Celestina of Porcón Alto, a rural region high in the Andes, whose family has lived on the same plot of land for generations. Credit: Andrea Vale/IPS

By Andrea Vale
PORCÓN, Peru, Oct 6 2017 (IPS)

Good healthcare can be hard to get – particularly when one lives on top of a mountain. The road to Porcón in the Cajamarca region of Peru, therefore, is as breathtaking as it is sobering. With every step further into its isolated natural beauty, a group of volunteers sent to deliver healthcare essentials are reminded how long the trek would be in an emergency.

After a bus has taken the volunteers as far as it can, to the rim of a sweeping valley dipping into the basin of a ring of mountains, they start their hike.“We have a lot of fear,” Celestina says. “The doctors are always telling us that they’re going to help us and heal us, but we can’t always get to them and they’re not able to get to us."

It’s not very long mile-wise, but they stumble over unforgiving drops in a rocky wind that leads them through tilted pastures resting on the sides of the mountains. The looming brown stillness is disrupted by their panting, at a loss of breath from the gasping altitude.

At the end lies a community of artisans who live in close proximity to one another in Porcón Alto, a rural region high in the Andes.

They’ve been waiting. Once the volunteers arrive, several women filter out into the pasture where they’ve set up shop and sit cross-legged around them, all accompanied by toddlers clutching at their long skirts and babies peeking out of the tops of the shawls slung over their backs to carry infants, or vegetables.

They have a flood of questions ready, about basic nutrition, exercise, disease prevention. They have a waiting list of ailments to look at – my child has this rash. My child can’t say his R’s. It hurts when I stand up from bed.

Immediately put to work, volunteers begin taking their blood pressure, weighing them, measuring their heart rates and their blood glucose levels. Under the shadow cast by one woman’s tall brimmed hat her skin is wrinkled in layers, leathery and toughened from years of work in the sun. She looks anywhere between 40 and 60, balancing a squirming toddler in her lap while she squints at the volunteer helping her with rapt attention and concern. But a glance at her chart reveals that she is only 22.

One woman sits in the center of the others, shucking corn with a baby tied to her back. Her eyes crinkle with smile lines and her elements-exposed skin is a mosaic of black freckles and brown creases. Her name is Celestina.

Porcón is home to her in a deep sense – her family has lived on this exact plot of land for generations.

“The house over there was taken down, but that’s where my grandmother and her mother lived,” she says in Spanish, gesturing out towards a rolling plot of land.

As to what life has been like, living high up here: “Sometimes it’s good, sometimes it’s bad. Sometimes I get worried. My daughter is sick right now, so I’m sad right now,” Celestina says, touching her daughter’s face as the baby girl plays in her lap. Baby Analee, she says, was bit by an insect just this morning. Analee’s cheek is already massively swollen with a red welt.

Fearing for her daughter is a constant reality of existence for Celestina.

“When I’m sleeping I can forget, but otherwise there’s always that worry for my child,” she says. “She needs to go to school, she needs to work, and I’m always worried about her, to know that she’ll be okay.”

Despite how long her family has lived on this land, Celestina says without a hint of hesitation that she wishes Analee could grow up in an urban area, perhaps the city Cajamarca below.

“Of course I want to live out in the city, but we don’t have land. Where would we build a house? Here, being out in the country, we just cook, we clean, we try to bathe, and we wait. All we can do is wait for the proper transportation to get to Cajamarca to try to get the proper attention if someone is sick.”

She says that there are no home remedies that she or anyone in the community uses to try to treat illness. Their best defense is simply the best level of hygiene they can achieve, and oftentimes it isn’t enough.

According to the Pan American Health Organization, only 19.1% of the urban population in Peru make up the country’s total poverty – as compared to 54.2% of rural peoples. In regards to extreme poverty, the contrast is even starker – 2.5% of the urban population, and 23.3% of the rural.

Celestina is 38 years old. She has the health of a 60-year-old. Plagued with health struggles since childhood, she currently suffers from chronic eyesight and stomach trouble.

But she brushes this acknowledgement off and automatically returns her attention to her baby.

“My daughter is sick and I am worried,” she says. “Always, I am scared for her.”

Celestina may worry about emergency illness striking, but what her and the other community members don’t realize is that the real threat of living in such isolation is not one-time tragedies, but rather chronic health problems. Of the children screened in Porcón, one-fourth were underweight and one-fourth were either at risk of being overweight or actually overweight. Of the adults screened, 33% were obese and 42% were overweight.

Most of the people examined during the health screenings, both in Porcón and across Cajamarca, had hypertension and were overweight. An inordinate number had diabetes and were completely unaware of it, ignorant to what caused the disease. One woman’s blood glucose level was close to 230 – the volunteer who tested her was so shocked that she tested the level twice more, sure that that initial reading couldn’t be possible.

Uneducated on signs of cancer and prevention techniques, many have had parents and grandparents pass away from the disease and simply chalked it up to having ‘just died,’ without a known cause.

According to the World Health Organization, the current national Human Resources for Health Density in Peru – meaning doctors, nurses and midwives – is 17.8 per 10,000 population. That distribution, however, is extremely inequitable, with rural areas usually having an HRH density of below ten. Lima, for instance, has three times more physicians per population – 15.4 – than Huancavelica, one of the poorest cities in Peru and populated in majority by indigenous peoples. 89.1% of births in urban regions are assisted by a professional – while only 42.9% of births in rural areas are.

