International

Diabetes in : overcoming the problems of care delivery Val Brown, Shitaye Alemu and Peter Watkins

Article points Introduction Most Ethiopians Ethiopia is a mountainous country with poor roads linking the main 1(85%) are farmers centres. Most Ethiopians are farmers and live in remote, inaccessible living in remote rural villages. Diabetes mellitus is not rare in Ethiopia: figures suggest that 75% areas. of rural patients may have type 1 diabetes. Yet until very recently, insulin and oral hypoglycaemic drugs were not available from the rural health Both type 1 and centres. A diabetes project, started in 1993, with the aim of establishing 2type 2 diabetes mellitus are not rare. a system of delivering diabetes care from the rural health centres, is now well established at . It hopes to extend the scheme to other areas Rural diabetic and thereby improve the quality of diabetic control, and hence the quality 3patients often have of life, for many more rural diabetics in Ethiopia. to travel 20–200 km to obtain treatment. thiopia is a mountainous and universities, are at in the south of Oral hypoglycaemic beautiful country whose capital, the country and Gondar in the north. 4agents and insulin , is about 8,000 feet The staff and teachers of these two are normally available E medical schools in small regional towns, above sea level. Most of the people (85%) only in the pharmacies are farmers and live in tukuls (circular both of which we have visited, have a strong of town hospitals. huts) clustered in villages which are often commitment to their medical students who, remote and inaccessible. Unsurfaced roads though lacking in some of the basic sciences, A new project aims are clinically well trained, dedicated men 5to take treatment out link the main centres, but many places can to rural health centres. be reached only by footpaths. Transport is (and very few women). either by bus and taxi, which is relatively expensive, or by mule and foot, which is Training of nurses Key words laborious and slow. Nursing, too, was dominated by men, l Ethiopia The growing tourist industry is now under the late communist regime. Before l Diabetes care helped by an increasing number of airstrips, 1974, all nurses were female and the l Rural health but aeroplanes are no help to the villagers present government is now trying to centres seeking local medical care. Indeed, the encourage women back into nursing. delivery of expertise and medicines is a The structure of their training is very complex and largely unresolved problem, imaginative: after each year of their studies which is magnified in the delivery of they can practise at the level achieved. Their treatment for chronic lifelong diseases first year is undertaken as a supervised (which are increasingly being recognised) student, leading to the grade of ‘junior such as diabetes, asthma and hypertension. nurse’, the second year leads to the grade of ‘senior nurse’ and the third year is devoted

Val Brown is Diabetes Specialist Training of doctors to optional specialties (public health nursing, Nurse at Guy’s Hospital/ Each year about 150 doctors graduate clinical or midwifery, etc.). Optimum Health Services NHS from the three medical schools serving the A BSc degree in nursing can be obtained Trust, London, Shitaye Alemu population of around 60 million people. during a fourth year. Nurses with a is Physician at Gondar College Some of them emigrate, leaving an even qualification in public health nursing are of Medical Sciences, Ethiopia, smaller number to serve in their own allowed to manage a health ­centre. and Peter Watkins is Consultant country. The largest medical school is Physician at King’s College located at the university in Addis Ababa; Delivery of health care Hospital, London the other two, which are not attached to There is a three-tier structure for the

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delivery of health care, although most is unknown. We can, however, calculate the medicines are available only at the hospitals, prevalence of known diabetes because up Page points which are themselves based in towns and until now the hospital has effectively been Insulin and oral often very distant from the patients they the only source of drug treatment. Thus, in hypoglycaemic drugs serve. 1996 the clinic at Gondar had 496 patients 1 are only available from The hospital at Gondar serves about (241 from the town and 255 from the hospital pharmacies 3 million people, only 120,000 of whom country), representing an urban prevalence in the towns. live in the town. Ten health centres are of known diabetes of 0.2% and a rural located in the surrounding countryside, each prevalence of just 0.009%. The typical diet of serving around 300,000 people. These act as Surprisingly, 40% of the town patients 2Ethiopian farmers has peripheral clinics for various disorders, apparently have type 1 (insulin-dependent) a very low nutritional including tuberculosis (obviously a large diabetes, and, even more surprisingly, 75% value, and many people problem) and the delivery of babies. of rural patients have this form of diabetes. have a body mass index While these observations may be taken Rural health stations consist of relatively of <20. at face value, it seems to us that type 1 small huts that provide facilities chiefly diabetics are more likely than type 2 The prevalence of for inoculations. Tuberculosis, leprosy and (non-insulin-dependent) diabetics to seek known diabetes is family planning clinics are manned by health 3 treatment when faced by long journeys. 0.2% in the towns and care assistants. Diabetes care, too, has to be In Addis Ababa, however, only about 0.009% in rural areas. delivered within this established framework one-third of patients have type 1 diabetes and its limitations. — a pattern of disease more akin to that in Three-quarters of the The availability of drugs is very limited. Europe and North America. 4rural patients have The majority, including insulin, are dispensed Some details of the diabetic patients type 1 diabetes. by hospital pharmacies in the towns. For attending the hospital at Gondar are shown the few people who can afford to pay for in Table 1. their drugs, there are some rural pharmacies which dispense a limited number of Journeys to hospital medications; however, this does not include Most of the 255 rural patients travel more insulin, which is therefore not available in than 20 km to hospital to receive diabetes country areas. Traditional ‘doctors’ will, treatment, but some travel much further — of course, provide patients with a range of a few in excess of 200 km (approximately alternative remedies. the distance from Birmingham to London). Some of these people therefore have to Farmers’ lifestyle The day starts at sunrise, and the farmer goes to the fields without having breakfast. During the ploughing or harvest season, home-made bread or cereal may be brought to him at work. He returns to his tukul Publisher’s note: This image is not available in the online version. (Figure 1) at about 6 o’clock in the evening — when his wife will bathe his feet by the fire and then provide him with a meal of injara (staple food made from the cereal tef), accompanied by wat (spiced meat or Figure 1. Most Ethiopians are farmers and live in circular huts (tukuls) such as vegetables) and followed by and some these. alcohol (a form of beer called tella). Sugar, cakes and biscuits are not normally available, Table 1. Diabetic patients attending the hospital at Gondar while fruit, though plentiful, is usually only College of Medical Sciences eaten by children. If honey is available it is often sold. Number Age in years Body mass index The overall nutritional value of the diet is (mean±SD) (mean±SD) low and many people are very thin indeed, Type 1 with a body mass index of less than 20. diabetes 281 30.4±11.6 17.6±2.8

