Measurement of a patient’s HbA1c level during a diabetes screening
August 4th, 2015
Editors’ Note: This summer, six students from Albert Einstein College of Medicine have traveled to Soroti, Uganda, to treat diabetes as part of Einstein’s Global Diabetes Institute (GDI). During this period, we are featuring a series of posts detailing their challenges and progress. In this post, second-year M.D. student Jayson Lian shares his experiences with a GDI diabetes education and prevention effort. The trip was funded by Einstein’s Global Health Fellowship Program.
Jayson Lian: We were heading northeast from Soroti to Ongutoi, Uganda, with our program manager. Our goals were to conduct a diabetes-screening day where we would detect diabetes in a population with limited healthcare access, educate patients about preventive measures and, hopefully, reduce the patient load at Soroti Regional Referral Hospital’s diabetes clinic. The diabetes-screening process consisted of patient surveys, anthropometry, and measurements of blood pressure and blood sugar.
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Right away we faced several challenges at the Ongutoi Health Center. As a result of advertising our screening over the radio, we faced an overwhelming number of patients. Furthermore, many of these patients had expectations that did not match our skills. After all, we had finished only our first year of medical school and possessed little more medical knowledge than the average person. We did not anticipate that so many patients would expect to receive diabetes medication and “superior” treatment from the American “doctors.”
It was difficult to explain to patients that we were far from doctors and were not allowed to prescribe medicine. It was even harder to explain that they would have to return to the Ongutoi Health Center another day or make the trip to Soroti if they wanted to receive actual treatment.
Largely thanks to Ongutoi Health Center’s administrator, we restructured the screening process midday and began seeing patients at a much quicker rate. The adjustment unfortunately meant there would be less time to educate diabetic patients and build relationships; priority was instead placed on seeing all patients as quickly as possible.
Despite these challenges, we were able to detect new cases of diabetes and encourage a number of patients to seek needed medical help – help they might not have gotten otherwise. By the end of the day, we had seen 250 patients and diagnosed new cases of diabetes.
In the long term, I believe we have helped spur the growth of diabetes-screening clinics in Uganda. Despite our initial difficulties, the structure and organization of our trial could be a model for future screenings.
Furthermore, our project promoted diabetes awareness around Ongutoi, and we hope it will help inspire the ministry of health and other diabetes organizations in Uganda to increase funding for diabetes treatment.
Though we could not educate all diabetic patients ourselves, organized village health teams around Ongutoi plan to visit the homes of patients with diabetes and help educate them about diet, medication, and hygiene, using educational materials that we developed.
Changing the culture around diabetes, given its growing foothold in Uganda, requires reform and action. The action would not have been possible without the warm welcome we received from the community, the Ongutoi Health Center staff, and our Global Diabetes Institute program manager.
As a medical student entering my second year, I am proud of what we accomplished that day and am indebted to the hospital employees for their help and collaboration, and to the local community for what they have taught me. I hope to build on this experience and to provide improved medical care to underserved communities like the one in Ongutoi.
This post originally appeared on August 4th, 2015 on The Doctor’s Tablet.
Six rising second year medical students from Albert Einstein College of Medicine working in the Diabetes Clinic at Soroti Hospital
July 10th, 2015
Editors’ Note: This summer, six students from Albert Einstein College of Medicine have traveled to Soroti, Uganda, to treat diabetes as part of Einstein’s Global Diabetes Institute (GDI). During this period, we will run a series of posts detailing their challenges and progress. In this post, second-year M.D. student Jeannie Tran shares her thoughts about medical care in Soroti. The trip was funded by Einstein’s Global Health Fellowship Program.
Jeannie Tran: Having never traveled outside the U.S. before and having only just finished my first year of medical school, I was nervous about going abroad under the auspices of the GDI to work at Soroti Regional Referral Hospital (SRRH), a facility with few resources and a patient population whose primary language I do not understand. To my surprise, the adjustment has not been too difficult. The lack of medical resources that initially seemed to be a drawback at SRRH is, in fact, eased by a collaborative hospital staff and a team of physicians with impressively widespread knowledge and skills.
