Proceedings_from_First_Diabetes_Briefing-13_July_2006

“Diabetes Epidemic in Africa, Latin America and the Caribbean”
Edited Proceedings
13 July 2006
First Session, Africa and the Caribbean
ELAINE M. WOLFSON, PH.D.: Please introduce yourselves so that we get a
sense of the range of people and organizations and missions that are here.
NAOKO YAMAMOTO: My name is Naoko Yamamoto. I'm in the Japanese
Mission.
AMBASSADOR JÉRÉMIE BONNELAME: My name is Jérémie Bonnelame.
I'm from the Seychelles Mission.
DR. WOLFSON: Thank you.
M’BALEMBOU PATO: M’balembou Pato, Togo Mission.
JEFFREY WELFEL: Jeffrey Welfel from the Grenada Mission.
KATHERINE MAYER: Katherine Mayer of Soroptimist International.
RHONDA GLENN: Rhonda Glenn, Soroptimist International.
KELLIANN COLEMAN: Kelliann Coleman from the Temple of Understanding.
CECILIA VOGEL: Cecilia Vogel from Temple of Understanding.
ANNA POWERS: Anna Powers from the Temple of Understanding.
ANGELA LEE: Angela Lee from the Temple of Understanding.
SIROON P. SHAHINIAN, PH.D: I'm Dr. Siroon Shahinian, psychologist, chair
of the NGO Health Committee, which functions right here, at the United Nations.
KULSUM JANMOHAMMED: I’m Kulsum Janmohammed. I'm an intern at the
WHO.
FÉLICITÉ NZE NGOUKOU: My name is Félicité Nze Ngoukou from Congo
Mission.
KOFFI YAO: Koffi Yao from Cote d'Ivoire Mission.
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LENNOX A. DANIEL: Lennox A. Daniel from the Permanent Mission of St.
Vincent and the Grenadines.
MICHELLE JOSEPH: Michelle Joseph, St. Lucia Mission.
DR. WOLFSON: Well, thank you very, very much for coming, and I would like
to welcome you and thank you for your interest. And, at this time, I would like to
introduce Ambassador Kenneth Brown, who is one of the moderators, and he will
introduce the deputy for Ambassador Rouse, Ms. St. John. And then Ambassador
Moutari will introduce Ambassador Abani from Niger and Dr. Ilondo.
Dr. Ilondo will make the major presentation and we will allow time for Q and A.
AMBASSADOR KENNETH BROWN: First of all, I want to invite some
members from the U.N. missions to come up to the round table here. I'm the treasurer of
the Global Alliance for Women's Health, a longtime associate of Dr. Wolfson and very
pleased to be here and pleased to join in welcoming all of you.
It's my pleasure now to introduce our first speaker, the Honorable Marguerite St.
John, who is counselor at the Permanent Mission of Grenada to the United Nations.
MARGUERITE ST. JOHN: I thank you very much. However, I'm not an
honorable.
AMBASSADOR BROWN: You're honorable in our eyes.
MS. ST. JOHN: Madame President, fellow co-sponsor, his Excellency, Mr.
Aboubacar Abani, distinguished moderators, presenters, delegates, colleagues, my
ambassador sends her sincere apologies for not being able to attend this highly important
and valuable event today, due to delays returning to New York.
It is an honor for Grenada to join with the Permanent Mission of Niger in
cosponsoring this briefing. We applaud the Global Alliance for Women's Health for its
initiative.
This briefing is timely, as it comes on the heels of the recently concluded 27th
meeting of the Conference of Heads of Government of the Caribbean Community,
CARICOM, where a briefing was given on the results of a study on the macroeconomic
implications of non-communicable diseases, which showed that the number of deaths
resulting from diabetes, hypertension and heart disease were 10 times higher than the
number resulting from HIV/AIDS.
The incidence and prevalence of diabetes in Grenada and throughout the
Caribbean region has been steadily increasing over the years, especially among women
over the age of 50. This and the high cost of treatment of both the disease and its related
complications, such as renal failure, circulatory, eye and podiatry problems remain a high
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concern to the governments of the region and it poses a major financial burden on the
economies.
It is in this light that we welcome this discussion and look forward to the
engagement today. We hope to foster a lasting relationship with the Global Alliance for
Women's Health beyond this event, as we look for ways and means to address this global
problem together.
Thank you.
AMBASSADOR OUSMANE MOUTARI: Good morning, ladies and gentlemen.
My name is Ousmane Moutari. I am consultant on African and international affairs, and
in my previous life I was a career diplomat as ambassador in the Permanent Mission of
Niger here in New York. I've been in 14 different, other countries, with different
institutions.
I would like now to introduce our next speaker, Ambassador Aboubacar Ibrahim
Abani, who is the permanent representative of Niger to the United Nations and who is a
colleague of mine and a career diplomat. We are from the Ministry of Foreign Affairs.
Ambassador Abani has been in a different, very important position in Niger
previously. He was a diplomatic adviser to the president. Before that, he was clinical
adviser to the minister of foreign affairs and Niger citizens abroad. And he was deputy
ambassador in Addis Ababa, Ethiopia, with also accreditation to the African Union.
Ambassador Abani, I have the honor to give you the floor and to invite you to
address the audience.
AMBASSADOR ABOUBACAR IBRAHIM ABANI: Thank you, Ambassador
Moutari. First of all, I would like to beg the pardon of the audience, because I have to
exercise my poor English. And I will just start saying that, Excellencies, ladies and
gentlemen, from the outset, allow me to express my heartfelt pleasure and honor in
participating in this meeting, organized by the Global Alliance for Women's Health on a
relevant and important subject, which is diabetes.
This meeting is just opportune and relevant, as the diabetes pandemic is speeding
amongst women and children, but clearly in least-developed countries, where tremendous
efforts have to be done in order to curb the trend of this quiet yet devastating health
disorder throughout the world. I would like, therefore, to convey my congratulations to
you, Dr. Elaine Wolfson, and your team as well, for your commitment in this noble
cause.
This is a cause aiming for a world where people with special needs may be taken
care of. Niger, which has already participated in precedent editions of this campaign,
assures you of its full support in your undertakings to fight diabetes. I would like also to
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thank the eminent panelists before us for speaking and shedding more light on this
pandemic, whose impact and speed makes us feel less secure.
We have sometimes a perception, a lesser appreciation of diabetes, associating it
with high sugar consumption, when it's more complicated than that. Anyway, I strongly
believe, we strongly believe in Niger, that public policies should lead to concrete
measures in identifying and bringing solutions to the needs of children, older persons,
pregnant women, indigenous people, migrants, et cetera, because diabetes affects
everybody.
Ladies and gentlemen, global estimates show 171 million affected people in 2000,
and the projection of 366 million in 2030, thus showing us how fast-spreading is the
pandemic. Therefore, there is a need for more effective strategies to bring people to a
change of behavior for preventing diabetes, particularly in developing countries.
According to World Health Organization, 108,000 cases were diagnosed in Niger
in 2000, and the projection goes as far as 382,000 cases in 2030, which means four times
increase of the actual prevalence in a so-short time span. This figure shows the
magnitude of the diabetes which Niger has to deal with if no effort is made in terms of
effective public policies to prevent the disease.
In developing countries, the fast-spreading prevalence of diabetes is more crucial
than ever for 80 percent of diabetes cases, and seven out of 10 of heavily affected
countries are developing countries.
Ladies and gentlemen, I wish I, or the speech, could bring a move toward
effective solutions to the diabetes pandemic. Such solutions should be accepted as
promoted with all stakeholders, governments, scientific communities, NGOs,
populations, et cetera.
Therefore, I think one should carefully listen to the eminent panelists, to learn
from the disease and to undertake what we can for preventing it. I thank you, and I beg
your pardon for my poor English.
AMBASSADOR MOUTARI: Thank you very much, Mr. Ambassador, and my
congratulations. I didn't know that you made such huge progress in English. Thank you.
I would like now to introduce a very important man, a very, very important
African, a militant, very much committed toward the fight against diabetes, Dr. Mapoko
Ilondo. Most of us who are used to the meetings on diabetes here at the United Nations
know him, because his corporation, Novo Nordisk, is very much committed on this issue.
And Dr. Mapoko is responsible for a good part of the money for projects which
are initiated and conducted by Novo Nordisk. A few examples of those projects are the
pilot project in Tanzania on diabetes and another one in Zambia, and of course we have
the sub-regional initiative in West Saharan Africa on diabetes.
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While working with Novo Nordisk, Dr. Ilondo is also associate professor at the
University of Kinshasa in the Democratic Republic of Congo.
Dr. Ilondo.
MAPOKO MBELENGE ILONDO, M.D., PH.D.: Thank you, your Excellency.
We are all aware of the extent of the health crisis facing developing countries and
the pharmaceutical industry is expected to contribute to solutions to the crisis. Five years
ago, Novo Nordisk, the pharmaceutical company that I work for, and which is based in
Copenhagen, Denmark, made the strategic decision to get involved with diabetes in
developing countries and, in particular, in Africa, Central and South America.
We work closely with the International Diabetes Federation, which is an umbrella
organization of national diabetes associations. Most countries have one diabetes
association, like the American Diabetes Association in the U.S., but some other countries,
like India or South Africa, have more than one diabetes association. And all those
organizations, which are patient organizations and have a large number of healthcare
professionals among them, all those associations are members of the International
Diabetes Federation.
So we work closely with the International Diabetes Federation, and in Africa we
have a close collaboration with the regional office of the World Health Organization in
Brazzaville, and in the Caribbean, we have a close collaboration with the Pan American
Health Organization in Washington, D.C.
During this briefing, I will be talking about the burden of diabetes, and in
particular certain aspects of diabetes in Africa and in the Caribbean, from a practical
point of view. I will be talking about ongoing efforts to address the epidemic, the
challenges that we meet, and then in the end I will say something about the project that
the International Diabetes Federation has been promoting for the last six months, and
which aims at getting a resolution on diabetes voted by the U.N. General Assembly.
There are two types of diabetes, type 1 and type 2. In type 1 diabetes, the body
doesn't produce insulin at all. Insulin is a hormone that is made by the pancreas, and that
hormone helps sugar to leave the blood and enter the cells, to be used as fuel. So the
body needs insulin in order to assimilate everything we eat.
In the absence of insulin, nutrients are not assimilated normally, so the level of
sugar increases in the blood and then it's eliminated via the kidneys. Elimination of the
sugar by the kidney is accompanied by large volumes of water, which means that the
person with diabetes, irrespective of whether it's type 1 or type 2, will have frequent
urination and the subject will tend to be dehydrated. In order to compensate for this
frequent urination, the subject will drink a lot of water.
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Actually, I forgot to define the type 2 diabetes. The body still produces insulin,
but the body is resistant to the action of insulin. But, ultimately, the symptoms are the
same, because insulin either is absent or it's there, but it doesn't work, so the symptoms
are the same.
It's primarily weight loss, frequent urination, as I said, and thirst, and there are
two aspects to diabetes: If it's diagnosed early, and treated properly, the person can have
a near-normal life. I wouldn't say a normal life, because it's a disease, anyway. But if
diabetes is not diagnosed in time, or not treated properly, it can lead to serious
complications, long-term complications, such as blindness, limb amputations, kidney
failure, stroke and many others. And these are very serious complications and, of course,
if you think of kidney failure in the context of Africa, for example, where diabetes is a
big problem, a person who develops kidney failure, is likely to suffer premature death,
because facilities for dialysis are non-existent, not on a large scale.
I will give you a few statistics. You have heard of some of the figures mentioned
here. These are the statistics that were released at the American Diabetes Association in
June, this year. Diabetes affects more than 230 million people worldwide, and the most
recent projections are that by the year 2025, there will be 350 million people affected
with diabetes.
Each year, another 6 million people develop diabetes. And, each year, over 3
million deaths are tied directly to diabetes. And when we say 3 million deaths are tied
directly to diabetes, this is an underestimation, because, especially in developing
countries, many diabetics die before they have been diagnosed, so they don't appear in
those statistics. So the 3 million deaths are an underestimation of the actual mortality
caused by diabetes.
Just to give you an idea of the seriousness of disease, every 10 seconds, a person
dies from diabetes-related causes. Every 10 seconds, two people get diabetes.
The epidemic that we are talking about is primarily type 2, because type 1
diabetes, the prevalence of type 1 diabetes is around 1 or 2 percent, but it's primarily type
2 diabetes. And the current epidemic of type 2 diabetes is caused by increased
urbanization and changes in lifestyles and, in particular, the adoption of a sedentary
lifestyle and dietary changes. Traditionally, especially in the countryside in developing
countries, you don't have the kind of processed foods that we buy in urban supermarkets.
We have foods that are based on starch which is released slowly after ingestion.
But the processed foods that we buy in supermarkets are processed differently, and this is
one of the reasons why we are having the current epidemic. But the changes in lifestyle,
and especially the adoption of a sedentary lifestyle are the major factors explaining the
epidemic.
On top of that, there is the obesity factor, especially in the West. Obesity is a
condition in which the body becomes resistant to insulin and with time a large proportion
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of persons with obesity will develop diabetes. In developing countries, the projections
that we are talking about here don't take into account the obesity factor, which means that
within the next 10 to 15 years, the problem actually will be much bigger than what we
think it will be.
In the particular case of Africa, epidemiological studies were conducted in the
'70s and the prevalence of diabetes at that time was around 2 percent. So when I went to
medical school, we were told that we don't have a big problem with diabetes, and that
was true, based on the figures that were available at the time. But during the last five
years a number of epidemiological studies have been conducted in Africa, and whatever
big city you look at, Dar es Salaam, Yaounde, Kinshasa or others, the prevalence of
diabetes has been around 6 percent.
But, on top of the 6 percent of persons with diabetes, there are 6 percent with
imperfect glucose tolerance, which means these people who have already developed a
certain level of insulin resistance. They are not diabetic yet, but they will develop
diabetes within the next few years. So, if you add those two figures, we are talking about
a prevalence around 10 percent or more, and this is in the general population. If you
consider some professional categories, for example, African executives or members of
parliament, the prevalence of diabetes is twice as high as in the general population. We
haven't looked specifically at the middle class, but you can conclude that maybe it would
be somewhere in between.
Six percent diabetes in big cities in Africa, and there is a clear gradient as you
move from the countryside to semi-urban to urban areas. Six percent is in big cities; in
the countryside, it's still around 2 percent. Six percent is a prevalence that is comparable
to a country like Denmark or the U.S., but the major difference between Africa and the
U.S. or Denmark, is that in the U.S. and in Denmark, they have strategies to deal with the
epidemic.
They have taken the appropriate steps to deal with this 6 percent, and in contrast,
in Africa, nothing has been done on a large scale to prepare for this diabetes epidemic.
Most African countries have not listed diabetes among their public health priorities, and
they don't have strategies for diabetes. So we are facing an epidemic that is on the rise,
but we are not doing anything to prepare for the worst to come, and that's the major
problem that we are having in Africa.
So, five years ago, the International Diabetes Federation, Africa Region, took the
initiative and in collaboration with the regional office of the World Health Organization
in Brazzaville, we decided to develop a regional strategy for Sub-Saharan Africa to deal
with diabetes, and we organized a series of workshops with the participation of as many
