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.

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