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The Global Diabetes Divide: Bridging the Gap with Ethics, Economics and Digital Health

October 2, 2023

As diabetes continues its insidious proliferation across the globe, especially in developing economies, there is an urgent need to re-evaluate how we approach its management and containment. While the stock prices of pharmaceutical giants like Novo Nordisk and Eli Lilly soar on the back of innovative weight loss therapies paint a picture of commercial success, they also spotlight an ethical imperative: the reinvestment of profits into global access programs for life-saving medications like insulin. This is not merely an issue of healthcare; it’s a confluence of public health ethics, economics, and emerging digital technologies.

As we delve into the complexities of diabetes—exploring everything from genetics and lifestyle changes to public-private partnerships (PPPs) and the promise of Universal Healthcare (UHC) —we’ll examine the potential for a paradigm shift. A shift where advances in medical treatments and digital health technology are harmonized to create sustainable solutions, saving millions of lives and potentially boosting emerging economies.

Diabetes, a lifelong disease that can be complex to manage, is becoming one of the developing world’s most prominent killers. The problem is shaped by sporadic access to insulin, a life-saving medication vital to the survival of those with type I diabetes (T1D). Insulin access across lower-income countries could soon receive a major boon – on the condition that the companies producing insulin are willing to invest more in access.

In recent months, two partnerships with African generic drug manufacturers have been announced to increase access to insulin in Africa. In August 2023, Novo Nordisk announced a contract manufacturing agreement with Aspen Pharma South Africa. Aspen will manufacture Novo Nordisk’s human insulin at its sterile manufacturing facility in Gqeberha, South Africa. In December 2022, Eli Lilly announced a licensing agreement with Eva Pharma of Egypt. Eva Pharma will manufacture and sell Lilly’s Humalog and Humulin insulin brands in Egypt and other African markets.

Novo Nordisk, Eli Lilly and Sanofi are the three giants of insulin access globally. Novo Nordisk and Eli Lilly have seen massive global investor interest on the back of their GLP-1 receptor agonist’s use as a weight-loss medication. Novo Nordisk has rapidly risen to become Europe’s most valuable company, with its market capitalization surpassing the annual GDP of Denmark, the country where the company is based. Likewise, Eli Lilly’s share price has risen by around 80% based on the belief of investors that its own weight loss treatment, tirzepatide, might prove more effective than Novo Nordisk’s.

There is growing evidence that these medications may also effectively treat addictions. It has been speculated that the GLP-1 system is involved in the neurobiology of addictive behaviors, and GLP-1 agonists may be used to treat alcohol-use disorders or in other areas, such as drug addiction. Oral versions of GLP-1 agonists, which would negate the need for refrigeration and subcutaneous injection, are currently in clinical trials. These new options would open up the possibility of further surges in the profits of these companies.

However, it must be noted that these GLP-1 receptor agonists began as treatments for type II diabetes (T2D). It is imperative that these companies do not leave behind this fact for more profitable shores. Reinvestment into diabetes access programs across the globe would mean saving the lives of millions of people, and this surge in profits could be the beginning of major advances in public health in the countries that need it most.

Diabetes in Lower-income Countries

According to recent estimates, 415 million people live with diabetes worldwide. This roughly equates to one in eleven of the world’s adult population. Of these individuals, it has been suggested that 46% of people with diabetes are undiagnosed. The figure is expected to rise to 642 million people with diabetes worldwide by 2040.

Diabetes has historically been thought of as a disease in affluent Western countries. This is simply not the case. Diabetes prevalence is two to three times higher in low- and lower-middle-income countries. Critically, this number is increasing rapidly.

There are many reasons why diabetes is increasing in prevalence in lower-income countries. Studies have found a correlation with age, as seen in high-income countries, and a positive correlation with obesity. The increase in many of these countries can also be attributed to major lifestyle changes. Rapid industrialization has resulted in many individuals moving from rural areas to urban, and this change brings a shift from manual jobs to more sedentary, office-based work. Eating habits have often shifted from natural plant-based diets to pre-packed, high-calorie, high-sugar foods. All of these are risk factors for the development of diabetes.

