The theme for World Health Day 2016 is “Beat diabetes”. How did diabetes become a public health issue? Maybe public health officers from the past can shed some light.
Diabetes is a complex condition. We’ve known of its existence for millennia. Although physicians learned more about it throughout the 18th and 19th centuries, its causes and treatment remained uncertain into the 20th century.
In the UK, the annual Medical Officer of Health (MOH) reports, written by the MOH for each district, provide an insight into the medical response to diabetes over the past 150 years. Surprisingly they also give a good account of milestones in the history of the disease. The MOH, certainly in the early years, had free rein to decide what went into their reports. Some found space to discuss the clinical value of the latest medical research. We can follow the story of diabetes from the perspectives of three medical officers.
In 1897, according to diabetes specialist Dr Joslin, the average life expectancy of a 10 year old diagnosed with juvenile (type 1) diabetes was 1.3 years, while a middle aged person with type 2 diabetes faired a little better at 4-8 years. Things were little better 10 years later when the MOH for Holborn (Islington, London), William Bond, reported that an average of 25 people a year died from diabetes in his district alone. He admitted that: “It is unfortunately one of those disease for which science has found no special cure, but it is also one about which constant investigations are being made”. It was a discovery by Oskar Minkowski in 1889 that gave him hope:
Despite Bond’s optimism, it took another 13 years to isolate the mysterious substance in the pancreas that might control diabetes. In the meantime, the failure to produce an effective pancreatic extract resulted in continuing debate about causes of diabetes and controversies over treatment. One of the main treatments was to severely restrict the diet of patients, with the result that the emaciated appearance of patients had as much to do with the treatment as the condition.
In 1921 the Canadian researcher Frederick Banding and his colleagues finally succeeded in extracting the mystery substance – insulin – from the pancreas. The progress from laboratory to clinical use was remarkably fast by today’s standards. In the United States Eli Lilly and Co. began producing insulin on a large scale within the year. The discovery and subsequent UK trials were discussed in an article by Dr George Allan, a professor at Glasgow University, in the 1922 MOH report for Deptford.
Allan mentions that “the manufacture and distribution of insulin are undertaken by several firms under licence from the Medical Research Council who holds the patent rights.” One of these firms was the Wellcome Foundation.
But by the winter of 1922-1923 just 50 patients in 8 UK hospitals had received insulin compared to hundreds of diabetics in America. The historian Elizabeth Furdell suggests that the MRC may have been sceptical about the significance of insulin and were slow to act. In addition the licenced companies produced only small amounts of insulin for the trials, so there was not enough to go round. As a result the MRC gave insulin to only the most severe cases. The article in the 1922 report echoes the MRC recommendations the limited use of insulin:
Allan also mentions the high cost of insulin. The state helped those on low incomes but most diabetics, excluded form health insurance by their condition, had to pay for multiple daily blood tests and insulin doses themselves.
He also cautioned against raised expectations: “the press has exaggerated the claims of this discover and has proclaimed to the public “a cure for diabetes”… when it is more correctly an adjunct to dietetic treatment”. Many issues remained in the treatment of diabetics:
In fact it took many years to develop effective insulin based therapies that got the balance of diet, testing and insulin dosage right.
By 1933 the MOH for Acton was able to say that “The first obvious results of the general use of insulin were to reduce the recorded mortality of diabetes and to advance its age of fatality.” However he notes that “the disease has increased steadily in incidence”.
He proposes an underlying reason for the increasing number of diabetics:
In 2016 the World Health Day campaign aims to “increase awareness about the rise in diabetes and its staggering burden and consequences”. The WHO fears the condition is reaching epidemic proportions – about 350 million people worldwide have (mainly Type 2) diabetes, a number likely to more than double in the next 20 years. The majority of these people are in lower income countries where insulin is often unavailable. Prevention is the best solution for a disease with no known cure that is linked to lifestyle – and this is where public health comes in.