Tackling chronic diseases in Ethiopia

Dr Alice Holmes and Dr Arla Gamper travelled to Gondar in Northern Ethiopia in the summer of 2016. There they assisted with data collection for a novel study concerning diabetes. Here follows an account of their time there.

Gondar University Hospital is situated in the Amhara region in the North of Ethiopia. It serves a population of 5 million, 90% of whom live rurally with poor access to the central hospital. There are 9 health centres in rural settings in the region, and much of the success of the work done by Sir Eldryd Parry and colleagues over the last 15 years is evidenced in these centres, where patients’ health care needs are being met closer to their home.

In our first week we travelled to Aykel health centre, 65km outside Gondar, where we met a 36-year-old male farmer, recently diagnosed with diabetes. If this had been 10 years ago, he would have had to travel a full day by foot to see a healthcare provider. Now, he is able to receive medical care for his diabetes within one hour’s walk of his home. This is one example of the major advances that the chronic disease programme in Ethiopia has made.

THET has been supporting the chronic disease programme for 20 years in Ethiopia to improve care of patients with epilepsy, diabetes, high blood pressure and chronic lung disease. The programme has contributed significantly to the strengthening of chronic disease care in rural Ethiopia. Patients with type one diabetes, that means those requiring insulin from the point of diagnosis, have different characteristics to those who are diagnosed with type one diabetes in the UK. The purpose of our work with the team in Gondar was to assist with a study looking at the reasons for this difference.

Previous studies in Ethiopia have described new diabetics as presenting later in life than in the West, which closely resembles the previously described malnutrition related diabetes[i]. The current study hypothesises that this alternative presentation is related to early malnutrition and possibly chronic illnesses in childhood[ii]. We assisted with data collection from diabetics and age and sex matched controls. We hope that the study will help to understand in more detail the nature of this disease which is seen across sub-Saharan Africa. This knowledge could contribute to better treatment options and prevention.

Treating an Ethiopian rural farmer, who may have had no formal education, to manage his blood sugar with insulin is no mean feat. Prior to the chronic disease programme, this patient would have had to travel many hours to Gondar, to collect insulin, often requiring him to take time off work, thus losing essential income for himself and his family. Educating such patients on the importance of good blood sugar control, managing low blood sugar, and preventing the complications of diabetes has been a remarkable success. The dedication and perseverance of Dr Shitaye and her team has enabled these patients to have an understanding of their disease, appropriate local follow up, and a reliable supply of free insulin. The creativity of the patients who have to keep their 3 monthly supply of insulin cool is admirable – they store their insulin in bags of sand, below ground level, ensuring its safety and efficacy even after some weeks in a hot climate.

During our time on the medical ward in Gondar University Hospital we observed the care of patients presenting with communicable and non-communicable diseases. Treating patients with diabetic complications, such as diabetic foot ulcer, highlights some of the challenges of providing effective health care in this setting. On the ward we met a 24-year-old farmer with a diabetic foot ulcer and underlying bone infection. We observed the difficulties the doctors had in managing his blood sugars on the ward. Without basic equipment, such as that to measure blood sugar, doctors are not able to provide optimal care. We observed limitations to acquiring equipment, reagents and medications on numerous occasions, which is a major limiting factor to providing healthcare in Gondar.

People’s understanding of disease and its cause in this area poses another challenge to providing care. Many patients wait for some time before seeking medical advice for their symptoms; consulting a traditional healer in the first instance, who is often more accessible, before presenting to the hospital. This combined with the fact that the vast majority of the population live rurally and many hours from the nearest health centre means that patients come late and with significant complications of their illness. Challenging health beliefs and educating patients about their medical condition is difficult in any setting, but especially here. The introduction of community-based Health Extension Workers over the past few years has contributed significantly to the reduction in maternal mortality, and increased life expectancy, and it is hoped that the integration of these professionals into communities will add to and enable better disease management and health literacy.

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[i] Alemu S, Dessie A, Seid E et al. Insulin-requiring diabetes in rural Ethiopia: should we reopen the case for malnutrition-related diabetes? Diabetologia (2009) 52:1842–1845

[ii] Fedaku S, Yigzaw M, Alemu S et al. Insulin-requiring diabetes in Ethiopia: associations with poverty, early undernutrition and anthropometric disproportion. European Journal of Clinical Nutrition (2010) 64:1192-1198. 

