"Our wards are always full of diabetes cases. Sometimes our surgical wards wouldn't be able to deal with the non-emergency cases because there's all this diabetes surgery to do," says Hawea.

Hawea, a leading non-communicable disease specialist in Fiji, says these figures would be common in major hospitals around the country, which has one of the highest rates of type 2 diabetes in the world.

Surgeons in the Pacific nation describe the amputations they are forced to perform as a "dirty business".

"It became so common and so unattractive I started not feeling anything about the work. I guess that's when I started to have a problem with this way of dealing with diabetes."

While in many countries, diabetes is detected early and can be managed through diet, exercise and medication, in Fiji, the disease is often not caught until amputation, or even death, are imminent.

‘I ate everything and drank everything.'

For Wilisoni Lagi Vuatalevu, this was the reality. Within a month of retiring at 55 years old from his clerical job, Vuatalevu was facing the amputation of one of his legs.

He should have been able to retire to his village where days are spent fishing and foraging for food from organic sources. Most Fijians start and end their active lives this way.

Instead, two years after finishing work, Wilisoni faces the prospect of sitting out the rest of his life in a wheelchair in his home at Delainavesi just outside the capital city, Suva.

"Two years before I retired, I noted a boil on my leg that wouldn't heal. When I had it checked out at the health centre, they did tests but didn't say it was diabetes. They said my blood sugar was fine."

Wilisoni admits he was not too motivated to investigate the wound further and soldiered on for more than a year with the wound. One month after he retired, the pain was unbearable and bled profusely.

"When they checked, the doctor was very kind and pleasant as she told me it was clearly ‘that sugar disease' and told me I'd lose that leg... I was frightened," Wilisoni said.

After an emotional conversation with wife Kelera during which they imagined and planned for a future without a leg, he reluctantly agreed to the surgery.

"We have been looking after each other all our marriage, why should this be different? I told him, I will look after you even if you lose both legs," Kelera said.

Like most indigenous Fijians, Vuatalevu's life story began in an idyllic island village - on Vanuabalavu in the Lau Group, the province bordering Fiji and Tonga. It is far from Suva and far also from processed foods, savoury treats and sugary delights which many Pacific Islanders have turned to in place of their usual diet.

"I was never fat, I'm quite tall so I've always had a good body when I was growing up," Vuatalevu said.

"But I ate everything and drank everything, I didn't really choose food that was good for me or even thought about what was good for me and what wasn't. I didn't have to. Whatever was available and came my way, I ate. It was the same with alcohol."

A call for change

Vuatalevu is far from alone. According to the Fiji government's department of health, 30% of the country's population has diabetes.

And the Pacific, more broadly, is devastatingly over-represented in its proportion of people with the disease. Ten Pacific countries are in the top 20 countries for rates of diabetes, led by the Marshall Islands, Kiribati, and Tuvalu.

The International Diabetes Federation says around 87,000 adult Fijians have diabetes - about 15% of the population - but estimates another 46,000 have the disease undiagnosed.

Diabetes-related amputations accounted for 40% of all hospital operations in the country in 2019, the professor of surgery at Fiji's National University told RNZ.

The top three causes of deaths in Fiji are diabetes, heart disease and stroke. Continue reading

In his early twenties Ben Tawhai was a 120kg lock, playing senior rugby for Otago.

In his mid-50s he's hooked up to a dialysis machine five hours a day, three times a week. "It's pretty hard," he says. "I watched my dad go through this too. I always said to myself I don't want to be in this position but it's too late."

Now his two adult children are watching him. "They have come in here a couple of times. They don't like to see me like this."

Plugged into the dialysis machine next to him is another Maori man, a little younger. His left leg has been amputated below the knee.

This is what end-stage renal failure looks like, explains Dr Brandon Orr-Walker, an endocrinologist at Middlemore Hospital, which has the largest dialysis service in Australasia.

The ravages of diabetes have killed off most of the kidney function and the dialysis machine has to do the work, removing waste from the body.

The faces in this room are all brown.

Maori have double the rates of diabetes, five times the rates of renal failure and three times the number of lower limb amputations compared to non-Maori.

"If type 2 diabetes was a city, it would be Hamilton," Orr-Walker says, as we head off to meet more of his patients.

"It would be our fourth biggest city. It's 240,000 people."

Yet Orr-Walker, who is also president of the Society for the Study of Diabetes, says New Zealand's access to type 2 diabetes medicines is atrocious: "We're working with a pharmaceutical kete which looks like the same one that you would use in a third world country. But the moment you slip into kidney failure, you will have first world provision of dialysis services."

Even our drug-buying agency Pharmac admits the insulin it funds isn't the ideal drug for type 2 diabetes. So, why, when we have a Hamilton-sized diabetes problem, don't we have better medication?

New Zealand's first-line type 2 diabetes medicine is Metformin. It works, Orr-Walker says, but it's been around since the 1970s and it's "dirt cheap", costing about 5c per tablet.

Many developed countries have been publicly funding three new classes of drugs to treat type 2 diabetes for the past five to 10 years.

The first class are gliptins, the second class are the GLP-1 agonists and the third class are flozins.

These drugs might sound like droids from a sci-fi movie, but actually help manage blood sugar control with less risk of hypoglycemia and weight gain than insulin. Orr-Walker calls them "game changers".

Pharmac has repeatedly turned down applications to fund these drugs.

It funded one of them in 2004, but it was another 14 years until it funded another.

The way Pharmac went about funding the latter drug, last year, left Orr-Walker asking whether Pharmac was more about commerce than health and science.

The drug it funded was Vildagliptin, and it funded it because of a key tool in Pharmac's commercial negotiating playbook, known as bundling.

Bundling, to use a blunt analogy, is the equivalent of buying a frying pan and a rice cooker and getting cheap steak knives thrown in for next to nothing.

Pharmac might cut a deal with a drug company for some medicines it really wants - and the drug company will throw in a couple of medicines Pharmac isn't so interested in as part of the bargain. Continue reading

• Guyon Espiner is a New Zealand print and television journalist.
• Image: Stuff