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We spent our first week familiarizing ourselves with the hospital, attending rounds, assisting at the hospital’s diabetes and hypertension clinics and meeting with doctors and administrators to implement our three main projects: data collection, education and a prosthetics workshop. Prior to arriving, I imagined that the hospital here could provide little for its patients. In my first year of medical school, I became accustomed to physicians who are experts in a certain segment of medicine, and to hospital care that requires the use of expensive machinery. SRRH has neither of these. Instead, it has physicians with expert knowledge that extends beyond their own specialties, who are capable of treating numerous patients based on physical examinations alone.
Though I am constantly impressed by the doctors I encounter in the U.S., I am even more impressed by the doctors I have met here. SRRH would benefit greatly if it had more resources. It lacks even the most basic supplies that many of us in the U.S. medical field may take for granted, such as clean note-taking paper. Despite these challenges, the doctors here have created a system of care that employs creative improvisation. For instance, during a surgical round, the doctors used a bag of water as a weight to help lengthen a fractured bone to ensure that the bone would heal correctly.
Consequently, as a medical student in her preclinical years, I have learned much more here in one week than I would have if I had spent the same amount of time in a U.S. hospital. Not a single medical question has been asked that a doctor has not been able to answer, and in many ways, it feels as if each physician here is an internist, a cardiologist, a pediatrician and so on, all in one.
After my first week, I was filled with awe and appreciation for the more raw aspects of medicine that we rarely see in hospitals in the U.S, and I cannot help thinking how amazing care here would be if SRRH had more basic resources, such as space. For instance, I have observed patient beds in the internal medicine ward literally touching each other because there is no other location to see patients, and it is incredibly disheartening to watch competent medical professionals not be able to treat patients simply because those professionals don’t have the means.
Overall, I don’t believe that one type of care (care in the U.S. or care here in Soroti) is better than the other. Rather, I believe that both have invaluable qualities to offer and that an integration of the two would be ideal. For the next few weeks—and, I hope, for years—our Einstein team under the auspices of the Global Diabetes Institute will promote and facilitate such integration at SRRH. I am excited to have the opportunity to be a part of this burgeoning partnership.
This post originally appeared on July 10th, 2015 on The Doctor’s Tablet.
Department of Physiotherapy at Soroti Regional Referral Hospital (SRRH) in Soroti, Uganda
May 21st, 2015
Anneka Wickramanayake: “This was extremely educative and humbling, to be honest we thought we knew diabetes but we realized there is more and more to be learnt in this new epidemic of diabetes mellitus…We as a hospital seriously want to champion DM [diabetes mellitus] research in Uganda and Africa, we already have a list of research topics that we hope to do in the near future.”
Those are the reflections of Drs. Wilson Etolu and Joseph Epodoi, two clinicians from Soroti Regional Referral Hospital in Soroti, Uganda. They practice in one of Uganda’s poorest districts, population 60,000. The doctors’ perceptions about managing diabetes changed considerably after attending an intensive training course in comprehensive diabetes management held at Christian Medical College (CMC) in India.
This particular course educates and trains physicians to provide high-quality diabetes care in resource-limited settings. Though diabetes treatment knowledge and information are widely known among doctors in the West, and at comprehensive facilities such as CMC, there’s much to learn. The goal of the CMC intensive is to provide doctors with the knowledge and tools to develop and offer high-caliber care at the diabetes clinic in Soroti. Bolstered by the training and experiencing first-hand the high-caliber care being offered at CMC, these doctors returned to Soroti with new energy to develop their own diabetes clinic.
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Enter the Einstein GDI
CMC has close research ties to Einstein. Aiming to address the rapidly growing global epidemic of diabetes, the GDI has fostered a triangular partnership with CMC and Soroti Hospital.
