Sun, Mar-26-17, 03:49
Sickly sweet: How diabetes conquered the world
From The Telegraph
25 March, 2017
Sickly sweet: How diabetes conquered the world
Since 1980 the global number of diabetics has quadrupled to 415 million. One person every six seconds dies of diabetes. Treating the disease costs £674 billion every year and by 2040, one in 10 of us will have diabetes. Tom Rowley investigates
At the end of a long, hot Mississippi day, eight middle-aged women wearing baggy T-shirts and trainers were leaping across a church hall, as if they had decided to swap the unremitting sun for the prospect of some real sweat. In unison – well, almost in unison – they kicked their right legs in the air, then their left. Someone had brought along a stereo, which was barking out instructions and goading them into ever-greater exertion.
"How low can you go?" the male voice wanted to know. "This is about it, baby!" quipped one of the women, gasping for air. "That’s as low as it’s going."
"If my kneecap pops out," wheezed another, "somebody will have to put it back in." On this Thursday evening, as on every Thursday evening for the past seven weeks, they had gathered in Plantersville, just down the road from Elvis Presley’s home town of Tupelo.
Some of them were very chubby, with big thighs and bulging stomachs; others, though, seemed not far from a "normal" size. They came to weigh themselves, learn new exercise routines and swap healthy recipes. Mostly, though, they talked.
They talked about how much exercise would burn off their favourite foods ("Holy moly! An hour of canoeing is not even a Snickers bar!"), about substituting turkey for beef, and about how much weight they had already shed. "I’ve lost five and a half pounds," one of them said – "and that’s with my shoes on."
This, though, was no ordinary exercise class. Unassuming though Plantersville may have seemed, we were in fact on the front line of a new campaign aimed at curbing one of the most pervasive – and costly – diseases facing America: diabetes.
These sessions, part of a programme being rolled out across the country, target people at risk of developing type 2 diabetes – by far the most prevalent variant of the disease, and the only one usually linked to being overweight. Lose a few pounds, the reasoning goes, and you might avoid a lifelong condition.
"It was set up a lot like Alcoholics Anonymous," said Sherry Smith from Mississippi State University, who runs the Plantersville class. "You know, having a food problem is a lot like that."
The world's food problem
Around here, plenty of people have food problems. Within five minutes on one Mississippi highway, I passed a McDonald’s ("Muffins all day"), a Burger King ("Two for $10 Whopper meal deal"), a Sonic Drive-In, a Domino’s, a Waffle House, a Dodge’s Fried Chicken and a Huddle House ("Try our fully loaded value meals – only $4.99"). The portions are huge, and even the chocolate bars are deep-fried. "In our state," Smith went on, "we love to eat."
So perhaps it is no surprise that more than 13 per cent of the state’s adults are diabetic – the second-highest prevalence in America – with another eight per cent categorised as "at risk". In the same region where evangelical Christianity was once on the march, waistlines are now expanding so fast that scientists have rechristened much of the area girding Mississippi – known as the Bible Belt – the country’s "diabetes belt".
The state’s Diabetes Coalition organises an annual conference on the crisis named, with a nod to the music that inspired Elvis, Giving Diabetes the Blues. But this food problem has long since burst over state lines and bulged across the ocean. Just as American health officials were at last beginning to grapple with the issue, diabetes diagnoses were spiking across the world.
First came Europe: the disease is now Britain’s fastest-growing epidemic. Then the Middle East saw a huge surge in cases, too. Since 1980, the global number of diabetics has nearly quadrupled, to 422 million. Ninety per cent of this number have type 2 diabetes, which occurs when the cells in someone’s pancreas that make insulin – an agent the body uses to process glucose – produce too little, or the body becomes resistant to it. This leaves the diabetic with surplus sugar in their blood, impeding its flow around the body and often leading to complications such as blindness or ulcers that can require leg amputations.
Diabetes eats £674 billion of health budgets a year, and it kills: in 2015, it claimed five million lives, according to an International Diabetes Federation (IDF) estimate – more than the combined death toll for HIV, tuberculosis and malaria. By 2040, one in 10 of us will have it. It is, said Cherian Varghese of the World Health Organization, "a tsunami in slow motion". And now it is heading for Africa.
For decades, television fundraising appeals and the worthier sort of billionaire have focused on tackling the many communicable diseases that have plagued that continent. But as it has slowly grown richer (really, less poor), it has also fallen vulnerable to what were once diseases of the West.
