcomings unfortunately have huge implications for diabetes patients who rely on nearly all levels of the healthcare system and infrastructure.
Dr. Bonnici and Lyn stress, “you have to empower the nurses.” Working with groups like DESSA (Diabetes Education Society of South Africa) to establish a curriculum to train diabetes educators in South Africa is critical. More importantly for the long-term, getting this role acknowledged by the government medical system will create a pipeline and legitimate career path nurses can pursue focused on diabetes. It seems that despite years of work to create this role and curriculum, there are more politics behind the scene that need to be addressed.
Creating a Vision for Diabetes Care in South Africa
I was profoundly moved by my time spent with Dr. Bonnici in Cape Town. After decades of working in this space, his perspective and experience is incomparable. First, he emphasizes, we need a vision. In business terms, the return-on-investment (ROI) will be different for the short and long terms. In the short-term we need to focus on complications of diabetes such as footcare and eye care to prevent amputation, blindness, and dialysis. These will help prevent expensive and life-deteriorating conditions for millions of patients in South Africa. In the long term, prevention is the key focus. Early detection, awareness campaigns, and elementary school healthy habits programs are all strong candidates for prevention, but only time will tell how effective they can be.
The billion-dollar question is still on the table - is lifestyle change an attainable goal? For the future of South Africa and larger global health - we truly hope so. Dr. Bonnici’s comments around lifestyle change reminded me of my conversation with Dr. Ashraf Ismail from Joint Commission International in Dubai relating to safety – “safety is a product of culture, not processes.” Lifestyle change will happen when eating healthy is “smart” and cultural norms refuse to accept other behavior. This is very similar to the evolution seen with smoking in the US over the past 20 years.
So how do we get here? Targeting obesity and multiple risk factors is a start. Improving opportunities for biking and physical activity in public (similar to the city gyms in Brazil or China) is another. However, Dr. Bonnici stresses that the true key to lifestyle change and the future of diabetes is women empowerment. Empowering female heads of households and nurses to educate and shift norms of daily living is critical to the long-term success of any diabetes program.
Dr. Silver Bahandeka, VP of the International Diabetes Federation for Africa, describes his vision of programs as three-fold in order of priority:
- Patient-focused diabetes education: nutrition, exercise, screening, management, compliance with complications
- Juvenile diabetes programs: access to insulin, education programs for family and educator.
- Medical capacity building: physician education, diabetes educator nurse training programs
Interestingly these focus first on patient/individual, then community/collective, then systemic/infrastructure needs in that order. As the champion for the Africa Diabetes Leadership Forum in September, Dr. Bahandeka has been a strong driver in promoting diabetes programs and policies at a national level. Working with Ministers of Health across the region, he has advocated for increased funding for diabetes despite many ministries small or previously allocated budgets.
In this journey, many will be looking for leaders in the region as role models for replicable efforts. South Africa and Cameroon, in Dr. Bahandeka’s opinion, have made great advances in their diabetes efforts with both strong programs and policies. Several interviewees in South Africa agreed that the national policies are very good but have been poor in implementation.
Translating vision to reality is going to be the largest challenge for countries in the African region. Top-down efforts may be a harder model for success - many noteworthy programs are led by one, very dedicated leader who has built it from the ground up. Incentives (financial or otherwise) that align with the national vision but promote ownership and self-starter initiatives may prove most successful in the coming years. Looking farther ahead, succession planning of these efforts will be critical to make them sustainable (and ideally self-sustainable) over time.
In the meantime, the Africa Diabetes Leadership Forum will be an invigorating impetus to getting a foothold on the right path.
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