Published in Mizzima Business Weekly on 11 September 2014

The Department of Endocrinology at North Okkalapa General Hospital, Yangon

The Department of Endocrinology at North Okkalapa General Hospital, Yangon

With the first nationwide survey on diabetes prevalence in Myanmar set to launch in September and a public awareness campaign already well under way, the country’s ability to effectively address one of the most common non-communicable diseases is gaining strength. However diabetes experts have expressed concern that prevalence rates will increase at an alarming pace as a result of changing lifestyles among urban populations and a widespread lack of knowledge about the disease.

“We’re seeing more and more cases of Type 1 diabetes among younger people – some are as young as 10. A decade or so ago, the vast majority of diabetes patients I treated were always over the age of 40. I’m also starting to see a lot of cases of Type 2 diabetes among pregnant women in their twenties,” said Professor Than Than Aye, who is head of the department of medicine and endocrinology at North Okkalapa General Hospital.

Professor Than Than Aye said that wealthy Yangonites are most at risk.

“People in Yangon are much less physically active than those in rural areas and their diets are rich in calories. The number of fast food chains opening really worries me, because most are unaware of the dangers of a bad diet. People are also spending more time on the internet or just using a computer and lead sedentary lifestyles,” she told Mizzima Business Weekly.

According to the World Health Organisation, diabetes is the leading cause of blindness in Myanmar. Its estimated prevalence is six percent nationwide and 12 percent among rural populations. The number of undiagnosed cases is estimated at over a million people.

However obtaining concrete data that is representative of the entire country is necessary to effectively address the public health risk, said Dr Ko Ko, a professor at Department of Medicine at North Okkala General Hospital.

“The results from the survey will show us the magnitude of the problem. At the moment all we know is that diabetes is a big problem.”

Dr Ko Ko

Dr Ko Ko

The survey is being funded by the International Diabetes Federation and will be carried out by the Ministry of Health, with WHO providing technical assistance. Preparations for the survey have been underway since last October and it will include random sampling of almost 10,000 people in 52 of Myanmar’s 350 townships.

In 2003 a survey of 5,000 people was carried out in Yangon – a sample set that Dr Ko Ko said is too small and socio-economically selective to be reliable. Although in 2009 a nationwide survey on non-communicable diseases was undertaken, diabetes was excluded because the budget allocated by the government was insufficient to cover the cost of blood tests, which is the only means of providing an accurate diagnosis of diabetes.

Fortunately, care standards have been improving since 2012, when Myanmar’s first Department of Endocrinology opened at North Okkalapa General Hospital. The specialist department adheres to guidelines set by the American Diabetes Association and is able to provide the comprehensive care package that other general hospitals lack.

“The benefit of having a separate department dedicated to the treatment and prevention of diabetes is huge. Staff at general hospitals have so many duties to carry out and they’re overburdened. Here we’re able to provide specialist treatment, particularly for life-threatening complications that occur as a result of not managing the condition properly,” said Professor Than Than Aye, who has more than three decades of experience in treating diabetes, including two years at a hospital in the United Kingdom.

A young monk receives treatment at North Okkala General Hospital in Yangon

A young monk receives treatment at North Okkala General Hospital in Yangon

The department treats around 100 patients every week and as many as a third have never been diagnosed with diabetes. Professor Than Than Aye said that her patients fit broadly within two groups: the first are those who arrive with acute complications, such as dangerously high blood sugar levels, urinary tract infections, ulcers, hypertension and fevers.

Others require treatment for minor associated illnesses, or have been recently referred by their GP after being diagnosed with diabetes.

“When a patient arrives for treatment for the first time, we carry out a comprehensive medical checkup that reveals any complications, such as numbness in the feet – which can lead to a permanent disability. We also provide education about how to manage diabetes, such as changing their diet to avoid a lot of carbohydrates such as rice, as well as leading a more active lifestyle. Patients also need to understand that even if they feel healthy, regular check-ups to test glucose levels are vital to delaying complications setting in for as long as possible,” Professor Than Than Aye said.

However the costs of managing this lifetime disease are too high for many of the general hospital’s patients, and although the government began providing free medicines to in-patients in 2011, this has not yet been extended to outpatients.

