Hot Topics in Global Health: Student Commentary - Insulin for the Future

Global Health

Fri, 02/14/2020 - 14:05

The rise of non-communicable diseases (NCDs) poses a significant burden to global healthcare systems moving forth: in 2020, nearly 1 in 10 adults worldwide are diabetic, with an estimated 629 million people affected by 2045 (1), (2). Moreover, the sequalae of diabetes are complicated and involve the care of multiple organ systems; notable examples include chronic kidney disease, foot ulcers and diabetic neuropathy, which is a leading cause of blindness (2). Medical management of diabetes is quite feasible with drugs such as insulin, metformin or gliclazide which effectively reduce complications and associated mortality, yet access to these medications is nowhere near universal (1). Amongst developed countries, particularly the United States and Canada, drug prices have been highly contested in recent years with the cost of insulin nearly doubling in the last decade (3). This issue is exacerbated in developing countries which may not have appropriate healthcare infrastructure in place to estimate and manage the impacts of complicated, chronic disease.

Ewen et al sought to understand the availability and affordability of insulin in 13 low or middle-income countries (LMIC) worldwide. Despite notable regional variance in drug coverage, the finding that unskilled workers had to work 3.5-3.9 days to afford a 10mL vial of insulin (based on median prices) is astonishing.1 This work was published in BMJ Global Health in light of the World Health Organization’s goal to achieve 80% availability of essential medicines by 2025. With the 5 years remaining to achieve this target, it is important to quantify progress towards such lofty goals in order to provide policymakers with evidence that current healthcare delivery is ineffective, and lobby for change.

Essential medications are unaffordable in many parts of the world. In reality, physicians are constrained by resource availability in the region of their practice and should understand local drug funding systems. Canadian medical students are privileged to be learning in resource-rich academic centres, where our personal development is prioritized. It can be easy to become self-centered and idyllic under these conditions. Global health research is important for broadening students’ understanding of how medicine is practiced outside of the controlled academic setting.

Along a similar vein, it is important to note that we are all subject to biases arising from where we are from, who we interact with and where we receive an education. For instance, Ewen et al discuss the relevance of increasing the availability of biosimilars to reduce medication prices, briefly mentioning that many healthcare professionals have misconceptions about the efficacy of these products (1). Although discussed in the context of LMIC, the debate surrounding biosimilar vs. brand-name drug coverage is ongoing in parts of Canada and directly influences prescribing patterns. By seeking information from other parts of the world, we can think beyond biases inherent to our life experiences.

Currently, universal pharmacare is at the forefront of debate in Canadian politics and fair pricing of insulin in particular has been a key issue in the lead-up to this year’s American election. Six of the 13 LMIC studied provided government coverage for insulin in some form, yet only four of them met the intended Global Action Plan for the Prevention and Control of Non-communicable Diseases 2013–2020 target. This discrepancy was due to the lack of availability of the drug in pharmacies in India and Pakistan (1). These findings demonstrate the importance of this research: only by quantifying the problem of drug access and identifying the causal mechanisms will we be able to improve healthcare delivery globally, and achieve the targets outlined in this article.

The implications of this work are tripartite. Firstly, existing disparity in drug pricing needs to be addressed; in other words, why are national governments paying vastly different prices for the same medications from suppliers? Is there a more equitable way to distribute market shares apart from the dominant multinational corporations which are currently contributing to issues of affordability?

Secondly, work is needed to support the development of safe and effective biosimilars. Ewen et al emphasized the importance of biosimilar development to saturate the market and lower the cost of diabetes treatment. Furthermore, rigorous drug development and physician education can help to overcome misconceptions about biosimilar efficacy, thus improving access to care globally. Finally, this research should remind us to look “upstream” at the causal pathway of chronic disease. Lifestyle modification – particularly in LMICs where NCD rates are rising – should be prioritized to decrease population-wide mortality and extraneous healthcare spending. The impact of globalization on diet and NCD incidence has been well-documented. Several studies have demonstrated a causal relationship between increased sales of Western-style fast food items and concomitant increases in NCD incidence, particularly in LMICs.4 Given that poor nutrition is a significant risk-factor for the development of diabetes, trends in food consumption and the availability of healthy food items in LMICs should be carefully monitored and problems corrected prophylactically.

The world at the dawn of 2020 is truly a global village. Ewen et al’s work should serve as a reminder that healthcare practitioners everywhere face similar barriers in providing optimal patient care in spite of constrained resources. It also does well to characterize the threat that NCDs pose to global healthcare systems and should inspire economic and policy changes to combat this.

By Gursharan Sohi, MEDS 2023

References:

Ewen, M. et al. Insulin prices, availability and affordability in 13 low-income and middle-income countries. BMJ Global Health. 2019; 4:e001410. doi:10.1136/bmjgh-2019-001410.
World Health Organization. Diabetes. WHO. 2018. Available from: https://www.who.int/news-room/fact-sheets/detail/diabetes. [Accessed 18 January 2020.
Hirsch, I.B. Insulin in America: a Right or a Privilege? Diabetes Spectrum. 2016; 29(3): 130–132. doi: 10.2337/diaspect.29.3.130
Pan A, Malik VS, Hu FB. Exporting diabetes mellitus to Asia: the impact of Western-style fast food. Circulation. 2012 Jul 10;126(2):163-5. doi: 10.1161/CIRCULATIONAHA.112.115923. Epub 2012 Jul 2. PMID: 22753305; PMCID: PMC3401093.