MoPoTsyo[Diabetes and Poverty] http://www.mopotsyo.org/diabetesandpoverty.

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DIABETES AND POVERTY

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Often, the costs of health services are the reason that people fall into poverty. The poverty
of many people with diabetes results in trade offs between expenditure for drugs and
transportation on one hand, and food on the other. The lack of consumer information makes
people vulnerable to marketing strategies.

There does not exist enough protection against such costs. From the sparse data that exist
on this subject, it appears that chronic diseases sharply increase the risk for people to run
into debt for health care. High risk debtors, which poor people typically are in the eyes of
their creditors, pay the highest interest rates for such debts: 2% per day is not an unusual
rate in an urban slum community. If the interest rates are high, the poor may lose one of
their few valuable assets as a consequence. An often quoted survey shows that half of the
poor who had lost their land, said it happened because of health care related costs (Making
the poor more visible, landlessness and Development Research Report, where has all the
land gone, Vol 4, Robin Biddulph, Oxfam GB Cambodia Land Study Project, 2000).

In the early nineties, Cambodia's public health system had to be rebuilt after decades of
war. International experts and donor agencies designed a public health system where most
resources are concentrated on communicable diseases, while ignoring the so called "non
communicable" diseases, many of whom are in fact chronic diseases. As a result of this
omission, Cambodia's "modernized" public health system is unsuitable for its future because
it does not know how to deal with chronic patients. Diabetes and hypertension are much
more prevalent than previously thought. The reasons for this are not well known, but
experts think that a certain genetic predisposition of Cambodians plays a role as it does
among people from Indian or Chinese origin. A new health reform is needed.

If we forget for a moment about the ethics, it appears to make sense that developed
countries prioritize the communicable diseases such as AIDS and HIV when they commit
their funds because it allows rich countries "to also help themselves by helping others".

Lack of policy also means that diseases are not recorded. As long as there are no data there
are also no problems, which perpetuates the lack of policy and vice versa. But as every
Cambodian medical doctor can tell you, Cambodia’s poor and extremely poor suffer from
non communicable diseases such as diabetes, hypertension, gastric ulcers, arthritis and
heart problems. Suffering from these and the chronic nature of the diseases cause people
and their household members to remain trapped in poverty. The surprisingly high diabetes
and hypertension prevalence in Cambodia are probably just the tip of the iceberg.

This invisible epidemic is an under-appreciated cause of poverty and hinders the economic
development of many countries. Contrary to common perception, 80% of chronic disease
deaths occur in low- and middle income countries.

If poverty is to be halved by 2015, the financial drain on households with a chronically

diseased family member needs to be reduced. More agencies need to wake up to the
challenges ahead and facilitate the design of appropriate low-cost technologies and
interventions that are affordable for a country like Cambodia.

Findings of diabetes treatment in Cambodia:

- Supplies of essential anti diabetic drugs including insulin through the regular public health
services need to be improved. At the moment, the public health system (except for vertical
programs like AIDS, Tuberculosis, Leprosy) prescribes medicine only for 3 to 5 days, but
diabetes and hypertension require medication for life.

- Insulin is sold at too high prices (USD 16 per 10 ml) and is difficult to get.

- There aren't enough medical doctors trained in treating diabetes and its co-morbidities. By
using peer educators to teach other patients how to self-manage the continuum-of-care in
diabetes and hypertension, treatment can be made "affordable".

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