Type 2 diabetes epidemic gripping Central Australia is crippling the hospital system
The disease sweeping inland Australia is not infectious but it is devastating — and it’s pushing hospitals to the brink of collapse. Medicos warn: ‘This is the real pandemic.’
The national diabetes epidemic is pushing hospitals to the brink of collapse, with up to a third of patients in urban centres affected by the condition and kidney dialysis clinics at absolute capacity in Central Australia, where four out of 10 Aboriginal people have the chronic disease.
Devastating accounts from patients and doctors have revealed a vast tide of human suffering as overloaded hospitals struggle to cope with continual admissions from diabetes complications – sometimes requiring amputations – and many thousands of patients vying to access preventative care.
In a national investigation of the impacts of the devastating disease at the frontlines of the epidemic, The Weekend Australian spoke to doctors in the hardest-hit zones who warned the nation’s health system would soon be overwhelmed by diabetes complications unless primary and preventative care is properly funded.
The type 2 diabetes epidemic – evolving over three decades – is escalating in an alarming manner, with children as young as four years old its latest victims.
Aboriginal women in Central Australia have the highest rates of type 2 diabetes in pregnancy ever reported globally, with almost one in 10 affected, making them 30 times more likely to develop end-stage kidney disease.
Nephrologists have described the “absolutely unprecedented levels” of kidney disease in Central Australia, which has three times more patients with end-stage kidney disease as a proportion of the population than as Taiwan, the world’s worst location for renal disease.
“Now is the time to prevent further premature loss of life,” said Professor Louise Maple-Brown, deputy director (Research) at Menzies School of Health Research and senior endocrinologist at Royal Darwin Hospital. “Now is the time that we need to invest more in prevention.”
Type 2 diabetes is a disease that occurs when blood glucose is too high and the body becomes insulin resistant. The body is then unable to use insulin, a hormone made by the pancreas, to help glucose get into the cells to be used for energy, and blood glucose further increases. The condition is strongly lifestyle-related but can be reversible. It is associated with devastating complications including foot infections that can result in amputations, premature blindness, heart attack, stroke and nerve problems.
Official numbers suggest one in 10 hospital admissions nationwide is diabetes-related, but frontline doctors say it’s a serious undercount and in many hospitals the true rate is between one in three and one in four.
Some 10 per cent of all deaths are attributed to diabetes – an increase of almost 75 per cent in the past 20 years, but that’s almost certainly a substantial undercount too. An increasing number of mothers nationwide already have type 2 in pregnancy. Every day in Australia, four people die from diabetes-related foot disease.
“At this tertiary hospital setting, we’ve shown that a third of all people hospitalised have diabetes and that’s a big problem,” says Elif Ekinci, Head of Diabetes at Austin Health, which services Melbourne’s northern and northeastern suburbs, and Director of the Australian Centre for Accelerating Diabetes Innovations. “It’s not just our hospital, that number has been consistent across other studies as well.”
Now, state health departments have granted The Weekend Australian extraordinary access to hospitals at the frontlines of the epidemic, where medics have frankly described their sheer despair at the disease’s trajectory, begging for a greater focus on prevention to stop the tide of patients who are losing limbs and lives.
The age of the children being diagnosed in the Northern Territory, according to data compiled by the Menzies School of Health Research, represents a trend that has never been recorded anywhere in the world.
“The emergence of type 2 diabetes in children in Central Australia is a catastrophe,” said NT Health’s Dr James Dowler, acting director of pediatrics at Alice Springs Hospital. “It’s going to ruin lives, it’s going to impact future generations,” he added.
Now, new statistics establish that Central Australia has the highest rate of end-stage kidney disease of anywhere on earth, after The Weekend Australian commissioned health statisticians to establish in numbers the “absolutely unprecedented levels” of end-stage kidney failure that doctors are observing unfold with their own eyes in Alice Springs.
The data from the Australia and New Zealand Dialysis and Transplant Registry reveals that the proportion of people who are undergoing kidney replacement therapy in Alice Springs is 10,234 per million head of population. That’s triple the rate of the worst-hit country in the world for end-stage-kidney disease, Taiwan.
