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Diabetes Is Not Just An American Problem


This week’s New York Times series on diabetes in New York City throws much needed light on the silent epidemic of chronic disease brought on by our sedentary, fast-food culture. But diabetes is not just an American problem. It is spreading fast to the rest of the world, too.

We think of McDonald’s as an American restaurant, but of the five new McDonald’s that open around the world every day, four are located beyond our borders. Coca-Cola is the quintessential American drink but that company has been buying up water licenses in poor countries-many still bereft of safe drinking water-where they sell soda for less than the price of a glass of clean water. In Africa, the number one employer is not a mining company or an agricultural firm, but Coca-Cola.

As the Times series has amply shown, our health suffers when we rely on fast foods and sugary drinks to sustain ourselves. But in places where malnourishment and poverty are rampant, the ramifications are even more profound.

In Western countries the transition from hardscrabble malnourishment to today’s drive-through, fast-food cornucopia occurred over centuries, with the happy result that our societies were able to control infectious diseases spread by hunger and poverty before facing the maladies of richly calorific diets, including diabetes, obesity and heart disease. As anyone who has seen the KFCs and Pizza Huts sprouting along the alleys of Mumbai and Cape Town knows, in developing countries, no such time lag exists. What experts call the “nutrition transition” is taking place within a single generation.

According to recent research, malnourished mothers tend to bear babies predisposed to storing excess energy as fat. This is a useful adaptive advantage in communities where calories are often scarce, enabling babies to survive nutritional deficits. But when such babies grow up to consume Western-style diets chock-full of fatty, sugary foods, that benefit turns into a deadly curse, leading them to gain disease-causing extra fat much more rapidly than they would have otherwise.

And so, hot on the heels of the multinational soft drink and fast food companies in poor countries has been an epidemic of chronic disease.

Today, four of out five people who die of chronic, noncommunicable diseases such as diabetes and heart disease perish not in New York or California but in developing countries, according to the World Health Organization. More Indians and Chinese suffer cardiovascular disease than Americans, Japanese, and Europeans put together.

Diabetes and coronary heart disease are epidemic in India, which is home to the greatest concentration of Type II diabetes sufferers in the world. In some areas of Africa, as many as one in five has diabetes. Nearly 20 million Africans suffer from hypertension. Worse, while diabetes in rich countries is primarily a condition of the elderly, in developing countries the disease strikes those in the prime of life, aged forty-five to sixty-five, slashing their average life expectancy by ten to fifteen years.

For developing countries barely treading water amid the flood of malnutrition, HIV infection, malaria, and tuberculosis, “the public health implications of this phenomenon are staggering,” the WHO has noted, “and are already becoming apparent.”

The era of strings-attached IMF and World Bank loans, which forced the dismantling of many indebted countries’ public-health infrastructures, is partly to blame. In Zaire, for example, World Bank and IMF “economic recovery” measures required the government to slash its spending on social services–in a single year, the government fired more than 80,000 teachers and clinicians. In Zambia, within just two years of such programs, the nutritional and health status of children had plummeted, canaries in a coal mine. Infant mortality rose by 25 percent while life expectancy dropped from 54 to 40 years. In Argentina, polio and DPT immunizations fell by nearly 25 percent between 1992 and 1998, and throughout Latin America, previously controlled diseases such as cholera and dengue fever re-emerged at epidemic levels. The flow of patients into clinics and hospitals in Nigeria, Kenya, and Ghana slowed to a trickle, dropping by half within days of the imposition of new fees. “Before, everyone could get health care,” one developing-country patient noted. “Now everyone just prays to God that they don’t get sick because everywhere they ask for money.”

Global trade agreements forged throughout the 1990s eased the entry of soda makers and fast-food companies into the emerging markets of the developing world. And western officials have willingly undermined public health protections in developing countries when they appear obstructive to U.S. business interests. In the mid-1990s, for example, U.S. State Department officials forced Guatemala to scrap a widely praised law that saved the lives of scores of infants. The law banned the use of images of chubby babies on infant-formula packaging, which tended to encourage illiterate mothers to forego breastfeeding their babies in favor of formula feeding, which in areas of sporadic access to clean water often ended up killing their babies. But when baby food manufacturer Gerber objected to the law, state department officials threatened Guatemala with trade sanctions. Guatemala later gutted the law.

Access to cheap medicines to address these ills is scarce. Multinational drug companies eager to access the growing markets of countries like Brazil and India pressure these governments to crack down on cheap local producers of medicines that undercut their sales. The problem is especially acute in India, where 1970s-era patent laws once protected only how products were made, not the products themselves. The rule had allowed local drugmakers who could reverse engineer drugs to manufacture knock-offs of the latest brand-name drugs at a fraction of the cost.

The biggest Indian drugmakers, such as Cipla and Ranbaxy, have reverse engineered some of the most important medicines of modern times, slashing the cost of treating AIDS from $15,000 a year on patented, brand-name drugs to just a few hundred dollars. What’s more, bypassing the turf wars of brand-name companies who would as readily add a competitor’s drug to their own as Coke would add some Pepsi to its six-pack, the Indian drugmakers combined several different HIV medicines into combination pills that could be administered in simple, once-daily doses. But when non-profit health organizations and activist groups across the developing world started importing the cheap, Indian-made generic drugs, the Western drug giants who had patented the compounds unleashed a firestorm of protest. In 1998, 39 multinational drug companies sued the South African government for allowing the cheap drugs into the country. By 2005, India, along with other developing countries roped into WTO agreements, was forced to strike down its relaxed patent laws, instituting instead 20-year patent protection for drugs and other products. The vibrant generic drug industry-and the cheap meds it made available–is now crippled.

For these reasons and more, as we start to address the deadly legacy of hyper-marketed fast foods and sodas here at home, we should remember that the problem does not end at the corner Burger King. We’ve spread the problem beyond our borders, where its effect is likely to be much worse.

Sonia Shah’s new book The Body Hunters: Testing New Drugs on the World’s Poorest Patients is forthcoming from The New Press in July 2006. A fully updated paperback edition of her 2004 book, Crude: the story of oil is forthcoming in April 2006.

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