countries as possible, English-speaking countries in Zanzibar, Nairobi and Arusha,
French-speaking countries in Dakar, Bamako and Brazzaville.
The outcome of all those discussions over a two, three-year period was a
document that we called "Diabetes Strategy for Africa" and that was circulated the last
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time I came. I believe it was in 2004. This "Diabetes Strategy for Africa" has been
submitted to the regional office of the World Health Organization for endorsement, but as
you all know, WHO is a bureaucratic institution. It will take some time before we get
there, but they are looking at it, and they will eventually endorse it.
It's critical that the WHO endorses this document, because that's the best way to
get it to the various governments in the region. But while we are waiting for WHO
endorsement, we are already working on implementation strategies of this document. We
had a workshop in Nairobi in March, in Brazzaville in April and in Bamako two weeks
ago. So the purpose is to start developing specific plans addressing specific issues in
each and every country, because I don't expect that, at this stage at least, without diabetes
being a public health priority, African countries can come up with a full-fledged diabetes
strategy.
But if we start with some plans, implementation plans, addressing specific issues,
we'll eventually get there. But there are a lot of challenges that we meet in doing that.
There is the poor infrastructure overall. The healthcare system in Africa, in particular, is
not geared for chronic diseases. It's a system that was conceived to deal with infectious
diseases: a person gets sick, goes to the hospital or to the health center, gets treated for a
limited period of time and leaves the system again.
But here we are talking about a chronic disease. Once you get diabetes, it's for
life. Once you get hypertension, it's for life. So these are people who will remain in the
healthcare system for life, and the healthcare systems in Africa are not prepared for that,
so that's one of the things we have to work on, and that's one of the things that we hope
this "Diabetes Strategy for Africa" will help us achieve. The other thing that we are
aiming at while we are waiting for WHO endorsement is to mobilize our governments in
each and every country in Africa to adopt this document. And one target date is the
World Diabetes Congress in South Africa, in Cape Town, in December.
At this Congress, the health minister of South Africa will publicly present this
document, and we hope to get a number of other health ministers involved as well, so that
at least the political level starts taking into account this factor and starts preparing for
getting diabetes on the list of public health priorities.
Concerning the Caribbean countries, a lot has been achieved, and in particular
they have managed to raise awareness of diabetes in the region among policymakers,
among the healthcare professionals and the population at large.
They have done a lot in terms of education and training of healthcare
professionals, but we still have two major problems. One is the lack of qualified
professionals, of course, and the other one is that the persons with diabetes don't have
enough education and are not empowered. And this reflects itself in the large number of
complications that we observe in those regions. In particular, the two complications that
have been mentioned: kidney failure and foot complications.
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We are working with Professor Errol Morrison from the University of West Indies
in Kingston, Jamaica, to try and address those problems, and of course with the Diabetes
Association in Jamaica and other diabetes associations in the Caribbean. One of the
programs that I have been personally involved with is about foot complications.
The Caribbean is the region in the world with the largest – I wouldn't say number
– proportion of amputations due to diabetes. There was a time when Barbados was at the
top. A study in Switzerland showed that it's possible to markedly decrease the number of
amputations only with education of healthcare professionals and the education of persons
with diabetes, and that's the program that we tried to implement in the Caribbean.
The first step is to train nurses, because these are the first healthcare providers
who come in contact with the person with diabetes and his or her family. Train the
nurses and then develop a program for training persons with diabetes themselves, because
there are two aspects. For the nurses and the healthcare providers, it's about treating
existing lesions. And for the person with diabetes, it's about what to do in order to avoid
lesions in the first place, and once the lesions are there, what not to do in order not to
aggravate them.
Foot complications have two major causes. One is a vascular one. It's a poor
circulation of blood in the extremities, especially the lower limbs. And then at some
point in time there is an ulcer that develops itself. And the second cause is a neuropathy.
Because they don't feel the pain, they keep walking, despite the ulcer, and they don't
realize that this ulcer, this particular ulcer, is getting worse and worse, because they don't
feel the pain.
Nurses should be trained to recognize ulcers at an early stage and determine the
appropriate measures in order to avoid aggravation of the lesion. For example, what kind
of shoes the person may use, or may not use, and then training the person with diabetes in
order to take care of his or her foot on a daily basis. These are the two programs that we
have been involved with, and we have also trained a number of podiatrists.
Podiatrists are healthcare providers that specialize in foot care. And these
podiatrists are very important. They are essential in a region like the Caribbean, where, as
I indicated, there is a large proportion of diabetics getting amputated.
That program is still going on, and recently, with the Pan American Health
Organization, we have developed an educational program which is comprehensive, and
of course it takes into account the foot care component. But it's intended for the training
of nurses in the region and ultimately, when the nurses and the doctors are well trained,
then they will be able to educate and train the persons with diabetes.
The diabetes epidemic is an epidemic worldwide, but during the next 10 years, the
most increase in the number of diabetics will be in developing countries. That's why the
International Diabetes Federation has taken the lead and is promoting a project aiming at
having a resolution on diabetes voted by the U.N. General Assembly.
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The initiative was taken last year, the first meeting was in December, and since
the U.N. is an intergovernmental organization, it must be a member state that takes the
issue up for discussion. The government of Bangladesh has agreed to take the lead on
this one, and they will be in contact with you in the next few weeks, if they haven't done
that yet, in order to promote this resolution on diabetes.
What do we expect from the resolution on diabetes? We hope that a U.N.
resolution on diabetes will increase global awareness of diabetes, especially in the part of
the world where the awareness is not like in the U.S. or in Europe. And there will be a
greater recognition of the human, social and economic cost of diabetes. We hope that
with this resolution it will be easier for most countries to put diabetes on the list of public
health priorities, and it will also allow the implementation of cost-effective strategies to
prevent diabetes complications. Because most of the complications that I mentioned here
– blindness, renal failure, amputations and all those complications – are preventable,
provided diabetes is diagnosed early and treated properly.
So it's possible to avoid the high social cost and also economic costs for the
society linked to diabetes by introducing preventive measures, rather than let the
epidemic develop the way it's doing, like in Africa, because then we will pay a higher
price than if we take preventive measures.
Talking about Africa, for example, in the epidemiological surveys that I
mentioned, in each and every epidemiological survey in those countries – Cameroon,
Congo, all of them – 80 percent of the persons who were diagnosed with diabetes didn't
know that they had the disease, so it's only 20 percent who have been diagnosed. It's a
big problem. And those 80 percent will eventually be diagnosed when they report to the
public health facility with complications. Of course, it's too late to do something about it
at that time.
We hope that the U.N. resolution will offer a very good opportunity for
governments to implement strategies to prevent diabetes complications. I'm not saying
it's easy, but it's feasible, because it has been done in Europe and in the U.S., and it will
also allow implementation of strategies to prevent diabetes itself, because type 2 diabetes
is preventable. Type 1 diabetes is not preventable, but type 2 diabetes is preventable, by
changing lifestyles.
I think I will stop there and give it to the audience to ask questions.
AMBASSADOR BROWN: Well, thank you very much, Dr. Ilondo. We will
pass to the period of questions and answers. You can ask your question either in English
or in French. (SPEAKING IN FRENCH)
Madame.
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DR. SHAHINIAN: I'm Dr. Siroon Shahinian. Dr. Ilondo, you spoke of the need,
certainly in terms of the victims who are not well educated and that you are trying to get
training towards them. There is a group here, an NGO labeled the International Health
Network, which does exactly that kind of work. While health professionals are on
vacation in these other areas, they do this work for about two weeks at a time. Perhaps
you could initiate some contact with them. They may not be thinking of it quite as such,
you might say. I've seen a program done by dentists right here at the United Nations, so
that's what occurs to me, for one thing.
But for another thing, I wonder how literacy impacts this as well, not only
education. Are they also illiterate to any extent?
DR. ILONDO: Thank you, Madame. Dr. Wolfson knows the International
Health Network and we will be contacting them shortly.
Concerning the question on literacy, it's a big problem, because most of the time
what we have developed for patient education is posters, and it goes without saying that
these posters are primarily for people who can read. And, most of the time, those people
who cannot read are left out. That's true.
But until we get national strategies to deal with the epidemic, it's difficult to
address that question, because, as you noticed, talking about Africa, for example, we are
still using a lot of energy trying to convince the main actors in countries that they have a
problem with diabetes.
Governments are involved. They understand the problem. That's not the issue.
There is no resistance or anything, but it's just that the public health priorities in our
countries are primarily about infectious diseases: HIV/AIDS, T.B. and malaria. And it's
difficult for them. I understand they have limited resources, and I mentioned lack of
qualified personnel and everything. Before they can take on another public health
priority will take time.
As long as we are still at the level of training doctors and nurses, it's difficult to
deal with the literacy issue. That's a real problem.
AMBASSADOR BROWN: Yes, go ahead.
NDUKU BOOTO: Yes, I'm Mrs. Nduku Booto from the DRC mission. And first
of all, I'd like to thank you, thank the Global Alliance for Women's Health, for organizing
this important meeting, as well as the mission of Niger and the U.N. And, of course, I'm
very glad to see my countryman, Dr. Ilondo, and I want to thank you for that.
You spoke about two types of diabetes. I understand that. I'm wondering if you,
being from the pharmaceutical industry, have addressed something that's very disturbing
for me. I've noticed in many cases in ICUs, people come with certain diseases. They get
treated with different types of medication. It seems to me every time their sugar level
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goes up, the treatment with insulin starts, although the patients, when they came, did not
have a problem with that.
So, how do you address that? Is that another type of diabetes that we start right
there? Or why is it that all the medication tends to have that result that brings the sugar
up? I think that's really a concern. Thank you.
DR. ILONDO: Yes, you are right. That's a special situation of persons who are
admitted to intensive care units. It's an observation that I wouldn't say a large proportion,
but some of these persons admitted to the intensive care units at some point develop
hyperglycemia, so they get high levels of sugars in their blood, and this is irrespective of
the cause why they entered the intensive care units in the first place. It doesn't matter
what the reason for their admission.
Some of them do develop hyperglycemia, so they get these very high levels of
sugar in the blood. And I'm not sure that it's very well understood what causes this, so
we adopt – we, I mean, the medical community adopts a pragmatic attitude. They just
address the hyperglycemia until the person is out of danger, and that's it.
But there is another study that was published not long ago in Belgium, at the
University of Leuven. That study shows that they took two groups of persons in
intensive care units, very serious conditions in both groups. One group was treated with
insulin in order to maintain the level of sugar at a normal level, and the other one was not
treated with insulin.
At the end of the day, the mortality in the group not treated with insulin was much
higher, significantly higher, than in the group treated with insulin. And the conclusion
from this study and similar other studies that have been conducted elsewhere in the U.S.
and Europe, the conclusion is that something happens when people are admitted to
intensive care units. And maintaining the level of sugar within normal limits provides
them with an advantage and facilitates their survival, but I wouldn't go further than that.
So we have data, these are observations, showing that insulin given to persons
admitted to intensive care units is a treatment that will help them survive better, but why?
I don't know.
AMBASSADOR BROWN: Dr. Yamamoto?
NAOKO YAMAMOTO: Yes, thank you very much. My name is Naoko
Yamamoto. I am from the Japanese mission. Thank you very much and Global Alliance
for Women's Health and also, thank you very much, Dr. Ilondo. Sorry, my pronunciation
is so bad. The topics are very interesting.
I have four quick questions based on the presentation. The first question is about
the other chronic disease issues. You've mentioned diabetes. I would like the resolution
to deal with hypertension, also high-cholesterol. Do you want to specify only diabetes?
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Because I'm concerned about the public health systems dealing with the whole
comprehensive health system, this is my first question.
Second question is about the children, especially those with diabetes type 1. Do
you have any specific strategy for the children to be able to control this?
And my third question is based on your recommendations or strategies. Are you
concentrating your activity on relatively high socioeconomic people or do you educate
for all the people?
And my last question is not so appropriate to ask you, but you picked up on Latin
America. Do you have any good observations on the Asia and Pacific regions as well?
Thank you.
DR. ILONDO: Well, thank you very much for your questions. Diabetes is one
among chronic diseases. There is hypertension, there are cardiovascular diseases and
lung diseases, cancer and everything, but it has been difficult to mobilize all the
stakeholders that are interested in chronic diseases. We did try, it didn't work out, and
that's why the International Diabetes Federation made the strategic decision to fight for
diabetes alone, irrespective of whether it's type 1 or type 2 or pregnancy related or
everything, diabetes alone.
But, by doing that, we are aware of the fact that the large proportion of diabetics
in the Caribbean – it's 40 percent – also have hypertension. And most of the diabetes
clinics around the world treat diabetes and hypertension. We are also aware that
cardiovascular diseases are one of the major complications of diabetes. Diabetes is a
major risk factor for cardiovascular diseases.
Having diabetes, the risk of developing heart attack, so to speak, is in persons
with diabetes is comparable to a person who has had a previous heart attack, so they are
at a very high risk of developing cardiovascular diseases. It would have been much
easier if the International Diabetes Federation had succeeded in mobilizing stakeholders
around the heart and lung problems and everything, but they haven't been able to do that.
So this is specifically about diabetes, diabetes alone.
Your question about children: I travel quite a lot in Africa, and one of the things
that is really striking is that there are not that many children around with diabetes. And
then the first reflex when we discuss with colleagues involved is to consider that maybe
there is a different proportion of children with type 1 diabetes in Africa, for example, as
compared to Europe and the U.S. But, because we don't have that statistic, so I cannot
say anything about it, but what we have noticed is that when you start implementing
some specific strategies, then the number of children with type 1 diabetes increases,
which is a clear indication that the fact that we don't see children with type 1 diabetes is
because they are dead. That's the reason. And they are dead because either they were not
diagnosed or they were misdiagnosed or they were not treated properly.
13

