Global Diabetes: Talking with the Only Endo in Bermuda

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We continue roaming the planet to bring you accounts of diabetes care in various countries for our Global Diabetes series. Today, we"re happy to share the story of Dr. Annabel Fountain, who happens to be the one and only endocrinologist in Bermuda!

She’s been practicing for many years, and has studied and practiced in places across the globe from Europe and the UK (when England was still a part of it), to New Zealand and the South Pacific. Her experience includes years of work at the British National Health Service (NHS), the largest single-payer healthcare system in the world, giving her a perspective on cost that many diabetes doctors don’t have.

Six years ago, Dr. Fountain returned to her native Bermuda to tackle diabetes in the country where she was born and raised. She is now director of endocrinology at the Bermuda Hospitals Board.

Just as negative legend surrounds the mystical Bermuda Triangle, Dr. Fountain tells us her tropical island is no paradise when it comes to life with diabetes. In fact, it has some of the scariest diabetes complications stats across the globe, and it’s often forgotten about and lumped into other parts of the world -- the U.S. and western-most part of Europe -- when it comes to diabetes services, supplies and needed treatments from companies. Some facts to know about Bermuda:

• Bermuda is an industrialized country, one with a high income level and high cost of living due to it being an international business center and offshore location. Cost of living in Bermuda is more than three times that of the US, 280% more than in Canada and 200% more than in the UK. As a result of all this, the Bermuda Diabetes Association is experiencing an increasing demand for assistance with medication costs, funding and supporting those who cannot afford to pay for their meds.

• Latest stats say that roughly 13% of the people in Bermuda have type 2 diabetes, or roughly 6,700 or more PWDs. Less than 200 are living with T1, according to Dr. Fountain.

• Bermuda Hospital opened a new wing with 90 beds for care of people with acute illnesses, and those 90 beds are consistently occupied 25-40% by people who have diabetes as one of their diagnoses.

• Diabetes complications are rampant. Bermuda has the highest rate of non-traumatic amputations in the top 30 countries worldwide. Rate of blindness is 4.6%, or 10 times the rate in other first world countries like the U.S. that has .4% and Europe with .3%.

• Of a population of 60,000+ residents, more than 150 people are living with end-stage renal disease, on dialysis (higher rate than the United States). There are many different causes of end-stage renal disease, but of those requiring dialysis approximately 50% have diabetes.

“I honestly don’t remember local people being very overweight when I was little,” Dr. Fountain says. “We used to comment on tourists from overseas who were often obese! Now, 74% of the adult population of Bermuda is overweight or obese and the prevalence of type 2 diabetes is extremely high here."

Yikes, those are some scary stats! But thankfully, there’s an endo like Dr. Fountain doing what she can to make a difference. We had a chance to meet in person a few years ago at the American Diabetes Association’s Scientific Sessions, and had a fascinating chat about diabetes in Bermuda and how access to education and supplies are so limited. We learned even more in a recent interview with her.

Becoming Bermuda’s Only Endocrinologist

Born in Bermuda in 1975, Dr. Fountain tells us she left at age 11 and attended boarding school in England. That’s where she stayed for many years, eventually studying medicine in London during most of the 90s and turning her attention to endocrinology and working in London and even for the National Health Services (NHS) for a number of years. She found her way at one point to the Solomon Islands in the South Pacific, and that’s where diabetes made a lasting impression that would forever change her professional path.

“While I was there, I met a teenage girl with type 1 diabetes. She did not have insulin and had been using tree bark to treat her symptoms, which was not working. I’m sure that she has long since died," the doctor says.

During medical school and post-grad studies, she regularly returned home and kept in touch with the Bermuda Diabetes Association, and the emerging diabetes happenings in her country made it even more appealing – the country was one of the international sites for the DREAM trial looking at two D-drugs, Avandia and Vasotec, and Dr. Fountain says the growing problem of type 2 diabetes there “showed me that my fascination with endocrinology was ideal for me to specialize in, as I planned to return to Bermuda to work.”

