Endocrine Unit

This week I rotated in the endocrinology unit at Mulago because I wanted to see how diabetes was managed in a big city vs rural Kumi. Almost all of the patients in the endo unit are diabetic and they suffer from various ailments, some related to their diabetes and some not. The reason for this is that any patient who enters the gates of mulago who is a known diabetic gets shifted directly to the endo unit regardless of what is wrong with them because it is the only unit that is capable (read: willing) to properly manage blood sugar levels during their hospital visit.
The conclusion that I have reached is that if you get diabetes in Uganda, no matter where you live or how much money you make (to a point) you’re in trouble, because the daily routine of many Ugandans simply does not align well with the proposed treatment plan.
They take good care of you in the unit and teach you about diet/exercise and give you some medication, but once you leave the ward, it is difficult to adopt the lifestyle necessary to slow diabetes progression. The social norms here simply do not align with the suggestions of the physician, so any orders are followed haphazardly at best, and who can blame a patient for ignoring instructions that would so drastically alter their routine? This is assuming you can afford to make said lifestyle changes in the first place.

Ideally, a newly diagnosed diabetic patient (who usually presents with sx that are quite advanced by American standards) should: monitor and control blood sugar levels, alter their diets significantly and begin an exercise regiment, but this is easier said than done here.

Blood sugar monitoring: No patients that I came in contact with (true, I was at a government hospital, so I was exposed to a lower-income portion of the population) owned their own glucometer, so day-to-day they had no idea what their blood sugar levels were. If they were extremely compliant (rare) they attended the diabetic clinic every two weeks and had their blood sugar levels measured and medications adjusted accordingly, but more realistically patients would attend the clinic once a month. So that’s one or two blood sugar reading a month for the average Ugandan who is lucky enough to live within traveling distance to Mulago and willing to sit for 4 hours to get a reading and a refill. Moreover, patients do not really take the blood sugar management seriously (or perhaps are not diagnosed as diabetic) until they have serious sx like neuropathy, visual problems or circulatory problems that cannot be reversed with treatment, so when they try to follow the doctors orders in hopes of “getting better” they are often disappointed. It is way easier to sell a cure than it is to sell “do all of this and you won’t get any worse…maybe.” So this poses a problem for practitioners. We need to catch patients earlier and make blood sugar control more manageable for the average person.

Diet: Soda is extremely popular here. Most people who can afford it drink at least one a day if not more (coca cola has done an amazing job marketing to the Ugandan public) The major affordable staple foods are starchy, often fried and void of protein and the rare teaspoon-sized serving of greens that appears on a plate packed with rice, matoke and cassava has been boiled to a mush…not so many vitamins. So the average Ugandan who seeks medical care at Mulago probably eats something like three servings of starches per day, something fried, something sweet and then if they’re really lucky, a protein source, probably beans, or on occasion chicken! When a doctor tells a poor patient to eat plenty of protein, cut down on the fried foods, limit the sugars and try to eat a lot of vegetables, it is just not a practical change. Vegetables aren’t commonly eaten and they’re more expensive than a plate of matoke (like mashed plantain) that will fill your growling belly much more effectively. The price of food, the foods available, the economic infrastructure, these things all need to change if the poor are to be well nourished, instead of just fed to the point of not starving. The sad thing is, once a poor person who has diabetes gets to the point of neuropathy in the feet, chances are injury (no shoes) and infection (poor hygine) will lead to amputation or other serious complications very quickly and the vicious cycle continues, because who can work with no feet or one hand?
I will admit that diabetes has typically been labeled as a disease of the affluent. There is some truth to this, but more and more, diabetes is developing in even the poorest of populations. This makes sense when you consider that starchy, sugary or fried food is often the cheapest and most filling.

Exercise:
I love running. I adore it in fact, and yet here in the equatorial heat I have to force myself to get out of bed early three times a week to go jogging through crowded smoggy streets where people stare at me wondering what the heck I am doing. There is no “the pedestrian is always right” rule here, quite the opposite holds true in fact because the law of the road is “biggest thing wins.”
With the traffic risks and the weird stares and the hopping-over-dog-poo-and-waste that accompany any jog within city limits, it is not a stretch to see why running hasn’t really caught on here. Many people walk during the day, but exercise for the sake of it is not really part of daily life (unless you’re a young guy whose mother still cooks for you and does your laundry, in which case you probably play soccer for several hours a day and sport Manchester United t-shirts) Walking is good, yes, but unless walking is already a part of your lifestyle, its hard to integrate it. If you are a 45 year old woman, newly diagnosed with diabetes, chances are you have between 3 and 9 kids and it will be hard to fit 30 minutes of burden-free walking into your day that is already packed with cleaning, cooking and laundry.

Bleak! I know! Diabetes is a hard disease to address here, or in any developing country for that matter. It was so hard for me to see the diabetic patients in the endocrine ward slowly deteriorating, losing a hand or a foot along the way due to injury secondary to the neuropathy and poor circulation characteristic of advanced diabetes. They seemed to have the attitude of “well, I’ll take these pills and we’ll see what happens next.” How do you change something that arises from such strongly established cultural norms? Start small and hope for the best I suppose.
Side note: Christine’s old professor worked for many years in Kenya with an AIDS support organization (how to live a positive life with AIDS etc). One of the things that she would encourage patients to do is eat raw veggies because they have so many vitamins and nutrients. If you have ever been to Kenya (or Uganda) you will know that raw veggies are simply not a part of the every-day diet. People don’t eat a lot of veggies. So, the people in the program started eating raw veggies, and before long there developed a stigma “if you eat raw veggies, you must be HIV positive,” so people were even less likely than before to eat raw veggies for fear of being labeled as HIV positive! It just goes to show that every action you take will have ramifications (both good and bad) that you could never foresee.
I feel that education is the first essential step to addressing the problem of diabetes in Uganda. The more people know about it (how to recognize the sx etc) the earlier it will be caught and the longer the advanced sx can be delayed. However, education is only a first step along a long path. Even if people know all about diabetes, they have to have the means to alter their lifestyle according to the Dr’s orders…this is more complicated as it ties into social, economic and cultural issues. Poverty, of course, is the main problem, just as with many diseases in the developing world. Give the population a means to thrive, lessen the gap between the rich and the poor, educate the populace, give people hope and a sense of stability and diseases will lessen. Man, what a daunting task lies ahead, because diabetes is going to sky rocket here in the next 20 years.