Diabetes Type 2 diabetes 215 54.7±10.7 23.3±4.7 The prevalence of diabetes in rural Ethiopia

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Page points

The main problem is 1how to make diabetic treatment more readily available in rural areas.

A project has been set 2up to establish links with the towns of Jimma and Gondar.

The aim of the 3project is to enable Publisher’s note: This image is not available in the online version. rural health centres to deliver diabetes care.

This scheme should 4substantially reduce travelling distance and encourage more people to come for treatment.

Figure 2. Rural health clinics will provide essential education and treatment for people with diabetes who might otherwise go untreated. (The boy in the picture is 13 years old.)

travel for up to 3–5­ days in each direction available. One approach has been to take the to receive their treatment. If supplies of necessary facilities to the rural areas, nearer insulin are short (as often happens) the to patients’ homes. This requires a change in journey may need to be repeated every 1 the present situation whereby hospitals are or 2 months. Understandably, patients may virtually the sole suppliers of insulin and oral restrict their insulin use to a minimum to hypoglycaemics. eke out their supply, and are often grossly In 1993, The Tropical Health and Education wasted from persistent underinsulinisation Trust, directed by Professor Eldryd Parry, and hyperglycaemia. provided a grant to establish links with One 18-year-old patient with type 1 the towns of Jimma and Gondar. We have diabetes attended the clinic after a 3-day visited twice (1994 and 1997) and two walk, sleeping overnight in the hospital of our diabetes specialist nurses went to grounds. He kept his equipment and insulin Gondar in 1996. Two nurses and three in immaculate condition in a plastic bag. At doctors from Ethiopia have come to King’s home he kept his insulin supply in a box, College Hospital, each for a few weeks, to covered the lid with moist sand, and buried maintain the link and exchange expertise. the box to keep it cool. He was thin and Sadly, some did not return to Ethiopia: there stunted with the gross hepatomegaly of are many lessons to be learned. the Mauriac syndrome. Hopefully, easier The aim of the project is to establish a delivery of diabetes care will enable him to system of delivery of diabetes treatment improve the quality of control and quality of at the rural health centres. This involves life in the long term. physicians and nurses taking records, The diabetes project equipment and medicines (in this case tablets The chief problem in Ethiopia, therefore, and insulin) on a regular basis to the health is how to make the treatment of diabetes centres and arranging for patients to attend (and other lifelong diseases) more readily these peripheral clinics. This scheme should

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substantially reduce the travelling distance and perhaps elsewhere. and time for many people with diabetes and Evaluation of the effect of reducing the Page points encourage them to attend more regularly travelling distance is needed, together with Nurses will have to or, indeed, to come forward for treatment increased attendances and perhaps less be trained in diabetes dependence on the delivery of traditional 1 in the first place. management so that they Some peripheral clinics have already been remedies. The scheme establishes a network can manage diabetes established and are well attended and much that will enable appraisals of diabetic independently from valued (Figure 2). More of these clinics will complications, of mortality, of the outcome physicians. certainly follow. of diabetic pregnancy, and of many other For this system to succeed in the long issues. The diabetes project term, nurses will have to be trained in The Ethiopian people have strong religious 2is now well diabetes management so that they can faiths, and are philosophical and always established and its scope manage diabetes independently from cheerful. They often come for medical should increase with new physicians. This process has already been treatment only in extremis. facilities and new energy. started: one of us (VB) has trained nurses There are rewards too. Our last clinic both in Gondar (six nurses over a 3-day patient was a smiling lady weighing 70 kg; she course) and at King’s College Hospital. The originally attended weighing 35 kg. She said purchase of a Landrover by the trust as a to her tireless and indefatigable physician: ‘I result of a lottery award for chronic disease was dried like a tree, you gave me life; my management will further enhance this work. villagers say I was reborn’. n

Further reading The future Alemu S, Watkins V, Dodds W, Turowska J, Watkins The diabetes project is now well established PJ (1998) Access to diabetes treatment in northern Ethiopia. Practical Diabetes (in press) and its scope should increase with new Gill G, Mbanya JC, Alberti G (1997) Diabetes in Africa. facilities and new energy. It will be applied FSG Communications Ltd, Reach, Cambridge Lester FT (1992) Clinical features, complications and not only in Gondar but also later in Jimma, mortality in type 1 (insulin-dependent) diabetic patients in Ethiopia, 1976–1990. Q J Med 83: 389–99

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