In much of Africa, famine remains a constant threat: the UN has warned that as many as 20 million people across the continent and in Yemen currently face potential starvation due to a toxic combination of conflict and drought. Yet in some rapidly expanding African cities, where people are splurging new-found disposable income on fast food, the problem is no longer too little food, but too much.
Ethiopia, whose horrific 1980s famine inspired the Live Aid appeal, still suffers from droughts that inflict hunger on its rural population even today. But as its economy booms, more and more of its city dwellers are being diagnosed with type 2. Across the continent, the number of diabetics is expected to more than double in the next two decades – "a health time bomb", according to the IDF.
"Our health system would be overwhelmed," said Ahmed Reja, the British-trained doctor who heads the federation in Africa. "The whole economy would be overwhelmed." All of which means diabetes is now a long away from home. "We thought of this as an American problem," said Edward Gregg of the US Centers for Disease Control and Prevention.
"It’s been fascinating – and disturbing in some ways – to see it unfold." How did diabetes spread so far? And can anything – or anyone – halt its march?
From innocence to insulin
To understand how diabetes spiralled, you have to go to Tokelau – and that is easier said than done. Marooned in the South Pacific, midway between Hawaii and New Zealand, this series of three tiny atolls has no sandy beach resorts, no mobile signal and no airport. The closest runway is on Samoa, a gruelling three-day boat ride away. Yet these islands – 300 miles from the nearest supermarket or restaurant – make up the world’s diabetes capital.
As recently as the 1960s, the condition was almost unheard of here; now, nearly a third of islanders are diabetic, the highest prevalence on earth. Unravelling Tokelau’s journey from innocence to insulin helps to explain how type 2 conquered the world.
The smallest of the atolls, which measures only 1.4 square miles, was "discovered" by the British commodore John Byron (the poet’s grandfather) in 1765. It is called Atafu, and it is governed by routine. Saturdays are for fishing, Sundays for church and strictly not for drinking, Tuesdays for fan making. At three every afternoon, the women play bingo in their thatched meeting place; anyone feeding their pigs after 6.15pm commits an offence.
Now a significant minority of islanders have submitted to another, less welcome routine. At about six o’clock every Tuesday morning, 29 men gather outside a consulting room at Atafu’s tiny hospital. At the same time on Thursdays, 14 women do the same. A nurse pricks their fingers with a needle then writes down their blood-sugar levels in a large red notebook.
When I visited one Tuesday last autumn, I was greeted by Rosa Toloa, who was born on Atafu in 1969 and has recently moved back from New Zealand (which has maintained the atolls as a dependency since 1926) to serve as Tokelau’s health-information officer. As the diabetics queued for medicine, she began to explain how her island has changed so much.
When she was a child, she said, islanders had a very simple diet of coconut and fresh fish. Chickens and pigs were kept but only slaughtered for occasional feasts. "When we were hungry, we would have a piece of dried fish and some coconut." Islanders were more active, too.
Her father was a carpenter but, like most of the men, he would also fish every day. Every Saturday, they would climb the trees to claim the latest haul of coconuts. After a party of researchers visited in the late 1960s, they remarked on the "low rates of coronary heart disease, obesity and diabetes".
Back then, seven per cent of women were diabetic and only two per cent of men. Then came the imports. More regular shipping brought unthinkably exotic foodstuffs: mutton flaps, turkey tails, even ice cream. Cooperative stores opened up on each atoll, and the United Nations supplied the islanders with freezers.
In the 14 years after the researchers’ first visit, coconut consumption fell by a fifth. Meanwhile, islanders discovered sugar: in 1961, each Tokelauan imported only 7lb; by 1980, it was 69lb. The effect was swift. When the researchers returned in the early 1980s, twice the number of women and three times the number of men were diabetic.
In 1979, cyclone damage prevented the islands’ supply ship calling for five months. Fishermen ran out of fuel for their motors and returned to more labour-intensive sailing. Sugar ran out. But when a ship at last called, the passengers did not discover starvation and misery. "Tokelauans had been very healthy and had returned to the pre-European diet of coconuts and fish," the New Zealand Herald reported that June. "Many people lost weight and felt very much better, including some of the diabetics."
When shipping resumed, so did the new eating habits. As well as white rice, potatoes, instant noodles and chocolate drink, islanders now import tinned mackerel and tuna. The shelves of Atafu’s shop, which dispenses change in chewing gum rather than coins, are lined with corned beef, pears in syrup, custard powder, chocolate-cake mix and crisps.