Diabetes has traditionally been considered a disease of the developed world; however, this is a misconception. A staggering 80 percent of new cases of diabetes are in low- and lower-middle-income countries. In Africa, approximately 19.8 million adults have diabetes, and projections for 2035 are as high as 41.1 million. The health and economic burdens of this epidemic are crippling. Our mission is to help alleviate this through visits from our staff and now our students.
The staff of Soroti Hospital is also committed to this mission, and wants to address the epidemic on a local level. But the hospital faces numerous challenges that include the burden of a large patient population and a scarcity of resources.
How Einstein Students Will Help in Uganda
To date, the Einstein program has sponsored four Soroti clinicians’ participation in the CMC training course and facilitated their formulation of long-term goals for diabetes care in Soroti. Now we will support their efforts by working on the ground, with six Einstein first-year medical students traveling to Soroti for five weeks this summer to provide assistance. The hospital staff has established clear, attainable objectives for improving the diabetes ward; the students will help them achieve these goals. The project has three main areas of focus:
- Data Collection: To date, there have been no national surveys published on diabetes in Uganda. We will gather local data on the prevalence of diabetes and its risk factors so interventions can be appropriately designed and their progress monitored.
- Education: The issues surrounding diabetes—its risk factors and its treatment—are still new to many people in Uganda. We hope to diminish the risk factors by increasing understanding among the general public and health practitioners. We will help by designing a curriculum and disseminating it throughout the region.
- Prosthetics Workshop: Many people in the Soroti region have had amputations due to diabetes, injury and other complications. Their quality of life is seriously diminished post amputation due to loss of mobility. Many of the patients die within the first year. Additionally, a prosthetic limb in Uganda costs between $250 and $500, which is prohibitive for most in a country where the median income is about $650 per year. We will determine the feasibility of using low-cost methodologies in Soroti, so more people can benefit from lifesaving prosthetics.
Despite the challenges the hospital faces, we are continually impressed by the staff’s passion and dedication to making positive changes. Students this summer will help kick-start these vital projects.
You can follow our progress through periodic posts on The Doctor’s Tablet, and here, on the GDI website.
This post originally appeared on May 21st, 2015 on The Doctor’s Tablet.
James Yuan visits with patients in the diabetes ward at Soroti Hospital.
September 20th, 2014
James Yuan: I just returned from a 5-week trip to Soroti, Uganda, where I had the privilege of working with Dr. Etolu and the staff of Soroti Regional and Referral Hospital. During my time there, I was able to help track the diabetic patients who visit the weekly diabetes clinic, and compile data regarding their social demographics and clinical characteristics—this included BMI, smoking history, education level, family history of diabetes, and more. Additionally, I was able to shadow the interns during ward rounds, help educate diabetic patients on proper management of the disease, and assisted staff whenever possible.
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I was most amazed by how the hospital and staff were able to run with such limited resources. What I mean by this is that several of the tests and exams we take for granted here in the US—such as an HbA1c machine, an ECHO machine, specialists (the hospital has an eye and ear clinic but no ENT doctor, only an audiologist), proper cancer treatment—all were too expensive for the hospital to have. Most of the aforementioned services had to be performed in the capital city of Kampala, 4 hours away by bus which costs 18,000 Ugandan shillings one-way (about $7 US). Just prior to my arrival, the entire hospital had run out of glucose strips, and luckily I had brought 1500 with me, along with 4 glucometers, which they desperately needed and were so thankful for. Despite these shortcomings, as we might call them in the US, the doctors and interns still provided quality care for the patients, no matter what they came into the hospital complaining of. They seemed catered toward their specific patient population and diseases unique to that group which we don’t see often here. For example, Soroti had adequate treatment for malaria, TB, and other infectious diseases which are very common there.
