The Vulnerability Assessment shows that socioeconomic vulnerabilities are exacerbated when people cannot engage with healthcare services. Barriers to care provision include lack of resources, lack of understanding of what services entail and lack of trust in institutions and care provision.
Various insights into vulnerability for type 2 diabetes and diabetes-related complications have emerged from the research, the most important of which are highlighted below.
How individuals and communities engage with healthcare resources in Mexico City is influenced by their trust or mistrust in the quality of care, their perceived right of access to those services, and barriers to accessing them. Insufficient insurance or the absence of insurance altogether can either be a motivator to manage one’s own health to avoid a precarious situation, or a disheartening experience for those who feel theirs is a ‘helpless’ condition.
With an abundance of needs but limited resources, it is logical to prioritise certain needs over others. In the face of socioeconomic disadvantage, people in Mexico City find themselves having to make a choice between food and medication; paying the bills or paying for transport to their hospital appointment. Similarly, when confronted with more than one health concern at a given moment, people choose to focus their attention and energy on illness at the expense of other health concerns.
Gender is very relevant to the experience of illness. In a society that places the emphasis on traditional gender roles, women struggle to manage their health alongside their domestic obligations. Not wanting to be perceived as selfish, burdensome or vulnerable, women in Mexico City are prone to neglect the dietary and physical requirements necessary to care for their personal health.
Women’s perception of themselves as vulnerable to the violence of others impacts their willingness to leave the safety of their homes and thus represents a major barrier to health-seeking behaviours, such as attending informative classes or doctor’s appointments on their own, or engaging in physical exercise. On the other hand, many men still depend on the care provided by the women in their lives. If there is no one there to assist them, men in Mexico City often struggle to manage their own care.
The type of care and treatment utilised and sought after is dependent on availability of particular options and attitudes towards those options. For example, in the presence of wide-spread distrust in the quality of services offered at hospitals, people tend to seek out alternative forms of care, including homoeopathic treatments, or ask their local pharmacist for health advice.
Data from Mexico City reveals that the negative consequences and symptoms of diabetes (such as loss of sight, amputation and kidney failure) are often based on a lack of understanding of the disease. In turn, a poor understanding of the disease and its dangers is the result of barriers to access resources and information.
Conceptualised as a place of stress, exploitation, social insecurity and delinquency, Mexico City is often referred to as causative of disease. A popularly held belief is that diabetes is caused by fear and other negative emotions, such as anxiety or stress (‘susto’). The belief that diabetes is a mental issue poses a barrier to meet the physical demands necessary to prevent and manage the condition. Though many recognise the impact of stress (particularly from the urban setting) and high-sugar diets on the development and management of diabetes, few acknowledge the role of exercise. However, recognition of the importance of exercise is only one of several barriers, such as absence of safe and appropriate places to exercise and availability of time to devote to exercise.
Three cases that exemplify some of the key insights into vulnerability to type 2 diabetes and its complications are presented here.
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 glucose 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 glucose level and enable her to carry on working.
Iztac and diabetes
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 lead to stress and later cause health issues. The 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.”
Iztac’s case is interesting because her story is shared by many people living in similar conditions in Mexico City, where a woman receiving less than the monthly minimum wage is a provider for her children and her grandchildren. Despite the hardship, lack of support networks and being almost blind, this woman is as strong and self-sufficient as she can be in the circumstances.
• 50 years old
• Access to public health insurance
• Type 2 diabetes
Camilo is a 50-year-old man living in the southern part of Mexico City. The neighbourhood is characterised by people from diverse socioeconomic conditions. Numerous tortilla stands, grocery shops, tiny clothing shops, pharmacies, etc can be found on the streets. Occasionally there is also a market offering a great variety of fresh fruits, meat, tacos, pizza and quesadillas.
Camilo was diagnosed with diabetes after an episode of exhaustion. The diagnosis did not come as a surprise to him as he had had experience with diabetes before. His mother passed away due to diabetes-related complications, and three of his brothers live with the condition. At first, his diagnosis caused him depression, feeling that diabetes implied many limitations. “Once you get diagnosed with diabetes, you don’t have the same illusion of growing old. Your wishes fade away and life shortens". As a result, he delayed seeking medical support until he started experiencing a deterioration in his health. Also, realising that his seven-year-old son is dependent on him influenced his decision to seek care.
Camilo and diabetes
Camilo acknowledges that without the support of the public healthcare system, he could not afford the medical consultations and medicines associated with his diabetes. He also holds his endocrinologist in high regard as she provided him with detailed information about diabetes-related complications. Avoiding these complications has served as motivation to foster a self-care routine.
For some years, Camilo has been trying to eat salt-free and avoid soft drinks and high-fat food, and instead eat more vegetables. He has realised that Mexican society “eats to get full, not to get nutrients”, and that the mission of diabetes is to “announce that we’re eating badly”. He thinks that maybe diabetes should be understood as a painful way to rectify bad eating habits, so the next generations can adopt healthier lifestyles.