Consequently, it’s perhaps not surprising that child mortality rates in Peruvian rural areas are almost twice that of urban areas – 40% to 26%.  According to the Pan American Health Organization, 35.3% of adults in rural areas of Peru are overweight, and 16.5% are obese. Only 40% of them perform any “moderate physical activity” – all of the health screenings concluded with group exercise classes.

Without doctors nearby, without easy and reliable transportation to get to the closest doctors, and without health education, Celestina has to live in constant fear. There is fear for her neighbors and for herself – but above all, fear for her baby. There is fear that disease will strike, that accidents will happen, that unexplained illness will come. Because when it does, Celestina and the rest of the community are left alone on top of the Andes with only their best abilities as a defense – uneducated, unequipped and without adequate and reliable transportation.

“We have a lot of fear,” Celestina says, “The doctors are always telling us that they’re going to help us and heal us, but we can’t always get to them and they’re not able to get to us. They’re always promising that they’re going to help us, but it never happens because they’re so far.”

For now, all that Celestina and the rest of Porcón can do is wait.

“The only thing we can do is wait until we can go to the doctor,” she says, “To go to the doctor and then wait again. Sometimes there’s nobody.”

Patient undergoing dialysis treatment at Mulago Hospital in Kampala. Credit: Rebecca Vassie

By Wambi Michael
KAMPALA, Jun 15 2015 (IPS)

Vincent Mugyenyi, a 65-year-old retired pilot from the Ugandan Air Force, has lost count of how many dialysis treatment slots he has had to attend in the eight years he has been fighting chronic kidney disease.

He spends eight hours a week on a dialysis machine in Mulago National Referral Hospital that filters toxins from his blood, performing the functions of healthy kidneys. The ultimate aim of dialysis is to bridge a gap until kidney functions recover or until a transplant is available for patients.

“I used to have a small farm with about one hundred animals. I sold all those animals for treatment because I still needed life. That is how this disease has affected me. It has depleted every resource of mine … land is very important but I have sold mine just to buy life,” Mugyenyi told IPS.

Mugyenyi is both luck and unfortunate. He is one of the minority of Ugandans with chronic kidney disease who has been able to receive dialysis treatment, but he does not qualify for a kidney transplant operation because of his advanced age.“We don’t have sufficient data on the disease. We understand more about HIV, malaria and tuberculosis, because these are diseases with lots of funding behind them. But funding for kidney disease isn’t there. Kidney disease deserves the same level of importance as HIV” – Dr Robert Kalyesubula, nephrologist at Mulago Hospital in Kampala

Chronic kidney disease (CKD) is a growing health burden in Uganda that is affecting the economic, social and physical livelihoods of patients and their family members.

Dr, Simon Peter Eyoku, a kidney disease specialist at Mulago Hospital’s renal unit, told IPS that CKD affects mainly Ugandan adults aged between 20 and 50, and that the commonest causes of kidney diseases in Uganda are HIV-related infections of the kidney, followed by hypertension and diabetes.

The World Health Organisation (WHO) says that with CKD being the 12^th leading cause of deaths worldwide and its incidence growing by around eight percent annually, it is a global public health concern.

Mulago National Referral Hospital is the only public hospital in Uganda treating patients with renal or kidney-related complications and, according to Eyoku, that often places a further burden on patients who have to travel long distances to the dialysis unit.

“I have seen patients migrate from far corners of the country to Kampala because that is where the dialysis machines are. That is how costly this disease can be to patients,” Eyoku told IPS.

A further problem is that the dialysis unit only has 33 haemodialysis machines for a total population of about 36 million people.

When the unit opened almost eight years ago with four dialysis machines, a patient had to pay the equivalent of 500 dollars for a week of dialysis treatment, making the cost of treatment prohibitive.

“Those who could afford it would fall out after selling land, houses, cars and then failing to continue. And at that time, the cost of a transplant was equal to the amount of money you paid in a year for dialysis,” said Eyoku.

In March 2014, the administration of Mulago Hospital decided to reallocate its budget in order to finance the renal unit and brought the cost of a week of treatment down to 40 dollars, but that is still out the reach of most Ugandans.

The hospital is now also offering two free sessions of dialysis, and Eyoku told IPS that this has led to an influx of patients with CKD, “so now we are struggling because we are getting many more patients on dialysis.”

Uganda’s health planners are accused of not giving priority to kidney-related diseases. “I wish we had more specialists managing kidney diseases,” Dr Robert Kalyesubula, one of the four consulting nephrologists at Mulago Hospital, told IPS.

“I wish we had more specialists managing kidney diseases, I wish we had more awareness programmes about kidney disease so that people know about it because it is devastating. I have seen big people break down on being diagnosed with kidney disease. And the pain, because it affects a whole family. If a father gets the disease then the children will not go to school.”

One of the difficulties with kidney disease is that in its early stages it has no specific symptoms so the patients who turn up for treatment are often in the final stages of the disease.

“Patients come in the dying stage,” said Kalyesubula. “You spend 90 percent of your time struggling to keep people alive rather than making them live.”

