An estimated one million people in Madagascar are diabetic, but only about half of them know it. Finding the other half presents a major challenge for this large, island nation in which 80 percent of the population live in rural areas where few people have ever heard of this chronic and potentially deadly disease.
With the country's underfunded public health sector barely functioning, this task has mainly fallen to the Madagascan Diabetes Association (A.MA.DIA.) which dispatches its doctors and nurses to the provinces to conduct blood sugar tests and raise awareness at fairs, schools and health centres.
"We have done this work for over five years now, and people are slowly starting to know more about the illness," said Jean Marie Andriamanonga, coordinator of A.MA.DIA.
"Malagasy people think that diabetes is not a problem in this country, because they don't drink Coke and don't eat cakes, like Westerners. But there are many components in the traditional diet that can cause the illness," Andriamanonga told IRIN. "In the countryside, for instance, people drink local rum made of sugar cane. They also like to eat fatty meat and plates full of rice. In the cities, people are starting to eat Western foods and they don't move as much as they used to."
Based on the tests that A.MA.DIA. has conducted, Andriamanonga estimates that 5-6 percent of Madagascar's population of 20 million has diabetes, while only about 3 percent have received a diagnosis.
"In the bush, people really die of this illness," he said. "We have seen cases where people's limbs were amputated. People often complain about vision problems, high blood pressure or wounds that don't heal well. We used to only find cases among the elderly, but now it is spreading among the young also."
If finding diabetes patients presents a challenge, treating them is even more difficult. Moussa Bako, a 69-year-old farmer who lives 160km north of Tamatave, a port town on the east coast of the island - which is also known as Toamasina, was diagnosed with diabetes three years ago after complaining of chronic fatigue. At the time, the doctor at the public health centre in his region gave him some advice on diet and treatment and administered one dose of insulin. "I felt better after this, but never had the opportunity to go back," said Bako, who thought one treatment would cure him; he lived too far from the clinic to return for regular check-ups.
Malagasy people think that diabetes is not a problem in this country, because they don't drink Coke and eat cakes
Today, however, Bako has decided to come to a mobile clinic A.MA.DIA. has set up in the centre of Tamatave and become a member of the Association. Membership is not free, but it gives patients access to regular check-ups from specially trained doctors at A.MA.DIA. clinics at half the normal price of a consultation in the private sector. During his introduction, Bako receives detailed information from educator Marcel Robiamanantena about how to manage his diabetes.
"I tell him how to eat a balanced diet, and to avoid anything toxic, like alcohol or tobacco. He also needs to come for a check-up every month. This is an illness for life and he will shorten his life span if he doesn't come to our centres regularly," Robiamanantena told IRIN.
Lack of equipment, insulin
A.MA.DIA. has established clinics like the one in Tamatave in a number of regions and, with funding from the World Diabetes Foundation, plans to open several more. A.MA.DIA.'s main clinic in the capital, Antananarivo, treats 1,500 people with diabetes every month and has 20 beds for in-patient treatment and a dispensary for out-patients.
Often the only treatment available through the public health sector is that provided by nurses or health workers who lack the training to manage diabetes patients. Rural health clinics usually lack the equipment to even conduct blood sugar tests, while patients that are diagnosed with diabetes are referred to private pharmacies to buy insulin at a high cost.
Despite being on the World Health Organization's list of essential medicines, insulin is scarcely available either through Madagascar's public or private health sectors. Even A.MA.DIA., which receives support from several donors including the World Diabetes Foundation, struggles to ensure a steady, subsidized supply of the drug to all its members. Andriamanonga said Madagascar's protracted political crisis had increased the difficulty of procuring insulin while the lack of drug storage facilities in the provinces posed another significant barrier.
"Many of the new cases we find are children with type-1 diabetes. They will have to take insulin for life at exorbitant cost. Someone who has an average salary of 100,000 ariary [US$45] a month will have to spend 25,000 ariary [$11] a month on insulin," said Andriamanonga.
[ This report does not necessarily reflect the views of the United Nations ]