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Panel discusses cultural, political, economic barriers to insulin access


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4 minutes

Sylvia Kehlenbrink, MD
Sylvia Kehlenbrink, MD

More than 100 years after the discovery of insulin, access, affordability, and availability of the lifesaving medication remain key challenges for millions of people living with diabetes worldwide. In the Friday, June 3, session, Insulin Access—Challenges and Recommendations, a panel of experts discussed the current barriers to insulin access and ongoing initiatives to address them.

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Of the estimated 537 million people worldwide living with diabetes, more than three-quarters live in low- and middle-income countries where the challenges of insulin access, and diabetes care in general, are particularly complex.

Sylvia Kehlenbrink, MD, Director of Global Endocrinology at Brigham and Women’s Hospital and Director of the Non-Communicable Diseases in Conflict Program at the Harvard Humanitarian Institute, addressed insulin access challenges in humanitarian and vulnerable settings.

Apoorva Gomber, MBBS, MD
Apoorva Gomber, MBBS, MD

“Insulin availability in many lower- and middle-income countries is a great challenge. It is often unavailable in the public sector and in humanitarian situations, as insulin is often reserved for inpatient use only,” she said. “And when insulin is available for ambulatory care, it is typically only dispensed at the hospital level, not at the primary care level, so patients may have to travel very far, often in dangerous circumstances, to get to the hospital to obtain their insulin.”

She cited results from the recently published Humanitarian NCD Interagency Study in Emergencies and Disasters, in which she and colleagues looked at diabetes care data from four humanitarian organizations covering 83 sites in 27 countries.

“What we found was that there was no insulin provided in about a third of the humanitarian sites,” Dr. Kehlenbrink said. “And the vast majority of insulin provided was regular human insulin and premixed human insulin in vials with syringes. Insulin analogs were available at only 9% of sites.”

Access to insulin is just one of the challenges faced by people living with diabetes in low- and middle-income countries, said Apoorva Gomber, MBBS, MD, Research Fellow in the Department of Global Health Equity at Brigham and Women’s Hospital. A variety of health system factors are needed for the management of diabetes, including access to syringes and other delivery devices, and education on safe insulin use practices, she noted.

Bashier Enoos
Bashier Enoos

“Access to insulin is not enough,” Dr. Gomber said. “The disparities and inequities in diabetes care, particularly in low- and middle-income countries, need to be addressed through multifaceted national and global actions.”

Bashier Enoos, Technical Officer in the Department of Noncommunicable Diseases at the World Health Organization (WHO), discussed the Global Diabetes Compact, a WHO initiative launched in 2021 to coincide with the 100-year anniversary of the discovery of insulin.

“The goal of the Compact is to galvanize efforts around the world to ensure that all people who are diagnosed with diabetes have access to equitable, comprehensive, affordable, and quality treatment and care,” Enoos said.

The initiative also focuses on diabetes prevention and health literacy.

“We have a real opportunity to collectively move together and improve access to the essential medicines and technologies and products to ensure that every person diagnosed with diabetes has access when they need it the most,” Enoos said.

Irl B. Hirsch, MD
Irl B. Hirsch, MD

Insulin access is not a challenge exclusive to low- and middle-income countries, said Irl B. Hirsch, MD, Professor of Medicine and Diabetes Treatment and Teaching Chair at the University of Washington, who discussed insulin access in the U.S.

“Insulin access is political—it’s always been that way, but now it’s more clear than ever,” Dr. Hirsch said. “From 2009 to 2019, the cost of insulin has gone from well under $100 for a vial to well over $250. Additionally, in that time, we’ve seen an increase in ketoacidosis, both in the [emergency department] and admitted to the hospital, and we know the No. 1 cause for this was insulin accessibility.”

In 2022, the three major insulin companies were in the top 25 contributors, of 483 total, to federal politicians, he noted.

“We have the Sunshine Act for physicians, but we really don’t have anything similar for politicians, but I think we should,” Dr. Hirsch said, referring to federal requirements aimed at increasing the transparency of the financial relationships between health care providers, teaching hospitals, and companies that manufacture pharmaceuticals, medical devices, and biologics. “Our system for the distribution of insulin is complex, is based on greed, and would not be tolerated in most, if not all, other countries in the world.”