Better prospects for sustainable healthcare?

Our new provincial government faces a litmus test in how it deals with diabetes-mongering.

THE FIRST LINE of Diabetes Canada’s 2017 Report on Diabetes in British Columbia contains a whopping big lie. But let me get to that in a bit.

The report outlines outrageous levels of diabetes in BC, how it costs the provincial health-care system over $400 million per year and how BC is awfully stingy in paying for diabetes-related products. For example, did you know that in BC not everyone can get a subsidized insulin pump? Nor do we pay for the newest diabetes medications. And don’t ask about foot care, because the state of foot care for people with diabetes in BC is appallingly bad. In other words, we’ve got an epidemic on our hands and we are inadequately supporting people living with diabetes. The report is basically saying to our new NDP government: Time to ante up.

Thank you for waiting, here’s the whopper:

Today, more than 1.4 million British Columbians, or 29 percent of the provincial population, are living with diabetes or prediabetes.

I remember standing on a parade square, an officer cadet in boot camp, with a bunch of other skinny teenagers with shaved heads and a sergeant yelling at us: “Look to the person on your left, then look to the one on your right. And by the time we’re done here, one of youse will be gone.” That’s the kinda drama that certainly gets your attention—because you, or your closest buddy, could easily become a statistic.

But wow. Nearly a third of us have diabetes or almost have diabetes? Diabetes can be serious, and if so many are at risk of getting it, it surely demands a weapons-grade response from someone. Hence the report and the eye-popping stats. But we are nowhere near having 29 percent of British Columbians living with diabetes or prediabetes. Why? It’s waaaaay more than that. Statistically, almost everyone who lives long enough will develop some kind of elevated blood sugars that are associated with diabetes. Not only do we all have pre-prediabetes, let’s not forget that 100 percent of us are also “pre-deceased,” struck by a condition that is universally fatal. But I digress.

Diabetes Canada is—how do I say this nicely—marinating in pharmaceutical funding. Able to hire some of the best public relations firms in the business, their job is to get provincial health officials focused on their bottom line, increasing the market for drugs, insulins and assorted diabetes paraphernalia. Maybe their report reads like it was written by a drug company because it is funded by Novo Nordisk Canada, one of the world’s largest producers of insulin; and it directs questions to Hill and Knowlton Strategies, a PR behemoth.

BOTH TYPES OF DIABETES, the adult-onset type, known as Type-II, and Type-I which typically develops in childhood and requires daily use of insulin, can undermine the quality of one’s life. The vast majority (over 90 percent) of people living with diabetes in BC are type-II diabetics, and so that’s where most of the marketing is targeted.

The term “prediabetes” has long been a controversial term so I turned to a colleague, Colleen Fuller, a Vancouver-based diabetes policy expert, and asked what she thought of the report. Fuller started her answer with a question: “Why does Diabetes Canada use terms like ‘prediabetes?’ In Europe they are highly critical of the term. Why? It causes panic. It is designed to scare people,” she said.

Fuller thinks that current Canadian diabetes guidelines should be used with caution, “because they are mainly designed to increase sales of drugs and devices.” She adds, “It is clear that the drive for these companies is to consistently grow the market.”

Sure enough, the report’s three key recommendations are focused on public spending for more diabetes stuff, recommending that “the Government of British Columbia immediately…Expand the provincial insulin pump program to include all British Columbians with type 1 diabetes who are medically eligible, regardless of age.” It also urges the government to “List diabetes medications with proven efficacy on the provincial drug formulary” and “Commit to public funding of offloading devices and foot care specialist visits, and improve screening for diabetic foot ulcers and education.”

I asked Don Husereau, an Ottawa-based expert on evidence-based policy who has a graduate degree in pharmacy, whether he thought the recommendations had any basis in evidence. He was quick to respond: “The first one will significantly increase expenditures for little advantage—pumps are only useful [for a] few people and necessary in fewer.” As for the paying for diabetes drugs, Don Husereau asks: “What is ‘proven efficacy’? Is that code for A1C [a test for measuring the blood glucose level] or code for heart attacks?” The latter, drugs that prevent heart attacks, might indeed be a good thing, yet the former, drugs that do nothing but alter the level of haemoglobin A1C, he says, could be “useless.”

