What is insulin rationing in Netflix’s Purple Hearts? Should it worry us in India?

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Does insulin rationing pose a problem in India? There is much conversation around this considering the Netflix film, Purple Hearts, has its protagonist, Cassie, a singer-songwriter and recently diagnosed Type 1 diabetic, rationing her insulin while working numerous jobs as she cannot afford the high costs. And the US has enough real life cases, which the film might have referenced.

There have been human stories, like that of 47-year-old Meaghan Carter of Ohio, a Type 1 diabetic for 18 years, who couldn’t afford her insulin, costing more than $ 800 a month, once she lost her job and insurance. She rationed insulin, resorted to buying NPH insulin (intermediate-acting insulin) from Walmart, which is cheaper but much more unpredictable than the insulin she normally used. On Christmas Day, 2018, Meaghan died of diabetic ketoacidosis. Kayla Davis of Kentucky died at 28 on June 5, 2019 while Stephen Zachary Alford died at 22 on April 26, 2019, because he failed to procure the required amount of insulin and went into cardiac arrest.

NOT CAUSE FOR MUCH WORRY IN INDIA

Considering that Type 1 diabetes percentage is still much lower in India (around 10 per cent of the population), will insulin rationing ever pose a problem? “Insulin rationing may be a problem for those only on insulin therapy or on very high doses of expensive insulin. In such cases, the low-cost version can be used if they are Type 1. Without insulin they would not survive, so somehow they make arrangements. For Type 2, they may resort to oral medication for a while but it could result in high sugar and complications. What’s important to clarify is that some oral drugs are costlier than low-cost insulin,” says Dr Anoop Misra, Chairman, Fortis CDOC Center for Diabetes.

“Besides availability, insulin prices in India are far more competitive than the US. A regular insulin vial, which costs anything between Rs 150 to Rs 160 costs $ 275 in the US. Of course, aids like insulin pumps are costly but insulin pens work well here with each cartridge of the regular kind costing something around Rs 350. More than 90 per cent insulin-dependent diabetics in India choose the injectable pen. Besides, insulin is available for free in government hospitals,” says Dr Mahesh Chavan, Consultant, Endocrinology and diabetology, Apollo Hospital, Navi Mumbai.

WHAT IS KETOACIDOSIS?

According to the US-based Centers for Disease Control and Prevention (CDC), diabetic ketoacidosis (DKA) “is a serious complication of diabetes that can be life-threatening. DKA is most common among people with Type 1 diabetes. People with Type 2 diabetes can also develop DKA. It happens when your body doesn’t have enough insulin to allow blood sugar into your cells for use as energy. Instead, your liver breaks down fat for fuel, a process that produces acids called ketones. When too many ketones are produced too fast, they can build up to dangerous levels in your body.”

WHY DID INSULIN RATIONING BECOME COMMON IN THE US?

The first wave of insulin production was harvested from pigs and cattle. Of course, it was refined later. Modern insulin, which began to be rolled out in the 1970s, is formed by bacteria injected with human insulin genes to produce the hormone. These came to be known as “biologic drugs.” But concerns were raised about safety compared to those produced through chemical synthesis. Also, unlike other drugs, the “generic” version of insulin is only around 15 per cent cheaper than its competitors.

As new forms of insulin flooded the market, the older animal-based insulin simply disappeared rather than remaining available as a low-cost alternative, according to Dr Jeremy Greene, a professor of medicine and history of medicine at Johns Hopkins University in Maryland. Now organisations like the Open Insulin Project want to democratise the manufacturing and availability of insulin in the US through a generic product. It will be the “first freely available, open protocol for insulin production,” according to a statement on the company’s website. On safety, it argues that if insulin is made in smaller batches, it would be easier to track down a bad batch rather than one being shipped in millions of units all over the world.





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