They are misdiagnosed because one of the major symptoms of diabetes in
children is dehydration. Dehydration is one of the most common causes for taking a
child to a hospital, dehydration due to diarrhea and vomiting. And the child who
develops type 1 diabetes will quite rapidly go into ketoacidosis, and one of the symptoms
of ketoacidosis is vomiting. So this child will be brought to the hospital with severe
dehydration and vomiting and then he will be considered as having gastroenteritis, and
since the child will not have eaten for a long period of time, he will be placed on
perfusion glucose, 5 percent. And, typically, what they do is to take blood and send to
the central lab and wait for the result.
For the diabetic child with the 5 percent glucose perfusion, the delay in getting the
results is a recipe for disaster. So this is one of the things that happened, and we have
been able to document that. And the other thing that happens is that when they
eventually report to a public health facility in ketoacidosis, they are mistreated. Because
of lack of qualified personnel, most of the doctors who treat these cases are generalists,
and they don't have the necessary skills for dealing with those situations.
But even those who have the necessary skills to treat a child with ketoacidosis do
not have a laboratory to support them, because when you start a treatment with
ketoacidosis, at some point in time you need a lab that follows closely with the results
and everything. They cannot get that, and then they lose many of these children during
treatment.
So we don't have statistics, we don't know how many there are, but we know that
many of them are dead, and only if we start implementing specific strategies to find them,
diagnose them, treat them properly, then after a few years we will be able to find out
whether the incidence and the prevalence of type 1 diabetes in those countries is different
from other regions or not, because we don't know now.
I don't believe there is a difference, because there is no reason for that. And
talking about children, we all know that children in Africa suffer under-nutrition, but,
paradoxically, we have started seeing children, especially in urban areas, who are
overweight, and some of them are even obese. So, with time, type 2 diabetes in children
that we can see in this country and in Europe will become a problem in Africa. It's not
actual, but it's coming.
I talked about the programs that we are developing in Africa and the Caribbean,
they are population-based. It's not specific for certain categories of populations.
Actually, one of the reasons why the civil society, and in particular the diabetes
associations, are very weak in those countries is that most of the time it's the poor people
that you find in diabetes clinics. It's the poor people who are members of those diabetes
associations. Many educated people do not participate in those activities, because they
can find solutions to their problems in private clinics, and some of them can travel abroad
and be treated there.
14

