In the rainbows-and-unicorns world of diabetes activism, it is often said that one of the most egregious oversights in international politics is the lack of available medical insulin in economically-depressed areas and emerging nations. Our standard-bearers act as if all we need to do is ship tons of strips, gallons of insulin, and forests-worth of needles to the middle of the African bush and every person with diabetes will live forever in the world of Blood Sugar Nirvana and No Complications.

The truth of the matter is much more complex.

Back in college, I audited a course that tied together energy production, energy policy, and the effects of free (or inexpensive) electricity upon society. In one of the first lecture sessions, the professor asked us what was the greatest medical invention of the 20th century. We answered with the usual litany of heart-lung machines, EEGs, antibiotics, vaccinations, and so on. We were all wrong.

The greatest medical invention of the 20th century wasn't designed specifically for medical use. The greatest medical invention of the 20th century was...

The electric refrigerator.

Refrigeration allows doctors and medical researchers to keep medicines, vaccines, and medical supplies stable; it allows them to store blood for transfusions, and organs for transplant. It allows researchers new and different ways of looking at compounds and pathogens; it allows doctors to perform longer-duration surgeries than might otherwise be possible.

The refrigerator is where most folk in the US store their insulin.

The tropical environments where much of our underserved population lives are areas in which electricity is often a luxury, provided by portable generators and cellphone batteries. There is little capacity for the refrigeration necessary to store insulin and test strips so they do not spoil before they can be used. While styrofoam and Frio packs can keep these lifesaving items in a stable temperature range for a couple of days, the road system -- or lack thereof -- means it may take longer than that for insulin to get from the nearest electrically-networked city to the remote village where it is needed. This is one reason why some of the people profiled in the International Diabetes Federation's Life for a Child video have to walk for hours to get their daily insulin.

Some years ago, dLifeTV did a segment that included childhood diabetes in South Africa. They focused on a residence facility for youngsters -- mostly boys -- with type 1 diabetes. Though it may be one of the two major reasons for allowing -- or requiring -- people with diabetes to live on, or close to, a clinic, access to secure refrigeration was the "side" issue.

The main issue was -- and is -- poverty.

Insulin, like any other medication, is a good. It can be consumed. Because it has to be produced before it can be consumed, it has a cost. Anything that has a cost has an associated value, and can be traded for that value.

Where a parent cannot sufficiently feed his children, food has a higher priority than medicine; therefore, even if it were proviede free of charge, the medicine -- or at least as much of it as will not kill the "cash cow" that is a child's chronic illness -- will be sold (on the black market) in exchange for food. We know that this sort of behavior will occur, because it has shown up (in the 1970s) when we have provided food aid to starving people in Haiti, and the high-ticket foods we provided ended up in the elite markets. While government corruption was the initial suspect, investigation showed that the recipients of meat and sugar traded them for the less-expensive beans, rice, and flour that could be acquired in greater quantities.

In short, the market will prevail.

The market means that as long as insulin has value, those looking to make "an easy killing" (pun intended where political, tribal, and racial violence prevail) will continue to attack doctors, clinics, and medical couriers to take their supplies, and resource-strapped families will trade it for food. The higher its value, the more difficult it will be to deliver insulin to those who really need it, in the quantities they require -- but even a low trade value may encourage the truly indigent to trade it away when necessities such as food are concerned.

In these areas, requiring those who need insulin to come to a clinic -- and to require the shot to be administered at the clinic, by a registered clinician (who is sufficiently compensated as to be unswerved by bribery and sufficiently protected as to be unswayed by violence and extortion), may be the only way to be moderately certain that a given person with diabetes receives any insulin, or any diagnostic testing, at all.

Of course, adding that level of service only hikes up the cost of delivering insulin to the area.

Eliminating poverty and improving logistics are the only way we can even begin to defuse violence and begin to reliably deliver insulin (and other medicines) to those who are dying without it.