31 October 2016
Gondar University Hospital is situated in the Amhara region in the North of Ethiopia. It serves a population of
5 million, 90%
of whom live rurally with poor access to the central hospital.
There are 9 health centres in rural settings in the region, and much of the success of the work done by Sir Eldryd Parry and colleagues over the last 15 years is evidenced in these centres, where patients’ health care needs are being met closer to their home.
In our first week we travelled to Aykel health centre, 65km outside Gondar, where we met a 36-year-old male farmer, recently diagnosed with diabetes.
If this had been 10 years ago, he would have had to travel a full day by foot to see a healthcare provider.
Now, he is able to receive medical care for his diabetes within one hour’s walk of his home. This is one example of the major advances that the chronic disease programme in Ethiopia has made.
THET has been supporting the chronic disease programme for 20 years in Ethiopia to improve care of patients with epilepsy, diabetes, high blood pressure and chronic lung disease. The programme has contributed significantly to the strengthening of chronic disease care in rural Ethiopia. Patients with type one diabetes, that means those requiring insulin from the point of diagnosis, have different characteristics to those who are diagnosed with type one diabetes in the UK. The purpose of our work with the team in Gondar was to assist with a study looking at the reasons for this difference.
Previous studies in Ethiopia have described new diabetics as presenting later in life than in the West, which closely resembles the previously described malnutrition related diabetes[i]. The current study hypothesises that this alternative presentation is related to early malnutrition and possibly chronic illnesses in childhood[ii]. We assisted with data collection from diabetics and age and sex matched controls. We hope that the study will help to understand in more detail the nature of this disease which is seen across sub-Saharan Africa. This knowledge could contribute to better treatment options and prevention.
Treating an Ethiopian rural farmer, who may have had no formal education, to manage his blood sugar with insulin is no mean feat.
Prior to the chronic disease programme, this patient would have had to travel many hours to Gondar, to collect insulin, often requiring him to take time off work, thus losing essential income for himself and his family. Educating such patients on the importance of good blood sugar control, managing low blood sugar, and preventing the complications of diabetes has been a remarkable success.
The dedication and perseverance of Dr Shitaye and her team has enabled these patients to have an understanding of their disease, appropriate local follow up, and a reliable supply of free insulin. The creativity of the patients who have to keep their 3 monthly supply of insulin cool is admirable – they store their insulin in bags of sand, below ground level, ensuring its safety and efficacy even after some weeks in a hot climate.
During our time on the medical ward in Gondar University Hospital we observed the care of patients presenting with communicable and non-communicable diseases. Treating patients with diabetic complications, such as diabetic foot ulcer, highlights some of the challenges of providing effective health care in this setting. On the ward we met a 24-year-old farmer with a diabetic foot ulcer and underlying bone infection. We observed the difficulties the doctors had in managing his blood sugars on the ward. Without basic equipment, such as that to measure blood sugar, doctors are not able to provide optimal care. We observed limitations to acquiring equipment, reagents and medications on numerous occasions, which is a major limiting factor to providing healthcare in Gondar.
People’s understanding of disease and its cause in this area poses another challenge to providing care.
Many patients wait for some time before seeking medical advice for their symptoms; consulting a traditional healer in the first instance, who is often more accessible, before presenting to the hospital.
This combined with the fact that the vast majority of the population live rurally and many hours from the nearest health centre means that patients come late and with significant complications of their illness. Challenging health beliefs and educating patients about their medical condition is difficult in any setting, but especially here. The introduction of community-based Health Extension Workers over the past few years has contributed significantly to the reduction in maternal mortality, and increased life expectancy, and it is hoped that the integration of these professionals into communities will add to and enable better disease management and health literacy.
[i] Alemu S, Dessie A, Seid E et al. Insulin-requiring diabetes in rural Ethiopia: should we reopen the case for malnutrition-related diabetes? Diabetologia (2009) 52:1842–1845
[ii] Fedaku S, Yigzaw M, Alemu S et al. Insulin-requiring diabetes in Ethiopia: associations with poverty, early undernutrition and anthropometric disproportion. European Journal of Clinical Nutrition (2010) 64:1192-1198.