So the programs that we are developing are population based, and, at the end of
the day, it's mostly poor people that we are dealing with, because the others don't come to
those facilities. They don't attend public hospitals.
Yes, I have some data from Asia and Pacific. We have programs in Bangladesh
and in India and in Malaysia. I didn't talk about that, because, well –Bangladesh and
Pakistan have a big problem with diabetes, but the two countries in the world with the
largest number of diabetics are also in Asia. One is India, number two is China. They
both have more than 20 million diabetics.
Of course, it's because they have large populations, but in India the prevalence is
also higher than in many other regions, so it's both the large populations and the
prevalence. And within the next 10 years, China will have more diabetics than India.
And the other big country with the large number of diabetics in the world is Indonesia.
So, out of the 10 countries with the largest number of diabetics in the world, it's only the
U.S. that is in the West. All the others are in developing countries.
AMBASSADOR BROWN: Yes, we had a question here.
LEYSA FAYE: Thank you. My name is Leysa Faye from the Senegal Mission.
Thank you for the very helpful presentation. As you already stated, we know that this
disease affects more developing countries than developed countries and, in my country,
for example, Senegal, we have a very important number of persons living with this
disease, including children. You already gave us examples of treatment and prevention
in the Caribbean.
I don't know if I missed some part of your presentation, but I want to know if you
have the same program in African countries, or how do you think we can fight this
disease? Thank you.
DR. ILONDO: Yes, I thank you for your question. Actually, Senegal is one of
the few countries in Africa with a national diabetes strategy, one of the very few. There
are three.
The big problem we are facing in Africa now is that diabetes is not recognized as
a public health priority. So there is still a major effort to be done on that level. Just to
give you an example, most ministries of health in Africa have a number of directors –
director for HIV, director for tuberculosis. There is no minister of health who is in
charge of diabetes, there was, let's say, in 2003.
We started with that. Now almost all countries in Africa have someone at the
Ministry of Health who is responsible for non-communicable diseases, all of them. That
was the first step. And now that we have a diabetes strategy for the region we have to
develop implementation strategies and select a number of activities that can be
implemented, depending on the country.
15

