High Impact Medicine 2022

India Fellowship Cohort

Capstone Project

Focus Area: Improving access to antidiabetic agents among patients suffering from T2DM
in Asian countries

A Brief Background
Before I begin, I would like to give a brief background about myself so that readers are aware
of the lenses which colour my perceptions as they go through the piece. I am an Indian
medical graduate from one of the foremost tertiary care hospitals in the subcontinent.
Attending clinical ward rotations during my medical school made me realize that medicine is
extremely hierarchical and though this organized structure looks incredible in theory, the
reality is unfortunately very different. My internship (equivalent to F1 in the UK) in India
involved rotations in primary health setups for 2 months in remote regions of the country.
This was followed by my government service bond (equivalent to F2 in the UK) in the
Department of Nuclear Medicine at the same hospital, where I continue to work at the time of
writing this. I have recently completed reading the phenomenal Doing Good Better by
William MacAskill and will use certain frameworks I discovered in the book to back my
arguments.

A Public Health Issue

During my postings at medical school, I realized the number of patients suffering from
chronic diseases in India on-ground was much more abundant even after having read the
epidemiology multiple times during med school. I spoke with my colleagues across Asia and
realized that this is common for all regions. Type 2 Diabetes and hypertension have
significant disease burdens in terms of their overall impact on disease progression in a
number of conditions [1]. These are also diseases that affect the elderly population subset
more. A concerning facet is the silent nature of this chronic disease pandemic. In my ward,
there have been numerous cases every week when patients scheduled for PET scans discover
their high sugar levels on a routine pre-procedure monitoring test and were completely
unaware of being highly diabetic till then. Now, India being an LMIC, many people tend to
avoid hospital visits due to the economic burden with a view to rather divert this money for
other causes like their children’s needs. The vast majority of the people in the country live on
meagre daily wages and this is a population which I have been privileged to serve in my
years since graduating. Thus, even amounts which may seem insignificant to us, hold great
value for these vulnerable subsets (as was nicely illustrated in Doing Good Better) and they
depend on government-run tertiary care centres providing affordable treatment for their
healthcare needs. Even among those for whom money is relatively not a concern, there is a
sense of ‘shame’ associated with asking their children for assistance during these visits due to
the associated paperwork and processes. The result being that eventually a lot of these
patients develop significant morbidity even though their diseases could have been easily
nipped in the bud. Type 2 Diabetes mellitus for example has been known to be associated
with an increased risk of a number of cancers as well[2].

Troubleshooting: A solution but does it help?

There are free chronic OPDs at the primary health centres (with funds being spent by the
State) where these citizens are also provided their medicine free along with routine
monitoring of their disease progression. These are manned by either medical officers in the
remote areas or community medicine residents in urban primary health centres. The idea
being that free provision of medicines at the community level would prevent the need for
these patients to visit hospitals where long paperwork and waiting times make the scenario
chaotic. Proper management of a chronic condition like diabetes would mitigate micro and
macrovascular complications in the long-run, economically resulting in benefits of up to 200$
per capita and significantly reducing the load on healthcare systems [3]. Since the OPDs are
run in the localities itself, there is also a lot of familiarity and the development of informal
support groups for these patients, making it a win-win situation for all. So, what went wrong?

Capstone Focus: The Implementation Challenge

On-ground, the reality is that even a simple drug like metformin is not available for
distribution through these channels. The stock is either dispatched inadequately or diverted
for selling privately at the various supply points in the chain. This results in patients who are
on polypharmaceutical regimens often receiving few to no drugs, ultimately causing disease
progression. I have had to repeatedly inform the patients that their medicine is unavailable
while providing hope that it will arrive soon: with the intention to keep making them follow-
up so that the disease is at least monitored and action can be taken in case of any warning
signs of impending complications. Though patients are also advised to procure the missing
drugs from any local chemist, this does not happen due to the reasons already mentioned.
Hence, though the solution was elegant, the benefit is not being reaped by the masses. Better
implementation of the existing framework would be a major step to improving national
health.

Scale: Restricting ourself to just South-East Asia for now, we have close to 46 million
undiagnosed diabetics [1]. Among the 44 million diabetics, the impact on the QALY is
dependent on a lot of variables including the region where they live, the nature of co-
morbidities and access to treatment [4]. While annual expenditure on uncomplicated diabetes
has been estimated to be in the range of around $92, for diabetes with complications, the
same figure shoots up to $300 [3]. Thus, very simplistically put, the investment of $92 now
will prevent these families from being burdened with rising hospital costs as well as time
spent as caregivers for a dependent relative, a few years down the line. Again, oral
antidiabetics are just a facet of the $92 disease cost and so ensuring access to oral
antidiabetics can be still said to safely provide around a 3x return economically, without even
factoring in QALY calculations. While a lot of awareness and advocacy still needs to be
effectively carried out, knowledge that cheap/free treatment options exist is also bound to
increase detection rates among the undiagnosed population who would no longer need to be
afraid about being financially burdened due to the ‘discovery’ of their illness. This heightens
the return on investment, especially when one considers the significant morbidity that
develops as a result of insidious disease progression eventually leading to say, amputation or
cancers.
Neglectedness: A search on Pubmed surprisingly yielded little data on access to oral
antidiabetics across the subcontinent with only a couple of papers from China [6,7].
Optimistic values put the availability of these drugs at a little over 50%. Though more data is
definitely needed, this pegs the number of diabetics not taking prescribed antidiabetics at
close to 65 million. (46 million undetected, 19 million unable to gain access)
Tractability: Collaborating with government channels is always challenging which is
probably the reason that prevents work from being done in this field. However, with the
drafting of informed action plans after considering disease epidemiology and existing public
health policies, it may be possible to draw the attention of relevant high-interest high-power
stakeholders who can make an impact. Ironing out the chinks in the existing framework, or
otherwise, allowing non-government organizations to start making inroads into solving the
challenge (a la say Space X vs NASA) of distribution is essential. A positive start may pave
the foundation for implementing such initiatives for other chronic disease as well.
References:

1. Diabetes in SEA (idf.org)

2. CebiogluM, SchildHH, GolubnitschajaO. Cancer predisposition in diabetics: risk factors
considered for predictive diagnostics and targeted preventive measures. EPMA J. 2010
Mar;1(1):130-7. doi: 10.1007/s13167-010-0015-4.
3. Singh K, Narayan KMV, Eggleston K. Economic Impact of Diabetes in South Asia: the
Magnitude of the Problem. CurrDiab Rep. 2019 May 16;19(6):34. doi: 10.1007/s11892-
019-1146-1.
4. VizHub-GBD Compare (healthdata.org)
5. Yang C, Hu S, Zhu Y, Zhu W, Li Z, Fang Y. Evaluating access to oral anti-diabetic
medicines: A cross-sectional survey of prices, availability and affordability in Shaanxi
Province, Western China. PLoSOne. 2019 Oct 16;14(10):e0223769. doi:
10.1371/journal.pone.0223769.
6. ShiweiGong, HongbingCai, YufengDing, WeijieLi, Xu Juan, JinlanPeng, Si Jin, The
availability, price and affordability of antidiabetic drugs in Hubei province, China,Health
Policy and Planning, Volume 33, Issue 8, October 2018, Pages 937–947

P.S.: Kindly note that this is a supplement to the slides that I prepared to present my capstone
which is my primary file. (Uploaded as a pdf on the Google Form)

-By Vishnu B. Unnithan