Good afternoon, my name is Dr. Yanira Pagan-Carlo. I'm a pediatric endocrinologist, and I will be welcoming you to the live webinar session for the Health Disparities Program. Today, we're gonna be talking about management of diabetes in developing countries and other resource-limited settings. Welcome you all. Thank you so much. That was Yan Pagan-Carlo, who will be our moderator today. My name is Claudia Barrett. I'll be assisting on the Endocrine Society side with the facilitation of this webinar. So, as our session begins, it's a pleasure for me to introduce our first speaker of the afternoon. Here we go. It's Dr. Ibrahim Ishaya. Dr. Abok Ibrahim Ishaya is a distinguished lecturer and consultant pediatrician and pediatric endocrinologist at the University of Jos. He's affiliated to the Jos University Teaching Hospital. He earned his MBBS from the University of Jos in 2003 and has received multiple prestigious fellowships, including a fellow of the West African College of Physicians in Pediatrics and fellow of the American Society of Pediatric Endocrinology. He completed a master's in science in pediatric endocrinology from the University of Florence and later completed his master's in science in clinical epidemiology from the University of Jos, where he expertly studied the socioecological risk factors associated with obesity in adolescents. Dr. Ishaya recently concluded a fellowship in pediatric endocrinology from the Pediatric Endocrinology Training Center for Africa in Nairobi, Kenya. His research and author dissertations include childhood diabetic ketoacidosis. Dr. Ishaya serves as the foundation editor-in-chief of the African Journal of Pediatric Endocrinology and Metabolism, a scientific journal published by the African Society of Pediatric Endocrinology. Today, he will be talking to us about diabetes health disparities in children and adolescents perspectives from a resource limited setting. Please join me to welcome our speaker, Dr. Ibrahim Ishaya. Welcome, Ibrahim. Thank you very much for that elaborate introduction. It's a pleasure to be with you on this webinar. I will be discussing the topic that is displayed above. And the aim of this presentation is basically to highlight the unique aspects of childhood diabetes in Sub-Saharan Africa, which is basically a low resource setting. I would go through an introduction through a descriptive epidemiology, and I'm going to highlight how patients with diabetes presents and how the diagnosis is made. And then I'll talk briefly about management, access to care, health outcomes, and then I'll summarize. We all are aware that the commonest childhood endocrine disorder is diabetes. And in our environment, 90% of childhood diabetes is as a result of type 1 diabetes mellitus. And we are all aware that this is an autoimmune disorder that affects the beta cells that results in the elaboration of several biomarkers, which we assessed or measure in the lab. The consequence of this problem is a metabolic disorder that is characterized by chronic hyperglycemia. This chronic hyperglycemia is multisystemic and affects various organs of the body. And therefore the approach to care is usually based on a team approach. However, in Sub-Saharan Africa, a low resource country, there is also limited healthcare resources. And most of the healthcare centers in Sub-Saharan Africa prioritize infectious disease such that the healthcare system in these areas are designed in order to address infectious disease. We're going to see in Sub-Saharan Africa, most of the infectious diseases like HIV, malaria, and TB have received a lot of donor funds unlike most of the non-communicable diseases like diabetes. Also, there's also paucity of research and publication in these areas. Incidence study in Sub-Saharan Africa are quite rare, they are limited, such that in the IDF, International Diabetic Federation 2021 Atlas, only six countries out of 48 countries had incidence study data. And from this map or from this sketch, you can see on my left, you're going to see as you move from up North Africa down to West Africa, you're going to see that the incidence of type 1 diabetes goes down. And North Africa, which comprises of countries like Sudan, has have an incidence of up to 10.1, Libya, and this goes down to 2.1 in Ethiopia and down to 0.75 in Gabon, which is a West African country. Now you can clearly see that there is a disparity in the incidence rate of type 1 diabetes across Africa. North Africa have probably an Arab heritage, unlike the West Africa where the Negro heritage is what is there, despite the fact that the genetic HLA typing is similar in West Africa compared to what is obtainable in Europe. The other problem with incident data is that about 50, over 50% of the population in Africa are misdiagnosed when they present with diabetes. Other areas of, sorry, my slide is frozen. Other areas of disparity includes gender. Now, if you look at this table, which is from the Rwandan Incidence Study, you're going to see the 2011 and 2010 data that the incidence between male and female is significantly different, it's higher, but this cannot be said to be true of other study. And then from this table also, you can see that number of new cases gradually increased from 2004 down to 2010 and 11. This indicates either there's an increase on the cases of diabetes or increased awareness as the program went on, as the study proceeded. It is, however, difficult to conclude whether socio-demographic variables in childhood diabetes, such as caregiver educational status, socioeconomic status, family setup, or rural or urban disparity exist. However, in order to be able to do that, this table, I pulled up study from Kenya, where there are 82 subjects. And if you look at the table, you can see that 47.6% of the