#3 Gaps in health care prevention, management and treatment of diabetes and TB disease in South Africa
Last week we introduced you to Tsolofelo and Melanie, the two African ladies of which one faced multi drug resistant (MDR) TB and the other faces type 2 Diabetes Mellitus (T2DM). These two ladies developed the diseases and were falling ill without knowing what happened and how this could have happened. Even though prevention measures came too late for Tsolofelo and Melanie, the South African government nowadays does provide measures in order to create more awareness for TB and T2DM. In this blog post, we will take a closer look into what South Africa is doing at a more regional and national level regarding the gaps in health care prevention, management and treatment of T2DM and TB disease.
Prevention of T2DM
Concerning T2DM, South Africa contributes to World Diabetes Day and has set up the Diabetes South Africa organisation with the aim to empower people that are affected by diabetes with support and knowledge and to raise awareness about T2DM to all people. This organisation is part of the International Diabetes Federation, which aims to promote diabetes care, prevention and cure on a worldwide scale.
Besides that, the Society for Endocrinology, Metabolism and Diabetes of South Africa developed guidelines for the management of T2DM in 2017. They did this together with a team of experts including among others members of different kinds of diabetes association as well as members of the South African Department. Within these guidelines, the screening for T2DM is recommended. They recommend to screen overweight adults at all ages when they have at least one other risk factor for the development of diabetes. For the other adults without one or multiple risk factors, they recommend to screen them for T2DM by the age of 45 as well. These screenings must be frequently repeated, however, the frequency depends on the individual risk. For example, someone with obesity and multiple other risk factors must be screened every three months, while an individual with a normal weight and no other risk factors has to be screened only every three years.
However those guidelines may seem well structured and hopeful, in reality they are not implemented as we would like. As a study of Pinchevsky et al. shows, there is still a significant number of individuals who were not tested at all. Because of that, those individuals are at an increased risk for the development of diabetes related complications, which we mentioned in an earlier blog post. Besides the fact that not everyone is screened, screenings are not equally divided among the country but they are provided in urban areas more than they are in rural areas, which increases the level of underdiagnosis in rural areas.
Prevention TB disease
To tackle TB disease, South Africa developed the National Strategic Plan on HIV, TB and sexually transmitted infections. Within this plan, the goal is to reach full eradication of those diseases by 2030. To achieve that goal, prevention is an important aspect. Therefore, the government decided to provide comprehensive prevention on a national level. To prevent people, screening methods are required to treat the disease as early as possible. People are screened using two sputum samples, which is the best way to find out whether or not you carry the TB bacteria. The results of the tests are available after two or three days. Research organisations like University Research (URC) help the government with strengthening their prevention methods to reach the best possible results.
To examine whether this approach is helpful in practice, a study of Christian et al. examined the gaps in TB screening in South Africa. This study shows that TB screening tests were routinely conducted within 84% of the cases. However, in only 28% of the cases, the importance of returning back to the health care facility after two or three days to receive the TB test results was explained, which makes the screenings inadequate. This indicates the lack of awareness regarding this problem. The earlier these sub-optimal TB screening programs are detected, the earlier the TB- related morbidity and mortality rate can be decreased.
Treatment method TB disease
Unfortunately, in the case of Tsolofelo and Melanie, focussing on prevention is too late, since they already have fallen ill, and the right treatment method is now the only thing that can help them. For TB disease there is a treatment method, as mentioned in our first blogpost. However, it is harder to treat the disease when someone has a MDR, just like Tsolofelo. Nevertheless, South Africa succeeded in providing patients with a time consuming and, because of the great amount of medication, highly toxic treatment method that cures this as well, of which Tsolofelo is an example! However, it is not self-evident that you are being treated and cured. As shown in the study of Christian et al., many people do not show up to receive their test results after being tested for TB, since 72% are not even informed about the importance of returing back to receive the test results. Because of that, those people suffering from TB without knowing won’t be treated. Moreover, the study of Dudley et al. shows that when people are being treated and discharged from the hospital, they experience a poor continuity of care. This problem won’t be solved unless the linkages between levels of care are being more intertwisted.
Treatment method T2DM
In contrast to TB disease, there is no medical treatment method available to cure T2DM. When an individual, like Melanie, is diagnosed with T2DM, management of the disease through glucose monitoring and the use of insulin is fairly important to prevent an impaired health. However, additionally to the earlier mentioned results of the study of Pinchevsky et al., there is a significant number of people that do not receive adequate health care, which means they monitor the disease in an inadequate way. Because of that, the risk of consequences that diabetes can cause, if not managed correctly, increases.
In conclusion, South Africa does offer great initiatives in order to tackle TB and T2DM. However, the suboptimal quality of care and the lack of linkages between different levels within a health care setting result in a poor continuity of care. To achieve the goals set by the South African government, it is important to focus on that and on equal access for everyone first.
Next week we will go more into detail about what other countries do about this problem in comparison with South Africa.
Written by Fleur Verhoeven
