Key message 2: diabetes and its consequences are costly to patients and economies We estimate that, in 2015, the overall cost of diabetes in sub-Saharan Africa was US$19•45 billion or 1•2% of cumulative gross domestic product (GDP). Around $10•81 billion (55•6%) of this cost arose from direct costs, which included expenditure on diabetes treatment (eg, medication, hospital stays, and treatment of complications), with out-of-pocket expenditure likely to exceed 50% of the overall health expenditure in many countries. We estimate that the total cost will increase to between $35•33 billion (1•1% of GDP) and $59•32 billion (1•8% of GDP) by 2030. Putting in place systems to prevent, detect, and manage hyperglycaemia and its consequences is therefore warranted from a health economics perspective. Key message 3: health systems in countries in sub-Saharan Africa are unable to cope with the current burden of diabetes and its complications By use of information from WHO Service Availability Readiness Assessment surveys and World Bank Service Delivery Indicator surveys and the local knowledge of Commissioners, we found inadequacies at all levels of the health system required to provide adequate management for diabetes and its associated risk factors and sequelae. We found inadequate availability of simple equipment for diagnosis and monitoring, a lack of sufficiently knowledgable health-care providers, insufficient availability of treatments, a dearth of locally appropriate guidelines, and few disease registries. These inadequacies result in a substantial dropoff of patients along the diabetes care cascade, with many patients going undiagnosed and with those who are diagnosed not receiving the advice and drugs they need. We also noted scarce facilities to manage the microvascular and macro vascular complications of diabetes. Additionally, despite calls for adding the care of diabetes and other cardiovascular risk factors onto existing infectious disease programmes (such as those for HIV), we found little evidence that such combined programmes are successful at improving outcomes.

Patients with heart failure and preserved ejection fraction (HFpEF) have a high burden of symptoms and functional limitations, and have a poor quality of life. By targeting cardiometabolic abmormalities, sodium glucose cotransporter 2 (SGLT2) inhibitors may improve these impairments. In this multicenter, randomized trial of patients with HFpEF (NCT03030235), we evaluated whether the SGLT2 inhibitor dapagliflozin improves the primary endpoint of Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CS), a measure of heart failure-related health status, at 12 weeks after treatment initiation. Secondary endpoints included the 6-minute walk test (6MWT), KCCQ Overall Summary Score (KCCQ-OS), clinically meaningful changes in KCCQ-CS and -OS, and changes in weight, natriuretic peptides, glycated hemoglobin and systolic blood pressure. In total, 324 patients were randomized to dapagliflozin or placebo. Dapagliflozin improved KCCQ-CS (effect size, 5.8 points (95% confidence interval (CI) 2.3–9.2, P = 0.001), meeting the predefined primary endpoint, due to improvements in both KCCQ total symptom score (KCCQ-TS) (5.8 points (95% CI 2.0–9.6, P = 0.003)) and physical limitations scores (5.3 points (95% CI 0.7–10.0, P = 0.026)). Dapagliflozin also improved 6MWT (mean effect size of 20.1 m (95% CI 5.6–34.7, P = 0.007)), KCCQ-OS (4.5 points (95% CI 1.1–7.8, P = 0.009)), proportion of participants with 5-point or greater improvements in KCCQ-OS (odds ratio (OR) = 1.73 (95% CI 1.05–2.85, P = 0.03)) and reduced weight (mean effect size, 0.72 kg (95% CI 0.01–1.42, P = 0.046)). There were no significant differences in other secondary endpoints. Adverse events were similar between dapagliflozin and placebo (44 (27.2%) versus 38 (23.5%) patients, respectively). These results indicate that 12 weeks of dapagliflozin treatment significantly improved patient-reported symptoms, physical limitations and exercise function and was well tolerated in chronic HFpEF.

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The war in Tigray region of Ethiopia that started in November 2020 and is still ongoing has brought enormous damage to the health system. This analysis provides an assessment of the health system before and during the war. Evidence of damage was compiled from November 2020 to June 2021 from various reports by the interim government of Tigray, and also by international non-governmental organisations. Comparison was made with data from the prewar calendar year. Six months into the war, only 30% of hospitals, 17% of health centres, 11.5% of ambulances and none of the 712 health posts were functional. As of June 2021, the population in need of emergency food assistance in Tigray increased from less than one million to over 5.2 million. While the prewar performance of antenatal care, supervised delivery, postnatal care and children vaccination was 64%, 73%, 63% and 73%, respectively, but none of the services were likely to be delivered in the first 90 days of the war. A conservative estimate places the number of girls and women raped in the first 5 months of the war to be 10 000. These data indicate a widespread destruction of livelihoods and a collapse of the healthcare system. The use of hunger and rape as a weapon of war and the targeting of healthcare facilities are key components of the war. To avert worsening conditions, an immediate intervention is needed to deliver food and supplies and rehabilitate the healthcare delivery system and infrastructure.