Sadly though, I noticed a significant lack of education on the patients’ part, in regards to their health problems. Although Dr. Etolu made it a point to teach each of his patients about their condition, modes of treatment, and possible outcomes, it seemed that many of the hospital staff did not place much emphasis on this. While I tried to help where I could, bringing along proper foot care brochures for the diabetic patients and even helping lead a training for health care workers about NCDs (non-communicable diseases), I felt that many of the issues we were seeing could be prevented with proper patient education. Taking a public health approach and enabling them to take ownership of their body and health could reduce the incidence of diabetes and associated complications (and other diseases prevalent in the area). However, by the time I left, the hospital was beginning to emphasize more the benefits of patient education and reducing the burden of disease by empowering patients. Hopefully with this step in the right direction, and a new partnership with the Global Diabetes Institute, Soroti Hospital can continue to improve and provide quality care for the people of Uganda.
A Uganda physician examining a 60-year-old Ugandan woman who will get an artificial leg custom-made by our partner institution in India
Thursday, October 21, 2010
Dr. Meredith Hawkins: Diabetes Ward Rounds provides a vivid reminder of why we are working in Uganda...or perhaps more broadly, why I went to medical school. Eager residents crowd around a patient's bedside to glean wisdom from Dr. Fred Nakwagala, a talented Ugandan endocrinologist who spent time at Einstein last year.
Over the past five years, I've seen a definite improvement in availability of laboratory tests and medications. Nonetheless, a constant mindfulness of scarce resources makes us rely more on symptoms and physical examination...we work together like detectives, combing over assorted clues to solve cases. With infectious diseases rampant on the Diabetes Ward, I probe the foggy recesses of my brain to recall which brain infections are common in HIV/AIDS and which physical signs are characteristic of endocarditis (infection of the heart's inner lining).
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The first patient is an emaciated elderly woman who has been losing weight since being diagnosed with diabetes. Her daughter proudly tells us that she has been "withholding food" after hearing in a radio broadcast that patients with diabetes need to lose weight! Fred soberly instructs the residents that patients with "thin diabetes" can be harmed rather than helped by restricting food. A subsequent patient illustrates the perils of treating diabetes when meals are unpredictable...an older woman with finely chiseled features is babbling incoherently, having been admitted a few hours earlier in a coma due to hypoglycemia (low blood sugar). This promotes discussion about how combining medications that decrease appetite (metformin), stimulate insulin secretion (glibenclamide) and suppress the symptoms of low blood sugar (propranolol) proved to be a nearly fatal combination in an elderly person.
Today's lecture on diabetes management went 35 minutes beyond the allotted time, mainly due to lively and practical comments from our Ugandan colleagues...innovative ways to store insulin without refrigeration, traditional dance as a form of exercise, and cost-effective approaches to diabetes treatment...Though given permission to leave at the scheduled ending time, most of the audience chose to stay. As the attendees mob us with questions afterwards, we are deeply moved by their motivation to learn and to provide the best care possible...
Dr. Elizabeth Walker, back left, and Dr. Jason Baker, back right, attend rounds on diabetic patients
Thursday, October 21, 2010
Dr. Elizabeth A. Walker: Let me fill you in on my main goal in coming with the team to Uganda this trip—further development of a Ugandan diabetes self-management poster focused on hypoglycemia (symptoms, prevention and treatment). This priority topic was chosen by the 19 Ugandan doctors and nurses who completed our structured interview.
Hypoglycemia in Uganda is especially deadly, as most people do not have access to blood glucose monitoring at home, many people are taking insulin injections, and food is often in short supply—so many risk factors for low blood sugars! Since people living with diabetes in Uganda have almost no educational materials for self-care, we focused on developing a teaching poster.
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The creative expertise of the Graphic Arts Center at Einstein produced a first draft of the poster that we then carried to Uganda. Logan and I have completed detailed interviews of three key Ugandan diabetes providers, with several more to come. This is thrilling for me as they patiently give us feedback about word choices, drawings of faces, foods, etc—all things related to prevention and treatment of a low blood sugar. Here’s an example: we had a drawing of an apple in a segment about healthy snacks. Each interviewee said something like “Oh, that’s very nice, but only the rich can afford them.” (Lose the apple!)
This is truly a translation of the concepts into something that Ugandans will understand, and hopefully utilize, to decrease their morbidity and mortality from hypoglycemia. After several more interviews, we’ll move on to draft #2 back in the States and continue the feedback over the internet.