In addition, said the nephrologist, in Uganda as in the rest of sub-Saharan Africa, the magnitude of CKD is unknown and is not given sufficient importance.

“We don’t have sufficient data on the disease. We understand more about HIV, malaria and tuberculosis, because these are diseases with lots of funding behind them. But funding for kidney disease isn’t there. Kidney disease deserves the same level of importance as HIV. We are ignoring a disease which can be treated in its early stages.”

Patients who cannot afford to pay the 40 dollars a week for dialysis are treated in ward 4C, and the impression is that they are prisoners condemned to a death sentence with no possibility of appeal.

When IPS visits the ward on a busy afternoon, the scene was one of pathetic chaos, with the few doctors and nurses available rushing round, attending to both adult males and young girls in the same ward.

A male patient in his mid-forties had just died from kidney failure, and at the entrance to the ward, IPS met Rosemary Kyakuhaire, packing the bags of a brother who had died earlier in the day. She said that he had spent three weeks in the ward receiving palliative care because her family could not afford the expensive dialysis treatment.

In Uganda, Kalyesubula told IPS, a person would rather be diagnosed with HIV than kidney disease. “I say that mainly because HIV has a lot of support systems in Uganda. But for kidney disease, you are there on your own.  I have also seen people sell their houses to go for a kidney transplant but you don’t have to do that for HIV/AIDS.”

Provision of CKD treatment in Uganda depends primarily on whether the patient has health insurance or can otherwise afford treatment through taking out loans, selling property or financial support from relatives and friends. There are two private hospitals offering dialysis but only a lucky few can afford them.

Twenty-seven-year old Benon Mulindwa is one of the lucky ones. His employer, the Uganda People’s Defence Force (UPDF), had medical insurance cover for his treatment and transplant costs. He told IPS that without that medical cover, he could not have afforded the 20,000 dollars or so a year for dialysis and another 20,000 dollars for his kidney transplant.

However, Mulindwa received the transplant not in Uganda but in India, with his employer’s medical insurance cover paying for the costs of transport to India and surgery there. He explained that most patients have to look for their own kidney donors at home.

Unlike developed countries which run public kidney donation registries, patients in Uganda have to find potential donors and that, said Kalyesubula, is where one of the difficulties for CKD patients lies.

Because of lack of awareness about the safety of kidney donations, many Ugandans are unwilling to donate a kidney to save the life of one of the growing number of patients on the kidney donation waiting lists.

But that is not the only difficulty, as Mulindwa explained. “It is very difficult because there those who come as thieves, there those who come expecting to be paid a lot of money. I know of one who promised to donate a kidney to one of the patients, but when the money was sent the ‘donor’ disappeared.”

Edited by Phil Harris   

Increasing people's consumption of fresh produce and daily exercise are part of preventing a non-communicable disease crisis in the Pacific Islands. Credit: Catherine Wilson/IPS

By Catherine Wilson
SYDNEY, Feb 11 2015 (IPS)

The rapid rise of non-communicable diseases (NCDs) in the Pacific Islands, which now cause 75 percent of all deaths, is one of the greatest impediments to post-2015 development, health ministers in the region claim.

The Western Pacific has the world’s highest regional prevalence of diabetes, an NCD disease that is exacerbated by unhealthy eating habits, obesity and sedentary lifestyles, according to the International Diabetes Foundation. National prevalence rates have reached 25 percent in the Cook Islands, 29 percent in Tokelau and 37 percent in the Marshall Islands.

“Many amputations are done in our Pacific hospitals each day and people are losing their vision constantly due to diabetes." -- Spokesperson for Fiji-based Pacific Disability Forum (PDF)
Experts are increasingly concerned about the impact of the disease on the rate of disability, particularly the amputation of limbs and visual impairment, which threatens to undermine efforts to reduce poverty and inequality.

In Papua New Guinea, a southwest Pacific Island state that is home to over seven million people, “diabetes is increasing its prevalence in the general population, including children 12 years and younger, and the amputation of limbs is known among adults as young as 23 years,” Gerard Saleu, senior nursing officer at the country’s Institute of Medical Research, told IPS.

“Diabetes is certainly having an impact on disability in the region where not everyone can afford wheelchairs or walking and visual aids,” he added.

There has been a marked rise in NCDs in the Pacific Islands since at least the 1970s, experts say.

The incidence of Type 2 diabetes in Apia, capital of the South Pacific Island state of Samoa, rose from 8.1 percent to 9.5 percent in men and 8.2 percent to 13.4 percent in women between 1978 and 1991.

Considerable blame has been placed on the lure of globalised consumer-based lifestyles in a region with a long history of subsistence living, and the increasing influx of imported processed foods, high in fat and sugar content.

Local diets originally based on fresh fish, vegetables and fruit now include a high intake of instant noodles, packaged biscuits and carbonated drinks. Less than 10 percent of adults in Kiribati, Nauru, Marshall Islands, Papua New Guinea and the Solomon Islands eat a sufficiently nutritious diet, while more than 60 percent are obese in American Samoa, Tokelau, Cook Islands and Tonga, according to the Secretariat of the Pacific Community (SPC).

Increasing urbanisation has accelerated people’s susceptibility to NCD risk factors, including decreased daily physical activity. In Fiji, one study revealed that diabetes afflicted an estimated 11.3 percent of women living in urban centres, compared to 0.9 percent in rural areas.