study participants were in urban area, which is compared to the general population where 27% of Kenyans stay in urban areas. Now, if you come down to the next, which is Nigeria, we're going to see that 71.8% of a study population in Nigeria were from the low socioeconomic status. However, from the Nigerian general data, 63% of Nigerians live below the poverty level. Now, in the last column on the table, which is Southern Ethiopia, with 116 participants, the urban population of diabetic is 60.3. Now, this compares to 22.7% of the national average of urban population. At the next row, the low socioeconomic status, 48% of the population, of the study population were of low socioeconomic status. It is difficult to conclude on whether these are disparity, but this indicates that there's an urban disparity, socioeconomic disparity, and no gender disparity from this different pooled data from different studies in different countries. Now, usually children with diabetes presents differently. On this first picture, you would think this is starvation, this is malnutrition, but this is a child that presented in a health facility in Nigeria with type 1 diabetes. He's wasted, and because of that, things like HIV, tuberculosis will readily come to mind. And if care is not taken, this will be misdiagnosed if there is no expertise in this facility to check for random blood sugar. Some of these children will present unconscious and will have to be put in the intensive care unit. And in such cases, infectious disease like malaria, my meningitis will be considered as possible diagnosis if care is not taken. While on the third picture, you would see a child who is more stable, and this is also the face of diabetes in Africa, the presentation are varied. Now, 75% of Utopians and 75 to 89% of Nigerian diabetes present with diabetic ketoacidosis, which is an emergency that is life-threatening and usually cause mortality and morbidity in children with diabetes. Now, these figures are three times higher than what is obtainable in the United States and in other developing countries. Now, a pooled data of incidents of decay at first presentation of diabetes in children linked that low Human Development Index is one of the major predictor of children presenting with diabetes in a specific country. These communities are usually, they have poor social infrastructures, poor schooling, poor income, and they're underprivileged population. A study in Kuwait, which is also a fairly high income country shows that a high incidence of decay at first presentation was noticed in families that have large population of low income families, migrant population, in populations that have poor awareness of decay. And this population was also educationally and economically disadvantaged, especially the women. Now, so this clearly indicates that the high rates of decay in Nigeria and other sub-Saharan countries might be linked to disparity that has to do with social infrastructures, poor schooling, poor income, and underprivileged population. The symptoms of decay at presentation is similar to what is obtainable, polyuria, polydipsia, polyphagia, which were all conversant weights and weight loss or weakness. And list on the chart is coma, loss of consciousness, which is seen in severe decay. The diagnosis is actually not different. Usually random blood sugar or plus a clinical features with weights, which we've explained earlier, will give us the diagnosis. But however, urine ketones is basically what part of the diagnostic tests we do. As many centers don't have access to serum ketones, you need to establish a metabolic acidosis. And if glycated hemoglobin is available, that can be done. O2 antibodies and C-peptides are however available, but expensive and not commonly used at the beginning, therefore making classification of diabetes a bit difficult in Sub-Saharan Africa. And other supportive investigations that need to be done at onset, serum lipid celiac disease screening and thyroid function tests are also expensive and not readily done among children with diabetes. The management is actually focused on the usage of insulin as the basis of treatment in order to get good glycemic control, prevention of complications, which will help in the prevention of complications, both acute and chronic complications. However, in smoke Sub-Saharan African countries, the insulin, even although all forms of insulin might be available, but the rapid, the short-acting, intermediate and long-acting insulin, however, the cheapest and readily available is the pre-mixed two times daily insulin. Most patients prefer that, and that is also easy for people to use. However, from the DCCT trial, the multiple daily injection is what's given via basal boluses has been found to be more effective and efficient in maintaining good glycemic control in children with diabetes. This is available for use mostly by pediatric endocrinologists in Nigeria, but not by the general doctors. Insulin pump, which is found to be as effective as the basal boluses regimens of injection is hardly available in our setting. In fact, in a survey of pediatric endocrinologists during one of our conference, 64% of the pediatric endocrinologists from Africa have never used pump for their patient. This is basically because most patients have to buy out of pocket, and it's very expensive, costing about $8,000. It improves the quality of life for children if available, and also gives similar glycemic control with the basal boluses, which most pediatric endocrinologists are trying to use in Africa now. Other pillars of care include blood glucose monitoring. Most of our patients use the glucometer. The continuous glucose monitoring, which is associated with better glycemic control is however not available. Considering the