A young man with a leg amputation walks the corridors of Mulago Hospital
Saturday, October 23, 2010
Dr. Meredith Hawkins: When I asked whether ward rounds happened on Saturdays, the ever-eager students and residents said that they would happen if I wanted them to!
When I arrived this morning, they announced with excitement that they had a case right out of one of my lectures! They led me to the bedside of a patient with classic signs of acromegaly (excess growth hormone presenting in an adult): her hands, feet, jaw, and even her tongue were enlarged, and the loss of peripheral vision in both eyes suggested a large pituitary tumor pressing on the crossing point of the optic nerve. Together, we devised a plan to follow the guidelines from the lecture, despite her lack of funds... a special fund for "teaching cases" would cover the hormone and imaging tests, and pituitary surgery and expensive medication (octreotide) would be arranged with a visiting neurosurgery team and a compassionate drug program, respectively... Where there is a will, there truly is a way...
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This morning, we received good news from India regarding two Ugandan patients with recent amputations. On previous ward rounds, I learned that the cost of artificial legs in Uganda, about $400, is prohibitive for most patients... So, our amputee patients were anticipating hobbling on crutches or being immobilized for the rest of their lives.
I remembered touring our partner institution in India, CMC Vellore, where artificial limbs ingeniously crafted from simple materials were provided to patients for a few dollars. My plea for help was answered immediately by our Indian colleague Nihal Thomas, who offered to provide a few custom-made limbs for our Ugandan diabetes patients, as well as to train a Ugandan technician in their methods. This epitomizes why we developed a collaboration with CMC Vellore... instead of introducing North American medicine into the developing world, we have much to learn from these colleagues about providing outstanding care in a resource-limited setting.
Isaac, a fifteen-year-old Ugandan orphan with type 1 diabetes who cannot afford insulin
Sunday, October 24, 2010
Dr. Meredith Hawkins: The most poignant story we have encountered is that of Isaac, a fifteen-year-old orphan (featured in Einstein's Annual Report) who would sell his insulin to buy food for his grandmother. Since children taking insulin need regular meals and medical attention to survive, we arranged to send Isaac to a boarding school for children with medical needs. Isaac's erratic blood sugars proved too complex for the school, necessitating many trips to the main hospital (Mulago), in Kampala. We recently found Isaac a school closer to the hospital, run by a caring woman named "Momma Rubinah."
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Josephine Ejang, diabetes nurse at Mulago and a good friend to Isaac, visited the school to make arrangements. We were excited that Parents' Day would coincide with our visit! However, our plans hit a roadblock when Josephine lost contact with Isaac. During school break, his grandmother was sent to hospital, leaving him alone.
Unable to reach Isaac by phone for two weeks, we decided to go find him. After Thursday's lectures, Josephine and I drove to the village named in his records. We arrived at the 'trading station' — a small clearing with a meager vegetable stall, surrounded by brick or mud-walled huts. Carrying our brochure with Isaac's photo, we headed on foot down a muddy path, trying not to slip on garbage and pig dirt. We encountered about a hundred people — bashfully smiling adults, excited children squealing "Hi Mzungu [white person]" — but no one recognized Isaac.
Back on the main road, we visited "Voice of Gayaza [region]", a loudspeaker on a short radio tower. For a dollar each, two booming announcements requested anyone with knowledge of Isaac to contact us. No one did. We returned to Kampala, rather discouraged.
But luck was with us, as Josephine learned of a second village with a nearly identical name, located five kilometers further down the road! We headed there this afternoon. The first person we met on the outskirts of this village smiled and pointed down the road when he saw Isaac's photo. A couple of hundred yards further, we found a mud-walled house surrounded by children... and standing in the doorway was Isaac! A kind relative had taken him in, but food was scarce.
