For nearly two years, Manoramani has made the three-hour bus journey on the first Sunday of the month to sit on a tiny plastic chair in a crowded hall and wait. Wrapped in a green sari, the portly 41-year-old was diagnosed with diabetes seven years ago. Her health deteriorated until a relative, and fellow diabetic, recommended she went to the Jnana Sanjeevini Medical Center in southern Bangalore, a long way from her small town in a neighboring state. The reason? Supplies of insulin and four other medicines, all free of charge.
In recent years, the two-decade-old clinic has seen more and more Indians like Manoramani pass through its doors — patients who reflect the shifting demographics of the disease nationwide. They are younger and poorer. They come from rural areas. And they often have alarmingly minimal health education. At a small table in the clinic, a counselor reminds a diabetic from a nearby village, whose sugar levels remain persistently high, that she should eat more fresh fruit and vegetables. “We repeat the same thing every month,” says Vidula Krishnaswamy, a volunteer. “They’re not used to taking care of themselves.”
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While people in some parts of India continue to battle malnutrition, many residents in the wealthier states have, during the past two decades of the nation’s boom, faced a menace of excess. Rising incomes paired with sedentary lifestyles and starchy, sugary diets have helped diabetes spread furiously. For years, most Indian diabetics fit one profile: urban, educated, with a cozy office job. Now that’s changing. More and more, Indians in lower income brackets, often living in rural areas, are being diagnosed with the disease. With their incomes rising and job opportunities broadening, Indians have been performing less manual labor and have been turning more readily to Western-style fast foods and sugar-laden drinks that were not available two decades ago. Also, while physical activity has fallen, consumption of polished white rice, a staple food strongly linked to the disease, has remained steady.
In 1998, researchers in the southern city of Chennai tracking the disease found that rates were high in the middle class and negligible among the poor. By 2008, however, the Madras Diabetes Research Foundation (MDRF) found that diabetes rates among people earning less than $94 a month more than doubled from 6.5% to 15.3%. Other rural areas with virtually zero prevalence a decade ago are clocking in at 10% or more. “The rural transition is very, very worrisome for us,” says Dr. V. Mohan, director of the MDRF.
Research on diabetes in India has meanwhile been scant, making it hard to build up a true picture of the crisis and, in turn, formulate an adequate national response. The first comprehensive study was not published until December 2011. The report, produced by Mohan and his colleagues at the MDRF, estimated that there were 62.4 million diabetics across the country — a 65% leap from their 2004 estimate. The study also hypothesized that an additional 77.2 million Indians could be prediabetic and that by 2030, 100 million Indians could suffer from the disease. The World Health Organization predicts that by 2015, India’s losses from diabetes and other noncommunicable diseases will top $236 billion, just $73 billion less than this year’s national budget.
As a proportion of the population, diabetics make up about 8% of India’s total — less than the U.S. figure of 10.3%, according to the International Diabetes Federation. Gulf nations have proportions hovering around 20%, among the highest in the world, and several Pacific-island countries exceed that. But what makes India different is the untold number of diabetics that fall through the net. Researchers believe there are nearly five times the total of undiagnosed patients and diabetes-related deaths in India than in the U.S. That’s especially alarming now that diabetes is moving to the villages, where health resources are rudimentary.
Patients are also getting younger. Mohan’s team recently examined teenagers in Chennai, where young people had no signs of onset diabetes two decades ago. Now 12% of girls screened between the ages of 12 and 19 show clear traits of the disease. “That can actually destroy a country if it reaches epidemic proportions,” Mohan says.
Officials in New Delhi have acknowledged the problem but have been slow in implementing remedial measures. In July 2010, the government unveiled a $230 million program for noncommunicable diseases — the first of its kind in India. Minister of Health Ghulam Nabi Azad promised diabetes screenings for some 200 million adults over the age of 30 in the program’s first year. That target was promptly scaled back to 70 million, and as of mid-March, the Ministry of Health and Family Welfare reported screening a mere 17 million. The problem is that the professionals needed for such an ambitious program simply aren’t there: just 693 medical officers of a hoped-for 32,000 have been trained in diabetes screening. Especially in rural areas, finding medically educated staffers, and affording to keep them, is a near impossible task. The situation is so acute that ordinary citizens are being trained instead. Sucre Blue, a new Bangalore social enterprise, has trained residents in two villages outside the city to screen other villagers. They found prevalence rates approaching a third of all adults.
Creative approaches like this — alongside dietary changes and education programs — are sorely needed. But even if they could be executed on a national scale, the real dilemma lies in whether a country with such an acute shortage of medical professionals and resources can even treat such a large number of diabetics. As Mohan says: “Screening is nice, but then what do you do after that?” India’s health officials had better come up with answers, and fast.