fact that most diets in sub-Saharan Africa is usually carbohydrate-based, it would be wise that most of our patients are taught how to do carbohydrate counting even on the basal boluses. Again, from a survey, only 50% of endocrinologists in Africa offer carbohydrate counting as an option. This might not be far from the fact that most of our nutritionists are not very conversant with carbohydrate counting. And even when they are conversant, the list of foods on the carbohydrate are mostly Western. There are no local study that's tried to show the carb counts in African-based diets. One of the basic pillar is exercise, which is found to increase insulin sensitivity, increase the cardiac strength, include glucose absorption. However, this again is not readily available if we look at the built-in environments where most people in sub-Saharan Africa live. The built-in environments from the neighborhoods to the school are not built in such a way that access physical activity facilities are created, is available, are easily accessible within the neighborhoods or even within school. Diabetic education is also an effective integral part of diabetic management, but lacking in most healthcare facilities in sub-Saharan Africa. Now, access to diabetic care, first, if you look at the chart here, it demonstrates universal health insurance in Africa. Now, if you look at Rwanda, it has the highest of about 80%. Over only four of the 36 countries in this chart have health insurance coverage that covers 20% of the population. In fact, in Nigeria, less than 5% of the 20 million people in Nigeria have universal health insurance coverage. What that means is that over 90% of the populace have to pay for health care whenever they need. And whenever they don't have money, what it means is that they can't present to the hospital until they have money. So that reduces timeliness in assessing health care, even when it is available. The other thing is that people in rural communities that can't access health care from teaching hospitals, like where I work, where we have pediatric endocrinologists, find it difficult to get timely care. Because most primary health care that's close to the individuals don't have health care workers that have been trained in the care of children with diabetes. That brings to focus the need for telemedicine, which again, is not readily available to reach the rural populace. The other thing, until January 2008, there was scarcity or paucity of pediatric endocrinologists in Africa. But from 2008, in collaborative effort by the European Society of Pediatric Endocrinology, the World Diabetic Federation and the International Society of Pediatric and Adolescent Endocrinology, saw to it that Pediatric Endocrinology Training Center for Africa was started in Nairobi, where I trained. And some few years later, the Pediatric Endocrinology Training Center for West Africa was also established in Lagos, Nigeria, where some other people have been trained to be able to care for children and adolescents with diabetes and other endocrine problems. Recently, the Anglophone-speaking countries' training has started, despite the same collaborative effort. As a result, over 100 pediatric endocrinologists have been trained across Africa. But still, considering the vast area of sub-Saharan Africa, this number is not enough. In my state, where there are over 3 million people, I'm the only trained pediatric endocrinologist. Now, again, there is also paucity in Africa, sub-Saharan Africa. The doctor-patient ratio is low, reaching up to 4,000 per one doctor, when compared to Western countries. We talk more of pediatric endocrinologists. Recently, the International Society of Pediatric and Adolescent Diabetes, in order to improve nutritional management and health education, started a training for Allied Health Care Diabetes Educator Course for Africa. This is the second year of that training. Health care workforce capacity is currently being built, but the disparity is still there to be able to attain to cases. Now, access to treatment has improved in the last two years, considering the programs run by Life for Your Child and Changing Diabetes in Children, which is a program sponsored by Novonodic. Now, these programs provide basic drugs consumable to children that are enrolled into the program, and has been a tremendous support for the incidence studies that we have in Africa. These programs tend to enroll and cater for children and young adults less than 25 years old. In addition, they also provide training capacity for primary health care workers towards diagnosing and managing type 1 diabetes. In my center, the Life for Your Child program has been running since 2013, and the CDIC program is about to kick off so that this can augment the care of children with diabetes. However, these programs are limited in the fact that when a child has an acute presentation, DKA, or other infection, these programs do not cater for that. And this is probably one of the limitations of this program. They have, however, helped in supporting access to treatment by providing insulin and also glucometer and free strips to these kids with diabetes. Now, the health outcome of children with diabetes, I will focus on two things, which is the glycemic control. The glycemic control in sub-Saharan Africa is still very, very poor, as only about one third of children who are diabetic and receiving care are able to have good glycemic control. In a study, pulling different study, I was able to find that if glycemic control might be as a result of father's educational status, the more educated the father, the more likelihood that the child would be having good glycemic control. Of course, this is easy to understand. And of course, caregivers' education, whether the father or not