The onset of diabetes, when the pancreas fails to produce enough insulin to regulate blood sugar levels, can lead to blood circulatory problems and damage to the nerves, heart, eyes and kidneys. This heightens the risk of blindness, stroke and amputation of limbs, commonly feet and lower legs.

Globally, NCDs, including diabetes, account for about 66.5 percent of all years lived with disability.

“Many amputations are done in our Pacific hospitals each day and people are losing their vision constantly due to diabetes,” a spokesperson for the Fiji-based Pacific Disability Forum (PDF) told IPS.

In the Pacific Islands, up to 47 percent of diabetes sufferers experience loss of sight and an estimated 17 percent require amputations, reports the Pacific Islands Forum.

From 2010-2012, the main referral hospital in Fiji, home to over 881,000 people, performed 938 diabetes-related lower limb amputations. Most amputees were aged 45 years and over, but more than 100 were in the 25-44 age group.

Meanwhile the main hospital in the South Pacific Island state of Tonga, home to some 103,000 people, witnessed a 400-percent increase in these amputations over the past decade.

The subsequent loss of mobility, decline in economic participation and increase in household medical expenses is entrenching hardship and inequality, especially for those families that are already economically disadvantaged.

For many islanders with disabilities, “most public buildings are not accessible, employers do not have reasonable accommodation in the workplace and many are unable to work, which is a lost income for the family,” said the spokesperson for the PDF.

While awareness of and political will to address the needs of disabled people, who comprise about 17 percent of the Pacific Islands population, is growing, they continue to be “among the poorest and most marginalised members of their communities…with limited access to education, employment and basic social services, which leads to social and economic exclusion and perpetuates poverty,” according to the United Nations Development Programme (UNDP).

In Fiji, for instance, an estimated 89 percent of people with disabilities are unemployed.

There is also an absence of rehabilitation services to assist those with diabetes-related impairment to cope with new physical and psychological challenges in their daily lives, the PDF reports.

The devastating toll that NCDs are inflicting on the lives of Pacific Islanders, in turn denying them better human development outcomes, is matched by the unaffordable economic burden on public health services.

The cost of dialysis for diabetes-related kidney failure in Samoa was 38,686 dollars per patient per year in 2010-11, with the total cost to government equal to more than twelve times the nation’s gross national income, reports the World Bank.

With Pacific Island governments currently funding up to 90 percent of national health services, there is little, if any, capability for them to increase health expenditure to address an NCD epidemic.

Pacific health ministers are driving a focus on prevention and calling for a scale-up of actions and investment in prevention and control strategies with a ‘whole-of-government and whole-of-society’ approach.

That means scrutinizing food industry practices in the interests of better public health. Samoa, Nauru and the Cook Islands have now introduced taxes on food and drinks with high sugar content and eleven countries in the region have developed plans to reduce salt levels in foods.

Non-governmental organisations, such as the Pacific Network on Globalisation, have also expressed concern about the impact of international trade agreements, which, in the aim of liberalising trade, can increase the influx of cheap, imported, but unhealthy foods and beverages and disadvantage local food producers.

But lifestyle interventions are also needed to change consumer and exercise habits among people of all ages, including children.

Saleu, the nursing officer for Papua New Guinea’s Institute of Medical Research, said that in PNG, some awareness about NCDs and education for prevention is being done among the general population, but in line with the view of regional health authorities, current resources and preventive efforts still fall short of matching the scale of the crisis.

Edited by Kanya D’Almeida

A soda-lemonade stand with soda bottles topped with lemons, in Rishikesh, India. Credit: Surya Prakash / CC-BY-SA-3.0

By Lyndal Rowlands
UNITED NATIONS, Nov 12 2014 (IPS)

Corporations marketing unhealthy foods to poorer consumers are being challenged for their role in the growing global burden of diseases like diabetes.

Over 340 million people are living with diabetes, and the World Health Organization predicts the number of people who die from diabetes each year will double between 2005 and 2030.  Nov. 14 is World Diabetes Day."Being poor also puts you at risk in countries like Indonesia where soda companies actually purposely market to poorer marginalised people with lower levels of education.” -- Dr. Alessandro Demaio

Dr. Alessandro Demaio, a postdoctoral fellow in global health and non-communicable diseases (NCDs) at Harvard University, told IPS that there is a clear link between poverty, diabetes and the marketing tactics used by junk food and soda companies.

“We know that globally about 80 percent of diabetes occurs in low- and middle-income countries, and we also know that in rich countries like Australia, the UK and the U.S., the worst affected populations are those who are most marginalised and impoverished,” Demaio said.

“The commonly held myth that non-communicable diseases are linked to affluence is pervasive and absolutely untrue.”

Diabetes is both a cause and consequence of poverty, Demaio said. “Diabetes care in a country like Vietnam or Malawi can cost 70 percent of a person’s income. We should remember that being poor also puts you at risk in countries like Indonesia where soda companies actually purposely market to poorer marginalised people with lower levels of education.”

Soda companies’ role in contributing to the diabetes burden is being challenged with the introduction of soda taxes in Mexico and Berkeley, California.

