Theresa Watts and Frances Lester confirm the consequences of inadequate and intermittent supplies of insulin for patients with type-1 diabetes in highly indebted poor countries. Lester suggests that insulin is very stable at moderate temperatures and effective long past its arbitrary expiry date. Two studies1
have shown that only 5% and 15%, of activity respectively, is lost by storage at tropical temperatures for up to 3 months. These findings are in sharp contrast to the situation described by Subhash C Arya for vaccines, the inactivation of which is both more hazardous and less readily recognised.
Ernst Chantelau points out the importance of tendering for insulin purchase at the best prices. Human insulin produced by the major manufacturers is, regrettably, priced very similarly in the world's poorest countries and in the industrialised world, at around US$10—15 per 10 mL vial of U100 insulin. In consequence, it can be calculated that 1 year's supply of insulin would cost around 2·5 days of per capita gross domestic product (GDP) in the UK, in contrast to 6 months' per capita GDP in India, and 9 months' per capita GDP in Tanzania. A serious commitment to the wellbeing of patients with type-1 diabetes in the world's poorest countries would demand a re-examination of pricing policy by these companies. In the interim, tendering for the cheapest reliable supplier is likely to allow substantial savings, something that will be pursued by the proposed International Insulin Foundation.
A Teuscher and colleagues described an innovative approach to cost-sharing for the purchase of insulin in Dar Es Saalam, Tanzania. Regretfully, the 50% of insulin costs falling to patients and their families has proven difficult to sustain, representing, as it does, 15—20% of family income. There are many other examples of poor sustainability in similar cost-sharing programmes in the highly indebted poor countries, as structural adjustment programmes have resulted in grinding poverty for individuals as well as for governments. It is only with debt-relief by unilateral and multilateral donor agencies that health services might again be permitted to re-establish effective services.