Compared to the rest of Australia, Alice Springs’ rate of renal dialysis is 10 times the rest of the nation, which has 604 people nationally per million population undertaking the therapy.
“There is just a vast epidemic of kidney disease in the Northern Territory, especially in Alice Springs,” said associate professor Phillip Clayton, acting head of the Australia and New Zealand Dialysis and Transplant Registry and kidney specialist at the Royal Adelaide Hospital, who has released previously unpublished end-state renal disease data in order to analyse the devastating trend against global averages. “One in 100 people are on dialysis in Central Australia, which is amazing. It’s amazingly high. It’s sad to say it doesn’t surprise me.”
Some diagnosed as teenagers or even younger are now already taking their place in Alice Springs’ renal clinics – which, together, make up the largest dialysis centre in the southern hemisphere. The youngest patient on renal dialysis in Alice Springs is 23 years old.
“It’s devastating when these young patients start their life on dialysis,” said Dr Cherian Sajiv, director of nephrology at Alice Springs Hospital. “Our hospital dialysis unit pretty much runs almost 24 hours a day.
“You can call it a disaster when you have young people transitioning onto dialysis in their 20s and 30s,” he said.
‘We are now looking at a situation where the life expectancy of some of our children will be less than their parents.’
Doctors nationwide are now issuing a rallying cry for attention and action, alarmed at the way the epidemic is accelerating as patients get younger and younger. Primary care has been “annihilated” in the NT by the pandemic, with staffing shortages at staggering levels. The NT GP Training Program this year has only 14 new registrars out of 60 available places.
“Currently, at the same time as there is a diabetes epidemic with amongst the highest reported rates anywhere in the world, Aboriginal health services like Congress are facing the biggest workforce crisis we have experienced since the 1990s,” said Congress CEO Donna Ah-Chee. “In this context, preventive healthcare has declined and this includes the health checks that help to detect diabetes early, and care planning which is vital for people who have complex chronic conditions like diabetes.”
Nationally, diabetes prevention programs are very thin on the ground, and the disaster is unfolding largely out of sight.
“I don’t think people are aware of exactly how big this issue is,” said Elna Ellis, head of endocrinology at Alice Springs Hospital and chair of the NT Diabetes Clinical Network.
“I would describe the surgical ward here as the wild west of diabetes with very high admission rates with diabetes-related complications, and sometimes also total limb amputations.
“And I am extremely worried about the youth-onset diabetes.
“That trajectory to me is absolutely shocking and heartbreaking. I also have children. If I had to envisage that that potentially was my child, I would be absolutely devastated. And even more so if I felt that there wasn’t enough action being taken to combat it and raise awareness of it.”
Australia has no specific national diabetes prevention plan, such as the one operating in the UK, and our 10-year National Preventive Health Strategy, signed off on in 2021, is unfunded.
Spending on preventive health is expected to slump to it’s ordinary low of about 2 per cent of the health budget now the acute phase of the pandemic is over.
“There is no specific investment in a national preventative health strategy, and certainly nothing explicit with regard to tackling obesity,” said Public Health Association of Australia chief executive Terry Slevin.
“It’s farcical and it’s ridiculous. Anybody who thinks about this for more than two minutes will come to a conclusion that 5 per cent or 10 per cent or more of the budget is a sensible and legitimate investment to stop people getting sick in the first place.”
Labor MP Mike Freelander said the evolving crisis had causes far deeper than poor dietary habits. Entrenched economic and social inequities are growing deeper in Australia, fuelling widespread chronic disease amid disparities in education, employment status and access to affordable healthcare.
The prevalence of the condition nationally – expected to affect one in 12 people by 2050 – is sparking warnings the trend is set to send gains in life expectancy over the past century into reverse.
“It really is time to take stock,” said Dr Freelander, who is chairing a current parliamentary inquiry into diabetes.
“We are now looking at a situation where the life expectancy of some of our children will be less than their parents. And that really goes against everything that we’ve seen in healthcare over the past 40 or 50 years.”
