Out of pocket expenditures
Although expenditures for the medical care of diabetes are much higher in industrialized countries, nearly all these countries have organized systems of medical care insurance and/or governmental provision of medical services. This allows families to survive financially when diabetes strikes. The exception is the United States, which lacks a comprehensive national medical care service or insurance system 9 .
In 2025, however, 80% of all cases of diabetes will be in low- and middle-income countries 1 2 . In Latin America, families pay 40-60% of expenditures for medical care from their own pockets 3 . In the poorest countries, people with diabetes and their families bear almost the whole cost of whatever medical care they can afford. In India, for example, the poorest persons with diabetes spend an average of 25% of their total income on private care 4 . In low- and middle-income countries, illness, injury and death is one of the main causes, possibly the main cause, of household impoverishment 1 2 .
Other direct economic effects
The direct economic impact of diabetes includes non-monetary as well as monetary effects. Non-monetary effects include changes in quality of life (or disability) and length of life. Disability, pain, and lost years of life are as important as financial loses.
Reduced years of life
Diabetes dramatically reduces life expectancy when glucose, blood pressure and lipids are not aggressively controlled. Diabetes is expected to cause 3.8 million deaths worldwide in 2007, about 6% of total world mortality, about the same as HIV/AIDS (see Diabetes Mortality).
From an economic point of view, the cost associated with these deaths is conceptualized as the years of life lost because death came sooner by diabetes rather than later by something else. For 2002, the WHO Burden of Disease project estimated that 8.59 million years of life were lost because of diabetes 5 . This is undoubtedly an underestimate because it is based on mortality rates obtained from death certificates, which under-report diabetes as a cause of death . The true estimate is probably at least three times higher — 25 million years of life lost annually.
Underestimation of diabetes mortality is less of a concern when diabetes is combined with cardiovascular disease, because CVD accounts for half of diabetes-cased death worldwide (see Diabetes Mortality). WHO estimates that, if the value of a year of life is set country by country at 100 times GDP per capita, then diabetes, heart disease and stroke cost about ID250 billion in China, ID225 billion in the Russian Federation, and ID210 billion in India in 2005 1 2 .
In poor countries, many children die because access to life-saving insulin is not subsidized by governments (who instead sometimes tax it heavily), or because insulin is not available at any price, or is of very low quality (see Insulin, Medication and Diabetes Supplies). In these locations, untreated type 1 diabetes can be particularly costly in terms of life years lost, because it attacks children and younger adults who would otherwise live for many additional decades.
Disability and reduced quality of life
Quality of life effects may be as deleterious as premature mortality to persons living with diabetes. Studies indicate that persons in perfect health would willingly give up 2.76-3.73 months of life to avoid a year of living with diabetes 6 7 . Interestingly, however, persons who actually have diabetes without complications rate their quality of life only slightly below similarly aged persons in the general population 8 .
But quality of life decreases when complications appear 8 . Persons with diabetes say they would sacrifice about two months of life per year to avoid a year of diabetes-caused blindness, about one month per year to avoid kidney dialysis, one to 3.3 months per year to avoid amputation, three weeks per year to avoid painful diabetic neuropathy, one to two months per year to avoid a stroke, and three weeks per year to avoid a history of heart attack 6 7 . Disability and reduced quality of life may be a proportionately larger problem in low-income countries 10 . WHO assumes that diabetes-caused blindness reduces the value of a year of life by more than half 11 .
Using estimates like these, the World Health Report 2004 calculated that the equivalent of 7.6 million years of life were lost to diabetes-caused disability in 2002 5 . This estimate omits the effects of complications such as heart attack, stroke and other cardiovascular complications, though.
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