Genetics also plays a role alongside lifestyle risk factors. In South Asians, several polymorphisms have been discovered that are associated with risk factors that predispose to diabetes – including insulin resistance, pancreatic β-cell function, adiposity, and metabolic syndrome. The two factors combined have been calculated to result in a potential sixfold increase in the risk of diabetes among this population.

The populations most at risk of diabetes are among the world’s fastest-growing. We need a sustainable system for these countries that acknowledges that in some countries, the population of people living with diabetes is as much as one in five adults. This is not an individual problem but a societal one, and public health policies should be handled with this in mind.

A Sustainable Solution Could Result in Millions of Lives Saved

Current access to insulin is frequently limited and, in some countries, only available sporadically through the private sector – putting it out of the reach of most of the population. For those with T1D, this is often a death sentence. For individuals with T2D, this potentially means years of mismanaged diabetes, leading to costly, long-term disability that puts a financial strain upon themselves and their governments. Consideration for delaying or deferring payment for access to medication is within reach as more economies look at comprehensive medical coverage.

A solution, however, could be a mutually beneficial arrangement. Those with T1D tend to be young. If they’re kept healthy, they work, earn, pay taxes, and continue contributing to society. This incentivizes governments to partner with pharmaceutical companies to integrate insulin access into the public healthcare system.

This could help to create a “demographic dividend”, or, put simply, an increase in economic growth potential resulting from shifts in a population’s age structure, mainly when the share of the working-age population is larger than the non-working-age share of the population. Access to a consistent supply of insulin will avert many childhood deaths due to T1D, resulting in a larger population reaching adulthood and joining the workforce. Likewise, access to insulin will allow for better management of both T1D and T2D. This will prevent the onset of diabetes-related disability, meaning many individuals will participate in the economy for far longer.

Overall, this will result in economic growth that could pave the way for a system of delayed or deferred payments, even loans from the government to cover the cost of insulin. Typically, a delayed payment would involve a payment scheme set up to cover the cost of an expensive, upfront price, for example, a costly medical procedure. In this case, the upfront cost is the price of insulin throughout childhood, in turn, covered by tax payments made throughout the individual’s life.

With more and more health systems moving towards UHC policies, this concept is a real possibility. However, to achieve this, PPPs are a necessity. Healthcare companies championing insulin access must reinvest their rapidly expanding wealth into their insulin programs.

This is already occurring, with Novo Nordisk’s, Eli Lilly’s and Sanofi’s access programs expanding to more countries every year. New partnerships that could be useful pilots for this expansion are being created. For example, Novo Nordisk has partnered with Babyl Health in Rwanda to leverage Babyl’s already existing digital healthcare infrastructure to allow for awareness campaigns, as well as improved management of diabetes for those who are registered to the platform.

Integration of Digital Healthcare

The Mobile Technology for Community Health (MoTeCH) program in Rwanda is a compelling example of how digital healthcare can successfully be implemented in lower-income countries. Launched in 2012, MoTeCH equips community health workers (CHWs) with real-time patient data, medical guidelines, and training resources via a mobile phone-based system. This digital infrastructure enables CHWs to deliver more efficient and targeted care even in isolated regions with scarce healthcare amenities. Having expanded its reach to include over 40,000 CHWs and serve more than 10 million Rwandans, MoTeCH has demonstrated marked improvements in health metrics like reduced infant mortality, higher child vaccination rates, improved maternal health, and better chronic disease management. Not only is MoTeCH cost-effective and accessible—designed to be easily used by CHWs with basic phones and minimal training—but its demonstrated efficacy has set a precedent. This success has catalyzed the development of similar digital healthcare initiatives in other low-income nations like Kenya, Uganda, and Malawi, further substantiating that technology-driven healthcare solutions can yield significant positive outcomes even in resource-constrained settings.

Among lower-income countries, India is the gold standard for digital infrastructure. The National Digital Health Mission (NDHM) has brought together numerous government departments to use digital healthcare to provide affordable and efficient healthcare to India’s vast population. Combined with “Ayushman Bharat,” the world’s largest free healthcare program, NDHM is an ambitious, constantly expanding system that is helping to address issues such as sporadic health access through aspects such as telemedicine. Earlier this year, the National Health Authority of India announced that over 100 health programs and digital health applications have been integrated with the Ayushman Bharat Digital Mission system.

