Thank you.
I would like to thank the honourable members of this committee for inviting me to share my personal experiences and perspective.
I practised for 20 years as a registered dietician, a certified diabetes educator, and now a diabetes case manager in rural New Brunswick. I'm embedded within the offices of 17 community family doctors and nurse practitioners in the Upper River Valley, in my area.
We know that for those who receive diabetes education, diabetes outcomes improve and their complication risk lowers. Many people, for many reasons, do not access the education they need. Access to care should be at the right time and arguably the right place. I would like to share comments made to me by a patient named Anthony: “I prefer to come to my doctor's office. No one knows why I am here. I am just here to see my doctor, just like everyone else. No one judges me.”
Making diabetes education accessible in family doctors' offices is the basis of our diabetes case management program in New Brunswick. It was developed out of a gap analysis that people were not accessing diabetes education at diabetes education centres, so we made it accessible in the family practice office. Our Diabetes Canada clinical practice guidelines and our own New Brunswick diabetes strategy have recommended this model of care. It's known to be as effective in meeting diabetes targets as attending education centres is. Diabetes educators, no matter where they are, make a difference.
About 80% of diabetes care is done within the family practice or family doctors' offices. Almost half are not meeting any of the targets we've set out in our clinical practice guidelines. Family doctors, as you know, are overwhelmed, not only with diabetes but with everything else they have to deal with in their practice. As a case manager, I am their specialist resource right in their office, and I can help them provide a collaborative model of care for the patient, the family, the physician, as well as a learning tool and making timely changes to patients' care.
We have significant and growing evidence that current diabetes therapies can keep people healthy and save lives. Unfortunately, many people live with untreated or inappropriately treated diabetes. They ration or don't take their medications, their insulin; they don't test their sugar; and they reuse their insulin pen needles.
I'm going to share another story with you. Helen is a senior and she has our New Brunswick seniors medical plan. She has type 2 diabetes. She is on insulin and metformin, and she had a heart attack about four years ago. Because she is already on insulin, I cannot help her get a medication with evidence of cardiovascular risk reduction, which may prevent her from having another heart attack, improve her blood sugar and lower her risk of hypoglycemia as well as weight gain. Adding these medications is recommended by our clinical practice guidelines, but our government has chosen not to abide by those guidelines as recommended, or even use the product monographs, which are evidence-based as well. If she had a private plan, we would not be having that conversation.
Standard diabetes care is accessible in New Brunswick, but it's not available to everyone. For diabetes foot care, you have to have coverage or you have to be on income assistance to equitably access it, and cost is a barrier. Many people have to pay up front for their supplies, their insulin and their medications before they are able to access coverage. This is a barrier. I will tell you that many people say—and I hear it every day— that they haven't picked up their medications yet because they have to pay up front and they have to wait for money to do it. Credit cards are not an answer.
Mental wellness specialists have long wait times, and diabetes eye exams, which can help reduce the risk of retinopathy through screening, are not always accessible. Family practice eye doctors certainly are accessible; however, you have to pay for the diabetes eye exam there. If you go to a specialist, it is free, but you have to wait for that. Who can wait?
Fear of hypoglycemia can affect life, and I think Victor outlined that very well. It can be a barrier to your own productivity. I'm not sure if any of the members here have ever had low blood sugar, but I will you tell you, and I know Victor will attest to this, that you feel like crap. You don't feel productive. You are not able to do the things you need to do because you're trying to eat to fix that low. Sometimes you overeat and end up with a sugar that's three times the height it should be. You don't want to wake up your spouse at night for help, so you fall down the stairs because you've had a low.
I've also heard this stigmatizing statement: “So what if they have low blood sugar? They can eat sugar. That's great.” It's not always the most appropriate thing. There are medications and insulins that can reduce the risk of hypoglycemia but are not readily available. Devices can make a difference.
Should I have to ask people living in my area, “What medical coverage do you have?” We've created a have and have-not system of access to diabetes care, medications and insulin. It is a system that festers with discrimination against those who have not.
If they have a private plan, I can help them with more options. If they don't, I'm sorry to say that I tell people every day, “I'm sorry, your plan doesn't cover a medication that I know can help you. It will cost you $200 out of pocket in order to actually have that medication.” We have compassionate programs and samples from doctors' offices, but that's not sustainable.
I would ask you this: Why are we able to provide people suffering from drug addiction with the coverage, free syringes and paraphernalia they need to stay healthy and safe, but we can't do this for people living with diabetes?
I've told people to move out of the country or out of the province to get better coverage. Some people have done this, and I'll tell you that people who have moved to New Brunswick have said, “I'm appalled. I can't believe I had coverage for this elsewhere. I can't believe I have to pay for this insulin. I can't get what I need.”
Should I have to make people choose between picking up insulin or getting groceries? Should they have to shop pharmacies to get the best price for insulin? These are things I deal with every day. It's frustrating, as well, when I have a plan that can provide some coverage but still people are denied that coverage, not because they didn't meet the criteria set out by our government, but because the people who are advising this plan have wrongly read the forms, or they inexplicably say that this is denied when it shouldn't be.
I shouldn't have to advocate for patients. There shouldn't be this issue.
Insulin is essential for life. People living with type 1 diabetes need insulin or they will die.
I'm going to share with you another story. Jeremy lives with type 1 diabetes. Now he's 42 years old. He's a seasonal worker, so of course he had spotty coverage for anything he needed for his diabetes. Now he has retinopathy, and he has nerve damage. He's on peritoneal dialysis. Why are we paying 100% of the cost of peritoneal dialysis for this person when we could have helped him and perhaps prevented this other chronic disease that he now has to live with?
Insulin and arguably all diabetes medications are essential for life. As a diabetes educator, I stand firmly behind that. I'm going to ask you this: Would Banting, Best, Collip and Macleod have thought that their discovery would be only for the rich people of this country, those with money or drug coverage? Would they have wished Canadians not to have access to the medications, supplies and devices needed to help keep them healthy and, of course, ultimately reduce health care costs?
We need to stop failing at what we are doing. We need to create a unified strategy, so that no matter where you live, who you are or what you are doing, you have access to what you need to live well with diabetes. It's crippling our country's health care costs. Diabetes needs to be treated with urgency and promptness, just like other life-threatening diseases. Of all diseases, diabetes is treated when we screw up, when we fail and when blood sugars are uncontrollable.
Let's prevent what we know is going to happen. Let's not react.
These are my asks to you: Support access to the model of diabetes case management, so that more people can gain access to the education and care they need; close the gap between the haves and have-nots to keep people healthy and make things accessible; and support the diabetes 360 strategy from Diabetes Canada, which also outlines a national and unified strategy to improve the lives of Canadians living with diabetes.
Thank you.