In 2010, she returned home and joined the Bermuda Hospitals Board, which is Bermuda’s second largest employer and is a “quango” hospital, meaning it has semi-government control. She was, and continues to be, the only endo there -- although her department now also includes two diabetes nurses and a dietician who are Certified Diabetes Educators. They see about 10% of the people diagnosed with diabetes in the country — wow!

That number actually reflects one of the very issues that Dr. Fountain faces in diabetes practice, one that deeply penetrates Bermuda and serves to make D-management even more difficult.

Poor Education, Low Expectations

Often, the PWDs that come to her practice are referred for education due to poorly-managed diabetes, rather than for initial diagnosis. Most diabetes care is carried out in the local community, she explains, and since there are no electronic records there, Bermuda has little oversight of healthcare practitioners collecting data, enforcing adherence to guidelines or measuring impact of interventions.

According to Dr. Fountain, one of the biggest challenges she sees as a physician is the low health expectations much of the Bermuda population has.

“Educating individuals about the power they have about their health works for many but others can’t get past that,” she says. “For generations, their relatives have gone blind, suffered amputations or required dialysis. These individuals feel that these developments are a result of diabetes, and do not concede that they can prevent them with controlled glucose levels. As diabetes is so common, individuals often blame their genetics for developing diabetes, and do not understand that developing diabetes 3-5 decades younger than their parents and grandparents is more likely environmental, and due to lifestyle and obesity, than their genetic predisposition.”

"Double-Dipping" on Diabetes Medications

Dr. Fountain says her time in Europe showed how health insurance could and should work, as did her brief time in New Zealand -- as both have universal health coverage. Insulin is free in the UK, along with screenings for diabetes eye disease. If you’re pregnant with any form of diabetes, you have access to a team of medical professional as a matter of policy.

“I never had to worry about whether a patient could afford to see a doctor and medications are free with a nominal charge for dispensing,” she says about the UK and New Zealand. “Although of course there is still the issue of people not always taking the medications they’re prescribed, they never need to worry about cost.”

Unfortunately, Bermuda has an insurance-based model styled much like the U.S.

Interestingly, Dr. Fountain says an advantage that Bermuda has compared to other parts of the world is that they can basically double-dip, between the U.S. and UK in the context of diabetes medications and supplies. It’s considered a “UK Dependent Territory,” meaning they can use medications approved in either the U.S., Canada or Europe and don’t have to wait for the FDA to approve! They can also source medications from any of those jurisdictions, and the Bermuda Diabetes Association shops around to get better prices.

Recently, they’ve been working with the Pan-American Health Organization to obtain HIV medications at much lower prices -- sometimes 100 times less! Dr. Fountain says they hope to start sourcing meds for diabetes and heart disease soon, too.

“Because we can get supplies from several different sources, it is rare that we have a shortage unless there is an international problem with supply,” she says.

Small Country, Big Challenges

In the same breath, she says being isolated geographically and logistically is difficult.

With such a small population, Pharma companies are not as interested in supporting patients in Bermuda with non-pharma programs. Those diabetes device, supply and Pharma companies aren’t as willing to work with insurance companies to help cover what Bermuda-based PWDs need, which is a huge problem since that’s how the healthcare system is set up. Without a U.S. zip code, patients often can’t access online forums and educational resources they need. And if there is a shortage of medication worldwide, Bermuda will likely be the first dropped.

Oh, and then there’s the natural disasters and weather woes that regularly present issues for Bermuda, such as hurricanes that often bring power cuts -- not ideal for PWDs using insulin that needs cold storage!

“So Bermuda has a lot of challenges,” Dr. Fountain says. “Hopefully when I retire (in about 25 years!) our diabetes stats will look better.”

We hope so too! Thanks for sharing, Dr. Fountain.

Disclaimer: Content created by the Diabetes Mine team. For more details click here.

Disclaimer

This content is created for Diabetes Mine, a consumer health blog focused on the diabetes community. The content is not medically reviewed and doesn"t adhere to Healthline"s editorial guidelines. For more information about Healthline"s partnership with Diabetes Mine, please click here.

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