Dr. Vicki Alexander from Berkeley vs. Big Soda spoke to IPS about the successful campaign for Berkeley to become the first city in the United States to vote to introduce a soda tax last week.

She said that the Berkeley campaign was able to learn a lot from the successes that Mexico has had since introducing a soda tax, of one peso (eight cents) per litre in January 2014.

“Mexico City came up here [to Berkeley] to give a presentation when they got their preliminary data out,” Alexander told IPS.

Mexico City has seen a decrease in consumption of sugary beverages by 10 percent and an increase in water consumption by 13 percent, she said.

“It is such an inspiration because it is nationwide in Mexico. It shows us that yes, these taxes will have an impact,” Alexander noted. “Mexico became a model that we could discuss, the same issue in terms of the impact on diabetes and obesity.”

Demaio agrees that addressing lifestyle diseases such as diabetes should involve taxing unhealthy foods and drinks.

“We’re going to need to look at taxing things like soda, the foods that we know cause disease, we need to make them less affordable but we need to use that money to make other healthier foods more affordable.

“The soda tax in Mexico for example was a great step forward. The limitations on sizing of soda in New York that [Mayor] Michael Bloomberg tried to bring through but wasn’t able to, was again a great step forward,” Demaio said.

The Berkeley vs. Big Soda campaign deliberately involved people of colour in positions of leadership, because they are disproportionately affected by the issue, Alexander said. She said that soda companies “make decisions to market their beverages to people of colour.”

“They make huge profits off people being sick and try to confuse the public with statistics which have been completely refuted,” she said.

Diabetes and Poverty

Speaking at the United Nations in July, United Nations Development Programme Administrator Helen Clark said, “For too long NCDs were regarded as a problem for high-income countries.”

She said that this has changed as the United Nations now recognises “that developing countries are home to eighty per cent of the world’s NCD-related deaths.

“Today, low and middle-income countries are bearing the brunt of NCDs. Therefore, understanding the far-reaching development consequences of this is very important.”

Clark added that the cost of the four main NCDs, including diabetes, to lower and middle income countries is predicted to exceed seven trillion dollars between 2011 and 2025.

Demaio also told IPS that low and middle-income countries are struggling to keep up with the rapid change in the health challenges they are facing. “[High income countries] have seen the same health transition over a hundred years that some countries like Mongolia are seeing in 10 or 15 years.”

Middle income countries like China and India are among the worst affected: 13 percent of China’s population now has diabetes compared with only one percent in 1980.

“We have a situation where in many countries around the world, particularly in middle income countries, we have obese people living in the same house as people who are malnourished. This whole complex situation where we have over-nutrition and under-nutrition in the same family shows how broken our food system is globally.”

Demaio said that this is an outcome of the globalisation of the food system and the loss of food related resilience.

He says that many people have now lost the resilience that is the ability to be able to cook, to know what is in season, to be able to choose foods that make sense based on where you are geographically.

This loss of food resilience impacts not only people’s diets and health, but also has environmental and cultural consequences.

Highly processed foods that are transported long distances are more environmentally damaging than food that is local, in season, cheaper, healthier and fresher, Demaio said.

This also contributes to a loss of food culture as  “a single homogenised food culture is spreading around the world, replacing traditional diets and traditional food practices.

“We are a global community, this is a global problem, they are global companies, and these are global determinants of health. That’s the way that we need to see this challenge.” Demaio said.

Edited by Kitty Stapp

Mexico is fighting obesity and accompanying diseases with a one-peso per litre tax on sugar-sweetened beverages that kicked in Jan. 1. France implemented its “cola tax” in 2012. Several U.S. states tax sugar-sweetened beverages, including Vermont, Rhode Island, Arkansas, Tennessee, West Virginia and Virginia. Illinois legislators are considering such a tax.

To date, no U.S. city has approved a tax on sugar-sweetened beverages. Advocates of the tax in San Francisco and Berkeley, California hope they will be the first. But they’ll have to fight the “big soda” industry lobby to do it."We don’t want to start a precedent - every time a corporation threatens to put a bunch of money in, we back down.” -- San Francisco Supervisor Scott Wiener

Proponents say the taxes would reduce consumption of drinks that contribute to costly diseases like diabetes. But the American Beverage Association, representing the 141-billion-dollar non-alcoholic drink industry, says the tax would hurt the poor by inflating grocery bills, and argues that the choice to drink sugary beverages should be made by the individual, not the government.

Berkeley and San Francisco residents will vote Nov. 4 on whether to tax sugary drinks.

Dr. Vicki Alexander, MPH, co-chairs the Berkeley Healthy Child Initiative Coalition, the tax measure sponsor in Berkeley. She said sweetened beverages can be even more harmful than cake or cookies.

“When [a sugar-sweetened drink] enters your mouth, it is quickly swallowed and enters the organ that regulates sugar in the bloodstream,” Alexander said at a recent council meeting. “You don’t even have time to feel full. So you drink more – you supersize it. This high sugar content can lead straight to diabetes.”

The ABA spent millions of dollars opposing sweetened-drink tax campaigns in Richmond and El Monte, California, soundly defeating both in 2012.

