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Diabetes. Democratized.



Diabetes is a HUGE problem globally.


Diabetes is deadly and affects in an asymmetric manner marginalized, under resourced populations (i.e. our center's patient population).


The more uncontrolled (higher HbA1c) one's diabetes is, the more likely one is to die (hazard ratio for mortality). See above graph. (1)


"More than 80% of the global burden of diabetes occurs in low- and middle-income countries, where limited infrastructure and capacity for managing chronic illness lead to disproportionate morbidity and mortality." (2)


"While the overall prevalence of type 2 diabetes and prediabetes is 9.3% in Guatemala, the prevalence amongst the indigenous community is 25%. "(3)


Noticing that a large percentage of the patients we cared for each day in clinic were suffering from uncontrolled diabetes, we started our Diabetes Program.


One of our nurses completed the Diabetes Educator course through the International Diabetes Federation and became a Certified Diabetes Educator (exceedingly rare in our corner of the globe). We began to enroll patients struggling with uncontrolled diabetes (using HgbA1C of >10 as our entry criteria). We ruthlessly eliminated all possible barriers to care and arranged for monthly follow-up visits.


Our approach is undeniably effective. Below is a graph demonstrating improvement in average HbA1c for this year's cohort of patients who went from 12.3 down to 7.8.



Outside observers may be tempted to point out that our approach is also quite resource intensive and perhaps not cost effective. To such critiques, I offer a couple of Paul Farmer quotes to ponder:



"This is something I’ve been struggling with since I was a student: socialization for scarcity. But scarcity for ourselves? No. Scarcity for our mom? No. For our own kids? No. We’re socialized for scarcity for other people, and they’re usually black or brown or poor. So then we start cutting corners."


If we possess the courage and imagination to reject a socialization for scarcity, diabetes care can be democratized to include those most in need.



 1. graph from: Viana, Marina & Moraes, Rafael & Fabbrin, Amanda & Santos, Manoella & Leotti, Vanessa & Vieira, Silvia & Gross, Jorge & Canani, Luís & Gerchman, Fernando. (2014). Contrasting effects of preexisting hyperglycemia and higher body size on hospital mortality in critically ill patients: A prospective cohort study. BMC endocrine disorders. 14. 50. 10.1186/1472-6823-14-50.


2. Rohloff P, Flood D, Tuiz E, Kurschner S, Nandi M, Tschida S, Wilcox K, Chary A. Adults' Experiences with Type 2 Diabetes in Rural Guatemala: A Qualitative Study. J Health Care Poor Underserved. 2023;34(1):208-223. doi: 10.1353/hpu.2023.0014. PMID: 37464490; PMCID: PMC10361624.


3. Nieblas-Bedolla, E., Bream, K.D.W., Rollins, A. et al. Ongoing challenges in access to diabetes care among the indigenous population: perspectives of individuals living in rural Guatemala. Int J Equity Health 18, 180 (2019). https://doi.org/10.1186/s12939-019-1086-z


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