"It's something that's not going to go away," said Rohin Sarin, a 17-year-old diabetic in New Delhi. His friends in their blue and brown school uniform know that Rohin always needs his special equipment. They have seen the ritual quite often. When Rohin starts feeling light-headed and dizzy, the pupil knows what to do. He removes his insulin pen from his school bag, gives himself one of four daily injections and takes a bite of an energy bar just to make sure that his blood sugar level improves.
'Growing burden on public health'
Rohin, a boy portraited by Associated Press, is by no means alone as a diabetic in India. The International Diabetes Federationestimates that 8.8% of Indians have diabetes. What sounds like a small share equals — in one of the world's most populous countries — a staggering 115 million people, some of whom don't even yet know they are affected by the illness. That makes India home to the second-largest number of adults living with diabetes worldwide, after China. The Indian Council of Medical Research (ICMR) concludes in a study called INDIAB (INdia DIABetes study): "Diabetes and other non-communicable disease risk factors like dyslipidemia, hypertension, obesity and metabolic syndrome are imposing a large and growing burden on public health."
What are the reasons? Economic growth has changed Indians' lifestyles. People eat out more often and prefer fast food such as burgers and pizzas or convenience food, instead of traditional vegetable meals. When Burger King opened its first Indian outlet in New Delhi, people queued outside. The changes have also brought a rise in obesity.
The danger of instant noodles
But it is not only a problem for the wealthy people in the capital. "Indians today are also much more likely to consume processed products and move less, in combination with a carbohydrate-rich diet," Sameer Valsangkar told DW. He's a doctor from the Catholic Health Association of India (CHAI), which cooperates with MISEREOR in Germany. Valsangkar argues that it's a kind of vicious circle.
"In cities, people eat fewer and fewer vegetables, fruits and grains, instead there are processed products everywhere. Take these instant noodles from Maggi — they are quick to prepare, small portions and available everywhere. And they are cheap: currently a kilo of tomatoes costs about 40 rupees (€0.51, $0.71), a packet of noodles 10 rupees. This is especially attractive for the poorer population. Many children eat the instant noodles two to three times a day," Valsangkar said.
It is a sign of a fundamental change in eating habits. "India is actually considered the land of small-scale farming," Valsangkar explained. "But in one study, we found that fewer and fewer people grow their own food in rural areas. Some had to walk around one-and-a-half hours to get to a market with fresh fruit or vegetables. Again, people prefer cheaper processed products from supermarkets."
A 'silent' disease
In general we have to distinguish between the different types of diabetes. Most of India's diabetes cases are Type 2, typically triggered when a person's weight limits their body's ability to produce or use insulin to turn food into energy. Type 1 diabetes, on the other hand, is a natural inability to produce insulin.
One of the challanges that doctors face: Many people remain undiagnosed. The IDF experts estimate that more than half of the people with diabetes in Asia do not know about it yet. Undiagnosed and untreated, diabetes can become life-threatening — the illness is already among the top 10 of death causes in India and Bangladesh.
"Diabetes is a 'silent' disease, typical symptoms like thirst or fatigue are not obvious," Valsangkar said. "In other countries, every citizen over 40 is regularly tested for diabetes — not in India. Our health care system is totally overburdened, there is not enough medical equipment or medicines to test people or to treat them in the long term. In many cases, the disease remains unrecognized or untreated. Sooner or later, they go blind, lose their limbs or get kidney disease."
Bangladesh — the worst example
India is not alone — neighboring Bangladesh is witnessing a similar trend: Today, around 11 million Bangladeshis have diabetes. By 2045, that number is expected to grow by a third. Zafrullah Chowdhury, a doctor and activist in Bangladesh and a winner of the "Right Livelihood Award," blames it on "the food habits, the lack of exercise and smoking." Chowdhury told DW that in rural areas, for example, fish has become a scarcity because they have to sell it for their livelihood. And prices for food are rising. "As a result people eat more carbs. So they eat more rice, and less vegetables. At the same time, and this is the worst thing that happens, they are copying the coca colas, energy drinks, and this is a general trend and this is costly," Chowdhury said.
Zafrullah Chowdhury, well known for founding rural health care organization Gonoshasthaya Kendra in 1972, is now 77-years-old. His advanced years don't prevent him from becoming animated. "These energy drinks! Take coca cola, smoking, the lack of physical activity. They don't realize! Even for small distances they don't take a bike. Schools don't have playing grounds, our city schools don't have playing grounds. The children do not play nor do they participate in sports."
The local newspaper Dhaka Tribune reported in 2017 that the Food Safety Authority of Bangladesh (BFSA) collected and tested some random samples from several brands of energy drinks like Speed, Tiger, Power, Black Horse and Red Bull. "A large energy drink generally has 54 grams of sugar, which is equal to 13.5 teaspoons," the newspaper reported.
What needs to be done is more information and health education, Chowdhury emphazised. "Enlightenment is easy to achieve. Like a promotion of preventive care. It's not expensive. They should train the people in our villages."
Rohin's improving his habits
Rohin Sarin, the young man in New Delhi, has changed his ways since his diagnosis. He told AP that he would now go to the cricket ground most mornings. In the seven years since his diagnosis, he's learned to avoid sweets and sugary soft drinks. He's accepted the situation.