But Berkeley City Councilmember Darryl Moore said the powerful industry doesn’t scare him. “We were the first community to divest [from South Africa], the first community to have domestic partner benefits, the first to put curb cuts for our disabled community,” he said at a recent city council meeting. “No city has been able to successfully pass a sugar-sweetened beverage tax, but it will happen here in Berkeley.”

Across the Bay, San Francisco Supervisor Scott Wiener is sponsoring San Francisco’s ballot measure to tax sugar-sweetened beverages. Like Moore, he said he’s ready to take on big soda.

“The beverage industry is a bad actor,” Wiener said. “They are going to put a lot of money into the campaign, just like tobacco and big oil put a lot of money in any time we try to do anything in California around taxes or regulations. We don’t want to start a precedent – every time a corporation threatens to put a bunch of money in, we back down.”

Tax measure details won’t be finalised until July. In its present form, the San Francisco measure would tax sugar-sweetened beverages at two cents per ounce; Berkeley’s levy would be one cent per ounce. Sodas, sports drinks, and sugar-sweetened teas would be taxed; the tax wouldn’t include milk and medical drinks, diet sodas and alcohol.

Distributors would pay the tax, which proponents believe would be passed on to consumers. Adding a penny-per-ounce tax on sweetened beverages across the U.S. would prevent 240,000 cases of diabetes per year, according to Dr. Kirsten Bibbins-Domingo, associate professor of medicine, epidemiology and biostatistics at the University of California San Francisco.

The San Francisco measure directs tax funds to nutrition, health and physical activity programmes. The Berkeley coalition is evaluating polling data to decide whether its measure will specify where funds are spent.

Advertising by the sweetened beverage industry often targets children. Credit: Judith Scherr/IPS

Retired cardiologist and former Richmond Councilmember Dr. Jeff Ritterman, who spearheaded failed efforts to pass the tax in Richmond, is advising proponents in San Francisco and Berkeley.

“Being first out of the gate, we didn’t have money,” Ritterman told IPS. “We didn’t have professionals running the campaign. And we didn’t have polling data. A cardiologist turned city councilmember flying by the seat of his pants is what we had in Richmond.”

The beverage industry spent 2.5 million dollars in Richmond, a city of about 100,000, and 1.5 million dollars in El Monte, with about 20,000 people, to defeat the measures. (Berkeley’s population is about 112,000 and San Francisco’s is about 825,000.)

With seven months before the election, tax proponents in Berkeley and San Francisco have instituted many elements the Richmond campaign lacked. They’ve tapped volunteers, raised funds, hired professional consultants, taken polls and launched websites.

The beverage industry also got an early start. It established the Coalition for an Affordable City, which sent mailers to San Francisco voters targeting the city’s “rising cost of living, escalating rents, [and] impending evictions,” arguing that instead of addressing housing costs, tax proponents want to make life harder by taxing sodas.

Supervisor Wiener said the mailer used “the very real anxiety around the cost of housing” to attack the tax. “To suggest that a two-penny per ounce tax on soda is even in the same universe as seniors who are losing their housing is pretty specious,” he said.

IPS asked the ABA for comment; they responded by directing this reporter to their websites.

An overarching question is how the Berkeley and San Francisco campaigns will compete, given that, no matter how much money they raise, the industry will outspend them.

San Francisco campaign consultant Maureen Erwin said they’ll depend, in part, on “enthusiastic” volunteers. “Person to person contact is absolutely the best method of getting the message out,” she said.

In Richmond, the beverage industry split the community along racial lines, garnering opposition to the tax from minority city council members and communities by claiming the tax was regressive and would hurt poor Latino and Black communities.

Dr. Alexander, who is African American, told IPS that although seven of the 15 members of the Berkeley coalition steering committee are people of colour, and the initiative is endorsed by the local NAACP and prominent Latino organisations, there is still need for vigilance.

“If they offer a [Black] minister 5,000 dollars for a church garden, would he accept it?” Alexander asked. “We’re prepared for attempts to divide the community.”

Another argument the beverage industry used effectively in Richmond, and the Coalition for an Affordable City is using in San Francisco, addresses the issue of personal responsibility.

“When it comes to our food and beverage choices and the choices we make for our families, we don’t need the city government’s input,” the Affordable City SF website says. “It should be up to parents to make responsible choices for their children. A beverage tax is no substitute for parental responsibility.”

But Sara Soka, consultant to the Berkeley pro-tax coalition, told IPS that while people have nominal choice about what they drink, “pervasive marketing from the beverage industry has made having a real choice a lot harder for all of us, especially kids and their parents.”

The beverage industry ads target children – especially children of colour, she said, adding, “About two-thirds of California teens drink one or more sweet drinks each day. And cheap drinks don’t help. A sugary drink tax is one way we can fund programmes that raise awareness for kids and parents.”

Berkeley Councilmember Laurie Capitelli cautioned it won’t be easy to fight the industry. “They’ll try to divide us by race, they’ll try to divide us by class, they’ll accuse Berkeley of trying to be a ‘nanny state,’” he said.

But Ritterman said understanding the tactics and messages big soda used in Richmond and El Monte, the Berkeley and San Francisco campaigns will “inoculate the public to what’s coming and take the power out of the beverage industry message.”

The disease itself may not discriminate on the basis of gender, but when it comes to healthcare for patients with diabetes, women in India find themselves at a disadvantage compared to men.