“It is urgent we do something about it because it is overwhelming our health services. It’s putting us in a situation where we are failing these families persistently and consistently, and urgent action is needed. We need to stop looking at solutions that clearly have failed. And that means some very strong decisions need to be made.”
The prevalence of people living with type 2 diabetes has tripled in Australia between 1990 and 2019.
“Unless we take urgent action, the impacts of type 2 diabetes, including debilitating and costly complications, will overwhelm our health system, said Diabetes Australia Group CEO Justine Cain.
In the outer rings of the nation’s cities, hospitals are already buckling under pressure. “The situation is already unsustainable,” said David Simmons, distinguished professor of medicine at the Western Sydney University Macarthur Clinical School and head of Campbelltown Hospital’s endocrinology department.
“From a southwest Sydney point of view, between 20 and 25 per cent of our inpatients have diabetes. And we don’t have the sorts of resources that we should have, particularly in Campbelltown.
“We have a large proportion of outpatients. People often go home without being seen by one of the diabetes team, and therefore they don’t have a plan for their diabetes.
“People are losing their lives either because they’re not accessing the care, or the care isn’t being delivered to the level that it needs to be. And that is because primary and secondary care are not working together. This is the real pandemic, but many of our patients can’t afford to go to anyone private (and) we don’t have the private specialists here even if they could.”
Professor Simmons said Australia was radically underresourced in specific diabetes treatment and prevention in every public hospital in the country.
“In the UK, you’re supposed to have one diabetes-credentialled educator for every 300 beds.
“At Campbelltown hospital we have about 600 to 900 beds and we have half a person.”
Further west in Penrith, a major multidisciplinary obesity clinic is also forced to discharge patients to an uncertain future. The waitlist for the service is almost four years long.
“For someone with very severe complicated obesity who really does need that wraparound support, when I discharge them I know that I’m just pushing them off a cliff sometimes,” said endocrinologist Dr Kathryn Williams, a senior lecturer at the University of Sydney.
While those in wealthier suburbs or with private health insurance can get bariatric surgery, allied healthcare and expensive pharmacological drugs, many in the hardest-hit diabetes hotspots are stuck on eternal waiting lists.
Sometimes, Category 3 bariatric surgery patients never make the waiting list at all, according to Perth plastic surgeon Adrian Brooks, speaking from his observations in WA public hospitals. “The secretaries categorise the cases according to urgency,” Dr Brooks says. “Category 1s and 2s are urgent … and all the others would be just put in drawers. They would put them in the never-never drawer because they then weren’t registered as received.
“They then weren’t part of a statistic of the number of people waiting for appointments.
“It would be essentially like filing them in the bin.”
It’s estimated that one in six Australians over the age of 25 – about two million people – are living with prediabetes or are at high risk of developing type 2.
But Diabetes Australia believes that there could be up to four million people, or about 15 per cent of the population, who are either living with or at risk of developing diabetes.
Amid a cost-of-living crisis and deepening social and economic inequalities, GPs are reporting that people are skipping appointments and can’t afford to buy medicines.
In southwest Sydney, GP Ken McCroary sees patients every day with “out of control” blood pressure, and patients with “crazy high” sugars because they can’t afford to buy prescribed medicines. Some have heart attacks, strokes or require amputations as a result. “They can’t afford to access the insulin, they can’t access the tablets and they’re having to go without.”
Nationally, a person with diabetes has a minor or major amputation removed every two hours, according to Diabetes Feet Australia. Four out of five of these amputations would have been preventable with timely preventative healthcare.
“We build these big new shiny hospitals that cut off more legs and do more kidney transplants, we build more diabetic clinics for dialysis, instead of investing a tiny fraction of that amount improving quality primary care that could prevent people getting diabetes in the first place,” said Dr McCroary.
Diabetes is also the leading cause of preventable blindness in working age Australians.
Drugs to ward off macular edema are among the nation’s most expensive subsidised drugs. Diabetes also causes cardiovascular disease and strokes.
“Behind each of these statistics is a person living with diabetes who is rising to the challenge of managing this complex condition every day,” Diabetes Australia Group’s Ms Cain said.
