How People with Diabetes in Developing Countries Cool Their Insulin

When it’s 100 degrees Fahrenheit and there’s no available refrigeration, the solutions are ingenious

MyMy friend Jon recently returned from a research trip to Sierra Leone. He’s a graduate student in sociology at Boston University and was observing the work at a new clinic built to improve care for patients with chronic diseases like respiratory disease, cancer, and diabetes. The clinic, supported by the global health organization Partners In Health, is based in Kono District, a region with poor infrastructure, devastated by the civil war fought in the 90s and early 2000s over diamonds and other mineral resources.

While accompanying a nurse and a social worker from the clinic on their regular check-in visits to the rural villages surrounding Koidu, the capital of Kono District, Jon encountered a patient named Samuel. Samuel (whose name has been changed for privacy) is a trader and farmer, and also a Type 1 diabetic in his mid-30s. In order to live, he had to inject insulin every day.

Insulin is a protein and to maintain its potency, it must be kept at or below standard room temperature (20–25 C/68–77 F). If it gets too hot, it denatures, like egg-white in hot water, and becomes less effective. In regions where the temperature is regularly hotter than 25 C/77 F and where people live without refrigeration, this is a problem. Without reliable insulin to maintain healthy blood glucose levels, insulin-dependent patients can experience life-threatening complications like kidney damage and cardiovascular disease.

When Jon, the nurse, and the social worker went to check in on Samuel, he brought them out behind his house to a shallow hole covered with a piece of wood. At the bottom of the hole was a small clay pot and inside was the insulin, cool and vulnerable.

Approximately half a billion people worldwide live with Type 1 or Type 2 diabetes. A 2018 study in Diabetes Technology and Therapeutics estimates that about 150 to 200 million of them currently require insulin therapy. A 2016 study by the International Diabetes Federation (IDF) found that at least 33% of the diabetics who live in low- and middle-income countries are without home refrigeration. That’s about 40–50 million people who need insulin and have no refrigerator in which to store it.

Samuel’s method struck me as a creative way of dealing with this troubling situation: He had been provided with insulin, this lifesaving, high-tech biologic, and yet he was without the basic infrastructure necessary to keep the meds working for him. His story highlighted some of the complexity involved in caring for chronic disease in the developing world. After hearing his story, I was curious about how other insulin-dependent patients in similar situations keep their insulin cool.

In a 2016 study by Life For A Child (LFAC), an organization delivering care for children with diabetes worldwide, researchers collected alternative cooling devices from a number of countries and compared their effectiveness in a “clay pot Olympics.” Dr. Graham Ogle, the lead author of the study and general manager at LFAC, had the idea for the experiment after a site visit in Khartoum, Sudan.

Besides clay pots, the researchers looked at a gourd and a goatskin filled with water from Sudan, a bucket filled with wet sand from Ethiopia, and, as a control, a FRIO cooling wallet manufactured in the UK.

“The senior pediatric endocrinologist there took me to the home of a family with a young boy with diabetes,” he explained. “They were squatting in a half-built house with no windows or electricity. It was very hot that day, and almost every day in summer. The boy stored his insulin in a plastic bag in a small clay pot under a large clay pot which was wrapped in hessian [burlap]. The large clay pot was filled with water, and was porous so the water slowly leaked out and collected in the hessian and then dripped into the smaller pot, cooling the insulin.”

Besides clay pots, the researchers looked at a gourd and a goatskin filled with water from Sudan, a bucket filled with wet sand from Ethiopia, and, as a control, a FRIO cooling wallet manufactured in the UK.

All of the traditional devices included in the LFAC study used evaporative cooling, which has been used to cool food and water for thousands of years. As the water in one of these devices evaporates, it absorbs heat from the surrounding air, thus lowering the temperature inside the device. Clay pots, which are usually semi-porous, encourage evaporation.

By measuring the change in temperature inside the devices over the course of four days, the LFAC study found that the most effective device was the suspended goatskin from Sudan because of its large surface area, which permitted more water to evaporate more quickly. Two porous pots without lids from Sudan and Ethiopia also performed well. The FRIO wallet, made of polyester and super-absorbent crystals, worked about as well as the top-performing traditional devices, not any better. The non-porous devices, such as the gourd and the glazed and cemented pots, were much less effective than the others.

Researchers then modeled how the devices were likely to perform in the hottest months of the year in various countries. They concluded that the top-performing devices were capable of keeping insulin at or near standard room temperature in all of the different climates studied except in regions where high humidity would limit the effectiveness of evaporative cooling.

In Karachi, Pakistan for example, the average humidity is 91.3% with an average daily maximum temperature of 32.7 C/90.9 F. Too wet and too hot.

I reached out to several of the doctors who sourced the cooling devices for the “clay pot Olympics” to learn more about where the devices came from.

In Nagpur, India (average daily maximum temperature in the hottest months 40.2 C/104.4 F), Dr. Sharad Pendsey runs The DREAM Trust, an organization dedicated to improving care for children with diabetes. He estimates that 10–20% of people in Nagpur — population 2.4 million — are without refrigeration. The pot he contributed to the LFAC study was an earthen pot common in India called a matki or matka. The pot-within-a-pot design he recommends to patients creates a dry compartment surrounded by water in which people can store insulin. In the past three years, the DREAM Trust has also distributed 210 refrigerators to insulin dependent patients in Nagpur who had electricity, but could not afford a refrigerator.

In Bamako, Mali (average daily maximum temperature in the hottest months 38.3 C/100.9 F) Dr. Stéphane Besançon directs Santé Diabète, a French NGO founded to address the lack of access to diabetes care in Africa. Dr. Besançon explained that people in Mali commonly use clay pots to store food and water and so it was natural to start using them to store insulin and other medications. They’ve become an important part of caring for diabetes in Mali, especially outside the city. The devices he contributed to the LFAC study were simply bought at the market in Bamako.

In Port-au-Prince, Haiti (average daily maximum temperature in the hottest months 35.0 C/95 F), Dr. Nancy Larco directs the Fondation Haïtienne de Diabète et de Maladies Cardio-Vasculaires (FHADIMAC), the only organization dedicated to diabetes and cardiovascular disease in Haiti. Though refrigerators are not uncommon in Haiti, the public electric utility is unreliable. As Dr. Larco put it, “You know you have electricity when you see it.” The only people who can rely on refrigerators to cool their insulin are people who can afford generators or solar panels. And the propane-powered refrigerators run by the Ministry of Health are reserved for vaccines, which also require cool temperatures to remain effective.

When Dr. Larco noticed many people using clay pots to cool water, she had an idea. Dr. Larco partnered with a manufacturer to produce small pots made from Haitian clay which she distributes to FHADIMAC patients. She contributed one of these pots to the LFAC study. Her patients add water to the pot every two or three days and have found them to be very effective. The pots even say insuline on them. She calls them, in Creole, krish pour l’insuline.

I asked my friend Jon what he thought of all this. “You can only understand the need for clay pot cooling in a site of extreme poverty,” he said, “It’s great that these things exist. And it’s great that they can be accessible, but it begs a deeper question, which is why are things so risky and difficult at these margins that people are forced into innovating in these ways?”

The International Diabetes Federation estimates there will be an additional 200 million people living with diabetes by 2045, raising the total to more than 600 million. Four out of five of them will live in low- and middle-income countries where issues around access to diabetes supplies and refrigeration are likely to persist. And what happens as the world gets hotter?

Writing on science/environment/misc. North East South West Twitter: @jamesNESW

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