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Solving “Impossible” Problems Starts Here
The chasm between the West and rest on healthcare quality and access seems insoluble. But we can narrow the gap.
If David lived in a richer country, he would still have both of his legs. But he doesn't – he has one leg. The other was amputated below the knee last year. He is 46, the father of two children. He lives in Kenya, where I met him three weeks ago.
We often hear people talking about the “gap” between rich and poor. The “gap” between the health care available in the developing and developed parts of the world. “Gap” is far too polite a term.
Because of poorly controlled diabetes, David lost his leg. Because he lost his leg, he lost his job. Because he lost his job, his marriage fell apart.
This would not have happened if David lived in a richer country. “Gap” does not cut it. “Vast and terrible chasm” is perhaps a better description.
People sometimes think of diabetes and other non-communicable disease as being Western problems. That’s not the case. Some 415 million people worldwide have diabetes, and the majority of them live in low- and middle-income countries.
People with diabetes need to do two main things day-to-day:
Monitor their blood sugar level, and
Inject themselves with the appropriate amount of insulin to keep that blood sugar level as close to normal as possible.
If they can do these two things well, they can live an almost normal life for many decades. If not, their blood sugar level often runs too high and the excess sugar damages the blood vessels in their eyes, kidneys, legs, brain – everywhere in fact – and it periodically falls too low, causing unpleasant and potentially life-threatening hypoglycaemic attacks -- or “hypos.”
David has essentially no idea what his blood sugar level is at any given moment. It could be anything – he really doesn't know.
He knows that monitoring tests exist, having used them just a handful of times. Prick your finger with a small lance, squeeze two drops of blood onto a test strip, wait two minutes, and read off the color change on the test strip.
He can't afford the lance or the test strip though. Simple as that.
Ask a diabetic in America or Europe if they monitor their blood sugar level and they'll look very confused. Of course they do! Those who have been diabetic for 20 years or more will remember having to drip blood onto a test strip and wait for the color change.
That's very old technology now though. These days, at the very least, they insert the strip into a small portable reader, and the result appears on the screen. Many diabetics now use a whole new generation of technology. They have a continuous blood sugar monitor attached to their upper arm, which transmits a live feed of their blood sugar level to their smartphone.
So – millions of diabetics using the latest technology have by-the-minute tracking of their blood sugar level. While David and millions of others like him have nothing at all – not this latest technology, not the generation of technology before it, not even the one before that.
That's the first of the two things that diabetics need to be able to do: to monitor their blood sugar level. The second is to inject themselves with insulin to keep their blood sugar level as close to normal as possible.
Here too, David and his richer counterparts might as well be living on two different planets.
David injects himself with 14 units of insulin in the morning and 18 in the evening. The same every day. Sometimes he injects himself with the wrong dose accidentally. The print on his syringe is small and his eyesight is getting worse, so this is an easy mistake to make. When he last got this wrong – just last week – he knew about it because he woke up in the middle of the night, sweating profusely and feeling terrible.
David uses the same needle twice a day for a month. He can't afford to replace it any more frequently than this. That means he's using the needle long after it has become blunt, which is painful and sometimes causes his skin to become infected.
To diabetics in developed countries, many parts of this story are unrecognizable in 2022. They don't give themselves the same dose of insulin every day. They adjust it based on the blood sugar level that they're monitoring, so that they can control that level far more precisely. And, obviously, they don't use blunt needles.
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Increasing numbers of diabetics are now able to go a giant leap further. Instead of injecting themselves two to four times a day, they have a small pump taped to their skin that provides a continuous infusion of insulin. This really does allow precise blood sugar control.
The continuous sensor and the pump can be connected, so that the pump rate adjusts itself according to the current blood sugar reading. Essentially these two technologies mimic what the pancreas does for those of us who are not diabetic – providing the body with a flow of insulin that is adjusted in real-time response to the blood sugar level.
It is wonderful to see technology like this…to see diabetics monitoring their blood sugar on their smartwatch, and tweaking their insulin pump. This level of information and control lets them keep their blood sugar level close to normal, and so minimises the damage that abnormal sugar levels caused to the body.
I didn't have the heart to tell David that technology like this even exists. He would love to be able to know his blood sugar level, even just once a day, even using the oldest and cheapest technology. He would love to have a needle that isn't blunt. More than anything, he would love to still have two legs.
Of course, there is always going to be a gap between what the richest and poorest can afford. Even the most idealistic could not realistically expect the latest technology to be available to all, immediately.
But is it acceptable that low-cost technology, now old hat, is not yet available everywhere? To our minds, absolutely not.
I was in Kenya, and talking to David, because we were launching our ApiLabs Field Research Network. Its ethos is about understanding problems accurately, deeply, and from the perspective of those who are affected. That’s something that sounds obvious but – if you think about it – is often not done.
Solving this problem for David, and for millions of others with comparable problems, begins with paying attention to their needs – close-up, personalized, open-minded attention. It starts with questions and a desire to understand.
I will share more about what we are learning in future posts. For now, let me just say that I am optimistic. These problems are tough, and there are no easy solutions. But being grounded in what we hear from David is absolutely the right way to go.
I’m a realist. There will always be a gap between the technology available to the richest and the poorest. But there is no need for that gap to remain a terrible chasm. That part, we can change.
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