This was the conclusion of the study, ‘Impact of Gender on Care of Type 2 Diabetes in Varkala, Kerala’, which analysed gender roles, norms and values in a household and found women patients to be more vulnerable.

Women in India face disadvantages when it comes to diabetes. Credit: K.S. Harikrishnan/IPS

And this vulnerability influences all phases of diabetic care, according to the paper by Dr Mini P. Mani at the Achutha Menon Centre for Health Science Studies (AMCHSS) in Thiruvananthapuram, the capital of the southern Indian state of Kerala.

Even when they themselves suffer from diabetes, women cannot abandon the ‘caretaker role’ in the family and have to continue to prioritise the health of other family members above their own, the study found. Further, inequitable access to resources prevents early diagnosis of the disease in women.

Women pay more attention to the health of the men and children in the family, leaving them with less time to devote to their own wellbeing, said Rosy Raphy, who teaches at a school in Munambam, near the central Kerala town of Kochi.

“As someone who has lived with diabetes for 26 years,” Raphy told IPS, “I can say that I was not aware of the disease and did not take due care because I was preoccupied with matters of the family. As a result, my case got aggravated.”

Of particular concern to women and gynaecologists in the country is Gestational Diabetes Mellitus (GDM), a form of the disease that affects pregnant women.

The incidence of GDM has grown fourfold in the last 10 years, according to Dr B. Rajkumar, a doctor of Indian Systems of Medicine at the Keezhariyoor Government Ayurveda Dispensary in the state’s northern coastal district of Kozhikode.

“Earlier, pregnant women would engage in physical activity while doing housework. Today, the lifestyle of women has changed. Lack of exercise affects the body. And obesity, too, is a cause of gestational diabetes,” he said.

One in five pregnant women in Ahmedabad in the western Indian state of Gujarat were found to be suffering from GDM, according to a study by the Diabetes Care Institute in that city, whose results were reported in February.

“What is alarming,” the report said, “is that of the five women found to have diabetes, two were diagnosed with the silent killer while the other three went undetected.”

And women with GDM were at higher risk of developing diabetes later in life, warned an earlier study in Kerala’s neighbouring state of Tamil Nadu, conducted by a group of doctors led by endocrinologist Dr V. Seshiah.

“They are the ideal group to be targeted for lifestyle modification or pharmacologic intervention in order to delay or postpone the onset of overt diabetes. Hence, an important public health priority in the prevention of diabetes is to address maternal health both during the ante- and post-partum period,” the study noted.

Medical researchers believe that the disease, earlier considered an ailment of the rich, is on the rise in India. Close to 70 million people – half of them women – in this country of 1.21 billion are living with diabetes, and the number is predicted to go up to 101.2 million by 2030.

Nearly 60 per cent of diabetics in India have never been screened or diagnosed due to a lack of awareness, according to a 2012 report published by the Brussels-based International Diabetes Federation (IDF), an umbrella organisation of diabetes associations in 160 countries. The study also noted that nearly 63 per cent did not even know the complications that arise from the disease.

Doctors attending the four-day World Congress of Diabetes in April, organised by Diabetes India in Kochi, suggested India-specific treatment guidelines for helping the rapidly growing number of patients in the country.

Dr Jothydev Kesavadev, the organising secretary for the fifth edition of the congress and the moderator for glucose monitoring consensus guidelines, told IPS that low-income patients suffer the most as they lack medical insurance.

“Though there are international guidelines for the treatment of diabetes, there is an urgent need for country-oriented guidelines,” he said, “especially in areas of glucose monitoring and use of insulin in hospitals, besides taking into consideration the socioeconomic status of a patient and the country.”

Healthcare experts say that a combination of dietary pattern, sedentary lifestyle, obesity, and genetic predisposition puts Indians at a unique risk of acquiring diabetes.

Analysing the increasing percentage of diabetic patients in the country, Dr Meenu Hariharan, director of the Indian Institute of Diabetes in Thiruvananthapuram, told IPS that Indians were more prone genetically to diabetes than Europeans.

“Reduced physical activity and obesity accelerate the onset of diabetes in genetically predisposed people,” she said. Starch-rich diets and increased intake of tinned foods with a high content of preservatives are other culprits.

A host of studies and screening programmes have highlighted the fact that diabetes is spreading fast across the country.

Cases of diabetes are higher in the four southern states – Karnataka, Tamil Nadu, Andhra Pradesh and Kerala – than in other states, according to the results of a countrywide blood testing campaign conducted under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Strokes by the country’s health ministry.

In Tamil Nadu, 11.76 per cent of people tested positive for diabetes, 10.2 percent in Karnataka, 8.83 per cent in Kerala, and 8.72 per cent in Andhra Pradesh, compared to just 2.95 percent in the central Indian state of Madhya Pradesh, which reported the lowest incidence of the disease.

Alarmingly, rural areas are also seeing a rise in diabetes rates, as a fall-out of rapid urbanisation. However, the incidence of the disease remains higher in cities than in villages, according to Dr V. Ramankutty, a well-known health activist and professor at Thiruvananthapuram’s AMCHSS.

