As early as in 2000, Lucini et al in a study that was published in Pharmacoeconomics, pointed out that if a patient with diabetes has one microvascular complication (that is peripheral nerve damage, retinal damage in the eye or early kidney disease) the cost of treatment goes up by 1.5 times. If a patient has one macrovascular complication (heart disease or stroke) the cost goes up by twice the amount that would normally be spent. However, if a patient has both one microvascular and one macrovascular complication, the cost of treatment goes up 3.5 times. This is totally unacceptable for the lower socioeconomic class in this country. If a patient gets advanced kidney disease (chronic renal failure) in India, the cost of kidney replacement would end up being in excess of `7 lakh. This would be beyond the reach of the average working class or blue collar job holder, and I would unabashedly recite, be the death warrant of 90% of patients with advanced chronic renal failure. A study conducted at Vellore published in Journal of Diabetes 2011, has shown that the commonest cause of death is cardiovascular disease (in general, a heart attack) or a stroke in 38% of the total number of hospitalised patients with diabetes. Urinary tract infections as a cause for death are far more common amongst the population with diabetes when compared to the non-diabetic population. There is an important public health message for administrators and also for the primary care physicians.Indeed the number of pharmacological agents, on the other hand, that have emerged in the market over the last decade are significant, as opposed to the 1980s, when there were just five oral tablets for the management of diabetes; there are 15 at present! They may be used in a number of permutations and combinations. If used properly and up to maximal doses, the potential for delaying the usage of injectable products is certainly there. For the majority of the population in rural areas and amongst the lower socio-economic classes, cost is a significant deciding factor. The harsh reality of incomplete and suboptimal therapy is a combination of the patient’s financial inadequacy and at times the inability of the health care system to meet with the growing demands of and increasing patient load. Going by the fact that prevention of complications is far more important than ultimately trying to treat or cure them, it brings us to a position where we would question ourselves as to where should we target our strategies, and whom should we work on to improve the overall impact with regards to the prevention and treatment of diabetes in the community.
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