Seeking to explore ways to improve diabetes care in resource poor settings a joint study by Médecins Sans Frontières/Doctors Without Borders (MSF) and University of Geneva, published in the journal PLOS ONE, has demonstrated that a range of insulins can be stored at temperatures ranging between 25-37 degrees for a four–week period of use. This study confirms the possibility for people living with diabetes in similar temperature conditions to be able to use insulin, for a period of up to four weeks, even in the absence of access to refrigeration.
“For far too long, we were unable to send people with diabetes back to their homes with insulin due to its cold storage requirements. Some of these people were travelling long distances daily and some even relocated to get their insulin injections at the clinic. With this new finding of no refrigeration requirement in a climate of up to 37 degrees and with a well-developed patient education and support programme, people with diabetes in resource limited and humanitarian settings will now be able to inject themselves in their homes greatly improving the significant disruption to their lives from having to attend hospital for twice-daily injections. The ability to self-inject insulin is a fundamental aspect of diabetes self-management and the ability of people with diabetes to be empowered for their health," says Dr. Philippa Boulle, MSF Non-Communicable Diseases Advisor.
Diabetes is a chronic, progressive disease that can be controlled with effective treatment. However, in many countries, people living with diabetes are not getting the treatment they need to stay healthy and alive. It is a shameful fact that only about half of people requiring insulin have access to it. Access to insulin has been largely prevented due to high prices, challenging storage requirements and complex treatment protocols.
Strict storage recommendations for insulin are difficult to follow in tropical regions and even more challenging in conflict and humanitarian emergency settings, adding an extra burden for people managing their diabetes. Storage recommendations for insulin require refrigeration until its expiry date, or until it is opened for use. Once in use, the storage recommendations on the label of most human insulins are below 25°C for 42 days. In many settings, this results in people being asked to travel to the health clinic for injections and monitoring, at least twice a day, for life.
Mohamed Hussein Bule's story: Journey with diabetes
Mohamed is a teacher in a primary school in Dagahaley, Kenya, where he teaches science to the two highest classes. Mohamed came to Dadaab in 1992 with his mother after fleeing violence in Somalia.
Mohamed Hussein Bule lives with Type 1 diabetes. He is a refugee and teaches in one of the schools in Dagahaley. © Paul Odongo/MSF
Mohamed was keen on football but had to stop playing when his health suddenly deteriorated. “I used to play soccer, but I stopped in 2014 as I would get exhausted,” he says. “I started passing urine frequently and lost weight, going from 68 kg to 35 kg.”
While visiting an uncle in Nairobi in 2016, he went to a health facility where his blood sugar was tested and found to be high. He was provided with insulin, paid for by his uncle, which he took three times a day. One month later, he returned to Dadaab and came to MSF’s Dagahaley hospital.
“I went to the hospital and my treatment was changed,” he says. “Said [the former supervisor of MSF’s home-based insulin management programme] was good. He trained me a lot to be how I am today. I don’t even feel like I am diabetic. He taught me how to inject, how to understand hyper and hypoglycemia. I always wish him a successful life in future.”
Mohamed injects himself with insulin twice a day and has a follow-up visit at the hospital every three weeks. “The doctor here plans the schedules for us,” he says. “Myself I go for review every 21 days, when they also replenish our supplies. The insulin in the bottle is usually enough for 21 days.”
Mohamed says the portable cooling box is even better than the refrigerator he used before. “When you use a refrigerator, sometimes it gets too cold, so that when you inject it makes you cringe a bit,” he says. “I carry mine even to class and it does not bother anyone. People know that diabetes is not contagious, and if something can’t be transmitted, then people don’t get too concerned.”
The main challenge of the regimen, says Mohamed, is that he can’t eat for at least 30 minutes after taking insulin.
Mohamed has no problems using the glucometer. “Interpreting glucometer results is quite easy,” he says. “It works very fast and makes a beep when it’s ready. I know what range is supposed to be high or low.” Occasionally he experiences hypoglycaemia, or low blood sugar, but he has developed strategies to deal with it. “The last time I experienced it was during Ramadan, when we usually fast,” he says. “It also happens when I travel or when I walk for too long. The best way is to carry sweets in the pocket, but only eat them when you feel hypoglycaemia kicking in.”
Being a refugee presents many challenges, says Mohamed, but life in Dadaab has improved in some ways since he was a child. “When you’re a refugee, you can’t get everything you need,” he says. “When I was a child, life was difficult, but the camp has really developed over time, even the market. Travel is also difficult as movement is restricted. I find it quite difficult when I have to go to the university for my classes.”
MSF works in over 70 countries worldwide and in most of these settings, insulin is often not available in public health facilities or private pharmacies. MSF has been engaged in providing treatment for diabetes care in multiple projects across number of countries (including Jordan, Lebanon, Iraq, Syria, South Sudan, Democratic Republic of Congo, Tanzania, Kenya, Zimbabwe, and Bangladesh) to people living in resource limited and humanitarian settings.