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We have arrived in Chennai after an excellent side trip to Trichy, the hometown of Yuvaram, wherein we received a daunting amount of hospitality from his family. They also kindly served up a wide range of health care settings connected to the Reddy family in various ways: a “Hansenarium” for lepers; a de-addiction center for alcoholics; a small private hospital (65 beds) owned and run by one of Yuvaram’s cousins; and the lab of that hospital. Ample food for thought from these experiences – I’ll end our evening with a quick reflection from Yuvaram’s cousin. His clinic has a heavy diabetic focus, and he noted that the medication regimen proposed by the ADA and IDF don’t necessarily work as well in the Indian population; he postulates this is due to a higher rate of “lean” type 2 diabetics who present with low c-peptide levels, supporting issues more with beta cell function over the insulin resistance we see in the US (I can’t find the paper he mentioned on a cursory search).  Too, the differences in diet (we can all well attest to the amount of carbs and lack of vegetables at this point of the trip) impacts patients and the appropriate medications.  He lamented the lack of clinical trials performed in India to help guide therapy, an issue that spans all of low resource settings; a prominent example of the failure of therapeutic approaches derived in high-income countries to work well in other settings is a recent trial looking at IV fluids in septic children.

No easy solutions, but a very good reminder that trial results from one setting do not necessarily apply to other settings, that we need to be cautious about making leaps of faith with our data, and that we need to be aggressive in repeating pivotal trials in other settings.

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