K. M. Venkat Narayan: Indian diabetes census – just don’t count on it!

venkat narayanThe Union Health Minister of India, Mr. Ghulam Nabi Azad recently announced a plan to hold a diabetes census across the country. “We intend to start mandatory testing for diabetes in the age group 25-70 years across the country in the next two years. The idea is to figure out the actual number of the population that is suffering from diabetes or is likely to suffer,” said Mr. Azad.

It is most welcome that the Indian Health Minister is paying serious attention to diabetes. Diabetes already affects an estimated 50 million people in India and is expected to double within 20 years. There are indeed serious concerns about the accuracy of the estimates of numbers of people with diabetes in India. Given the rate at which diabetes has been sweeping across the country, some are worried that these existing numbers may be under-estimating the true size of the problem. But rushing to screen and test all people aged 25-70 years for diabetes in a population of 1.1 billion people is not the best use of resources. There are two major problems with doing this.

Firstly if the goal is to get an accurate count of the number of people with diabetes and those at risk of developing the disease, trying to test everyone in the population is not only unnecessary, but also organisationally cumbersome, and extremely expensive. It is likely to lead to hugely biased results because of non-adherence and difficulty with standardisation of methods. A far better approach to getting an accurate count of the numbers with diabetes would be to carefully sample the population, and to rigorously and systematically conduct a nationally representative survey of the country. Not only will this be cheaper, but it will also produce more reliable data to assess the problem and to monitor future trends. 

Secondly it appears that Mr. Azad wishes to use the census to trigger action to prevent diabetes and its complications. “We will study all three categories of diabetes and decide on the next course of action accordingly. State governments will help those on the borderline to bring about behavioural changes in food habits and exercising,” Mr. Azad said.  The intention is laudable, but Mr. Azad needs to think of several issues. Can people with diabetes be accurately identified using the Glucometer test he is proposing?  In general, most people who test positive with this test will need another diagnostic test for confirmation. Some with negative tests may also have diabetes. More importantly, are the infrastructure and resources in place to treat those estimated thirty-something million people who will be newly diagnosed with diabetes, and to start preventive action for another fifty-plus million people found to be at high risk of diabetes? These are overwhelming undertakings, and cannot be taken lightly.  Management of diabetes is complex, costly, and requires lifelong care.  The existing system is simply not able to deliver quality care even for those known to have diabetes, leave alone those who don’t know they have the disease. Only a third or more people with known diabetes in India currently get adequate care. 

Mr. Azad deserves kudos for taking the war against diabetes so seriously.  It is true that diabetes hugely threatens India’s health and economy, and that urgent action is needed. But Mr. Azad can actually win the war against diabetes by using the resources more prudently rather than mounting an impossible census to count everyone with diabetes in the population. 

What is needed is a well considered and strategic approach, based on the best evidence currently available, to preventing and controlling diabetes.  One place to start might be the priorities identified in the World Bank/NIH Disease Control Priorities Project’s chapter on diabetes.  

It is possible to halve the incidence of diabetes among those at high risk of the disease, and to halve the incidence of diabetes complications among those with the disease by systematically applying what we already know.  What is needed is an effective and integrated prevention and control strategy, and not a population census of diabetes.

K.M. Venkat Narayan is Ruth and O.C. Hubert Professor of Global Health and Professor of Epidemiology and Medicine at Emory University Atlanta. He is a product of three continents, having lived and worked in India, United Arab Emirates, United Kingdom, and United States of America.