A need-to-know guide for those who have been diagnosed with diabetes Diabetes can affect various organs and systems of Diabetes may damage the cells …
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Access to diabetes care in northern Ethiopia
Shtitaye Alemu and Peter Watkins
Ethiopia is a mountainous and beautiful country The capital city, Addis Abba, is about 2500 m 8000 ft above sea level Around 85 of the people are farmers who live in circular thatched huts called tukuls These are grouped into small villages which are often remote and inaccessible While unpaved roads link the main centres, many areas can be reached only by footpaths Road transport is either by bus or taxi, both relatively expensive; or by mule or on foot, which are laborious and slow In this article, Shtitaye Alemu and Peter Watkins look at the needs of people with diabetes in Ethiopia and report on a programme in the North of the country which is bringing significant improvements to care
these figures is due either to the condition remaining underdiagnosed or to people with diabetes not seeking, or being unable to seek, treatment In urban areas,Type 2 diabetes accounts for 71 of the people with the conditionWhen compared with the urban population, the proportion of people in the rural areas who are known to have Type 2 diabetes appears to be relatively very low 23 of the people with
the condition
Chronic medical conditions are a growing cause of death among people in developing countriesThis situation is exacerbated by the migration to the towns and cities of subsistence farmers and their families from the rural areas Diabetes, though less common than in the wealthy countries such as those in Western Europe and North America, is not rare in Ethiopia The condition represents a considerable health problem and is a growing cause of death in the country The overall prevalence of diabetes in the Gondar region of northern Ethiopia has been reported as approximately 03 However, our own studies have suggested that the prevalence of known diabetes amongst a rural community is as low as 00141 The difference between
In Ethiopia, the average age at death of people with Type 1 diabetes is of just 32 years
Early deaths through diabetes? The rate of death mortality of people with diabetes throughout sub-Saharan Africa is high, chiefly among those with Type 1 diabetes
A mortality of 31 of people with Type 1 diabetes has been described in Addis Abba, with a similar rate 32 reported by us from the Gondar region1 The most common causes of death among Africans with
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Type 1 diabetes are ketoacidosis and infections Those who die are often in their twenties and thirties; we reported an average age at death of people with Type 1 diabetes of just 32 years The default rate is very high among those attending for treatmentThis has particularly tragic consequences for people with Type 1 diabetesThis is a common problem which is also experienced in other countries of the region In Nigeria, it was reported that among a group of people with diabetes who had experienced a heart attack, 53 of the people stopped attending treatment prematurely The reasons given included: poverty, moving home, misunderstood instructions, and difficulties in reaching the medical centre
Ketoacidosis is caused by a lack of insulin in the blood It requires emergency treatment Ketoacidosis may occur through illness when insulin needs are high or lack of insulin injections The body starts using excessive amounts of stored fat for energy, and acids ketones build up in the blood The symptoms include nausea, vomiting, and excess urination This can lead to loss of body fluids, stomach pains, and hyperventilation If the person is not given
replacement fluids, insulin, and salts right away, even death
mauritius
ketoacidosis can lead to coma and
We reported an average age at death of people with Type 1 diabetes of just 32 years
compounded by the inadequate provision of insulin and other medication The people with the condition in the area receive only enough diabetes supplies for a few weeks at a time and must therefore travel to and from hospital more often than is really necessary Our study showed that most of the rural people with diabetes had to travel more than 40 km to reach their nearest hospital, 23 travelling more than 100 km and 13 over 180 km2 These journeys take as long as 5 days in each direction Paying for food and travel on these long journeys eats into any savings the people may have For this reason, a number of people with diabetes are forced to move from the country to the towns As a result 
, they often lose employment and are forced to beg in order to survive Others, through exhaustion or the inability
to pay the costs of travel, give up the struggle to attend hospital
This default rate could be reduced significantly if a system were introduced using a trained health worker to trace where
necessary and follow up the treatment history of people with diabetes and other medical conditions
Through exhaustion or the lack of money to pay for travel, many people with diabetes give up the struggle to attend hospital
Or through economics? Access to care is a major problem which contributes to the poor prognosis for people with diabetes in the rural areas These people have to travel walk long distances to the nearest medical centre in order to obtain insulin and diabetes supplies and receive medical care This is
There are few long-term survivors Only a few people with diabetes attending the clinic in Gondar had had diabetes for more than 10 years 14 of people with Type 1 diabetes and 17 of those with Type 2 diabetes, compared to 29 in Addis Abba In Gondar there were scarcely any people with Type 1 diabetes over 50 years of age
Bring the care to the people The inevitable conclusion from these observations is that treatment must be delivered directly to the local population Medicines and medical
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Most rural people with diabetes have to travel more than 40 km to reach their nearest hospital
disorders such as diabetes
in developing countries are to improve, the delivery of health care needs fresh vision and a substantial increase in resources The scheme described in this article may go some way towards addressing these problems, and could be applicable not only in many developing countries but also in the wealthier nations where the logistics of managing the growing number of people with diabetes are also stretching existing resources to the limit
nurses and together they run clinics for chronic disorders as a team More than 80 of the people with diabetes living in the areas served by this scheme are now receiving treatment nearer their homes expertise must be made available at the country health centres which serve people in the rural areas A project at the Gondar College of Medical Sciences, supported by the UK-based Tropical Health and Education Trust THET, has now trained nurses in the management of diabetes and other chronic disorders such as asthma, epilepsy, high blood pressure and other cardiovascular disorders Care for chronic medical conditions, including diabetes, is now delivered at a network of clinics in 5 of the 10 rural village health centres in the Gondar district Thus, the
distances which people with diabetes must travel are greatly reduced The team of medical health professionals doctors and trained nurses reach the health centres in four-wheel-drive vehicles provided by THETThey are joined at the health centres by trained local
The shortage and relatively high cost of insulin remains a very serious problem in most of the subSaharan and other developing countries
Shtitaye Alemu and Peter Watkins
Shtitaye Alemu is a Physician at the Gondar College of Medical Sciences, Gondar, Ethiopia Peter Watkins is Honorary Consultant Physician at the Diabetes Centre of Kings College Hospital, London, UK
The shortage of insulin, which is still too expensive, remains a very serious problem in this region as in most of the sub-Saharan and other developing countries In order to save precious supplies, as many as 48 of people with diabetes in Ethiopia interrupt their insulin treatmentThere is an urgent need for insulin at affordable prices in many developing countriesThis is an issue which is being addressed by the International Insulin Foundation and the International Diabetes Federation Task Force on Insulin,Test Strips and Other Diabetes Supplies If the
quality of life and prospects of the many people with chronic
Please visit the THET website: wwwthetorg and the International Insulin Foundation website: wwwaccess2insulinorg
References
1 Watkins P, Alemu S Delivery of diabetes care in rural Ethiopia: an experience from Gondar Ethiopian Medical Journal 2003; 41: 9-17 Alemu S, Watkins VJ, Dodds W, Turowska JB, Watkins PJ Access to diabetes treatment in northern Ethiopia Diabetic Medicine 1998; 15: 791-794
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Source:fsis.usda.gov
