A Tale of Two Cities

The form and composition of cities – their size, density, diversity and complexity – provide tremendous opportunity for understanding the drivers behind type 2 diabetes, thus making cities a focal point for developing interventions that can break the rising curve of diabetes. Getting to these solutions requires an understanding of how societal factors and individual behaviour associated with urban living influence an individual’s risk of developing type 2 diabetes.

In November 2015, the partners behind the Cities Changing Diabetes programme, including University College London, Steno Diabetes Center, city partners and Novo Nordisk, completed a yearlong assessment in the programme’s five study cities. Anthropologists and public health researchers took to the streets in Copenhagen, Houston, Tianjin, Shanghai and Mexico City to begin uncovering the social factors and cultural determinants that make some people more vulnerable to the development of type 2 diabetes.

Going forward, the insights gained from the Cities Changing Diabetes research will guide the development of local actions to tackle the diabetes epidemic in cities. Prompted by the findings, Novo Nordisk has pledged to invest 20 million USD of expert resource and research funds by 2020. In 2016, Vancouver and Johannesburg will become the next cities to join the programme and contribute to the international pool of evidence.

Here are a few of the field notes from two of the cities located in opposite sides of the world, showing that whether living in Shanghai or Mexico City, availability of healthy food options, access to healthcare services and the financial burden of type 2 diabetes are impacting the lives of urban citizens.

DESTINATION SHANGHAI  - MEET LIU

Liu is a well-groomed 70-year-old man. He is retired and lives together with his wife and son, who has returned from studying abroad.

Diabetes has cost Liu his left foot. His foot was amputated 30 years ago after a small wound on his toe developed into a large ulcer – this is a common complication of diabetes. He is now confined to a wheelchair as a result of his disability. This experience has left him disappointed with the medical system available to people like himself. He has suffered a lot as a consequence of diabetes, but this does not stop him from engaging in medical care and looking after his health.

Consequently, Liu is keen to prevent and control any diabetes-related complications, and keeps himself informed about what challenges can arise as well as how he can treat or avoid them. He believes that diabetes is caused by lack of exercise or by dietary habits such as eating fried foods or consuming excessive sugar. Furthermore, he holds the view that a big risk factor for developing diabetes is genetic predisposition.

Although he and his wife each receive 2,500 Chinese yuan (just below 400 USD) a month from their pensions, this is not enough to meet their needs. So to support his family’s needs, Liu sells newspapers, cigarettes and soft drinks on the streets in his neighbourhood. “My son has returned from studying abroad and doesn’t have a job as yet, so I have to earn money.” Fortunately for Liu, he has the support of many of his neighbours, who keep in regular contact with him and help Liu carry things up and down the stairs at his home.

DESTINATION MEXICO CITY - MEET IZTAC

Iztac is a 44-year-old woman from the borough of Iztacalco in Mexico City. She has two sons and two grandsons, and they all live in a simple building near a main street with heavy car and foot traffic. On one corner of her street is a primary school, and there is a metro station nearby. Along the street are the customary roadside food stalls selling quesadillas and tacos.

Since she was seven years old, Iztac has been blind in her left eye, and her right eye only has 15% visibility. This makes it hard for her to read and write. Her type 2 diabetes, which was diagnosed 10 years ago, has led to and exacerbated her vision loss. Iztac sees diabetes as just ‘another disease that you get’, because since childhood she has been ‘living with disease’, referring to both her vision and mobility problems due to a leg injury as a result of being run over.

Even though diabetes tires her and causes pain in her feet, both of which affect her work performance, Iztac sells bottled gas door to door each day. She has had episodes where her blood sugar level has dropped during her workday and she has had to be given medical attention, meaning that she was unable to continue working. When she has only a little money available, she buys a chocolate bar and a soft drink to raise her blood sugar level and carry on working.

Her current situation means she cannot maintain a healthy diet due to lack of time and money, even though she knows it is important for those with diabetes. In general, Iztac feels that her diabetes is a consequence of living with stress due to family and working problems, a fact that she believes is inherent in the city and its dynamics. Her view is that labour exploitation, noise, hurry and widespread insecurity also lead to stress and later cause health issues. Mexico City is a setting ‘that makes you ill’, according to Iztac.

“You can give me a nice talk about nutrition, but no, … I won’t be able to stick to it … Partly for economic reasons, partly because sometimes you just pick something up from the street vendors … In my case, because I’m diabetic, it’s bad for me not to eat, and so sometimes I just have tripe tacos and coke … With that, I can go all day.”

The name given to each case is fictitious in the interest of anonymity.

For more information, see http://www.theguardian.com/cities-changing-diabetes-partner-zone/2015/nov/24/study-of-urban-diabetes-international-perspectives  and https://www.youtube.com/user/citiesdiabetes