the father, that is also difficult, I mean, easy to understand why that is so. However, children that have lipodystrophy at injection site have been found to have poor glycemic control. Unlike in developed countries where younger children have poor glycemic control, in sub-Saharan Africa, children who are two or more years, who have two or more years of diabetes have been found to have poor glycemic control. Children who are not able to keep to their food also have a higher risk of poor glycemic control. Where the family is unable to have at least up to three meals per day, these children also have poor glycemic control. This might be linked to the fact that this might be food insecure families that are unable to get what is prescribed for them. And in order to survive, might eat anything that is available to them, irrespective of the glycemic index of this food. And it was discovered that any family that is unable to afford insulin also has about six times more odds of developing poor glycemic control. I tried putting this on the social ecologic model to see if at policy level, availability of free insulin is going to help. Then intrapersonal level, caregiver education, active involvement in care by the parent, discontinuation of treatment during follow-up are all predictors of glycemic control. At the individual intrapersonal level, injection sites, if there is lipodystrophy, less than three years age of onset and poor food choices are factors that will predict poor glycemic control. However, no study had looked at the neighbourhood country factor, what happens in school, what happens in the neighbourhoods, in the hospital, in churches and other places that will influence glycemic control. At the policy level, availability of insurance has not been looked at. So there is still a paucity of data on what needs that factors that will be predictors of glycemic control. Mortality amongst children are the only thing we looked at in children that were enrolled in the program, that's the CDIC program. They found that if the child stays in urban area, it is a good predictor of survival, also predicts survival. They conclude in this study that despite free insulin provision, mortality remains high in Cameroon and is substantially higher in rural setting and in areas without, in families with no formal education. Now this found that the mortality in Cameroon and in Rwanda, also an African sub-Saharan country, the figures were less compared, but higher when compared to the United States. Then, when we looked at what are the factors that, when a study looked at the incidence of and predictors of mortality in children, we are present in DKA, and again, the age of the child, rural residents, female gender, and hypoglycemia were found to be predictors of mortality. So, in summary, I will say that the incidence of childhood diabetes is increasing, and the glycemic control has been improving. Mobility and mortality has also improved in the last two decades, due to probably availability, access to free care, improved capacity of healthcare workers. But the social-ecologic environment in Africa, or sub-Saharan Africa, aside few countries appear to be on a decline with increasing poverty and migration of health workers. However, if deliberated in place, from the policy level down to affect the individual child, and these policies are championed and owned by individuals in low-medium income countries, there is a likelihood that the glycemic control, morbidity, and mortality that is associated with childhood diabetes in Africa will be improved. Thank you very much. Thank you, Dr. Ache for that beautiful presentation. As we are limited in time, I would like to proceed and introduce our second speaker, Dr. Marie Nancy Charles-Larco. She's an accomplished physician specializing in metabolic diseases, particularly diabetes. She serves as Executive Director of the Haitian Diabetes and Cardiovascular Disease Foundation, Fondation Haitien de Diabetes et de Maladie Cardiovascular in Haiti. Dr. Larco has been a dedicated advocate for the global fight against diabetes, and following the devastating earthquake in Haiti in 2010, she played a crucial role in managing the foundation's diabetes clinics. She worked tirelessly to provide medicine and intensive care to thousands of diabetes patients in need, and her outstanding efforts earned her an award from the International Diabetes Federation in 2012. Dr. Larco has collaborated with many organizations such as the World Diabetes Foundation, AmeriCares, and Helmsley Trust, and she has developed educational materials in Creole to demystify diabetes and cardiovascular diseases, thus breaking the taboos and empowering patients and their families. More importantly, her recognition of significant contributions, she received decorations from the Rotary Club and an award from the International Diabetes Federation for her exceptional work after the 2010 earthquake. Please join me as we welcome Dr. Marie-Nancy Charles-Larco, as she will be talking to us today about the practical strategies and solutions that healthcare providers can employ to optimize available resources and deliver effective diabetes care in developing countries. Welcome, Marie-Nancy. Thank you, Jai, and hi, everybody. So I have been asked to talk about practical strategies and solutions that healthcare providers can employ to optimize available resources and deliver effective diabetes care in developing countries. As you see, the title is wrong, so there is a lot of things to do, but I am thanking the Under Clean Society for choosing me to talk about it, and with my small expertise, I will try to tell you how we do that in Haiti at FADIMAC. Okay, so as Jai was saying, FADIMAC stands for Haitian Foundation for Diabetes and Cardiovascular Disease, and