“In the past, Myanmar’s health budget was just o.4% of the GDP [gross domestic product], while now it’s 4 percent – and the ministry has promised us it will be increase in the future. It’s given us some breathing room,” said Dr Ko Ko.

However donations from private individuals remain the lifeblood of the entire hospital’s ability to care for its patients – who consistently outnumber the number of beds available.

Up until two years ago, North Okkalapa General Hospital lacked an elevator: patients were carried up flights of stairs on stretchers – and were then required to pay for the labour involved.

The situation changed when Professor Than Than Aye saved a man’s life, who afterwards returned with his wife to express his willingness to make a donation to the hospital.

“I didn’t realise that they were very wealthy – I’d jokingly asked for a lift but never expected us to get one,” she said.

Professor Than Than Aye

Professor Than Than Aye

Professor Than Than Aye retired in March this year but recently returned to work at the hospital due to its lack of human resources. As well as teaching the hospitals’ young medical graduates twice a week about how to treat diabetes patients with particularly severe complications, she also donates her entire salary of K150,000 to the hospital and lives off the money she earns from working at a private clinic in the evenings.

“K100,000 can cover the cost of a CT scan or an MRI scan,” she said simply.

The hospital relies on generic drugs made in India, which Dr Ko Ko said are considered just as effective in most situations. The cost varies according to the severity of a patient’s condition, which can be made worse by a late diagnosis.

“While some people only require one tablet per day, others need as many as 10 – and this can cost up to US$15 a day,” he added.

Moreover, some diabetes patients require a host of additional medications to manage associated health problems such as hypertension.

And should the condition become severe enough to cause the kidney to malfunction, the cost of dialysis is prohibitively expensive for most.

“The onset of diabetes most often occurs in the mid-forties – that’s within a person’s working life. Imagine a trishaw driver who is the sole breadwinner and becomes blind or disabled as a result of not having diagnosed the illness or treating it. Who will take over his role in the family, while someone else in the family must take on the role of being his carer?” Dr Ko Ko said.

“The message I want to convey to the public is that early diagnosis is vital. If someone has a family history of diabetes – or even just the one relative who has it – they should be tested for diabetes as early as possible,” said Professor Than Than Aye.

She recalled situations where a relative caring for a family member with diabetes had themselves failed to be tested for the condition.

“One of my patients was caring for her sister and we discovered after a blood test that her blood sugar levels were extremely high. By then it was too late and she, the carer, died before her sister,” she said.

North Okkala General Hospital

North Okkala General Hospital

Another challenge confronting the effective treatment of diabetes in Myanmar is the prevalence of traditional medicines, which remain popular even within urban areas such as Yangon.

“Advertisements claim these medicines can cure diabetes with a tablet and are even handed out as free samples – and they’re a cheaper alternative to Western medicines, which is attractive to many. While I believe that traditional medicines can be effective to some extent when someone is in the early stages of diabetes, failing to test blood sugar levels is dangerous. Solely relying on traditional medicines can lead to the early onset of very serious complications,” Professor Than Than Aye cautioned.

Spreading awareness

The Myanmar Diabetes Association was established in 2013 and aims to disseminate knowledge about the care and prevention of diabetes. Dr Ko Ko is general secretary of the association and said he used his own savings to get the association off its feet, and that it is in desperate need of donors to keep up its activities. The association is comprised of health professionals, diabetes patients and their family members. Dr Ko Ko regularly gives public talks to promote awareness and the association is actively engaging with local media to spread their message, as well as doing so by distributing posters, leaflets and brochures.

“Awareness is increasing as a result of our programs: patients are starting to come to the hospital and saying, ‘I’m urinating a lot and I’m thirsty all the time and I think it could be diabetes.’ But we’re not winning – it’s still just the tip of the iceberg in terms of the general public having a real understanding of the disease and how it can be prevented and managed. And a lot of people remain reluctant to get tested for diabetes because they say they will only feel depressed if they know that they have this lifelong condition. We don’t see it that way: prevention is always better than cure,” Dr Ko Ko said.