The coronavirus pandemic is a wake-up call for all nations, including Mauritius. As the rapid transmission of the virus catches the world off-guard, we all hold our breaths for a miracle cure from scientists across the world, who, until now, have remained the unsung heroes even following breakthroughs in deadly diseases like cholera, AIDS and Ebola. It is thanks to medical research that diseases such as type 1 diabetes are not fatal anymore. And yet, this sector has been struggling for funding, investment and recognition for years. 

Whilst the penny has finally dropped for French President Emmanuel Macron as he solemnly states that “La crise du COVID-19 nous rappelle le caractère vital de la recherche scientifique et la nécessité d’investir massivement pour le long terme. J’ai décidé d’augmenter de 5 milliards d’euros notre effort de recherche, effort inédit depuis la période de l’après-guerre’’, other countries have also followed suit. It is therefore critical that our decision makers too awaken and accept that the time has come for Mauritius to claim its place in medical research. Here is why.

That Doliprane that you casually pop in your mouth at the slightest headache, that tuberculosis jab that you consent to for your newborn or that insulin pen that you confidently prod into your tummy to regulate your blood sugar level, did you ever wonder about their safety and efficacy? I think I can confidently guess that the answer is ‘no’. It is ‘no’ probably because you feel safe as you assume that these drugs were tested on people like you. But were these drugs really evaluated in people representative of you? How can you assume so when, as an individual, you have a unique phenotype and genotype, which is specific to your environmental setting, diet, unique genetic makeup and patho/physiology (that is whether or not you have a co-morbidity)?

We have known for decades that Mauritius has one of the highest prevalence of diabetes globally, and even in 2020, the second highest number of deaths worldwide directly due to the disease. We seem to have developed complacency on this, perhaps even accepted that this is ‘normal. Political leaders came and changed over the decades but all failed to bend that curve. Why is that? Surely, the health of the people would be on the top agenda for any government? 

“The Covid-19 outbreak should serve as a strong reminder of the ongoing challenge of emerging and re-emerging infectious diseases and the need for constant surveillance, prompt diagnosis, and robust research…”

If not now, when?

As a nation of smart thinkers, like me, you too would have wondered why on earth we have such a high prevalence of type 2 diabetes (T2D). And let us be clear that with the outbreak of Covid-19, the crisis of diabetes in Mauritius does not go away. The International Diabetes Federation (IDF) Report 2019 is literally a life sentence for the island, with serious economic and health implications. Did you know in just ten years, we would have bred the second highest number of young people with diabetes in the world? It is predicted that the trend would persist for another decade, that is, 2040, unless we choose to do something about it.

First and foremost, we have to accept that this is not ‘normal’. Then, we need to evaluate what are the root causes that have shackled the past, present and future generation to the disease. The truth is that we do not really know. Sadly, like most of my counter-parts, I too, do a lot of hand-waving! We have been speculating for years, that the likely reasons may be a lack of physical activity, a diet rich in carbohydrates and possible genetic predisposition. The last reason is even more debatable since several genome-wide association studies have demonstrated that heritability accounts for less than 10% of disease risk. 

As a scientist, one is trained to believe in data-driven evidence and if such evidence is missing, the hypothesis remains unproven and thus, holds very little scientific value. And yet this is where I beg to differ. The studies that have demonstrated a low impact of genetic predisposition to diabetes were all done in larger countries, and specifically not in island settings like Mauritius, where given its sheer small size and limited people’s mobility, there is bound to be inbreeding in the population, and so enrichment of the disease-carrying genes, which would be less likely in a larger cohort of population. Regardless, you would want to know whether this is indeed the case so that we could potentially address this causal factor. Alas, that’s not possible because we simply do not hold such data on the Mauritian people. 

The physicians among us would all know the gold standard of diabetes diagnosis, that is a glycated hemoglobin test, also known as HbA1c test. This single test can identify prediabetes, diagnose diabetes as well as monitor how well one’s treatment is working. According to the American Diabetes Association, a normal HbA1c level should be less than 5.7%, whilst 6.5% and above signifies a diagnosis of diabetes, which means that anything between 5.8-6.4% would be prediabetes. These are data-tested guidelines from multiple international studies, but notably not including islands such as Mauritius and Rodrigues

So what? We must be representative of the population of the world you might argue! Well, apparently no, and here is why. In a rare study by Hare et al., published in Diabetes Care in 2013, an analysis in 1219 adult Mauritians and 1505 adults in Rodrigues demonstrated ethnic differences in HbA1c in people without known diabetes. The study reported that people of African ethnicity from Rodrigues had a higher HbA1c of 6.1%, compared to 5.7% in the South Asian or African ethnicity from Mauritius for reasons that cannot be explained by differences in blood sugar levels or other common parameters known to influence blood glucose levels in the body. 

This is not only clinically interesting, but also of concern, since an HbA1c of 6.1% would indicate prediabetes in the cohort of people from Rodrigues and borderline prediabetes in the Mauritian participants. The authors went on to recommend that further research should be done to elucidate this disparity and its implications in the clinical diagnosis of T2D for island-type of populations. Nevertheless, the question arises as to whether the recommended diabetes guidelines are accurate for our ethnicity, and if not, how can they be made to incorporate our population? Whilst you take a moment to understand the implications of a rare study like this, let me explore another interesting phenomenon currently unfolthding on the island. 