In the particular case of Senegal, Professor Diop in Dakar has a very good
diabetes center and they are more advanced than many other places on the continent. But
as far as I am aware of, they have a program for foot care, treatment and prevention of
foot care complications, but there is no African country that has a program for prevention
of diabetes. Prevention of foot care complications is available in Senegal, yes.
I know that there's one in Dakar. I wouldn't say about what happens in the
countryside. That's something different, but in Dakar, it's Diop.
AMBASSADOR BROWN: Yes, sir, you had a question?
ABDUL ALIM: My name is Abdul Alim. I am from the Bangladesh mission.
First of all, I would like to thank the distinguished moderators, Mr. Kenneth Brown and
Ousmane Moutari. The Bangladesh delegation would also like to appreciate the
permanent mission of Grenada and Niger for co-hosting this briefing.
The severity of this disease has been well articulated by the distinguished
presenters. Ambassador Abani has very correctly stated that by the year 2000, 171
million cases were detected, and every year another 7 million are being added to the list,
and 3 million are dying.
The presentation of Dr. Ilondo was really illuminating and very informative. In
Bangladesh, as he has mentioned, diabetes is a big problem. Now we have around half a
million affected people, including my own father-in-law. I am not an expert on this issue,
but as an economics graduate, I know the huge economic and social costs of this disease.
It does not only affect the productivity of the affected people, but also imposes
huge costs on the government exchequers in terms of treatment and care. One study has
shown that in developing countries, around 40 percent of the total healthcare budgets are
being spent for treating this disease.
So, at this point in time, the Bangladesh delegation would like to flag two things.
And number one is treatment. As I have said, this disease entails huge costs and burdens.
Although this disease itself is not very serious, the offshoots are multifaceted. The body
becomes vulnerable and the people become affected with many other diseases, as Dr.
Mapoko has very correctly pointed out.
Thus the treatment also requires very specialized types of management, including
the consultants, nurses, medicines and equipment. So for developing countries it is
extremely difficult to arrange all these things for these diseases, so what we need is both
financial and technical resources to address this big challenge.
Number two that I would like to flag is the prevention, which is related to health
education and awareness building that can result in huge awareness among the
population, which ultimately can prevent the spread of this disease. We know that World
16

Health Organization and the International Diabetes Federation is working on this issue,
and there is a day, which is 14 November, observed as the World Diabetes Day.
Bangladesh strongly feels that the U.N., as an apex of multilateralism, is the right
forum to discuss this issue, to build awareness and conscience of the people to halt the
spread of this disease. And we are working on this issue with the interested delegates and
International Diabetes Federation, we are working on the possible elements for a draft
text. Our foreign minister has already written a letter to all his counterparts. We have
circulated it here in New York and we are receiving many interests from a number of
delegates, so once the draft elements are ready, we will certainly circulate it to all
members here. And we hope that a resolution on this issue will be adopted by consensus.
Thank you.
AMBASSADOR BROWN: Thank you very much, obviously a very important
measure that you're pursuing. If we have no other questions, I'll ask I think the final
question, then we'll wrap it up.
Do we have one here? Yes, good. Please.
UNKNOWN: Thank you, sir. I'm going to speak in French. (SPEAKING IN
FRENCH)
DR. ILONDO: (SPEAKING IN FRENCH)
AMBASSADOR BROWN: Dr. Ilondo, would you just do a brief, very quick
summary of your response?
DR. ILONDO: Yes, the question was specifically about Cameroon. I told her
that all the initiatives that I mentioned about Africa are coordinated. We have four to
coordinate those initiatives, and one of the four persons is from Cameroon. This person
is Jean-Claude Mbanya from the University of Yaounde. He is vice president of the
International Diabetes Federation at the international level and Cameroon is quite well
advanced.
They have what I wouldn't call it a national program, but at least they have
activities going on. They started with an epidemiological survey, and then they
developed a set of implementation strategies that have been taken over by the Ministry of
Health, so it will develop into an international program. And one major activity that they
are working on now in Cameroon is to look into attitudes and behaviors, because it's true
for Africa, it's true for the Caribbean as well, people are not used to the notion of a
disease that cannot be cured, because we are used to getting infectious diseases. You get
malaria, you get an infection, you go to the hospital, be treated, and after a certain period
of time the person is cured.
17

Now they are faced with a disease like diabetes, where they are told that this
disease cannot be cured. And then what typically happens is that the person visits the
healthcare facility and once they tell him that we cannot cure diabetes, they conclude that
this is a failure for the Western medicine, as they call it, and then they go to the
traditional healer, stay with the traditional healer for some period of time and then come
back to the hospital to get amputated.
So now one of the issues that they are working on in Cameroon is to study how to
address that particular aspect of a chronic disease in the context of the populations.
AMBASSADOR MOUTARI: There is one question. I think she asked a
question concerning the contents of the resolution to be presented at the General
Assembly and Dr. Ilondo referred her to the Bangladeshi mission, so maybe he can
answer that.
MR. ALIM: Thank you for this specific question. Actually, we are working on
the draft text. The main focus of this text will be announcing 14 November as the World
Diabetes Day in the United Nations and for this type of international day, we have no
other substantive elements. There will be some preamble or paragraphs, and that would
highlight the severity of this disease and the operative paragraph's main focus would be
announcing the 14th
of November as the World Diabetes Day. And there would be some
aegis to the U.N. agencies, U.N. funds and programs to observe this day, and there will
also be some aegis to the member states to highlight the days in a befitting manner and
highlight in such a way so that it could get focused attention by the wider scale of
populations and it reaches to the remote levels so that everybody gets acquainted with
this disease and how to prevent this disease.
AMBASSADOR BROWN: We'll take a final question.
DIVINA SEANEDZU: Thank you very much for giving me the floor. My name
is Divina Seanedzu and I'm from the Ghana Mission. My delegation also wishes to
express its appreciation to the main organizers of this meeting and also to Dr. Ilondo for
the briefing. Just as a matter of interest, is this disease skewed towards women?
Because, of course, we have certain diseases that are gender based now, so is it skewed
toward women?
Thank you.
AMBASSADOR BROWN: A good person to perhaps address that, Dr. Ilondo, if
you want to? The final word will be by Dr. Wolfson, but perhaps first, Dr. Ilondo.
DR. ILONDO: Yes, well, based on the available statistics, there doesn't seem to
be a difference between men and women in terms of prevalence of diabetes. Ninety
percent of diabetes is caused by type 2, and only 10 percent by type 1, but there is no
disproportion between men and women. But it just happens that when you look at the
cardiovascular complications, for example, because as I mentioned, diabetes is a major
18

risk factor for cardiovascular complications, there seems to be more women than men
with these cardiovascular complications. Women have additional risk factors for the
same complications. But there are some countries in the Caribbean, and also Mexico,
where diabetes is the leading cause of mortality among women.
AMBASSADOR BROWN: Dr. Wolfson, you have the final say.
DR. WOLFSON: Thank you very much for bringing up a very important point,
which is we at the Global Alliance support the efforts of the International Diabetes
Federation and Bangladesh and the countries that want to move a U.N. resolution, but we
want you to remember that gender must be put back into the agenda of this issue. There
are components that do suggest that women's health must be addressed in addition to the
aggregate addressing of diabetes in general.
And I don't want to labor the issue – we talk about this often – but I really
appreciated your question and your comments, and I want to just remind you of one other
aspect. Most of the care giving, the first responders in terms of health, are women, in
terms of their families, in terms of their children, their spouses, their parents, their in-
laws. So diabetes has a double whammy effect for women, not only those who become
patients and who have diabetes, but women who generally oversee the care in the family.
So, as we move internationally and nationally to programs of education and
prevention, it would be very helpful to target women who convey much of that basic
information before they get to the professional establishment in terms of nutrition and
exercise, et cetera.
These issues, of course, run across many different conditions, both infectious and
chronic, and so we at the Global Alliance feel that we have to proceed in pushing these
issues from disease and condition as we move along and as we begin to see the world
addressing health issues as an important part of life, development and developing
countries.
I want to thank all of you for coming on this hot summer day. I want to thank all
of the missions for coming and participating, and if you would like us to help the
continuity of this network, we would be delighted if you would leave your contact
numbers with us, and we will work with Dr. Ilondo and the others and Bangladesh in
keeping you informed and directing you to those people. We will be happy to facilitate
that.
I look forward to seeing you again, and thank you, once again, and all of the
participants and the staff at the Global Alliance – Alice Shiller, Caroline McHugh, who is
in South Africa right now and Anne Neumann. This event would not have taken place
without their efforts.
Thank you very much.
19

