Mucormycosis is a rare fungal infection from an organism found in soil, that occurs in the setting of immune dysfunction. In the US it is often associated with poorly controlled diabetes and persistently high blood sugars causing immune dysfunction (Organ transplant recipients are another group that can be affected). It can be catastrophic when it occurs, frequently infecting the nose and face requiring debridement and long courses of IV anti-fungal agents (amphotericin B which is lovingly referred to as “amphoterrible” due to its very serious side effects) and is often fatal ( I won’t post any photos here but I encourage google image searching for it). I always think of it as a disease occurring in the setting of over-nourishment, in part because that is often the setting in which it occurs in the US. When thinking of infectious diseases in India, one thinks of dengue or malaria and less so a fungus associated with diabetes. So when a woman walked into the clinic in Hyderabad (after traveling 12 hours from a rural town to get there) with a history of mucormycosis in the setting of poorly controlled DM, I was surprised that it had occurred, but I should not have been.
Obtaining adequate nutrition has historically been one of the biggest, if not the biggest, problems facing humanity since our beginning. However over the last twenty years or so we have seen a global shift from a problem of undernutrition to a problem of over nutrition. from 1990 to 2010 the estimated amount of global Disability Adjusted Life Years (DALYs for short and a way of estimating/quantifying morbidity due to disease) due to Protein-Calorie malnutrition dropped by 42%(1). During the same time period the amount of global DALYs for diabetes rose by 69% while childhood underweight dropped a staggering 60% (1). In large part this improvement is due to campaigns to end childhood hunger and more efficient food production in general. Now we are beginning to see diseases that primarily cause morbidity in high income countries transitioning to global health problems.
Diabetes plays a significant role in the morbidity of the population of india, in 2013 an estimated 9.1% of the population has the disease (2). Overall the disease is increasing in frequency (3) with genetics likely playing a significant role in the development of disease as there is regional variation in disease frequency associated with different demographics of those regions. For example 6.1 per cent of the people in Kashmir Valley (Northern India) have the disease while it occurs with a frequency of 16.6 per cent in Hyderabad (south India), one theory for this is due to the differing genetic makeup of these populations (with the north tending to have a higher concentration of migrant asian populations) (3). This situation is similar to the native american populations in the US who have a significantly higher frequency of diabetes when compared to the non-indigenous populations. Genetics can predispose to the disease but lifestyle changes (decreased physical activity, better availability of calorie dense food) seem to be what ends up pushing the disease process over the edge.
So the problem to solve for global health professionals not only becomes how can we prevent diabetes, but also how can we get the medications to people who need them, especially insulin, especially in rural areas? Thinking back to the patient I saw in clinic who had to travel 12 hours to be seen by her primary care doctor, something unheard of in the US, this is no easy task.
(1) Murray, Christopher et al “Measuring the Global Burden of Disease” N Engl J Med 2013;369:448-57.
(2) Reddy, K Srinath “India’s Aspirations for Universal Health Coverage” n engl j med 373;1 July 2, 2015.
(3) Seema Abhijeet Kaveeshwar, “The current state of diabetes mellitus in India” Australas Med J, 2014; 7(1): 45–48.