I have been flabbergasted by the anecdotal prevalence figure of apparently over 40% of pregnant women who develop diabetes! Gestational diabetes (GD) is when a woman develops diabetes during pregnancy, and would not normally have the disease. So what is the implication of this? First, GD is one of the main complications in pregnancy with associated risk to both the mother and baby. Second, emerging data strongly indicate that children born to mothers with GD, tend to develop T2D early on in life. The youngest child with T2D in Mauritius in 2018 was reported to be only 9 years of age, a diagnosis not consistent with conventional definition of T2D, which is described in the Textbook of Medicine, as a maturity-onset disease, that is not occurring in younger people.

Given the fact that 20% of school age children are either obese or have increased body weight, which is the biggest risk factor for T2D, in simpler terms it means that we are breeding a generation of diabetics not only in utero, but also within the society. Shouldn’t this be deemed a public health concern, deserving of research to understand the causality and thus, ways to prevent this? This is a problem innate to Mauritius and being complacent and expecting a solution from elsewhere is simply not acceptable anymore. The most valuable asset of any nation is its human resources, so if our next generation is already challenged with the burden of a chronic disease such as diabetes and obesity, can we really afford to do nothing to reverse this trend? 

“Did you know that, in just ten years, we would have bred the second highest number of young people with diabetes in the world?”

To recap, obesity is the biggest risk factor for T2D, but it is also modifiable. Evidence suggests that just by reducing body weight by 25% over the next 25 years would result in 700,000 fewer people with diabetes worldwide, and save a whopping 3.5 billion USD on associated healthcare bills. In response to the global crisis, the pharma giant Novo Nordisk initiated a first-of-its-kind prevention programme in partnership with University College London and Steno Diabetes Center Copenhagen, named Cities Changing Diabetes. This initiative is to tackle the rising urban diabetes crisis across the globe and has been helping cities identify how they can integrate diabetes prevention into their strategies in order to create long-term and sustainable change. Six years later, despite the extremely high prevalence of the disease here and despite the fact that we are the number one consumer of anti-diabetic therapeutics from Novo Nordisk in the whole of Africa, Mauritius has still not signed up to the Cities Changing Diabetes programme. 

As one of the major megacities of the world, with more than 20 million inhabitants, Mexico City has faced a diabetes epidemic for years. The disease has been deemed a public health emergency as it affects 16.0% of adults (that is 2.3 million people) in the city alone, with a huge diabetes-associated death toll. In response to the challenge of addressing the disease, Mexico City was the first to sign up to the Cities Changing Diabetes programme in 2014. In an unprecedented joint collaboration with the health authorities and researchers, a massive data collection spanning housing, demographics, health status, diet, physical activity, anthropometry, lipid profiles and biomarkers for diabetes, was made possible for the first time. 

A Diabetes Vulnerability Assessment proved that socioeconomic vulnerabilities are exacerbated when people cannot engage with healthcare services, as well as other hurdles to care, including lack of resources, lack of understanding and lack of trust in institutions. These outcomes have been the turning point in understanding causality and implementing evidence-driven strategies to finally tackle the disease. Due to its outstanding success, this pilot programme has been permanently integrated into the core of Mexico City’s healthcare service. These sort of success stories not only instill confidence in a government, but also illustrates how research can help address age old disease challenges.

As a hub for business, we stand out, not only in the African continent but also globally, even outdoing nations like Australia and the UAE. So why do we lag so behind in medical research? If we can breed outstanding economists and businessmen, why haven’t we borne, empowered and retained our own scientific intellectuals? Today we face the first pandemic that most of us would have ever encountered. Every outbreak provides an opportunity to gather crucial information, some of which is associated with a limited window of opportunity. For example, Li and colleagues (New England Journal of Medicine, 2020) have reported a mean interval of 9.1 to 12.5 days between the onset of illness and hospitalization following Covid-19 infection. Such data on the delay in the progression to serious disease may be useful in dissecting the pathogenesis of this novel virus, providing a unique window for timely intervention and optimization of a measured response.

The fear is palpable. A bug of a microscopic size has brought the world to its knees, relentless in its passage and indiscriminate of social status, GDP or geographical location. The Covid-19 outbreak should serve as a strong reminder of the ongoing challenge of emerging and re-emerging infectious diseases and the need for constant surveillance, prompt diagnosis, and robust research to understand the basic biology of new microorganisms and our susceptibilities to them, as well as develop effective countermeasures.

Had we invested in sound health care and medical research, perhaps the outlook could have been significantly different. With just another couple of thermal cyclers or PCR machines in our armory for up scaling time-sensitive Covid-19 testing, and investment in competent scientists to run the diagnostics, detect any potential mutation in the virus which has now travelled thousands of air and nautical miles, and collect and analyze unique datasets on whether the experimental treatment with hydroxy chloroquine and azithromycin is safe and efficacious in Covid-19-positive Mauritians, could have been a game changer.