Second Session, Latin America
ELAINE M. WOLFSON, PH.D.: The Global Alliance for Women’s Health with
our corporate partner Novo Nordisk and with our public donors helped to facilitate and
organize this program. We've been working on women's health issues since 2003, and
actually submitted a statement to the commission on the status of women in 2005 to
address diabetes and women's health. And, currently, there is an effort by the
International Diabetes Federation to address a U.N. resolution on diabetes in the world.
So we have been working with a number of actors to create visibility and
awareness about diabetes internationally, and particularly at the United Nations, among
diplomats and member states. We're delighted that you were able to make this session
today, but I regret to have to say that our speaker from Argentina was unable to come.
The weather yesterday was very bad, and at the last minute we were unable to get the
translation or the interpretation services.
So I don't know if any of our speakers speak Spanish, but perhaps some of you
can come and fill the gap, if it's needed. I'm afraid that we will indeed be talking in
English, predominantly.
I'm very pleased that we have had so many permanent missions come this
morning, and we have several this afternoon, and I'm very pleased to introduce
Ambassador Ken Brown, who is a member of our advisory board, as is Dr. Ilondo and
Ambassador Moutari.
Ambassador Brown.
AMBASSADOR KENNETH BROWN: I'm also treasurer of the Global Alliance
for Women's Health. I've been associated with Dr. Wolfson for a long time and know the
important work that the Global Alliance has been doing. And my function today is really
a limited one, but a pleasurable one in that I have the opportunity to introduce one of our
speakers, Ms. Marguerite St. John, who is a counselor of the Permanent Mission of
Grenada to the United Nations, and formerly a member of the staff of the Grenada
Embassy to the United States in Washington.
Ms. St. John.
MARGUERITE ST. JOHN: Thank you very much. I would just like to welcome
everybody, and it was an honor cosponsoring this event, because diabetes is a major
problem in the Caribbean area. This meeting comes at a time at the heels of our
CARICOM heads of government meeting, and one of the big issues that arose from that
meeting was the matter of diabetes, hypertension and heart attack in the Caribbean.
20

Diabetes deaths are said to be 10 times higher than that of HIV/AIDS, so that in
itself is a big problem for the Caribbean. The incidence and prevalence of diabetes in
Grenada and throughout the Caribbean region has been steadily increasing over the years,
especially among women over the ages of 50. This and high costs of treatment of both
disease and its related complications, such as renal failure, circulatory problems, eye and
podiatry problems, remain a high concern to the governments, because they also pose a
major financial burden on the economy.
We are hoping that today's discussion does not end here, but that it will foster a
lasting relationship, both with the Global Alliance for Women's Health and other U.N.
agencies in addressing this global problem, so we do look forward to the discussion and
also we'd like to applaud the Alliance for this initiative.
Thank you.
AMBASSADOR OUSMANE MOUTARI: Thank you very much, Madame. I
am Ousmane Moutari. I'm from Niger, a West African country, former diplomat from
Niger. I'm now a consultant and a member of the Advisory Board of the Global Alliance
for Women's Health.
I will have the honor now, and the privilege, to introduce one of our best
specialists on Diabetes, Dr. Mapoko Ilondo, who is originally from the Democratic
Republic of Congo and now living in Denmark, working with Novo Nordisk, which is
one of our best partners in advocacy on diabetes and on other diseases.
Dr. Ilondo has been working with the Global Alliance in previous years, and he
will now explain why diabetes should be considered one of the most important public
health issues.
Dr. Ilondo, you have the floor, please.
MAPOKO MBELENGE ILONDO, M.D., PH.D.: Thank you, your Excellencies,
ladies and gentlemen.
Diabetes has reached epidemic proportions all over the world. I have a few
statistics here that were released at the last meeting of the American Diabetes Association
in June. Diabetes affects more than 230 million people worldwide, and the projections
are that this figure will increase to 350 million by the year 2025.
Each year, 6 million people develop diabetes. Each year, 3 million deaths are tied
directly to diabetes. Every 10 seconds, a person dies from diabetes-related causes. Every
10 seconds, two people get diabetes. So it's a big problem, and maybe I should start by
defining the condition.
There are two types of diabetes, type 1 and type 2. Type 1 is caused by a
complete lack of insulin, so the body does not produce insulin at all, and we need insulin
21

in order to assimilate everything that we eat. And, in the absence of insulin, sugar
accumulates in the blood and is eliminated through the kidney.
Elimination of sugar is accompanied by a lot of water, so the subject becomes
dehydrated and in order to compensate for that loss of water, the subject starts drinking
enormously. And, of course, there is a loss of weight, a major loss of weight. In some
conditions, even more than 10-kilo weight loss. So irrespective of whether it's type 1 or
type 2, the main symptoms are weight loss, frequent urination, thirst and tiredness.
There are two aspects to diabetes. One is that if the disease is diagnosed early and
treated properly, the person can have a near-normal life. But if the disease is not
recognized or is not treated properly, then it may lead to serious complications, long-term
complications, such as blindness, limb amputation, renal failure, stroke and
cardiovascular complications.
These complications of diabetes, which are very serious, are relatively easy to
prevent, but this needs that specific programs are in place in order to prevent the
complications. And, needless to say, treatment of complications is very expensive and
prevention of complications is much cheaper than treating them.
The current epidemic of diabetes is caused by rapid urbanization, with people
moving from the countryside to big cities and the changes in lifestyle that accompany
urbanization and, in particular, the loss of physical activity, people adopting a sedentary
lifestyle, and also dietary changes, especially consumption of processed foods like the
ones that we buy in supermarkets also contribute to the epidemic. But the most important
factor is the lack of physical activity.
In the particular case of Latin America, 10 years ago, governments and health
ministers and all stakeholders involved in diabetes adopted the Declaration of the
Americas, DOTA. And the Declaration of the Americas developed a very good action
plan addressing most of the issues linked to diabetes, and if we look back at what has
been achieved by DOTA during the last 10 years, we can see that there is increased
awareness of diabetes among policymakers. There is increased awareness of diabetes
among healthcare providers, and there are a lot of doctors who have been trained through
those programs.
But there is still much that needs to be done in Latin America. Most of the
countries in Latin America are developing countries, like as well in Africa and Asia.
There is not enough qualified personnel, I mean specialists, for treating diabetes, so that
most of the care has to be ensured by general practitioners. And in that context, nurses
become very important, as they are the first line of contact with the patient.
There are three important problems that we have met during our work in Latin
America in relation to diabetes. One is the lack of systemized programs for the training
and education of healthcare professionals, and the second one is the lack of programs for
education and empowerment of persons with diabetes, because diabetes is a chronic
22

condition and visiting the doctor once every three months or once every six months will
not help them solve their problem. These are people who need to be fully educated, fully
aware of their conditions, so that they can make the necessary decisions on a daily basis.
Personally, I have been involved with some activities in El Salvador and in
Central America as a whole, and in the future we will be involved with activities in
Mexico and in the Andean regions, Bolivia, Peru and that region. And I can talk about
some of the aspects of the programs that we have developed.
In the particular case of El Salvador, they have a national diabetes program, at
least a draft. But that program has not been launched, because the government doesn't
have the necessary resources for implementing the program. And that illustrates one of
the difficulties that we have in developing countries in general, and in Latin America in
particular.
Most of the resources on health are directed towards infectious diseases, and there
is very little resources left for non-communicable diseases. So when a government has to
add one additional public health priority to what they already have, then they first look at
the resources at hand, and if they feel that they don't have enough resources to embark on
a new initiative, then they prefer not to start with that initiative. And that's what
happened.
So because DOTA has been working with these governments closely for many
years, some of them, like the one in El Salvador, has developed a national diabetes
strategy, but that strategy has remained in a draft format for many years. And it has been
very difficult to convince the authorities that there are ways to start implementing these
programs, step by step, because governments tend to think in terms of the whole country,
in the first place. They don't want to start with a pilot program in one place. They want
to start with all the regions at the same time, which is quite understandable.
And then the other thing is that because most of the specialists in the particular
case of El Salvador are concentrated in the capital, then nothing of significance can be
organized outside of the capital. But in order to circumvent that difficulty, we partnered
with the Diabetes Association of El Salvador, which is a patient organization, and with
them we started organizing educational programs for persons with diabetes and their
families, with the purpose of raising awareness of the treatment of diabetes and how to
prevent the complications among these persons who are directly exposed to the disease.
Also, using those activities to raise awareness of diabetes among the general population.
This has worked quite well, in the sense that we can see now that – we don't have
the final statistics yet – there is a clear effect on the level of complications, and the Pan
American Health Organization is looking into that. They call it quality of care. They are
looking at the quality of care, trying to compare the results before and after these
educational programs to see what the education of patients actually has brought to their
treatment.
23

