Several kinds of battle

Several different battles are illustrated by the contents of this Issue of Diabetes Voice. The first of these is the battle individuals face to maintain any kind of diabetes self-care in the wake of cataclysmic natural disasters – hurricanes, typhoons, inundations, earthquakes, forest fires or whatever form these disasters may take.

People who don’t succumb from the disaster itself face a serious battle to survive with reasonable health in its aftermath.  In addition to the shelter, clean water and food that they and everyone around them require, people living with diabetes urgently need more specialist support to keep them alive and well – the kind of support organisations such as SEMPER (Stanford Emergency Medicine Program for Emergency Response), Insulin for Life, Sweet Alert and other similarly altruistic organisations can provide. These are at the leading edge of the swift humanitarian responses that are needed to ensure that those who have diabetes can claw their way back to a reasonable existence. The particular example of this in these pages is that of Typhoon Haiyan in the Philippines which, in November last year, shocked us all with its extreme, brutal violence. Though several months have now passed since that occurred, the need for assistance goes on and will continue for some considerable time.

The second battle is that which individuals face when battles of a more obvious kind are raging all around them – in war zones such as Syria and previously in Mali. If, as has been said, ‘the first casualty of war is truth’ then its second casualty, not far behind, is order. Social order is a prerequisite for delivering essentials for the care of any long-term condition and without that social order all is chaos. In the case of diabetes these essentials may be insulin and the means by which to administer it, oral hypoglycaemic and other oral agents or the kit and equipment needed for the monitoring of blood glucose. Like me, I’m sure your heart will bleed when you read our article on conditions in the heat of the battle in Syria.

The third type of battle is the hidden, silent battle which takes place at the molecular and cellular levels in those in whom a cancer is developing. The relationship between diabetes and cancer (a ‘double whammy’ if ever there was one) is featured in several contributions to this Issue. Andrew Renehan reports on a number of aspects of this relationship including the question of whether insulin treatment in people with type 2 diabetes increases the long-term risk of developing cancer. This, and the analogous question for cardiovascular disease, is also addressed in our two contributions to the ‘debate’ section. This particular question of the long-term safety of insulin is important enough for us to seek contributions from a cancer expert (Renehan), a diabetes expert (Bain) and pharmacoepidemiologists (Holden and Currie). The question is complex. Interpreting the evidence is not easy and not all the evidence we need is available.

My own current view on this important matter is that the question of whether long-term insulin treatment in type 2 diabetes increases significantly the risk of cancer or cardiovascular disease is, at present, ‘unproven’. However, the answer to the deeper, related (and more important) question of whether the benefits of insulin treatment in type 2 diabetes – better blood glucose control leading to reduced microvascular complications and so on – is likely to outweigh any increased risk of cardiovascular disease or cancer in the long-term is ‘yes, it is’.

It’s not so long ago that healthcare professionals would not utter the word ‘cancer’ to a patient. More open use of the term and a greater optimism in the face of it have, there’s no doubt, been the result of improvements in treatment. Where people living with cancer have access to specialist help from cancer teams with surgery, chemotherapy, radiotherapy and other interventions available to them, the chances of a successful ultimate outcome are often quite good. As with diabetes, however, many millions are denied access to the services they need and the outcome is not at all what it should be.

World Cancer Day this year fell on 4th February. The ‘Four Cancer Myths’ that were focussed upon for ‘debunking’ were: ‘we don’t need to talk about cancer’; ‘cancer … there are no signs or symptoms’; ‘there is nothing I can do about cancer’ and ‘I don’t have the right to cancer care’. How similar they are to myths about diabetes.

Among many other features to look out for in this Issue are: the in-depth examination of diabetes in Asia by Juliana Chan and colleagues; observations on World Diabetes Day and the World Diabetes Congress in Melbourne; important new information about hyperglycaemia of pregnancy and diabetes in older people while our ‘Diabetes Voices’ slot this time focuses on diabetes educators and the debt which their patients owe to them. Read on and continue, please, to send us your observations on Diabetes Voice to [email protected]!

Editor-in-Chief, Editorial, D