From September 17 to October 5, Dignitas International’s Dr. Colin Pfaff will be cycling from northern Malawi to Nairobi, Kenya to raise awareness about the urgent need for better diabetes care in Africa. Find out how you can support him and Dignitas’ efforts to bring lifesaving health care to people around the world by visiting the Ride for Health page.
By Dr. Colin Pfaff, Dignitas International
It is commonly thought that diabetes and other non-communicable diseases (NCDs) are exclusively the plight of richer countries, but this couldn’t be further from the truth. Diabetes, hypertension and other NCDs are rapidly increasing in poor countries as well, and are expected to become a larger cause of death than HIV. In Sub-Saharan Africa in particular, the WHO is already predicting that NCDs will become the leading cause of death by 2030.
I am a South Africa-trained physician working with Dignitas International in Malawi, and see this burgeoning epidemic fist hand in my day-to-day practice. In the past 4 weeks alone, I have seen four different patients in diabetic comas at the hospitals I work in across southeastern Malawi. They were all brought in unconscious because their blood sugar was too high.
Two of them died – a teenager and a 34-year-old-man that was both diabetic and HIV+. The teenager’s death is almost unthinkable, and so is the death of the HIV+ patient. His HIV was well managed, and his death came from falling into a coma from high blood sugar. In western countries, both patients could have been successfully treated.
Even for the two diabetic patients that survived, management of their condition and consistent access to care is a major challenge. One of them, Christine, is a 12-year-old girl. Both of her parents are not available to care for her, most likely because they have died. Christine was diagnosed with diabetes a year ago and was being treated with insulin injections. When the relative she was living with in Lilongwe, Malawi’s capital, also died, she was sent back to her home village to live with her older sister. Her sister did not know she was taking insulin – or anything about diabetes – until Christine grew weaker and weaker and eventually became unconscious.
Measuring blood glucose is a simple procedure, involving a finger prick of blood inserted in a small hand-held device. In western countries, most diabetic patients have their own device. But the 200 bed hospital where I saw her had only one functional machine that was shared between three wards. As Christine initially had to have her blood sugar measured every two hours, this made care very challenging. On my second visit, her blood sugar hadn’t been measured all day.
When I saw her again a short time later for a follow up examination, she had two lingering wounds on her toe and her heel that were healing slowly but still infected. There is considerable risk that this infection may spread and require her leg to be amputated, so I am hoping she can attend weekly until the wounds have healed.
At the same clinic, I also saw Victor, a 14 year-old-boy. Victor is diabetic and has been using insulin for two years. He lives in a remote village about 1-hour journey from the hospital that borders on the Liwonde Game Park. He came with his twin brother as both of his parents were sick and not able to make the journey on the back of a bicycle and then by minibus. Victor was managing his insulin injections well, but his blood sugar was very high today as the regimen he had been given was incorrect.
In western countries, a mix of short and long acting insulin would be available in a single preparation, often in a pen-like injectable device or even a pump. But in Malawi these two forms of insulin are injected separately, twice a day, in a simple syringe. For a 14-year-old with little family support, poor schooling and a rural home of mud walls with no electricity or running water, this is a real challenge. I teach Victor and his twin about a new insulin regimen, diet and what danger signs to be aware of. I arrange to see him again in one month.
HIV and NCDs
Something that’s often overlooked is that many people living with HIV also have high rates of diabetes and hypertension. I have been involved in caring for HIV infected people since I became a doctor in 1994 – the extra resources that are available now for HIV care were unthinkable at that time. I see many HIV infected teenagers each week, many of whom are acutely ill. But our resources for managing HIV, even in adolescents have greatly increased. This isn’t the case for people impacted by NCDs, particularly teenagers. Though far from perfect, the resources that HIV+ teenagers in Malawi have access to probably gives them a greater chance of survival than those diagnosed with insulin dependent diabetes. I have seen four such teenagers in the past three months, and they walk a very thin line in their chances of survival.
Yet there are so many parallels between treating HIV and other chronic diseases. My desire is that we take the lessons we have learned from HIV care in Africa and apply it to helping children such as Christine and Victor.
People living with HIV are especially vulnerable to NCDs such as hypertension, diabetes and invasive cervical cancer. Learn more about how Dignitas is building much-needed capacity within Malawi to manage this looming health challenge here.