And those results are very important, because in Latin America diabetes educators
are not recognized as healthcare providers. Diabetes educators are not doctors, they are
not nurses, but it's another category of personnel. So far, it's private organizations like
diabetes associations and others, like ALAD, who have been training these people. But
they are not employed by the government, because it's very difficult to categorize them
within the healthcare system.
But when we get these data from a quality of care study that is being done in
several countries, including Nicaragua, Guatemala and Mexico, then we hope that the
results will convince governments that if they want to improve the outcome of diabetes
care in their countries, they need to find a solution to this problem of diabetes educators.
That's one problem that we have specifically in that region.
But in the particular case of El Salvador, the program we conducted with the
diabetes association has finally convinced the government that it's appropriate to start
implementing their national plan stepwise instead of waiting for the implementation of all
aspects of the plan at the same time.
You know that El Salvador is a country prone to earthquakes and one of these
earthquakes actually had serious consequences on the National Hospital, Rosales, and the
Diabetes Center was not the only one to suffer from that. And subsequent to that natural
disaster, what happened was that the persons with diabetes admitted to the national
hospital were kept in separate departments depending on the complications that they had.
For example, in surgery when it was foot complications or in cardiology, or elsewhere.
So, what happened in the long run is that, for example, when they had a wound,
that wound was taken care of, but the diabetes was not evaluated. And this was a
complete waste of time, because you can treat a wound as good as you want. You can
have a good surgeon and everything, but as long as the basic problem that caused that
wound in the first place is not taken care of, nothing will happen.
So, after renovating the Diabetes Center, what will be done – and the reason I'm
talking about this project in El Salvador is it's considered a pilot that would be extended
to other countries in the region. Then this Diabetes Center will be the focal point where
all persons with diabetes admitted to the hospital will remain, where the diabetes will be
controlled. And then the various specialists involved, whether it's on foot care or heart
complications or renal failure, will come and visit the person at the diabetes center.
In this way, we expect that the outcome will be much better than what have had in
the past. The other specific problem that we have had in Latin America is the fact that
the civil society is very weak. It's general. It's the same problem in Africa, as well, but in
the particular case of Latin America, although they have this International Diabetes
Federation, SACA region – SACA, South America, Central America – and it's
specifically for Latin American countries. They subdivided the federation in two parts
based on language. The SACA is primarily Spanish, and the North America, Central
America, is for English speaking – Caribbean.
24

One major problem in that region is that this particular federation, the
International Diabetes Federation, SACA, is not very functional. It's very weak, the main
reason being that it's a patient organization, and it's managed by persons with diabetes,
whereas many other diabetes associations are managed by healthcare professionals. I
don't know why. I haven't seen this in Africa. I have seen this in some parts of Asia, but
this is very strong in Latin America, this kind of antagonism between healthcare
professionals and persons with diabetes when it comes to the actual management of the
diabetes association.
But we are working on that, and hopefully it will be solved soon. So the major
problems, as I said, we have two major problems, still – no, three. One is the lack of
qualified personnel. The other one is the lack of clear status for diabetes educators, and
the third one is the lack of programs for education and empowerment of persons with
diabetes, and this third problem is made even more difficult because of the – I would call
it antagonism between healthcare providers and persons with diabetes, not in the clinics,
but in the management of diabetes organizations.
During the last six months, the International Diabetes Federation has been
promoting this project of getting the U.N. General Assembly to pass a resolution on
diabetes, and I personally believe that the resolution on diabetes will be a very good thing
for Latin America, in the sense that it seems as if the efforts that were launched by DOTA
are not being sustained.
People are getting tired with what was initiated, and this will be a very good
opportunity for them to relaunch the process and then regain the initiative, and then move
forward. What the resolution hopes to achieve is the following: an increased global
awareness of diabetes, a greater recognition of the human, social and economic burden of
diabetes. And we hope that diabetes will become a health priority in the individual
nations, which it is not currently, except in Mexico, which declared last year diabetes as a
public health priority because diabetes has become the leading cause of mortality in
women in Mexico. And we hope that the resolution will be a good opportunity for the
implementation of cost-effective strategies to prevent diabetes complication, and also a
good opportunity for developing public health strategies for the prevention of diabetes
itself, because type 2 diabetes, not only the complications, can be prevented, but type 2
diabetes itself can be prevented as well.
One last difficulty when dealing with Latin America is the lack of funding for
activities on diabetes. We have had difficulties mobilizing funding for diabetes projects
in Latin America, and I have noticed that in all the compacts that we have had with
governments in the U.S., in Europe and international organizations that are funding
health products in developing countries, it has been very difficult to make them
understand that diabetes is a problem for developing countries.
They do understand, for example, in the particular case of Africa, people
understand that diabetes is a big problem for African Americans in the U.S., but they
25

don't understand that this is a problem for Africans in Africa, as well. So it's very
difficult to get that message across. So this kind of resolution I hope will be something
that we can use when dealing with those organizations to make them understand that
diabetes is a big problem in developing countries, and in particular in Latin America, and
hopefully mobilize the necessary funding for programs in that region.
I think I will leave it there and open for some questions.
AMBASSADOR MOUTARI: Thank you very much, Dr. Ilondo. So now we
will start the questions and answers. Please, if you wish to ask a question, you will first
give us your name and tell us which country are you coming from, so that we can get it
on mike. Does anybody want to ask a question or make a comment, or observations?
MELANIE SANTIZO: Hi, I'm from the Mission of Guatemala. My name is
Melanie Santizo. Thank you for your presentation, but I don't understand what type 2
diabetes is.
DR. ILONDO: Type 1diabetes is due to complete lack of insulin, and type 2
diabetes is due to the organism becoming resistant to insulin. The body becomes
resistant to the action of insulin. Insulin is produced, but it doesn't work.
MS. SANTIZO: Type 2 is the one that's preventable.
DR. ILONDO: That is the one that is preventable by changing lifestyles and by
physical exercise.
MS. SANTIZO: Thank you.
DR. ILONDO: It's preventable and, also, it's evolution can be controlled.
MS. SANTIZO: OK, thank you.
AMBASSADOR BROWN: I have question.
Dr. Ilondo, you said in a separate conversation that there was a problem – well,
first of all, you stressed the importance of training nurses to recognize the symptoms of
diabetes, particularly the lesions on the feet, and you said that it was important, therefore,
to train those nurses, and that it was also important to sensitize doctors to accept this role
of nurses, that African doctors tended to be reluctant to do that. Is that a problem in Latin
America, and, in general, how can one address that problem?
DR. ILONDO: Yes, it's a problem in Latin America, as well. Given the level of
care in Latin America, which is slightly higher than in Africa, in the context of diabetes,
what we are working on in those countries is to get healthcare providers to work as a
team. And that hasn't been easy, because doctors have some prerogatives, and they feel
that if nurses would start doing some of the things that the doctor has traditionally done
26

they would be delegating part of their authority. And it takes time before they understand
that when the nurses are trained, actually it facilitates the work for everyone involved, for
the entire team. But it takes time before we get there. Yes, we have the problem in Latin
America, as well.
BELEN SAPAG: My name is Belen Sapag. I am from the Third Committee,
health affairs and social affairs from the Permanent Mission of Chile. I thank you very
much for this briefing. It's been very useful and it affects me very personally because
both my parents have diabetes, and they have been very lucky, because they received
very good health support from the private Chilean health system. Chile now is also
enforcing the public prevention programs.
I would like to ask you, regarding the matter of the declaration, Chile is
supporting it, obviously, but we would like to know whether you're also working with
congressmen in Latin America because I think it is important to raise the conscience of
legislators. The legal system in many countries of Latin America contemplates norms
regarding the health care givers and the supporters of the health system such as medical
doctors, nurses and other health care givers to establish responsibilities and duties for
certain professions. It is also our Congress that approves the budget for the Ministries
programs.
We believe that it is very important to promote these initiatives, such as the Day
for Diabetes, in Congress, so we encourage you to contact legislators, especially those in
the Health Committee of Congress in order to inform them about diabetes in women.
I would like to know if you are you working with programs regarding media? In
Chile we're working with tobacco, so prevention is being gradually included through
television programs, such as soap operas or news.
Are you working on that? Because I think that it is of great interest for us in Chile
for the public health programs that we're working on.
DR. ILONDO: Well, concerning your first question, in the framework of the
resolution, we are organized in such a way that there are groups representing various
regions in the world. For example, there is a group for Africa in the Middle East. There
is a group for Latin America, and there is a group for Southeast Asia. And that group that
is in charge of Latin America is the one that is supposed to contact the local politicians
and discuss the problems with them and find appropriate ways of getting the message
there.
What we are doing here is to speak to agencies like this one and try to get the
message to as many diplomats as possible, hoping that they will provide feedback to their
home countries, and in this way we can spread the message around. So it's the group
responsible for a given region, in this case Latin America, that will be in contact with the
politicians. And that group will coordinate with the group in Central America and North
27

