The isolation of insulin in 1921 and its subsequent delivery to a 14-year-old boy in a diabetic coma in Toronto in 1922 was a ground-breaking scientific and clinical achievement that has transformed diabetes care and is celebrated in this themed issue of The Lancet. But despite the altruistic sentiments of the discoverers—Banting, Best, Collip, and Macleod—that “insulin belongs to the world”, the lack of access to insulin over the past 100 years reflects an appalling policy and implementation failure.
A Review describes the scale of the problem when it comes to insulin access in low-income and middle-income countries. There is a paucity of data—fewer than half of countries in central and east Asia and western sub-Saharan Africa have the necessary policies and registries to account accurately for the numbers and needs of patients with diabetes. Globally, an estimated 76% of children with type 1 diabetes are unable to stay within the recommended glycaemic ranges, putting them at risk of life-threatening short-term and long-term complications. More than 50% of patients with type 2 diabetes are unable to receive the insulin they need. A lack of data makes knowing how these failures affect life expectancy hard to quantify. But in one longitudinal study with 20-year follow-up from Soweto, South Africa, the mortality rate for people with type 1 diabetes was 43%. Early deaths from type 1 and type 2 diabetes globally have increased by 5% since 2000, in stark contrast to premature deaths from other non-communicable diseases, which have been decreasing.
When it comes to insulin access, cost is a major barrier. Global production and supply of insulin are dominated by three companies—Novo Nordisk, Eli Lilly, and Sanofi. Despite efforts such as the WHO prequalification of insulin, which aimed to encourage more insulin manufacturers and lower costs, together with the inclusion of long-acting insulin analogues and their biosimilars on the WHO Essential Medicines List (human insulin has been on the list since 1977), insulin remains unaffordable for many people. A move this year from the WHO Essential Medicines List expert committee to create a working group on highly priced essential medicines is welcome.

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02479-X/fulltext