Concerned about low blood sugars, Isaac had not taken insulin for a week — so we brought him to Mulago to stabilize his blood sugars before taking him back to school. Isaac's arrival on the diabetes ward causes some excitement. He is very familiar to the residents and nurses, who gather around to give him medical attention. Isaac's story is sufficiently heart-rending that these overburdened health professionals go the extra mile...
Certificates awarded upon completion of the first Ugandan Endocrinology Symposium at Mulago Hospital
Monday, October 25, 2010
Dr. Jason Baker: Our last day in Uganda! Waking up with mosquito netting again somehow wrapped around my head (didn’t know I was so restless at night!) Immediately going to kitchen for a cup of good Ugandan java, the flavor is out of this world! Off to a power-round of good-byes at the hospital, and follow-up on a few patients before leaving for a very bumpy, hot and dusty two-hour drive to the airport. Meredith and I now head to Cairo for a Global Diabetes Alliance meeting, plane to stop in Nairobi and Khartoum, and I’m looking forward to seeing Africa from the plane’s window!
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Part of me wants to fly home instead, missing loved ones and time to process all of the experiences. Experiences that need to be processed, experiences that are simultaneously draining and energizing (seemingly opposite emotions, I know, but this place is too rich not to ride the full spectrum).
Yesterday was particularly hard for me in that I met with a type 1 diabetic with whom I had gotten to know well the past few years. She was diagnosed at age three, and is now 29. After her mother died from HIV, this woman’s care was sporadic and inadequate in large part due to a lack of meds and diabetes supplies. In the last few years, she has had access to more treatments, and has become an amazing peer-educator. She has had numerous diabetes-related complications and is currently on hemodialysis awaiting a kidney transplant (would be done in India most likely).
The sad reality is that the transplant will not likely happen, in part because of immediate expense but even more so that her follow-up and treatment in Uganda would be very limited. No meds, no post-transplant treatment center, no to little chance at success. She has been canvassing families, friends, and organizations for donations toward the operation. I sat with her for over two hours, discussing her treatment, discussing the reality of her situation. Astonishingly, she regarded me with peaceful eyes, eyes that saw the reality of the situation without anger or sadness. I said good-bye, wondering if I would ever see her again. I watched her walk away with a knot in my heart. Again, motivation to help make changes here.
A nurse checks a blood glucometer reading
Tuesday, October 26, 2010
Dr. Elizabeth A. Walker: Endocrine ward rounds these past two days include discussing Isaac, the teen with type 1 diabetes who has no means of support — his family is gone. The students and residents try to sort through the difficult social and physical history; they all show a compassion for his overwhelming situation and a motivation to help him, just as we do.
“If I look at the mass I will never act. If I look at the one, I will.” (From a statement by Mother Theresa of Calcutta)
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The quote above…I think this quote is at the heart of what inspires us: He’s just a boy.
Isaac is hospitalized to stabilize his high blood sugar and figure out the source of his cough and weakness. He has a bed at the end of the ward hallway — a little corner to himself, except for other patients’ family members sitting on the floor. Problems with his care include not yet getting important tests done, including a sputum sample and a Chest X-ray. Why are his blood sugars high again? Why is he anemic? (To do many of these tests, patients must first figure out payment. Nurse Josephine is reluctant to use our funds, since simple tests should be free for disadvantaged patients. Meanwhile, the tests need to somehow get done...)
Food availability in the hospital is an issue as well; patients need money to purchase food other than the one meal a day provided in the hospital. In Isaac’s case, the nurses always collected money to feed him during past stays, and this time our team is eager to step up to the plate. His first night in hospital, I tried to be helpful by bringing him my available American food from our guest house. While he did munch on my Luna bars (9 grams of protein), he rejected my vacuum-packed tuna and salmon. He’d definitely prefer the comfort of Ugandan foods! Tomorrow marks the final day here for Logan and me, and it’s hard to discern how to help. For now, we’re trying to do as much as we can for Isaac and the kind staff caring for him… trusting that, in the process, we will learn more about sustaining the precarious lives of children with diabetes in Uganda.
UPDATE: We are deeply saddened to report that, since the writing of these posts, Isaac has passed away.