we are a civil society group founded by Haitian physicians, nurses, and patients, and FADIMAC is the only foundation that has signed with the United Nations. So they recognize our expertise in the field of diabetes and cardiovascular disease. So we are a private institution, a non-profit institution, organization playing an active role in the fight against exclusively diabetes and hypertension and other cardiovascular disease in Haiti, because there are so many organizations taking care of infectious disease. So we thought that it would be important for the population suffering from diabetes and cardiovascular disease to have their own group. So FADIMAC provides basic vital patient-centered care by a multidisciplinary management team, 2,000 of patients who are unable to afford the cost of long-term treatment for this chronic disease. I should tell you that my first language is French, so that's why sometimes it's difficult to have some English words, but I go with it. So in Haiti, we should know that Haiti is the fourth country with the highest prevalence in the North American region, and it's about 500,000 people, so half of a million people living with diabetes, and half of them, they don't know that they have diabetes. So it's about when you couple men and women, so it's about 7% of the population, and 1% or 9% has diabetes in Haiti. So that's a study that FADIMAC has done many years ago. So we should say that we have identified many challenges, and we'll go through that. So the first one, the first challenge that Haiti is facing is a limited access to diagnosis. So patients, they don't know they have diabetes until a serious complication, they develop a serious complication, or there is also a lack of testing facilities, so that's something which is very heavy. So what we try to do at FADIMAC is to have to be always on the radio and TV, encouraging the population to screen, and we have even a slogan that to tell them, you have to know if you have diabetes. And also in those interviews or videos, we educate them using popular beliefs to demystify diabetes. You know, in our country, there are a lot of mystical reasons to have a disease, so it's very important to show them that diabetes is real, and they have to do something about it. And also FADIMAC use control to find donation. And when you talk to people, and in Creole there's something saying that when you don't ask for you, you don't need to be shame or shine about it. So that's why we are asking and to showing that the work that we are doing so we find people helping it in that matter. And also we do have and we'll see that later that we have affiliated center that help us do the job. It's freezing, what's wrong about it. Sorry about it, but okay. So another challenge that we have that's the limited access to care, due to many reasons. One, the low economic status of the population, we'll get back to that. Secondly, diabetes not being considered as a public health priority, specialized centers for chronic disease, mostly for diabetes, are inexistent, and qualified health professionals are not always available. Another reason for limited access is lack of information and education, and we'll see that later. So for the low economic status, I'm sorry about the so many words on my slide. So low economic status of the population, half of the Haitian population get less than $2 per day, so they can afford regular care to care for their diabetes. Secondly, there is an absence of social security, so everything is out of pocket. Only 4% of the population is covered by an insurance, so that's really something difficult for them to face if they have a chronic disease. And another reason, no concrete action by the Ministry of Health to make diabetes a public health priority, meaning that the patients are left behind because they cannot afford the cost of care. Another reason, there is non-continuous program which is supported by the state to help the patient with chronic disease. So sometimes they find a medicine, and sometimes they can have two years without receiving anything, so they have to buy it. And also, we found that with our youth population, that the patient, they are not at 25, 30 years of age, they are not independent economically, so they can afford the cost of their care. So thanks to Life for a Child, who have extended for Haiti until 30 years old, because that's something very difficult that we were facing. So to face this challenge, we must find a third party that can support our subsidized programs. And I always will be grateful to Life for a Child, because without them, we would have most of our young patients dead, not be able to buy insulin. So a solution proposed by FADIMAC for the low economic status, it's one we have developed a membership program, so it's lower the price of the services for patients who don't have the means to pay it. Secondly, we create a sliding sale regarding the patient's economical status. Third, we have low cost medicine, so by bringing them by bulk, it's less expensive. And also, we create in our population, those who are more, I mean, who have more money, so we ask them to have an individual sponsorship, so they can choose someone to help. And it works quite a good way. And also, of course, I was mentioning Life for a Child, but also Insulin for Life, who help us for all the patients needing insulin and so on. So given to the deterioration of the economy and security situation, so national and international contribution have decreased, making the situation more difficult. So we have a special group, we have more than, it was almost 500 children across Haiti, but we have lost a lot of them. So there was a program for them and camp and everything, so they can accept and be with other children with type 1. So we had to