Every week, adult Tokelauans work their way through 236 teaspoons of sugar. And, although walking from one end of town to the other takes only 10 minutes, many drive imported cars. The results are predictable. Nine in 10 adults are overweight; two-thirds are obese. None of the adults I met was skinny, but after a while none of them looked fat either – when everyone is carrying a stone or two too much, it is hard to remember what "normal" looks like.
"If you look at some of the old photos of the weddings, there’s a big difference," said Toloa. "There were a lot of elderly people dancing – very lean, healthy-looking people. You hardly see old people now. There are only a small group of them that are past the age of 65."
Toloa and the nurses are trying. Atafu’s first gym will open this year, and its only advertisements warn about the dangers of smoking and eating badly. Yet it is difficult to tackle the causes of the epidemic. "It’s not like somewhere where you have a choice of food. The food you get is the food you get," Toloa said.
It is very difficult to grow vegetables on the coral and islanders cannot always rely on good weather for fishing. Besides, she continued, they are now hooked on sugar. "They just have a taste for it." One of the nurses, a kindly but spirited middle-aged woman named Valisi Rikim, knows this well.
Her mother, sister and sister-in-law, and her sister-in-law’s mother, are all diabetic. Her aunt is also at risk. But, she explained when Toloa introduced us, she was most troubled by the condition of her brother, Foliga Filo. Filo had been diagnosed 10 years earlier, in his late 30s. Like many type 2 patients, his initial treatment involved only taking tablets, but now he needed to come to the hospital twice a day so that a nurse – sometimes his sister – could inject insulin into his stomach.
It was not going well. The target blood-sugar level for type 2 diabetics is less than 8.5 mmol/l (millimoles of glucose per litre of blood) – Filo’s had sometimes reached 19. His feet had twice been treated for sepsis and often he could not feel his legs. When he arrived for his injection, Rikim introduced us.
Filo was nervous and appeared withdrawn. "You know, sometimes I have to go and look for him," Rikim explained. "He just doesn’t want to come. He says he is tired of getting the injections. But I always try to talk to him and emphasise the condition he is in and how important it is to take his medicine."
Sometimes, she no longer recognised her brother’s character. "He liked to go fishing. He liked to husk coconuts. Now, most of the time, he just sits. It is very sad." As his sister spoke, Filo, whose black hair was sprinkled with a little grey, rested his forehead on his elbow and gave out long sighs. "There are so many diabetics in my family," he said. "I wish I was the only one." Was he scared? "Sometimes, when my blood-sugar level is high. But I am prepared," he said, pointing to the sky, "whenever He calls me."
The final frontier
Ten thousand miles away from Tokelau, on a tattered beige sofa in his fly-ridden home, Berhe Gebremedhin looks on as his city remakes itself. Almost every day, it seems, the dusty streets spawn a new concrete tower and the interminable traffic jams grow longer and longer. Addis Ababa is on the up. Gebremedhin is not.
This 60-year-old Ethiopian ought to be prospering: he is a building-site foreman and, right now, it seems his entire country is under construction. Recently, the economy has grown as much as 10 per cent a year. But he was forced to give up work two years ago and is unlikely ever to return. Since both his legs were amputated last year, when his diabetic foot ulcers grew gangrenous, he has been confined to the sofa.
During the day, he sits there; at night, he sleeps there. He can’t afford a wheelchair. His sole companions are his wife, who is also sick, and a little grey radio, which he uses only occasionally in case the batteries run out. He can’t afford those, either. "The only thing I do is sit," he said, when I visited recently. "I feel very trapped."
Like many Ethiopian diabetics I met, he was thin and did not at all resemble the diabetics of Tokelau or Mississippi. Many have shed a lot of weight since being diagnosed; others, like Gebremedhin, say they were never overweight. Gebremedhin is one of the first of a new breed of diabetic, as Africa grapples with the same changes in consumption patterns and lifestyles that first swept through the West and then reached as far as Tokelau.
In 1982, shortly before the famine, only 0.34 percent of Ethiopians were diabetic, according to one study. Since then, that figure has increased more than sevenfold. As urbanisation continues – the urban population is due to triple by 2037 – diabetes rates are expected to surge, too.
"I mean, we want economic development," said Dr Reja, the Africa head of the IDF, who also runs Ethiopia’s own diabetes association. "There is no doubt about it: we have to come out of poverty. But we are also saying, it has to be regulated. Addis and the other major cities are growing like anything. When I was a high-school student, there were only two pastry shops for the whole city. Now, on every corner you will see pastry shops, fast-food shops. People’s dietary habits are changing dramatically."
