Editorial
LTH NHS Trust/Science Photo Library
Type 1 diabetes—progress and prospects
For the National Paediatric Diabetes Audit Report 2011–12 see http://www.rcpch.ac.uk/ system/files/protected/page/ NPDA%20report%20201112%20high%20res%20FINAL.pdf
In England and Wales, only about 17% of more than 25 000 children and people younger than 25 years with type 1 and type 2 diabetes have controlled disease (glycated haemoglobin [HbA1C] < 7·5%), as discussed in a report by the Royal College of Paediatrics and Child Health released on Dec 10, 2013. The report thus concludes that the proportion of patients receiving diabetes care remains low. Type 1 diabetes is now one of the most common chronic diseases among children, as emphasised in a Seminar in today’s Lancet. Mark Atkinson and colleagues discuss the epidemiology, pathology, diagnosis, and treatment of type 1 diabetes and highlight prospects for patients with the condition. Although type 1 diabetes cannot be prevented or cured with existing treatments, some research areas offer glimmers of hope, such as islet-cell transplantation, stem cells, primary and secondary disease prevention, and reversal of type 1 diabetes. Autoimmune destruction can be stopped by induction of immune tolerance against β cells.
Insulin, discovered nearly a century ago, is still the mainstay of treatment for type 1 diabetes. Results from the Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications study (EDIC) show that intensive glucose control has beneficial clinical outcomes. In DCCT, the effect of intensive glucose control in terms of diabetic retinopathy, nephropathy, and neuropathy showed benefit after a mean of 6·5 years follow-up; while in EDIC, intensive diabetes treatment showed benefit in cardiovascular disease outcomes after a mean of 17 years follow-up. These findings support the existence of metabolic memory—diabetic vascular stresses persisting after glucose normalisation. The trials also demonstrate that those patients with good β-cell function do better in terms of glucose control and complications. Whether this experience applies in the long-term to patients who have been treated with monoclonal antibodies, such as teplizumab, is unknown. Despite substantial advances, more progress is needed in treatment options for type 1 diabetes beyond intensive glucose control. ■ The Lancet
Indonesia strides towards universal health care
Crack Palinggi/Reuters/Corbis
On Jan 1, Indonesia began the roll-out of its plan to provide universal health care (UHC), the Badan Penyelenggara Jaminan Sosial (BPJS). Their brand of coverage will draw together existing insurance services and initially provide comprehensive care to 180 million people, expanding to cover all citizens by 2019. At present, civil servants, formal sector workers, and the poorest individuals are covered by separate public and private health-care providers, to varying degrees, leaving a large non-formal working group neglected. The benefits of UHC are clear. Catastrophic health expenses deter patients from treatment. In 2010, 30% of total health expenditure in Indonesia was in the form of out-of-pocket payments. Some 60 million people without health care will begin to benefit by 2019. After a similar roll-out in Thailand in 2002, out-of-pocket payments reduced by 18% in 6 years and inpatient care increased by 8–12% in 4 years. But there are challenges too. A pilot scheme in Jakarta early last year exposed flaws in rapid expansion 2
of existing health-care infrastructure. Indonesia has few doctors (two for every 10 000 citizens) and there are few hospital beds; and availability of health professionals and hospital care is unevenly distributed across the country. Pooling of health financing should help with expansion of services, but how quickly this can be delivered has been questioned. Furthermore, not everyone eligible enrolled for Jamkesmas, a government health insurance scheme that provides health care to the poorest third of the population, raising the spectre of low enrolment in a universal system. These issues need to be addressed, but they are not a reason for Indonesia to hold back. Indonesia’s economy is growing, and early introduction of UHC will reap future rewards. The World Bank has greatly supported UHC in southeast Asia, led by Japan, and ought to be praised. That support will need to continue. Indonesia has made an extraordinary commitment to provide health services to all comers, and should be commended wholeheartedly for it. ■ The Lancet www.thelancet.com Vol 383 January 4, 2014
LTH NHS Trust/Science Photo Library
Type 1 diabetes—progress and prospects
For the National Paediatric Diabetes Audit Report 2011–12 see http://www.rcpch.ac.uk/ system/files/protected/page/ NPDA%20report%20201112%20high%20res%20FINAL.pdf
In England and Wales, only about 17% of more than 25 000 children and people younger than 25 years with type 1 and type 2 diabetes have controlled disease (glycated haemoglobin [HbA1C] < 7·5%), as discussed in a report by the Royal College of Paediatrics and Child Health released on Dec 10, 2013. The report thus concludes that the proportion of patients receiving diabetes care remains low. Type 1 diabetes is now one of the most common chronic diseases among children, as emphasised in a Seminar in today’s Lancet. Mark Atkinson and colleagues discuss the epidemiology, pathology, diagnosis, and treatment of type 1 diabetes and highlight prospects for patients with the condition. Although type 1 diabetes cannot be prevented or cured with existing treatments, some research areas offer glimmers of hope, such as islet-cell transplantation, stem cells, primary and secondary disease prevention, and reversal of type 1 diabetes. Autoimmune destruction can be stopped by induction of immune tolerance against β cells.