adapt, like they were receiving insulin supplies, so we had to, because of the difficult situation that we are living in Haiti, so to adapt the program, so because of the unstable political situation and insecurity, we modified the care of the children. So they used to come, most of them are still coming when they can, but we try to make them receive insulin in the area where they live. And also, we did a survey to assess their needs, and we were able to find a psychologist who could talk to them and organize group meetings and preparation of videos that topics that they have asked for, so it's something that really helped for them to manage their daily lives. So despite our effort, unfortunately, we lost many children last year. Other challenges that we are facing is limited access to health centers. As I was saying earlier, there are not a lot, so because of the propriety of the patient, the restriction of health centers because of natural disasters, centers being too far from their house, so they don't go there, and constant roadblocks, because that's how we unfortunately live. So there is also a lot of patients leaving their place of their area of their house because there are too many gangs attacking the population. So what we have done, and this was before the situation worsened, so we, after the earthquake of 2010 and like two years ago, so we were able to have some money to go in remote areas affected by earthquake. And when we go there, we try to do a lot of things, awareness, radio, TV, screening, and you can see I put GM Type 1 is because our volunteer are mostly the Type 1, and they are very happy to help us in those activities. So there's some picture of an earthquake, and which happened in the south of Haiti, and another way to get there, it was via helicopter or plane, and it's always important to work with other groups. And when you are that way, you are not alone. And we were helped by different organizations who transported us to the place that needed clinics for diabetes and cardiovascular disease. So when we arrived there, we were able to make awareness for the population and screening for the patients, I mean, for everybody, and having medical clinics, education. So each people in our team, like we were two physicians, one social worker, one nurse, and two young Type 1 who was going around the centers to call people. So about 2,000 people benefited from that activity. So that are the pictures that we have. And I wanted to put that one because when you give something to someone, and this person like this guy, he used to work three hours to have a glycemic test done. So giving him a machine, even if it's only 50 strips, that was something marvelous for him. And for that young girl that we found in GKE, when we arrived in a hospital at 385 milligram per deciliter. And unfortunately, she was taking an insulin bought from a pharmacy, but it was a counterfeit insulin. And this is something which happened. And we'll see that later. So after three hours, she was better and she could go home. So other challenges that we are facing, that's the limited qualified health professionals, like because when they are not enough, we have mismanagement. We have a high turnover because they are trying to find better life. And also a brain strain because of the social, political situation. So the health sector is really affected by this matter. So at FADIMAC, what we did, we used to do and we are still doing is training young physicians at the end of their studies. We go to centers, we train physician and nurses and social workers and all different health professionals. We this one and also so we are employed by certain organization to go and do trainings. So when we can go, we do Zoom. And this is a program that we have done last year. Like on information and education, that's another challenge and information is not widespread in Haiti, unfortunately. And the cultural beliefs, there is a lot of misconception because of that. And the education concept are not standardized. That's why we try to do more training that can be done. So we haven't designed something called Affiliated Center. So when we find a center across Haiti, you know, with adequate services and health professionals, we train them. We give them skills to organize educational programs and patient centered care. And it has been really something very interesting across Haiti. And we can see that we are very happy that they can do it. So this map was showing different places that we have Affiliated Center. This one is very long, but we're not going to throw it. It's many things that we exchange in the contract that we have with the Affiliated Center so they can be part of our program. So something that for sure, and Dr. O'Brien talked about it, that the limitation, limited access to medication. OK, so patients can't buy medicine in certain areas. There are no availability of medicine. And I was talking earlier about the counterfeit medication. So when you have a black market, there is no medicine. So people who are not nice, they, you know, change the medicine. And unfortunately, our patient pays the price. So solution we don't have for this part. So we encourage our patient to really have a balanced diet according to what they can buy and have a constant physical activity so they can burn and control their blood sugar. So lack of knowledge, that's something that we are facing and information, as I was saying earlier. So recently we have organized a fundraising just for that to develop video in Haitian Creole so it can be available on telephone, on Facebook, on any places. So not yet, but we are working on it. So also we use also to develop visual educational material so our patient can see themselves and understand what we are talking to them about. And we