Sunday, August 21, 2011

DIABETES – making communities poor . . .

I remember the cold Wednesday morning in the OPD at NJH sometime in Winter 2004. There was a old man in his middle 60s sitting in front of me. He had come to NJH for his foot which was decaying. His problem was very obvious and not at all uncommon to me who came from the south of India. He had diabetes and had an ulcer in his right foot which was refusing to heal. But for NJH it was something rare. Diabetes was believed to be uncommon in this part of the country. That was the first and the only patient with diabetes whom I saw at NJH during my stinct in 2003-04.  

Fast forward to today (21st August, 2011), the last patient I saw in emergency - someone I shall call SDP. SDP has been hypertensive for quite a long time. He claimed that he is not a diabetic. His relatives even showed me a blood test which showed GRBS as 141 mg%!!! SDP has come in very sick. He has been having a angry looking swelling of the right foot and obviously he had infection - he was febrile and breathing heavily and fast. His GRBS was above 200 mg%. Obviously he must have had high sugars and somehow it was not picked up. 

In the wards, we have 3 patients who have diabetes. On an average, in the out-patient department we have about 3 new diabetic patients every week and more than a dozen of them coming for them coming for their repeat medications every week.

However, what I need to tell you about a very peculiar history that many of them give. Quite a lot of them have been diabetics for 10 years or more. So, where were they when I was at NJH in 2003-04? I've not done a detailed study on this - but have been asking quite a lot of the present patients about the same. The answers have been shocking. It seems that quite a lot of them had been frequenting hospitals at Ranchi (135 kms away) and Kolkota (12 hours by train) just for the treatment of diabetes. When I ask them about the reason they did not come to NJH - the answer was that they thought that mission hospitals are mainly for surgical management and there was no 'diabetes specialist'.

It was very unfortunate. The minimum amount of drugs which many of the 'diabetic consultants' wrote for these patients were about five and the expenses involved has been quite huge.  Many of the patients had also been misled by traditional and alternative healers for radical cures of the disease - and they had also spent quite huge amounts on them.

Quite a large number of our present diabetic patients who had been on treatment for long durationsand the treatment have literally made them paupers. And that was the reason that they started coming to us.

So, how are we going to respond? We have already planned to start a chronic diseases clinic of which diabetic management would be one of the major components. I wish we can send one of our doctors and few of our nurses for training for diabetes management. To decrease the load in our laboratory and to streamline management we are going to get a Nycocard machine for HbA1C and urine microalbumin.

As I finish writing this, Angel informs me that one of the new admissions in the ward who is a diabetic has ketoacidosis. It is ages since I’ve managed one. I fondly remember my MBBS days at Trivandrum as an intern in Medicine 2 where we honed the art of managing diabetic ketoacidosis.

Unfortunately, the major question remains on how much is rural India ready to take on the demon of diabetes and hypertension. With the requirement of regular treatment – which is a concept quite alien to the Indian psyche – there has to be major shift in the attitude of communities towards chronic diseases. We are still grappling with infectious diseases and inadequate reproductive health care. The additional burden of non-communicable diseases could quite increase the morbidity within communities, the consequences of which we may be facing sooner or later.

The concern is that, many of us, especially in the rural agrarian societies of the country do not know very clearly on what the consequences could be.  


  1. Very insightful blog. As you rightly point out, in the name of 'evidence based medicine' many of our well-meaning doctors land up becoming expensive, unaffordable prescription writers. Added to this is the issue of access to these specialists, for which many a patient pledges the last remnants of their property and in turn their honor. Evidence Based Medicine has to be contextualized and practiced with extreme conscientiousness. Your blog is another testimony to the numerous problems facing our health care system. I wish you could write this up for the newspaper as well and be read by a larger number of people! Good Luck!

  2. This is an very interesting post which gives us an picture of how the society is and what prevails in the minds of people about the mission hospital.@vijay Evidence Based Medicine is not just the research evidence in which prescribing unaffordable medicine to the patients.It is an integration of Clinical Experience, Research Evidence And Patients Preference & values.The highest level of evidence is formed by a good systematic review& meta analysis.The leader in providing best evidence for health care is" the Cochrane Collaboration" make use of it. Good luck for your work. God bless.