Some countries are now providing continuous glucose monitors for individuals with T1D. These monitors use implanted devices to measure blood glucose levels, with data readouts available on a mobile app. These devices are cost-effective and considerably improve health outcomes for those with diabetes. They replace the usual pinprick tests with a digital readout for continuous monitoring. Integration of such devices within a wider digital infrastructure could allow for historical glucose monitoring data to be made available to the patient’s doctor and insulin stockpiles to be allocated where most needed.

Artificial Intelligence (AI) has been a game-changer in managing T1D, offering real-time data analysis to predict blood sugar levels, suggest insulin doses, and identify long-term complications. Technologies range from artificial pancreas and smart pens to mobile apps for carb-counting. AI even aids in scientific research by aggregating global data. However, the technology has limitations, such as high costs and data requirements. Additionally, AI’s mathematical models may need to pay more attention to nuanced human factors like stress or hormonal changes that impact blood sugar levels, thus not fully replacing the expertise of healthcare professionals.

Turning Profits into Purpose

Lilly and Novo’s impressive financial gains from their weight loss treatments bolster the companies’ commercial standing and offer a golden opportunity for both to be leaders in ethical corporate practices. By reinvesting a portion of these profits into making essential treatments like insulin more accessible in underserved markets, pharmaceutical companies could build brand loyalty and deliver future revenue streams. This is particularly relevant in emerging economies where the healthcare system might need more robust assistance to meet demands where their products are desperately needed.

While delivering essential drugs is a start, the roadmap to being recognized as a purpose-driven organization requires a more nuanced strategy that bolsters healthcare ecosystems. This means going beyond being a drug supplier to becoming a healthcare partner, especially in systems adopting UHC. Partnering with local governments and organizations, these companies can elevate healthcare infrastructure, assist in training medical professionals, and integrate a wide array of other products needed for the care of people with diabetes—beyond just insulin—into comprehensive healthcare plans. This collaboration achieves a social good in a world where PPPs are becoming increasingly crucial. It solidifies the companies’ position in new or growing markets, thereby driving sales. As lower-income countries develop, with better infrastructure, they will pay for more insulin in the future.

Patient education is another pillar in this strategy, and it’s an investment with twofold benefits: it prepares the market for the company’s products. It ensures those products achieve their intended public health benefits. By setting up or expanding educational platforms that can train healthcare providers and guide patients in diabetes management, they can foster the proper usage of their full range of diabetes products. Given our digital age, using online platforms for these educational efforts can increase reach and effectiveness, boosting the company’s reputation as a purpose-driven entity and promoting product usage. The sudden digitalization of health due to the COVID-19 pandemic is closing the digital divide.

In sum, adopting this multifaceted strategy—product availability, healthcare ecosystem support, and widespread education—can offer pharmaceutical companies a powerful way to marry their profit goals with purpose. It allows them to be viewed as more than profit-driven entities, transforming them into impactful global health players while exploring new markets and customer bases for their products.

Huge Promise

As we stand at the intersection of rapid technological advancements and an escalating global health crisis, the role of pharmaceutical giants like Novo Nordisk and Eli Lilly becomes undeniably critical. The path ahead requires several approaches to assure success: reinvestment of profits for increased product accessibility, partnerships with governments to build resilient healthcare ecosystems, and comprehensive educational initiatives to ensure optimal product use.

Yet, this is not solely the work of the corporate world. Governments must come to the table open to negotiations for long-term payment schemes supporting sustainable health programs. Technological enterprises, particularly those innovating in digital healthcare, can collaborate to enhance the reach and effectiveness of health interventions. This is an urgent call for an orchestrated, cross-sector effort.

The promise is huge: millions of lives saved, improved public health metrics, and a boost to emerging economies that can further global economic stability. It’s high time to turn some of these new profits into purpose. By adopting this robust, holistic approach, pharmaceutical companies can elevate themselves from being mere profit centers to becoming pivotal players in solving one of the most pressing public health issues of our time. In this endeavor, the role of PPPs is crucial and can serve as a linchpin for global change on a scale we’ve yet to see.

To realize this vision, all stakeholders must act now, leveraging emerging digital technologies, breakthrough medical treatments, and novel economic models. The potential benefits are astronomical, not just measured in lives saved, but in a more equitable and sustainable world for all.

TAGS: Health

POSTED BY: Christopher Nial

Christopher Nial