America, and the coordinator of the three groups is a director at the Center for Disease
Control in Atlanta (CDC Atlanta).
DR. WOLFSON: I'm sorry to jump in, but I thought perhaps you also were
talking about the declaration in Latin America?
DR. ILONDO: I was talking about talking to the congress.
DR. WOLFSON: The Chilean?
MS. SAPAG: No, I think it's two issues.
DR. WOLFSON: Two issues?
MS. SAPAG: To create a consciousness, we believe that it's important to get into
it, because for the structure of Latin American democracy, congress is very important, it's
a key factor in the implementation of health politics. Regarding the problem with the
lack of specialized care givers authorized for giving certain treatments, you know there is
a different responsibility awarded to medical doctors, nurses and caregivers, medical
doctors have strict ethical codes offering a certain guarantee of good practice to the
patient and the system.
DR. ILONDO: OK.
AMBASSADOR MOUTARI: Now, for the resolution, you're saying that the
Chilean delegation will support this resolution. We also have other countries. I think
Bangladesh will be initiating the resolution, so if you could get in touch with the
Bangladeshi mission, either directly or through the Global Alliance for Women's Health,
we can help work it out.
DR. WOLFSON: Yes, I have a question. I'm so very pleased to find that there
are so many women here who are interested in health, and many of you who are on the
Third Committee. And I want to throw this question out, to hear your response, see
whether, in addition to diabetes, whether within the Third Committee you think there is a
core of people who would like to work on general health issues that we could help
facilitate. We would start with diabetes and this resolution and perhaps hold meetings or
luncheon meetings, and then try to see if there is a core group that we could then in
subsequent years take to visit other aspects or diabetes or other diseases and conditions.
What is the possibility for that, in your judgment? I'm asking the audience, rather
than asking Dr. Ilondo?
AMBASSADOR BROWN: Focused on women or...
DR. WOLFSON: Well, in the Third Committee, since the Third Committee
addresses health at the United Nations, it seems to me that there are issues that come up
28

sometimes, episodically, every two or three years, but I think there are core groups that
are really interested in health, and I'm wondering whether or not we could help facilitate
their meeting and developing that network and perhaps kicking it off with diabetes and
this U.N. resolution.
Well, think about it.
MS. SAPAG: We spoke before the meeting. President Michelle Bachelet’s
Presidential Program is encouraging initiatives regarding public health. We are lucky to
have a president who is herself a medical doctor and a former Minister of Health. So we
are very pro this initiative and we will be supporting you with the diabetes resolution to
be presented by Bangladesh, yes.
AMBASSADOR BROWN: One other thing I wanted to bring up.
Dr. Ilondo, you talked about the lack, or the low number, of national plans in
regard to diabetes. Would you elaborate a bit on the importance of the national plan and
how many countries either do or don't have a national plan on diabetes?
DR. ILONDO: Thanks. National plans are especially important for developing
countries. If we take an example in Africa, the priority in all public health programs is
about HIV/AIDS, tuberculosis and malaria. So, without a high-level initiative in the
country, there will be nothing systematically done on diabetes or cardiovascular diseases
or anything. We have tried, on many occasions, to take up the discussion at the Regional
Council of WHO, for example.
They wouldn't take up an issue that hasn't been submitted by several countries at
the same time, but it's very difficult to get ministries of health from different countries to
come up with the same priorities at the same time. That's why we have opted for national
diabetes strategies, because once we have draft national diabetes strategies, then it's easier
to focus the attention of the health ministry on one specific problem.
In the particular case of Africa, there are only three out of more than 40 countries
that have a national diabetes strategy, just to give you an idea. In Latin America, most
countries don't have a national diabetes strategy, but they have a regional strategy as part
of this Declaration of the Americas. So countries that don't want to engage themselves
prefer to rely on the DOTA program, so to speak, so that they don't have to take the next
step and then develop a plan themselves.
But, to answer the second part of your question: how important is a national
diabetes strategy? I would say it depends on the circumstances, because Denmark doesn't
have a national diabetes strategy. But Denmark spends I don't know how many billions
on health, so I'm sure that they are wasting a lot of money on diabetes because it's done in
an uncoordinated way.
29

Developing countries don't have that luxury of overspending in an uncoordinated
way. And, given the limited resources that they have, it's to their advantage to have a
plan.
For example, in Kenya, we noticed that in the main hospital in Nairobi, the Jomo
Kenyatta Hospital, on January 1st
, when they made their plans, diabetes and
cardiovascular diseases are considered as a minor condition. But on December 31st
, when
they look at the overall spending during the year, they had used 40 percent of their
resources on these two diseases, but they had not planned to do so. And these funds were
used for treating, amputations and all those serious complications.
If they had planned ahead, they wouldn't have had to deal with all those
complications, and they would have spent much less money. So that's why it's so
important, and they know, governments can see it. But if they would have a national
health plan, then it would be much easier for them to add diabetes as a priority, because
that plan would help them spend much less than what they are doing currently.
CONNIE TARACENA SECAIRA: I am Connie Taracena, from the Mission of
Guatemala, too, and I would like to add my voice to all those to thank you for organizing
this event.
I don't know if I understood right. Is Bangladesh going to be in charge of the
resolution?
DR. WOLFSON: If you'd like to contact them, we can help. The representative
from Bangladesh had another meeting, otherwise he would have been here this afternoon,
but he asked me to speak on his behalf. He's interested in working with many countries,
and that he will be happy to contact and develop the work program with you.
MS. TARACENA SECAIRA: I don't know if I have it right, but is China having
something on public health, a resolution on public health? There's nothing related that
will be issued to insert a paragraph on diabetes, or the idea is just to have a whole new
resolution on this?
DR. WOLFSON: Yes, we're talking about a separate resolution. I'm not aware of
a Chinese resolution.
LUCIA MAIERÁ: Thank you. My name is Lucia Maierá. I'm from the Mission
of Brazil. Thank you very much for your very informative presentation, and my question
regards the general strategy for diabetes. I understand that you're working on two bases,
one, aiming for contact with different countries, and you have three different groups
working with three regional groups. And now you are working also with the U.N., trying
to raise the awareness for the danger of diabetes.
At the mission, we already received a draft from the Bangladesh mission. It's a
short resolution, which proposes one day for diabetes. Is that the one? Yes?
30

DR. ILONDO: It's the third level. You mentioned two levels here at the U.N.,
the contact with the different countries, and the third level is at the grassroots
organizations, national diabetes associations mobilizing people within the country so that
they can influence policies within their own country, is the third level.
DR. WOLFSON: I don't know if you got this program. We did not include the
resolution, but presented a statement that the Global Alliance offered to the commission
on the status of women in 2005. It has not been taken up, but I think there might be some
language you might find interesting with regard to women and diabetes. And perhaps
there's a way of expanding the resolution from Bangladesh, including parts that would
address gender issues, women as healthcare providers in the families and so on and the
fact that they suffer from at least as much diabetes, and in some situations, as in Mexico
and many other countries, they actually suffer greater levels and incidence of diabetes.
In addition, Dr. Ilondo, could you tell us something about women and heart
disease and diabetes?
DR. ILONDO: Well, a person with diabetes is at risk of developing
cardiovascular diseases, and the chances of having a heart attack is comparable to that of
a person who has previously had a heart attack. You know that after a first heart attack
the probability of getting a second or a third heart attack is higher than in a normal
person. So a person with diabetes is comparable to a person who has already had a heart
attack, which means that the risk of developing heart complications is much higher in a
diabetic person than in a normal person. Although there is no difference in the
prevalence of diabetes between men and women, the fact that women have additional risk
factors for cardiovascular diseases makes them more susceptible to that kind of
complication.
So, if you look at the number of diabetics, there is no major difference between
men and women, but if you look at heart complications, there is more among women as
compared to men, because of these additional risk factors for cardiovascular diseases in
women, as compared to men.
DR. WOLFSON: Are there any other questions?
Well, we thank you very much for coming and for joining with us, and we hope
that we can help facilitate the resolution from the point of view of an ECOSOC NGO,
and from the point of view our history of partnering with public and private sectors so
that we could hold additional meetings on this.
Please feel free to contact us if you need further information, and we will follow
up with some information for you in about a week or 10 days, telling you of additional
things that are happening vis-à-vis the resolution. Moreover, there is a Web site on the
resolution that you can check and follow. I think it's on the page in the program that says
31

"Campaigning for a U.N. Resolution." At the bottom, you will find the citation for
"Unite for Diabetes" Web site that is available, too, that's addressing the resolution per se.
Therefore, I thank all of you. I thank our speakers and I want to thank the staff of
the Global Alliance for Women's Health. In particular, Caroline McHugh who is in
South Africa, Alice Shiller who is sitting at the desk and Anne Neumann, for their tireless
work in putting this program together. It would not have happened without them, and we
thank you very much for joining with us and coming today to talk about the diabetes
epidemic.
Thank you.
32

Proceedings_from_First_Diabetes_Briefing-13_July_2006

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