In Camilo’s opinion, the public health sector does not adequately communicate the services provided at healthcare centres, nor does it have sufficient clinics to take care of the total population who have diabetes.
Camilo’s case is interesting because Camilo has adopted an active self-care role towards his diabetes, resulting in fairly good blood glucose control. He has created a strategy to feel and live happily with the support of his nuclear family, which contrasts with their socioeconomic level. Even with a sedentary job as a taxi driver, he sticks to his eating habits and his treatment.
• 64 years old
• Access to public health services
• Type 2 diabetes
• Diabetes-related complications
Otto is a 64-year-old man who lives with his wife and children in the Álvaro Obregón area of Mexico City. His home is a single room in a building off an avenue with very heavy car traffic. There are grocery stores and food businesses on the street outside. Otto lives in a critical financial situation: all family support comes from just his monthly pension, which must cover his medical expenses, the basic needs of a family of four as well as provide for the education of his two sons.
Otto was diagnosed with diabetes 22 years ago, but at the time he did not care about the disease and “kept a life of excess”. When he noticed he was losing weight without trying, he made a medical appointment. For the past 15 years, he has been receiving regular medical treatment. His medical expenses, including medications, appointments, surgeries and hospitalisation expenditure, are covered through the Instituto Mexicano del Seguro Social (IMSS). However, the town where Otto lives is highly politicised, and he needs to belong to a political party to have access to various public services.
“I feel like I’m not going to last much longer… I feel alone, even though I’m with my wife and children.”
Otto and diabetes
In common with many in Mexico, diabetes is seen here as a result of ‘susto’ – experiencing emotions that can be described as shocking, such as fright, fear, joy and anger. Otto has been robbed several times, most of them at gunpoint, and he suffered an accident where he was in a bus that rolled over. According to him, one of these ‘scares’ caused his diabetes. He has requested help from several institutions, in the hope of receiving some kind of support, but with no success.
The main problems Otto faces regarding his health are foot complications due to diabetes, which prevent him from walking with ease and mean that he needs to use a walking frame or wheelchair to move. He has recently undergone an operation on his feet. His current medical condition means that he is confined to constant rest, as he is weak and exhausted. Poor surgery recovery could cause further health complications.
At his last medical check-up at the IMSS, staff members stole his walking frame, a situation that dealt a hard blow to his morale and finances. Otto’s greatest worry is that he may be unable to help his family due to this physical and emotional state: “I feel that I won’t last long, I feel death. I already want God to take me, but then I think of my children and don’t want them to be left alone; what will they do when I die?”
Otto’s case is interesting as Otto is receiving only a small pension, but must fulfil his traditional male role as provider for four people. His health and economic situation cause him considerable anxiety, and have led to persistent suicidal thoughts. Hypertension and complications from diabetes can worsen quickly given the precarious financial circumstances.
The Rule of Halves reveals that 13.9% of adults in Mexico City live with type 2 diabetes. Of those, 29% are not diagnosed and, thus, not aware of the condition. Of those who have been diagnosed 14% do not receive care. Among those receiving care the majority - 75% - do not achieve treatment targets.
The research additionally shows that there are significant differences in the prevalence of type 2 diabetes for different age groups. A significant percentage of the population is impacted in the prime of their working life (age 30–59). The highest prevalence is among those between the ages of 60 and 69 at 38.8%.
Furthermore, the rates of complications are high among people diagnosed with type 2 diabetes. Almost 63% of people with diagnosed diabetes report complications related to eyesight, while over 39% report neuropathy-related complications.
The research also shows that 19.8% of the adult population in Mexico City is estimated to have impaired glucose tolerance, commonly referred to as prediabetes, putting them at increased risk of developing type 2 diabetes in the near future.
Underlying the high prevalence of type 2 diabetes in Mexico City are many demographic, epidemiologic and nutritional transitions which, in turn, have led to one of the highest obesity rates in the world. The recent research shows that 74% of adults in Mexico City are overweight or have obesity (39% and 35% respectively). Among women, the prevalence of obesity is almost 40%.
The last pillar is estimated based on the general Rule of Halves due to lack of data.
The research was performed by the National Institute of Public Health of Mexico led by Dr. Simon Barquera.
Read more about the research and results in Mexico City in Urban Diabetes – Understanding the challenges and opportunities
Surveys were conducted among a representative sample of 2,500 people aged 20–69 living in the 16 delegations that constitute the Federal District of Mexico City. Information about the characteristics of housing, demography, health information, food consumption and levels of physical activity was collected along with information about anthropometry. In addition, blood samples were collected from 1,300 participants for measurements of biomarkers for diabetes and lipidaemia.
The vulnerability assessment was based on 220 individual interviews with people with type 2 diabetes performed by trained fieldworkers in people’s homes.