Middle East Meltdown: Diabetes in the Arab Context

Diabetes, it can be said, is one of the unpleasant side-effects of being human. Few other medical conditions are so heavily influenced by lifestyle and patterns of individual behavior, reinforced by a mix of economic, social and cultural factors.  Nowhere do these form a more potent combination than in the Arab countries of the Middle East, where diabetes has become a major public health threat:  according to the World Health Organization [WHO], one of every 10 adults in the region is now a diabetic.

Managing this condition from a patient and public policy perspective was the focus of a special session at Monday’s US-Arab Healthcare Summit held in New York. Moderated by Merck, the session also featured experts from local health institutions in the region, government and academia.  The relevance of diabetes to the region is almost syntactical:  in the Arabic language, the word for diabetes translates as “sugar.”

The common idea that diabetes is little more than a nuisance condition, with minimal impact on public health, was refuted at the very start of the panel.  The region recorded some 400,000 deaths from diabetes last year; more than half of the victims were under the age of 60.  Likewise, panelists highlighted the complexity of the disease in terms of its significant burden of co-morbidities, many of which are only now being discovered as a consequence of advances in molecular biology and genomics. The interaction between markers of inflammation and blood sugar level was cited as an area deserving of further investigation.

Not surprisingly, the Arab region shares with other parts of the world the roots of the diabetes management problem.  Low public awareness; scattershot approaches to education and prevention, especially in reinforcing the importance of lifestyle adjustments like diet and exercise; and poor patient adherence to drug regimens were agreed as the most important factors.  But in the Middle-East, these are deemed a degree worse than elsewhere.  For example, statistical measures show that drug adherence is a chronic off and on situation, with some 70 per cent of local patients cycling off a new medicine only four months after the initiation of treatment.  Most diabetics see a physician too infrequently to keep pace with the progress of the disease; primary care practitioners, which are the most common reference point for patients, often rely on old and outdated knowledge due the lack of a good clinical education infrastructure.

Efforts at education by clinicians and the pharmaceutical industry cannot make up for inadequate public funds, the absence of organized patient advocacy networks, and a distracted media presence. More important, everyone is aware that advocacy around diabetes has to start with the family, the epicenter of Arab culture, where unfortunately economic and behavioral incentives are aligned around fast foods, fizzy drinks, shopping malls, functional indolence and other elements of the urban lifestyle.

Practical steps forward
The session concluded on a more optimistic note when panelists brainstormed around a question from Merck Emerging Markets Region President Kevin Ali:  what can be done differently to reconcile these aberrant trends and move the ball forward against diabetes?  A consensus formed around five integrated proposals, as follows:

• Confront pervasive “silo thinking” in diabetes management through an “ecosystem” approach that binds government, industry, academia and professional groups together around projects that provide a data base for evidenced decision making.  An example is creation of country-specific population health registries to quantify and characterize co-morbidities and establish consistent clinical guidelines covering drug therapy and other treatment interventions.

• Refocus education to attack the hidden face of the epidemic: rampant underdiagnosis. Begin awareness-building efforts much earlier in the patient life cycle, where the pre-diabetes metabolic syndrome state is addressed as a treatable condition in itself, and deserving equal priority in health planning.

• Expand the coalition against diabetes complacency, raising the profile of the pharmacist as an intermediary to the patient and facilitating the growth of patient organizations with the clout to represent this constituency and lobby for more attention to the disease.

• Explore how technology – like mobile app connectivity – can help patients directly in managing their diabetes and seamlessly sharing data with their physician.

• Initiate new areas of research that cover unique aspects of the regional environment that may be contributing to higher incidences of type-II diabetes. The link between stress, stress-related hormones such as cortisol, and higher levels of blood surgar is one such area:  a growing proportion of citizens are suffering from stress due to urbanization; gender inequities, cultural and religious barriers; and political unrest.