In the West, obesity is often a marker of poverty. In Ethiopia, the ability to eat large quantities of fatty or sugary food implies affluence. "In this country, when people become rich and their living standards improve, they tend to eat unreasonably," Dr Reja said. "The children of this newly affluent middle class also assume a very unhealthy diet. Being overweight and obese is regarded as a sign of status." Ethnicity may exacerbate the looming crisis in Africa.
In Britain, black people and those with South Asian ancestry are two to four times as likely to develop type 2 than are white people or Brits with mixed ethnicity. On Tokelau, the odds are weighted by Polynesians’ natural predisposition to the condition. Ethiopians might also prove particularly susceptible since, according to one theory, countries where the food supply has historically fluctuated breed people better equipped to store fat and therefore survive periods of scarcity.
In previous centuries, Polynesians would have found this capability useful for surviving long journeys by sea; so might Africans whose countries endured periodic famine. But the same capacity to store fat, when coupled with a ready and constant food supply, could wrong-foot them. Predisposition, though, only becomes problematic once there is too much food readily available.
The point is best illustrated by the Pima tribe of Native Americans, who live on reservations in Arizona. A related group of Pima live in the mountains of rural Mexico, largely cut off from outside influences. The two groups are genetically similar, but when scientists studied them, they found much less obesity and far higher rates of physical activity among the Mexican Pima. While 38 per cent of the American Pima had type 2 diabetes, only seven per cent of those in Mexico had the condition.
In Ethiopia, famine has been a persistent danger for centuries. During the famine of 1983-85, as many as a million people are thought to have died. Even today, despite the rapid pace of development in cities, about 80 per cent of Ethiopians live off the land, making them vulnerable to droughts. In the countryside, cases of type 2 diabetes remain rare.
But I did meet one rural diabetic, in the northern village of Arato Shugala. Taeme Taddesse was only 12 when his village ran out of food during the 1980s famine. But he was lucky: his family was taken in by relatives in another, more prosperous part of the country. Now, though, his luck is running low.
The 45-year-old’s sight is so poor that he cannot make out his family. "From the shape she has, I can understand she is my wife," he said. "But I can’t clearly see any changes in her face. I can’t tell." He has been forced to give up farming and now spends his days sitting in the family’s one-room, tin-roofed hut, as flies buzz about him. "I feel depressed that somebody is out working and I’m sitting at home," he said. "I can’t do anything."
Back in Addis, I met Hailu Mamo, another diabetic who remembers the famine well. The 65-year-old, who wore grey trousers, a yellow sports jacket and a checked felt cap, suffered a retinal haemorrhage in one of his eyes three years ago. A year later, he lost his sight completely. Yet the images that linger in his mind are as vivid as ever.
When the famine struck, he was working as a policeman and was roped into relief work, driving around rural areas distributing food. "The memories are very horrible," he told me. "I remember a woman carrying two children in her hands. She was trying to support everyone then suddenly she fell down, dead. That incident is always in my mind."
After the famine, Mamo became a taxi driver. By the time he was diagnosed, he had grown obese. Why, I asked him, were his countrymen now succumbing to diabetes? "These days people eat so many things and they don’t do exercise. People eat and then they sleep. They don’t do hard work like they did in the past."
Britain's 'foot attack'
In the staff-training room of a brightly lit hospital in south-east London, Professor Mike Edmonds was talking his audience through a series of horrific pictures. Flicking through the handout he had passed around, each page made you feel queasier than the last: there were feet bleached yellow, feet stained the colour of dried blood, and feet that appeared to have gorged on themselves.
The title on the front of the pamphlet made his message plain: "FOOT ATTACK!!!" Unlike their counterparts in Africa, British doctors are now well used to treating diabetic foot ulcers. Prof Edmonds established this specialist foot clinic at King’s College Hospital in 1981. In the next three years, 240 patients came through his doors. Now, 200 arrive each week.
Even so, Prof Edmonds and his colleagues worry that British diabetics do not get the attention they deserve. "Cancer takes priority in the NHS," Hisham Rashid, a vascular surgeon at King’s, told me. "I had a meeting only last week, trying to explain that actually strokes and diabetic feet kill patients quicker than cancer. But because of the political importance of other diseases, diabetic patients are at the bottom of the scale of interest."
