QUOTE OF THE WEEK
"If men were angels, no government would be necessary. If angels were to govern men, neither external nor internal controls on government 
would be necessary"
-- James Madison

Prof Zimmet, IDI and the Genetics of Diabetes in Mauritius 

-- Satya Ratnam

Professor Paul Zimmet AO MD PhD FRACP FRCP FTSE is the person who can be said to have put Mauritius on the world map of diabetes and the non-communicable diseases (NCDs). He is the Founder-Director of the world-renowned International Diabetes Institute(IDI) in Melbourne, Australia. He first came to Mauritius in 1982, invited as a World Health Organisation (WHO) consultant by the Ministry of Health which was concerned about the apparent high rate of diabetes. Following a second similar visit in 1986, a recommendation for an NCD survey was enthusiastically agreed upon by the then Minister of Health Hon Jugdish Goburdhun (probably the best Minister of Health since 1982).

It was carried out in 1987, and this led to the surveys of 1992, 1998 and 2004. The last survey was done without the benefit of the expertise available for the first three surveys, under the umbrella of WHO and three of its Collaborating Centres. Leading the project was the IDI which helped to plan the survey, train the staff, and finance and execute the survey. Prof Zimmet arranged for the participation of the two other Collaborating Centres, namely Newcastle-upon-Tyne UK (Prof Sir George Alberti) and the National Public Health Institute of Finland (Prof Jaako Tuomilehto). Profs Alberti and Tuomilehto were inducted in as international advisors, but they also supplied staff and resources. On the Mauritian side at the MOH, their collaborators were Drs Gareeboo, Tulsidas and Chitson, and the teams had the full support of Drs Mohith and Purran as Chief Medical Officers.

At the beginning of last year, during a private visit here, Prof Zimmet paid a courtesy call to Prime Minister Dr Navin Ramgoolam. He also signed a Memorandum of Understanding with the MOH, in the presence of the Australian High Commissioner. Under this MOU, IDI immediately released 30,000 Australian dollars for the Mauritius Disease Surveillance Survey. The results of this survey were presented and validated in January this year, in workshops run by two experts of the IDI: epidemiologist Dr Diana Magliano, and epidemiologist-cardiologist Prof Stefan Sonenberg from Sweden. Prof Zimmet and Prof Sir George Alberti happened to be here with their families on a private visit, but took time off to participate in these activities.  After all, they had been the ‘fathers’ of the previous surveys and been part of the Mauritian scene for over two decades, and it was but natural that they should show their interest. During this visit, they also met with the Minister of Health and the Senior Chief Executive.

The involvement of Prof Zimmet with the NCDs, in particular Type 2 Diabetes, took a significant turn after the 1998 survey. The unique ethnic and demographic profile of Mauritius, with its high prevalence of diabetes and given the amount of data available from the surveys, made it an ideal setting to study the genetics of diabetes. Thus was born the Mauritius Genetics Research Project 1999, organised by IDI in collaboration with the SSR Centre for Medical Studies and Research (University of Mauritius) and MOH, and funded by Autogen, Australia. 

The objective was to identify the candidate genes for Type 2 diabetes, obesity and related afflictions of the Metabolic Syndrome in Mauritius, the sample population being 1000 patients from the NCD survey 1998. All participants were individually informed about all aspects of the survey and their consent obtained by due process, according to an MOU and a Research Agreement signed between IDI and MOH on October 10, 1998. The Project Protocol was approved by the Ethics Committee of the UOM held on September 29, 1999 in the office and under the chairmanship of Mr Andre Robert, Solicitor Emeritus.

The Project was overseen by Dr J Jowett of IDI, Dr R Kotea  and Prof MG Deo of the SSR Centre, and Dr P Chitson of  MOH. The blood samples taken from the patients were kept at the SSR Centre, and a proportion of them was sent to IDI to be analysed for DNA Extractions and Genotyping, as no such facilities exist in Mauritius. For the latter, an external genotyping contractor, the Australian Genome Research Facility-ARGF (which subsequently became Autogen-Chemgenex) was engaged because of its high degree of expertise, automation facilities and reasonable cost.

Because of a change in policy when the new government was elected in 2000, the analysis of the samples was stopped. The change was the result of some misperceptions about the methodology and financial aspects of the Project, and these were entirely cleared following an enquiry commissioned by the then Minister of Health Ashock Jugnauth, who had a thoroughly professional approach in the fulfillment of his mandate and was a pleasure to work with, according to several high cadres who were associated with him. These misunderstandings resurfaced prior to the January 2008 visit of Profs Zimmet and Alberti, but were again clarified when they met the SCE in the presence of PS Oozeer, the CMO, and PMO Dr Pauvaday after their meeting with the Hon Minister. They handed over both to the Minister and the SCE a complete set of the documents in relation to the Project.

The samples at IDI are awaiting a renewal of the agreement before further analysis; as far as the samples at the SSR Centre is concerned, there probably has been some deterioration because the storage facilities at UOM are not as sophisticated as at IDI. The Research Agreement covers all aspects such as product commercialization, ownership of intellectual property, confidentiality, publication, etc. Once the green light is obtained, Mauritius can be poised to become a leading laboratory for research into the genetics of diabetes, with all the fallouts that this can generate. This may well propel it into a more positive limelight than the negative one currently associated with high prevalence of NCDs, the control of which seems to be stagnating for some time now. It would appear that a lack of genuine leadership and a skewed strategic orientation is responsible for this stagnation.

Mauritians must be grateful to Prof Zimmet in particular, but also to Prof Sir George Alberti and Prof Tuomilehto, true giants in their fields who have helped Mauritius to become internationally known on the medical front. The next step, a resumption of fundamental research into the genetics of diabetes, is squarely in line with the official policy of turning the country into a medical hub. Just as Prof Zimmet and Prof Paul Lefebvre personally pushed the case of Mauritius to secure funds from the World Diabetes Federation on the strength of the work done during the previous NCD surveys, IDI will undoubtedly again help to mobilize both grants and resources for such research, as it has so successfully done in the past. For this to happen, a proper local structure is required, like, for example the National  Public Health Institute of Finland, or the National Public Health Institute of  Mexico founded by Dr Julio Frenk who has recently been appointed Dean of the Harvard School of Public Health. But first, Mauritius has got some cleaning up to do.

Satya Ratnam