Talking to IPS, he charted the rise in the incidence of the disease. A survey in the early 1970s, he said, found only 2.3 per cent of the urban population and 1.5 per cent of the rural population to be suffering from diabetes. But by 1992, the proportion had gone up to 8.2 per cent and 2.4 per cent for urban and rural areas, respectively. A repeat survey after five years found an even higher prevalence of the disease in urban areas, at 11.6 per cent.

But if it’s any consolation, insulin-deficient diabetes in children is less common in India than in Western countries, said Dr G.D. Thapar, former director of the Ram Manohar Lohia Hospital in New Delhi. In his book ‘How to Lead a Healthy Life despite Diabetes’, he emphasised how crucial breast-feeding is to prevent the disease in children.

After years of delays and obstacles, a law regulating the pharmaceutical market has come into effect in El Salvador, giving its people access to medicines at more reasonable prices, with discounts of over 50 percent for some drugs sold in high volumes, like diabetes medication.

“The Medicines Law is a major step forward for health rights” in El Salvador, Margarita Posada, the head of the Salvadoran Association of Community Health Promoters and one of the first activists to present in 2002 a bill to limit the abusive practices of drug manufacturers and retailers, told IPS.

In early January, the Dirección Nacional de Medicamentos (DNM, National Directorate of Medicines), newly created by the law, published maximum retail prices for 4,406 medicines that are on average 35 percent lower than before.

Within this list of named medicines, the drugs with the highest volumes of sales and the highest costs had their prices slashed by an average of 69 percent, good news for consumers who for decades have been paying high prices fixed by an under-regulated industry which has been accused by social organisations of committing marketing abuses.

For instance, the DNM list shows that a medicine for treating high cholesterol, previously sold at 68 dollars, will now cost 37 dollars, and another for diabetes, formerly 23 dollars, will cost 10.73 dollars. (These are chronic conditions, so savings over a year are substantial.)

The price control measures apply only to prescribed medicines, not to over-the-counter preparations, according to the law that was approved in February 2012, but only came into effect Dec. 29 when the executive branch provided it with the necessary regulations to translate it into policies.

Pharmacies have until Apr. 1 to adopt and display the new prices established by the DNM rules.

The World Health Organisation recommends that medicines should not be priced at over five times the international reference price (IRP), but in this country that multiple has been exceeded many times over, according to studies carried out by the state University of El Salvador.

“Of course, there have been abuses on the part of the pharmaceutical industry,” said Posada. The same medicine for treating high blood pressure costs the equivalent of four dollars in Ecuador, but 17 dollars in El Salvador.

The prices on the DNM list were arrived at by comparison with the cost of medicines in the rest of Central America and with IRP listings. A new list of around 7,000 products with significantly lower new prices will be issued in February.

“In (two) months’ time, all these products must be labelled with the maximum retail price,” the head of DNM, José Vicente Coto, told IPS.

As these prices are announced, the pharmaceutical sector remains as hostile as when the legislation was first being debated.

Pharmacy owners, the final link in the chain that has to absorb the price changes, met in December with DNM officials for clarification of the scope of the new regulations. But the meeting turned into a forum for the business owners to voice their collective disagreement with the enforcement of the law.

They say they will lose out because, in two months’ time, they will not be allowed to sell products they bought under the old price regime at their original cost.

“There is no doubt that we will suffer losses. We cannot lower prices just because the law says so,” said Ricardo Iglesias, the owner of La Divina Providencia pharmacy in Chalatenango, in the north of the country.

In general, the pharmacy owners complained that the regulations are forcing them to change their prices, but not the pharmaceutical laboratories that produce the medicines, nor the distributors or middlemen.

The DNM director told them that the law only regulates the retail price, but obviously it is expected that the whole production chain will have to adapt to the new rules, including the laboratories and the distributors.

Meanwhile, the Pharmaceutical Chemistry Industry Association of El Salvador (INQUIFAR), which represents the laboratories, said the sector will not survive with the prices set by the law.

Carmen Estela Pérez, the executive director of INQUIFAR, said they have identified a large set of medicines that they will not be able to sell because the prices fixed by the regulations are below the cost of production.

“The prices we have seen (on the list) are non-viable,” Pérez told a television channel. She underlined that 7,000 direct jobs and 110 million dollars a year from pharmaceutical exports are at stake.

In October 2012 the Supreme Court agreed to try the case of a constitutional challenge from a private citizen against some of the articles in the Medicines Law. This represents the pharmaceutical industry’s last card in its bid to have the legislation, and the price cuts, repealed.

Pérez hinted that the law, promoted by the parliamentary bench of the governing Farabundo Martí National Liberation Front (FMLN), might be an attempt to displace national industry in favour of ALBA Médica (Medical ALBA), an initiative she says aims to follow in the footsteps of ALBA Petróleos, an oil company that is a joint venture between FMLN mayors and the Venezuelan government.

Everything related to the Bolivarian Alliance for the Peoples of Our America (ALBA) is a source of severe irritation among conservative sectors in El Salvador, due to the close relationship between leaders of the FMLN, a former guerrilla group, and the Venezuelan government of President Hugo Chávez and his 20th Century Socialism, which promotes this alliance of Latin American governments.

Political analyst Kirio Waldo Salgado said in a television interview that if ALBA Médica enters the market, there is no need for alarm, because that is what the free market, loudly advocated in El Salvador, is all about.