NIH-Rwandan Fellow Develops Cost-Effective Diabetes Test

At a very young age, Jean de Dieu Gatete, M.D., understood the importance of investing in health and health care systems. Growing up in a rural area in Rwanda where malaria was endemic, Dr. Gatete was frequently sick as a child and teenager. This affected not only his academic performance but also his ability to take his final high school exam—a major national exam that would determine whether he gained admission to the university and program of his choice, and if he would qualify for the government’s scholarship. A few days before the exam, he got sick with malaria. Fortunately for him, the school decided to pay for the only medication that, albeit expensive, worked quickly enough to enable him to take the exam. This investment paid off when he emerged as the top-scoring student in the exam, which also helped the school’s academic performance ranking.

Having experienced firsthand the high cost of health care and difficulties in health services access in Rwanda, Dr. Gatete decided to pursue a career in medicine to address the suffering of people seeking affordable, low-cost, effective health care. After graduation from the University of Rwanda Medical School, he worked as a primary health care physician in a public hospital. There, Dr. Gatete faced challenges in the health system, including limited resources, poor supply chains, and other inefficiencies that hinder delivery of quality health care to Rwandans, especially those in the rural areas.

He also realized that he should become a public health professional to fulfill his long-term desire of providing affordable and quality health care to the Rwandan people. In this arena, he would be able to make a more significant and far-reaching impact by contributing to health policies, strategies, and interventions that could positively impact the patients he saw daily in his clinic as well as communities in general.

Most of the conditions that brought patients to the hospital (such as diabetes) were treatable or even preventable if diagnosed early. Yet many patients presented late to the hospital with few to no options to address their conditions. Dr. Gatete was particularly affected by the case of a 42-year-old patient with diabetes and hypertension who presented to his clinic with end-stage renal disease. The patient needed dialysis 3 times a week, which could not be provided due to a lack of resources. As a result, the patient died. This experience, among many others, stirred Dr. Gatete’s focus on prevention, early screening, and diagnosis of diabetes and other chronic diseases.

In July 2022, as part of a joint research and learning collaborative between Partners in Health (PIH), the University of Global Health Equity (UGHE), the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), and the National Institute on Minority Health and Health Disparities (NIMHD), Dr. Gatete joined the NIH-Rwandan Health Program as the 7th program fellow. This program, funded by NIMHD, helps to build the capacity of the research workforce in Rwanda by training one physician for a year, who then returns home as a clinician scientist to apply the knowledge and skills acquired from the program to help improve the health of Rwandans.

At NIH, Dr. Gatete’s study focused on the development of an optimal, low-cost diagnostic test for diabetes in African populations under the mentorship of Anne E. Sumner, M.D., a senior scientific investigator at NIDDK.

New Frontiers in Diabetes Diagnosis in Africa

Diabetes is a chronic disease characterized by elevated blood sugar, which when untreated or over time can result in damage to the eyes, nerves, blood vessels, heart, liver, and kidneys. In 2021, 24 million adults aged 20-79 were living with diabetes in Africa, and this number is projected to increase to 55 million by 2045.

With early screening and diagnosis, diabetes can be treated, and its consequences avoided or delayed with a healthy lifestyle, medication, and regular screening and treatment for complications. However, Africa has the highest prevalence of undiagnosed diabetes in the world, estimated at 54%, indicating that most people living with diabetes are not aware that they have this condition. Dr. Gatete believes that the prevalence of undiagnosed diabetes in Africa may be even higher than this estimate, because the A1C test commonly used to diagnose diabetes in Africa has a diagnostic sensitivity that is below 50%.

Working at PIH as a clinical director in Kirehe District Hospital, Dr. Gatete directed a mass screening for diabetes and related conditions using random glucose test in over 90,000 people; however, this test was not sensitive enough to confirm diabetes in the 1,200 people suspected of having this condition. To diagnose diabetes, the confirmatory oral glucose tolerance test (OGTT) requires a patient to fast, drink glucola (a sweetened noncarbonated drink that is very high in sugar), and then have their blood sugar levels measured after 2 hours. But glucola is expensive and not available in rural clinics in Rwanda.

Under the NIH-Rwandan Health Program, Dr. Gatete explored several diagnostic strategies for diabetes in African-born, Black individuals living in the United States to find a cost-effective test that could work like the OGTT. In this study, he worked with Dr. Sumner to experiment with a beverage tolerance test using pastry sugar, which is available and affordable in Rwanda. Dr. Gatete hopes that this test (also known as the pastry sugar tolerance test) could help to increase screening and diagnosis of diabetes in Africa by reducing cost, thereby, addressing the problem of undiagnosed diabetes on the Continent.

While this diagnostic test holds great potential, Dr. Gatete plans to conduct a similar study when he returns to Rwanda to further validate this novel diagnostic diabetes test. Speaking of this, he said that “if we confirm the same results in Rwanda, it will mean then that the test becomes standard; because if you have a good result with an adequate sample size, then there is statistical evidence that the pastry sugar tolerance test works and it can be recommended for diagnosing diabetes. Although we do not have that yet, we are on a good path.” If the results from the preliminary U.S. study are confirmed in the Rwandan population, this cost-effective test would increase access and improve diabetes care, for example, through early diagnosis and treatment as well as lifestyle modification.

Dr. Gatete also advocates for a preventive health approach because it not only promotes individual health but helps to reduce the burden on under resourced health care systems in developing countries. Hence, during his fellowship year at NIH, Dr. Gatete and other researchers conducted a scoping review study on the use of lifestyle interventions alone (such as physical exercise and diet) to induce diabetes remission.

How the NIH-Rwandan Health Program Is Making Impact

Reflecting on the NIH-Rwandan Health Program, Dr. Gatete stated that in addition to building his capacity in conducting research, the program has had a positive impact on him in ways that cannot be measured: “I think one of the gains is inspiration, looking at how many people are involved in the system to find solutions to health problems; it is the inspiration that you cannot get unless you come to an ecosystem like NIH, and in that sense, this program has motivated and inspired me in a way that cannot be quantified.” He also expressed that the program has provided him with unlimited professional opportunities, such as participation in an international network of researchers, clinician scientists, and past program fellows who he hopes to continue to collaborate with when he returns to Rwanda.

NIMHD Director Eliseo J. Pérez-Stable, M.D., a strong supporter of the program, remarked that “Dr. Gatete's experience and contributions to the program reflect what the program is about—creating immersive research training and capacity building opportunities where knowledge acquired can be immediately transferred to implementation in health settings.” And in Rwanda, “the program has already produced positive outcomes as evidenced in the number of physicians that have been trained and with graduates from the program already making significant contributions in the country’s health sector,” said Paul Tomlin, MBBS, Dean of Research, Innovation and Quality at UGHE. This is precisely why the NIH-Rwandan Health Program was established in 2016—to help build a trained research workforce in Rwanda to improve population health, a goal that supports the NIMHD mission.

Page updated August 21, 2023