After seeing doctors struggle against overwhelming odds in Ethiopia and Tokelau, it surprised me to hear such a complaint on my own doorstep. With its imposing stone frontage and glass portico, King’s was by far the grandest hospital I had seen on this journey – and its team the most skilled, renowned throughout Britain for saving diabetic patients’ legs.
Yet even here, tackling diabetes was proving a battle. So much seems to depend on the patient’s own attitude to the obstacles they are facing. On Tokelau, Foliga Filo had appeared weighed down by the burden. But at King’s, the team introduced me to one of their regulars, a 71-year-old called Joan Olgun.
The retired telephonist from Dulwich, south London, has been an amputee for 20 years, but you would never notice. She has a prosthetic leg and walks without a stick. In outpatient waiting rooms, she is often mistaken for a patient’s relative. She chatted to me about amputations as if she was comparing notes on a new television drama.
"They’re just blips!" she said, with a chuckle. "My mother was a diabetic – she lost her leg – and I said, 'Is it the last resort?' [Prof Edmonds] said, 'It’s your life or your leg.' I said, 'Well, there’s no competition'.
"I’ve had infections but my life has gone on. I drive. I live on my own. I don’t have anyone in to do anything. I’m dropping myself in it now," she went on, with a nervous glance towards the doctors. "I even go up ladders and do my own windows. No one comes into my house to do anything."
She looked up again. "Sorry about that. I shouldn’t be going up ladders."
Most patients, of course, are not like Olgun. Rashid beamed at her as she made her little confession about the ladders, in the manner of a mother indulging a favourite son. "You are a unique woman," he explained. "You’ve had an amputation and you still manage to live a normal life. The majority do not achieve this."
Others grow resigned to their fate: as every diabetic knows, the condition is permanent – there is no cure. Or, as Taeme Taddesse put it to me in Ethiopia, "I have left everything to God." Yet there are people who refuse to accept that diabetes should remain a lifelong condition. Even as Olgun and I spoke, two very different men on opposite sides of the Atlantic were dreaming of a breakthrough. Could one of them eventually alter the disease’s course?
The doctors and the dreamers
On another boiling Mississippi day – the sort that takes people hostage in air-conditioned homes and offices – builders were nevertheless at work in one corner of the state, their hard hats and sunglasses offering only a little shade. Some were inspecting the steel frame of a new building; others were scooping up parched earth in diggers and dropping it atop mountains of soil.
There were deadlines to be met and the man for whom they were working, Joseph Canizaro, is not the type to let anything get in the way of his latest obsession – least of all the weather. All across the 150-acre site, Canizaro’s vision of a "medical city" was taking shape. Soon, these bulldozed plots would house a new pharmacy school, a nursing college and – the crowning glory – the new National Diabetes & Obesity Research Institute.
"I’m in a hurry," Canizaro, who turned 80 earlier this month, said when he joined me to inspect progress on site. "I don’t have a lot of time." Canizaro made his money in Louisiana, building high-end hotels and skyscraper office blocks.
He has sculpted so much of the skyline that he has been called the Donald Trump of New Orleans. But he was raised across the border in Mississippi and retains a fierce loyalty to his home state. "I’m a Mississippi boy," he said, in gravelly southern tones, "and Mississippi has always been bottom of everything in the United States."
When the state’s governor complained recently about its high obesity rates, Canizaro, who has been taking tablets for a decade to treat his type 2 diabetes, decided to tackle the issue. Rather than joining some board or giving a little money to a local charity, he settled on a characteristically grand ambition: he would solve the problem himself, by building a world-class research centre here, just up the road from his home town of Biloxi.
It will cost Canizaro – and the billionaires from whom he plans to cajole donations – £80 million just to get it running. "That’s a little gutsy," he conceded. "But I’ve done it before."
For years, governments have focused on preventing diabetes. Britain, like Mexico and South Africa before it, has set its hopes on a sugar tax. The NHS is rolling out a programme of national educational classes similar to the Mississippi scheme. And in 2014, Tokelau imposed a blanket ban on fizzy drinks (many islanders now drink sugar-laden orange juice instead).
But Canizaro will set the scientists he recruits a bolder task. "If you’re going to spend money on research, why would you not spend your money to look solidly towards a cure? What greater challenge? And why not an expectation to go along with it? If I don’t think we can, we shouldn’t even work on it."
A Christian who prays for an hour and a half each morning in a chapel attached to his home, Canizaro believes he has a mission to tackle the condition, helping some of the world’s poorest people. He recalled the huge strides Bill Gates has made in tackling HIV in Africa. "So why not for diabetes? That’s the real epidemic today. It’s just nobody’s doing it. Thank God we’ve got an opportunity to make a difference."