also use the peers to educate patients. It's easier for them to believe to a peer than believe to the physician or the nurse. So there are some pictures that we have and we have also some Zoom that we are organized for them, for the patients. So also we have our virtual services that we just started to do. And this is some pictures of our materials so our patient can understand. And on the placemat, you can see that we use as quantity, we use part of the body and of the hands. So on the top of the challenges mentioned above, Haiti faces particular situation, natural disaster, hurricane, earthquake, floods and also main, main disaster, unfortunately, during our constant political instability and all what you can hear there. So really, it leads to life threatening and even fatal issue for our patient. So in conclusion, FADIMAC, we have proposed some practical strategies and for UNS. So with our affiliated center, we are working on and on educating the population, informing them by screening, screening when we do find materials and for the World Diabetes Day and for LifeGivers, a lot of trips so we could share it with other centers so they could do that in their areas, medical clinics. So we have developed protocols. So it's easier for the health professionals to see how to know how to take care of their patient, education for patients. So as I was saying that we train nurses so they can have the same language to the patients so they don't get confused, training for health providers. So FADIMAC is the only entity recognized by the Ministry of Health to provide training to all level of health professional and availability of medicine. So that's how we, for sure, when you buy in bulk, it's less expensive, but even some patients, they can buy it. So we have to find other ways to to do it. And Advocacy, FADIMAC, for the past 10 years, I've worked with the Ministry of Health so they can have a focal point for chronic disease. And so we can develop a national program for this kind of disease. So even though innovative solution and support system can help improve diabetes management in these resource limited settings, without outside financial donation, it will be difficult to apply those ideas to our health system. But we should say that sometimes we don't need a lot of money to talk. So that's why I say to my students, so God gave us the opportunity to talk. So we have to teach and train as long as we can. So and constant advocacy from civil society should be done to force entities like government, governmental, national, international to follow suit and invest in this area, the one of chronic disease. And thank you for your attention. I have one minute left. Thank you. Thank you, Mary Nancy, for that wonderful presentation. I think we have just five minutes for Q&A and the Endocrine Society staff will be reading the most upvoted questions. Yes, absolutely. Thank you so much. I'm going to start with. And please excuse me, everyone, I'm going to do my best with pronunciation. Adelit Sultan, what is Dr. Ishaya's view on the data of type one index and included was the link T1DinDex.org. Should I go ahead and answer immediately? Sorry, can you repeat? Should I answer immediately after each question? I saw like three or two questions on the platform. OK, thank you. It's the type one diabetes index. It's a platform that tries to project the impacts of diabetes on the life of people all over the world. It's a projection based on available data from literature, and therefore, since it's based on statistics and other information, it's worth looking at. It also provides areas of impact and therefore what should be done for areas of patients that need to be supplied. I mean, that needs to be provided for patients with type one diabetes. So it's I think it's highly recommended that we look at it. It's based on national data from country to country. It's a very informative website that provides a lot of data and information. That's my personal opinion about that. Thank you, Dr. Isha. Do we have a second question? We have two minutes. Yes, one more question for Dr. Isha. Do you think there is there is underreporting of T1DM in peds, pediatrics and adults and SSA? Is the problem actually worse than reported? Ibrahim? Yes, I think I agree with this person asking that question, that's this and underreporting, especially in sub-Saharan Africa. I give reasons that many times diabetes is confused with other infectious diseases, especially when the present has decayed in such patients end up dying and they have never diagnosed as diabetes. Secondly, most health care facilities, primary health care in sub-Saharan Africa that is close to the populace, don't have access to facility to be able to make diagnosis of type one diabetes, to be able to do a random blood sugar. And the information is one to believe that that is underreported. Since most in most African countries, the center is not specialized in childhood diabetes. Even adult physicians sometimes will miss the diagnosis that this child has diabetes. OK, so thanks again for your your input. I think we need to wrap this up. So I just wanted to take a moment to thank both our speakers. Thank you so much for your time. And even with all the time differences, you're here for our Health Disparities Program. Thank you for all for joining us today. Keep an eye out for future Health Disparities Programs and webinars, and you will soon be receiving a program evaluation and your feedback will improve the content of this series while keeping them relevant. We're looking forward to hearing from you. Thanks so much.

diabetes management

developing countries

resource-limited settings

Sub-Saharan Africa

type 1 diabetes mellitus

healthcare challenges

improving access to care

Haiti diabetes care

FADIMAC