Insulin, discovered nearly a century ago, is still the mainstay of treatment for type 1 diabetes. Results from the Diabetes Control and Complications Trial (DCCT) and Epidemiology of Diabetes Interventions and Complications study (EDIC) show that intensive glucose control has beneficial clinical outcomes. In DCCT, the effect of intensive glucose control in terms of diabetic retinopathy, nephropathy, and neuropathy showed benefit after a mean of 6·5 years follow-up; while in EDIC, intensive diabetes treatment showed benefit in cardiovascular disease outcomes after a mean of 17 years follow-up. These findings support the existence of metabolic memory—diabetic vascular stresses persisting after glucose normalisation. The trials also demonstrate that those patients with good β-cell function do better in terms of glucose control and complications. Whether this experience applies in the long-term to patients who have been treated with monoclonal antibodies, such as teplizumab, is unknown. Despite substantial advances, more progress is needed in treatment options for type 1 diabetes beyond intensive glucose control. ■ The Lancet
Indonesia strides towards universal health care
Crack Palinggi/Reuters/Corbis
On Jan 1, Indonesia began the roll-out of its plan to provide universal health care (UHC), the Badan Penyelenggara Jaminan Sosial (BPJS). Their brand of coverage will draw together existing insurance services and initially provide comprehensive care to 180 million people, expanding to cover all citizens by 2019. At present, civil servants, formal sector workers, and the poorest individuals are covered by separate public and private health-care providers, to varying degrees, leaving a large non-formal working group neglected. The benefits of UHC are clear. Catastrophic health expenses deter patients from treatment. In 2010, 30% of total health expenditure in Indonesia was in the form of out-of-pocket payments. Some 60 million people without health care will begin to benefit by 2019. After a similar roll-out in Thailand in 2002, out-of-pocket payments reduced by 18% in 6 years and inpatient care increased by 8–12% in 4 years. But there are challenges too. A pilot scheme in Jakarta early last year exposed flaws in rapid expansion 2
of existing health-care infrastructure. Indonesia has few doctors (two for every 10 000 citizens) and there are few hospital beds; and availability of health professionals and hospital care is unevenly distributed across the country. Pooling of health financing should help with expansion of services, but how quickly this can be delivered has been questioned. Furthermore, not everyone eligible enrolled for Jamkesmas, a government health insurance scheme that provides health care to the poorest third of the population, raising the spectre of low enrolment in a universal system. These issues need to be addressed, but they are not a reason for Indonesia to hold back. Indonesia’s economy is growing, and early introduction of UHC will reap future rewards. The World Bank has greatly supported UHC in southeast Asia, led by Japan, and ought to be praised. That support will need to continue. Indonesia has made an extraordinary commitment to provide health services to all comers, and should be commended wholeheartedly for it. ■ The Lancet www.thelancet.com Vol 383 January 4, 2014