He would not tell me exactly how much of his own money he has put behind the search for a cure. "But I’ve got it in my will, and it is what I’m going to spend the rest of my life doing. I’ve made all the money in the world – the Lord’s been good to me – and I’ll fund whatever’s necessary."
Across the ocean, in his office in Newcastle, another grey-haired man is also focusing relentlessly on the condition. Professor Roy Taylor speaks in a much more circuitous, donnish fashion than does Canizaro: at one point he told me, "I’ve been trying to destroy hypotheses for a lifetime, but I’ve never had such a cataclysmic defeat" – which was his way of saying, "My hunch was right."
Yet he is equally committed to his task, and closer to what could well prove a significant breakthrough. This September, Taylor, who is a professor of medicine and metabolism at Newcastle University, will travel to the European Association for the Study of Diabetes’ annual meeting to address scientists from across the continent. His topic? Reversing diabetes.
"This is the first session on reversing type 2 diabetes that there’s been at any diabetes meeting, national or international," Prof Taylor said excitedly. It will, he added, mark a "watershed". In his quiet way, Prof Taylor has spent the past five years probing the assumption that type 2 is a lifelong condition. "That is not a belief that has come out of thin air," he conceded. "We know that if we follow up people with type 2 diabetes, the condition gets steadily worse. The insulin-producing cells get less and less competent. It’s a dismal picture.
"What nobody so far has fingered is that every one of those studies has involved a group of people who have stayed at least as fat as they were at the beginning." So Prof Taylor instead subjected 11 diabetics to a very low-calorie diet for eight weeks.
The results were startling: every one of them saw their insulin production return to normal. Their diabetes was put into remission. The results pointed to an error in our understanding of how type 2 affects the body. "It is standard belief among experts in diabetes that at the time of diagnosis about half the insulin-producing cells have already died off," Prof Taylor went on.
But his study suggested that rather than dying, the cells only stop working temporarily, when there is too much fat in the pancreas for them to produce insulin. "If you take away the fat, the metabolic stress goes away and, remarkably, they switch back on the insulin gene and are happily making insulin again." As Prof Taylor put it, everything suddenly seems "startlingly simple": shed enough fat and the diabetes will go away.
It is, of course, rather more complicated than that. Or, in Prof Taylor’s phrase, "we need to be quite precise about how optimistic" we are. The first trials were conducted with only a small group of volunteers, monitored by Prof Taylor. The diet could have hidden downsides, and some patients may not be motivated enough to stick to it. And his method did not work for those who had been diabetic for more than 10 years.
Since those with type 2 often do not know they are diabetic until they develop complications – sometimes years in – this could significantly reduce the number who could benefit. Still, even the cautious professor conceded that his research provides a "glimmer of hope".
"We’re facing up to a battle here," he said. "Understanding the enemy is crucial."
The latest casualty
One recent evening, I received an email from Rosa Toloa, the hospital worker I met on Tokelau. "Can you recall Foliga?" she asked. "Nurse Valisi’s brother." He died, she told me – on 8 November last year, only five days after we met. He was 50. He had suffered a heart attack, brought on by his diabetes.
I thought back to that day at the hospital, when he had pointed to the sky. "I am prepared," he had said. Now, so soon, the epidemic had claimed another casualty. "He was one of the people we struggled to get to understand his condition," Toloa wrote. A few days later, his sister, Valisi Rikim, also wrote to me.
The pictures taken by The Telegraph’s photographer, Julian Simmonds, when we met were the last to show her brother alive. She asked for copies. "I remember telling you that I am scared to lose a loved one. He was the closest of my siblings."
Our exchange reminded me that, despite the hope offered by the likes of Prof Taylor, people are dying from diabetes every day. In fact, according to the IDF, every six seconds.
Relying on potential medical advances will not be enough: concerted political action is needed before the crisis spreads still further. "We need to get the politicians on board," Prof Taylor told me. "This is the most difficult step." In the absence of an effective global plan, ordinary nurses such as Rikim are left to fill the void as best they can.
When we visited Atafu, she was preparing to travel abroad for training. She learnt of her brother’s death on the outward journey. "I almost couldn’t make it," she said. "But his courage as a brother motivated me to come this way and this far." For so long, she had seen her patients struggle with diabetes; now, it had taken her beloved brother. And if it will not halt, Rikim decided, neither can she.