As for avoiding diabetic foot ulcers, which the report says costs us up to $120 million a year, Colleen Fuller supports that recommendation, because “people need to pay attention to their feet,” but she adds, “they should educate people generally about diabetes, not just about feet.” She reminded me that we used to have very good diabetes education programs operating out of hospitals in BC. “If you went to a diabetes educator [she went every year for 20 years] it was good—you found out about food, and different aspects about what you need to know about diabetes.” In her opinion, “the lack of education about food is a major contributor to the increase in Type-II diabetes.” But what has happened in BC? “They got rid of the education programs,” says Fuller.

Even though the World Health Organization tells us that “unhealthy diets and low physical activity are among the key risk factors for major chronic, non-communicable diseases such as cardiovascular diseases, cancers and diabetes,” this merits a small mention in the Diabetes Canada report: “about 40 percent of residents are not physically active, 60 percent do not eat enough fruits and vegetables, and half of the adult population is overweight or obese.”

Instead of suggesting ways to get people more active and eat better, let’s just berate the BC government for not paying for more diabetes stuff. As Don Husereau reminded me, the bulk of the evidence on diabetes drugs shows that they may be very effective at lowering blood sugar, but have very little effect on the things that matter: the complications of diabetes that include kidney disease, strokes and heart disease. In fact, despite the piles of medications available to treat type-II diabetes, there is shockingly little evidence of overall benefit. A recent report by the Therapeutics Initiative at UBC was an eye-opener. It found that most of the drugs that lower glucose for people with type II diabetes are “approved without any evidence that they reduce mortality or major morbidity.” They are, of course, very effective at making massive amounts of money for the companies producing them.

DIABETES COULD BE the poster-child for what happens when we allow the medical-industrial complex to “educate” governments about diseases: disease-mongering on a massive scale. Convince policymakers that we have an out-of-control epidemic of “predisease” (which some say doesn’t really exist) and then promote the most expensive drugs and devices to deal with it.

Colleen Fuller, who has watched the diabetes industry for decades, has a suggestion about such “polluted” recommendations: “The government needs to raise the bar of evidence to justify public funding.” She wants more independent study, and more objective analysis of public coverage of diabetes paraphernalia, and adds that “Pharmacare as our public drug program has to be an advocate for rigorous studies around diabetes.”

Groups such as UBC’s Therapeutics Initiative have spent the last decade in the wilderness, sidelined by the Liberal government, the Ministry of Health firing scandal, and numerous attempts to disrupt their work. Things now may be looking up, especially since Premier John Horgan recently mandated our new Minister of Health Adrian Dix to, among other things, “provide the Therapeutics Initiative with the resources it needs to do its job effectively.” This means better science and independent advice—not tainted by the drug companies and the societies they fund—so that our diabetes-related resources will be used to maximum impact.

This was confirmed when I asked the Ministry of Health what they thought of the report. Spokesperson Laura Heinze wrote that the ministry “will be looking at enhancing evidenced-informed decision-making for new and existing drugs in relation to formulary coverage decisions.”

As a final note, Colleen Fuller reminds me that the World Health Organization has linked the growth in diabetes to poverty. Too often, she says, people with type-II diabetes are “blamed for being lazy and fat, yet if we want to prevent diabetes we’d address the socioeconomic or environmental causes of the disease.” Those don’t seem to be priorities of the disease-mongers, which Fuller characterizes this way: “Their job is to push products—not strategies, not things that would prevent people from getting diabetes in the first place.”

There is hope. However, this new report shows the Diabetes-Industrial Complex has targeted our new NDP-Green government. The ministry will need all the help it can get to stand up to them. Will the ministry have the cajones to take on the Diabetes-Industrial Complex? This is a litmus test. We’re watching.

Alan Cassels is a Victoria writer and health researcher.  His most recent of four books is The Cochrane Collaboration: Medicine’s Best Kept Secret.