U Ye Myint is 62 and was diagnosed with diabetes one year and 7 months ago. He tells me about how he was admitted very unwell to hospital with breathlessness and found to have unrecordable blood sugars. When he was told he had diabetes he became very afraid; many of the neighbouring patients on his ward died from complications of diabetes so he knew how serious his condition was. Now he has been coming to the North Okkalapa General Hospital (NOGH) diabetes clinic, the only public diabetes clinic in the country. He has been finding it hard to keep to the prescribed diet, but takes smaller portions of rice and more meat and vegetables instead.
U Ye Myint’s sister is his only living relative and main carer, who administers his three-times-a-day insulin and other prescribed medications. He also takes a local fruit that he heard about on television as a good treatment for diabetes, and says it gives him energy to feel better. Sometimes the thought of living with his disease makes him depressed and scared for his life.
U Ye Myint is one of the very few regular patients attending NOGH diabetes clinic telling us about his experiences of the condition. A 2014 national survey funded by World Health Organisation (WHO), suggests 10.5% of Myanmar’s population have diabetes and a further 19.5% have impaired glucose tolerance, which if unchecked will lead to diabetes. To put that into perspective, UK prevalence was quoted as 7.4% in 2012 with an estimated 14% (1 in 7) with impaired glucose tolerance. Although prevalence data in Myanmar is sparse, the studies that do exist set it as one of the emerging NCD capitals of the world. The World Health Organisation (WHO) 2014 global report on NCDs shows that South-East Asia is showing the fastest rate of increase in premature deaths from NCDs, and a staggering 82% of premature deaths from NCDs occur in low and middle income countries (LMICs).
Another patient, U Thaung, comes from a family of nurses and was himself a healthcare-training coordinator. He is admirably stoic and feels in control of his diagnosis; he has been living with diabetes for 20 years. “I was not afraid” he says, “my mother had diabetes and I expected it would happen to me too.” U Thaung has excellent knowledge of the ‘diabetic diet’ and says he finds it easy to play to the dietary rules because he only eats at home. Few people would feel the same eating the rice infused Myanmar diet reminiscent of the John Betjemen poem; ‘Rice paper, rice noodle, fried rice, Rice minds, rice breath’. Then of course there are all the deep fried snacks and with oil, once a scarce commodity, now used as the currency of hospitality.
Already genetically predisposed to diabetes, the increased availability of produce due to opening trade borders will lead Myanmar through the well-trodden paths of other emerging LMICs. According to the WHO 2014 report a multi sector and primary health care focused approach is needed to tackle this growing burden, and Myanmar is looking to adopt exactly that. Professor Ko Ko of NOGH is the country’s lead physician for tackling diabetes. He quotes 59% mortality in Myanmar (2012) is from NCDs and 80% of those could be prevented with risk behaviour modification. In the past the focus has been mainly infectious diseases and maternal and child health, in line with the former Millennium Development Goals (MDGs), whereas NCDs have largely been ignored. With the advent of Sustainable Development Goals (SDGs) however, he hopes the agenda will change.
Professor Ko Ko sounds optimistic as he tells of a new government NCD operational branch to co-ordinate the country’s healthcare approach: “There are four major groups of NCDs that we need to target: cardiovascular disease, respiratory disease, diabetes and cancer. I am focusing on diabetes but I cannot do it alone. There needs to be political will to make it possible”. Historically this will has been lacking. Health expenditure in Myanmar was quoted as 1.3% GDP in 2013 whilst 3.7 % GDP was spent on the military (2014), which means public health services have been largely neglected in contrast to the well developed private sector. Subsequently, much of the national health initiatives in Myanmar are funded by NGOs, which according to Professor Ko Ko, “won’t invest in a lack of ‘sure win’,” leading to mostly vertical programmes. Although these have been beneficial for the country, for example in the elimination of trachoma, and the National Tuberculosis Programme, the health system is struggling to provide an integrated NCD intervention.
Professor Ko Ko has been piloting a rural health care service, which targets diabetes and hypertension by training midwives to screen, diagnose and instigate treatment, free at the point of service. The challenge of gaining political commitment to expand the programme countrywide has only recently moved forward, and is in the initial stages of expansion. For Professor Ko Ko, health education and the political commitment to safeguard population health when making trade negotiations are crucial.
A street in Yangon © Sophie Ross
Already in the country, Pepsi and Coca Cola have accessed the most remote villages and Kentucky Fried Chicken billboards are dotted throughout Yangon’s avenues. Nestle is fast establishing itself as the leading provider of ‘3 in 1’ coffee, catering to the nation’s sweet-tooth, and in the process eliminating the possibility of cutting sugar from your coffee. Healthcare campaigns run on the ground cannot mediate the influence of the billion dollar investments these MNCs make in marketing; current tools of local education talks and pamphlets can’t compete with the glamour and status of big brands.
Although new preventative strategies are much needed in Myanmar, access to specialist services and pharmaceuticals are also lacking. U Thaung, who has had diabetes for 20 years and has been working locally in that time, has only recently discovered the NOGH, the only unit of its kind nationally: “I wish I had known that this diabetes clinic had existed sooner” he muses. Instead, he has been seeing private generalists at his own expense. He feels coming to the specialists has made a big difference to his treatment, and wants to raise awareness of specialist services available. Excitingly, Professor Ko Ko reveals that they have gained permission from Ministry of Health to start two new Endocrinology units in Yangon and Mandalay. This will greatly increase coverage of specialist diabetes treatment, although drug availability, especially insulin, remains problematic.
There is an air of optimism for the future here in Myanmar, although the actions of the new government are awaited with baited breath. It is not known how stringently they will be able to keep to their promised priorities of health and education when there are so many other needs in the country, such as eliminating corruption and building infrastructure. Professor Ko Ko explains:
The government has a lot to do…but I think things will be better now they have acknowledged NCDs as an issue and we will have a budget to work with.
Featured image: Entrace to the endo ward © Nazaneen Nikpour Hernandez
Dr Nazaneen Nikpour Hernandez completed her Core Medical Training and is currently in her final year of MSc Global Health Policy at the London School of Hygiene and Tropical Medicine (LSHTM). She is an Improving Global Health (IGH) Fellow in Yangon, Myanmar and is leading a project for the first state retinal screening system for diabetic patients at NOGH. Nazaneen has a strong interest in non-communicable diseases and elderly care.