Could do better. Must do better

The 20th Anniversary issue of Practical Diabetes International is an opportunity to pause, to reflect and to take stock; to look back on what has been achieved in the field of diabetic care in the last two decades, on what should have been achieved but has not, and on future developments and on the way forward.

Nearly 15 years have elapsed since representatives of government health departments and of patient organisations in Europe put their names to the St Vincent Declaration,1 and yet how many of those countries can claim to have made any significant progress towards implementing the five-year targets for reducing complications? (See Table 1.) Could we have done better? Should we have done better? The answer to both questions has to be ‘yes’. Of course, all health care professionals, even those in the wealthiest countries, will argue that they would have done better if only they had been given adequate resources. That may well be true, but we must also admit our own deficiencies. For example, as we are reminded in this issue of Practical Diabetes International, the potential for effective prevention of macrovascular disease has been transformed in the last 20 years,2 but that potential has not always been fully exploited, whether in the United Kingdom3 or in Holland4 or elsewhere, because we do not always implement treatments which are proven and available.

Our potential to implement lifestyle interventions, which are so vital in both the prevention and treatment of type 2 diabetes, is often limited by resistance to change among those we seek to influence. Much of this resistance is cultural. It is unlikely that clinicians alone can make a significant impact in this area, even though we do now accept that our dietary advice must be more realistic than it used to be.5 Governments could help but many of them show little interest in reducing smoking and pay only lip service to the importance of changing dietary habits and encouraging physical activity. Bans on advertising and taxes on the less desirable food products are weapons which are only available to governments and which are essential if the epidemic of obesity is to be stemmed.

Changes in government often lead to major changes in health care policy, with consequent disruption to the planning and organisation of health care delivery, as Pedrosa describes in Brazil in this issue.6 In the United Kingdom, and probably elsewhere, such changes are usually expensive, frequently unproven, and often disrupt professional relationships and working practices which have to be laboriously re-established. In diabetes care this can be particularly harmful when the changes disrupt relationships between primary and specialist care.

The increasing burden of all the chronic diseases presents a major problem in both the developed and the developing countries. Of all these diseases, the epidemic of diabetes should cause the greatest concern, not just because of the magnitude of the epidemic, for which the predictions continue to grow,7 but also because diabetes begets other chronic diseases, most notably the macrovascular pathology, renal failure and blindness. Health care planners and policy makers will undoubtedly respond with yet more ‘models of care’ which they will claim, often on rather dubious evidence, are more effective and efficient, but we will all be overwhelmed if the epidemic remains unchecked. Prevention is essential, but effective prevention is dependent on governments to instigate social and cultural changes. Will governments grasp the nettle? The precedent of global action on greenhouse gases is not encouraging. The time has surely come for the International Diabetes Federation and the World Health Organization to lead and co-ordinate a massive and sustained programme of lobbying by all national diabetes associations.