Diabetes Clinic

I have spent last Tuesday morning at the diabetes clinic. It is estimated that 5% of the adult population of Malawi has diabetes. The diabetes clinic runs once per month and this morning about 40 people were present. The armamentarium of medication available to the clinicians is very limited, metformin, glyburide, and insulin (beef and pork) either regular or lente. Very few people are on insulin. None of the patients that I have seen today, although in Canada several of them would be candidates for insulin. Several people presented with peripheral neuropathy of different stages.

There was more similarities than differences as to how the clinic was run. Patients arrive at 6:30 am (so before their first meal of the day) to get their fasting blood glucose measured. No one had their own glucometers. In fact, there are barely enough supplies to get the glucometer of the clinic working. People’s blood pressure was taken, their feet checked then a discussion with the clinician about lifestyle modifications mostly nutritional counselling, they have plenty of exercise as most people walk several kilometers per day. No personal transportation to speak of. Nutrition is a challenge. Their diet is very heavy in starches. The main staple of Malawian diet is nsima which is dish of cornmeal cooked with water to dough-like consistency. Potatoes and rice play also a significant role. Little protein (very expensive) and some fruits and vegetables which are locally grown. Being overweight is sometimes seen as a sign of health. Some women are proud to be heavy, it shows to the world that they do not have HIV. There are campaigns to shift that way of thinking and promote more healthy weights. Their relationship with food is very different. If you have been deprived of food or starving in the past you may be more likely to over eat when you have a chance to do so.

Surprisingly (or may be not), very few people with type 2 diabetes at the clinic today were overweight, only one exception. Adherence to therapy is a big problem in view of the price of medications. Some people have a drug plan call MASM but no governmental support here. Today the president of the Diabetes Association of Malawi was speaking to the patients at the beginning of the clinic. He is trying to have diabetes medications covered by the government the same way that antiretroviral agents for HIV/AIDS are covered. One big gap is the lack of access to lab work monitoring. A1c is not monitored and treatment decisions are based on that single blood glucose reading on the morning of the clinic which operates once a month. Very difficult to manage people that way and expect any success at preventing complications. Not surprising to see so many people with peripheral neuropathy. And this was assessed crudely with the point of a pen. Whatever works in a pinch. As to nephropathy, who knows, kidney function is not monitored. Too expensive. As to retinopathy, people are asked if they have any problem with their vision, no retinal exam, not even an eye chart. Even is retinopathy was diagnosed, no fancy laser treatment or intra-ocular injection to curb the progression of complications. So much more could be done with more resources…  I am no sure if Canadians truly appreciate how fortunate they are.

Back to Africa

A lot has happened since my last blog entry. This is the first opportunity that I have had to upload any material to this blog. Even in the large town of Limbe connectivity has been a struggle. I have been using an Internet Hotspot (free Wi-Fi) in the lobby of the hotel. Unfortunately, the Internet has been down for the last 6 days.

Jezman has been attending pharmacy school at Rhodes University. He started in February, has completed his first term successfully and is presently in his second term. We have been communicating regularly over Skype. Jezman is discovering a brand new world full of promises and opportunities.

A new pharmacy technician has now been hired at St. Joseph’s hospital. His name is Thoko. He is 23 y.o. a just recently graduated. This is his first job. Before that he was working with his dad at their family farm. Working on a farm in Malawi is hard work. Only rich people can afford a plow and an animal to pull it. Thoko’s family is not rich so all the labor is done by hand. Turning the soil and all field work is done with simple hand tools.

Jezman was my main contact at St. Joseph hospital so after his departure not much progress has happened at the pharmacy. Checking emails is not part of the usual activities and communication has been difficult. The internet at the hospital is patchy at best, often down all together, for days at a time.

Since I had been working all along on further developing the Inventory management software for St. Joseph’s hospital, I wanted to make sure that it could be fully implemented. To accomplish that I decided to go back to Nguludi and St.Joseph’s hospital. I was fortunate to have my second application to the Leave for change program accepted and have an opportunity to finish the project that I had started a bit more than one year ago.

I have been back to Malawi since Aug 25th. I was able to fly directly to Blantyre which is the town next to Limbe where I will be staying the 3 weeks of my stay. I was greeted by Sister Mary whom I had worked with last year and one of the drivers that I had come to know at my last visit. Very warm welcome and nice to see familiar, happy, faces.

The next day was my start at the hospital. Nothing had changed since my last time, almost as if I had left just for the weekend. Nothing except for the fact that the pharmacy is now down to only one working computer, my old laptop. Jezman had informed me of the state of affairs over the winter. A few months ago, at the Hamilton Family Health Team, we were in the process of changing our computers. In the past, we had donated the older computers to charitable organizations. So this time, I asked for setting aside 14 computers to be donated to St. Joseph’s hospital. Sending them to Malawi has been a challenge. I have contacted DHL (the courier company) and they were kind enough to provide shipping at a discounted price. Unfortunately, I have been trying for over 6 weeks to ship the computer at no avail. For the first 4 weeks my contact at DHL was away in India. She had left instructions for someone to follow-up with me but they never did. Now from Africa, I am trying to coordinate the shipment and I am afraid that it will not happen. I will keep my fingers crossed.

I am been working with Sister Mary and Thoko at fine tuning the software as they are bringing good points for improvements. We did a full inventory count, down to the last single tablet. Many of the inventory items are pretty fast to count, the quantity being zero. This is probable the caser for 1/2 the items on their inventory. I am pleased with our progress so far and things are looking like they will be working well. Every one here is excited about the possibilities that will become available from a management point of view. The process will also be faster for the staff at the pharmacy. So far a win win for every one. 

On a lighter note, I have had the chance to rub elbows with the Malawian National soccer team which are staying at the same hotel as I am. They won against Benin a couple of weeks ago and they are playing Ethiopia on Sept 10th. The stadium is close to where I am staying. I am hoping to get a chance to see the game. I have not watched any soccer games since my departure from Canada. I am in withdrawal. My team (Manchester United) apparently is doing poorly, maybe I am not missing much.