Maximising the potential for further funding in Mozambique.

We asked Sarah Cavanagh, Pharmacist and Peter Donaldson, Consultant Surgeon, to reflect on what they did to increase the chances of their project lasting beyond Health Partnership Scheme funding; by forging links with the Rotary Club they have secured potential funding for the future. Their project aims to develop patient safety programmes at the Central Hospital of Beira, Mozambique.

Tell us more about how you started to engage with the Rotary Club and where you are at now.

We began to engage with the Rotary club fairly early on in our partnership. We attended the 2014 THET conference which provided inspiration in the form of a workshop that covered fundraising strategies, as well as local stakeholder engagement. 

What was the issue?

The main issue was that our partnership did not have a very high profile locally, either within our hospital or in our local community. We also had no certainty that we would secure funding after the project end which is set for February 2017.

Who said or did what, and when?
We presented to Ipswich-Orwell Rotary Club in December 2014, October 2015, July and September 2016. In October 2015 we also presented to Woodbridge Rotary Club. In March 2016 we were invited to attend a drinks reception with local business leaders and our local MP and former Health Secretary, Ben Gummer, who has over many years been very supportive of both Ipswich Hospital and The Rotary Club. We also met with MP Ben Gummer separately, in his constituency office.

Ipswich-Orwell Rotary Club greet Health Professionals from Mozambique

Photograph taken by Eleanor Bull in Ipswich Hospital, April 2016.

What were the immediate reactions and results? What challenges did you face?

Immediately our profile was raised because we had spoken to these influential people. We also had increased press coverage, specifically in The East Anglian Daily Times and the Ipswich Star, through a Rotary-Orwell contact.

We did face some challenges however, as the vision to involve the Rotary Club and seek wider support, as well as additional funding was not universally shared within the team. This led to some debate and delay, but eventually it was seen to be a good idea for the future of the partnership.

What were the longer-term results?

After presenting twice, and without asking for any money, Rotary-Orwell asked whether they could support us financially. They organised a fundraising event in July 2016 and prior to that held a raffle; the two events raised over £700 for the project! As the July fundraising event (Rotary Mastermind Competition) was held in collaboration with the other three Ipswich Rotary Clubs, it has led to friendly contact with these clubs as well as Ipswich-Orwell. The partnership’s involvement has also helped raise awareness of the great work of the Rotary Club and Rotary International.

Sarah Cavanagh presenting the Rotary Ipswich-Orwell banner to Dr Wingi Olivier in Beira 2016

Photograph taken by Eleanor Bull in Ipswich Hospital, April 2016.

Have you solved the problem of sustainability? What will you do next?

We feel that we have to a certain extent solved this problem. There is a much greater understanding and awareness of our partnership both within our hospital and our community, and we have established good links with five of the local Rotary Clubs. After our next visit, in November 2016, we will have a clearer idea of the next steps with the partnership. We will be maintaining our established links with Rotary, with a view to maintaining or even increasing their involvement in the future.

What have you learnt, and what advice could you give to other partnerships?

One of the most important lessons we learned was that asking for money straight away is not necessarily the best way to maximise fundraising, neither is it the best way to forge longer term relationships with potential funders and local opinion leaders. These things take time and it is important to nurture the relationships.

Orwell Rotary Club presenting a cheque for £703 to our partnership in September 2016 for medical and maintenance equipment for Beira Hospital.

Photograph taken by David Vincent, 2016.

Rotary Club and Rotary International consist of 1.2 million neighbours, friends, and community leaders who come together to create positive, lasting change in local communities and around the world. Differing occupations, cultures, and countries give Rotary a unique perspective. Rotary support a variety of causes both at home and abroad. They are specifically identified and targeted to maximize local and global impact. Rotary uses its network of resources and partners to focus service efforts in promoting peace, fighting disease, providing clean water, saving mothers and children, supporting education, and growing local economies. As such this ethos ties in very nicely with Health Partnerships.

If you would like more information on the work of the Rotary Club and  Rotary International, please visit https://www.rotary.org/en/about-rotary

BMET training in Zambia: the money

As described in a previous blog, I am supported by THET to work at a Technical College in Zambia to train local students to become hospital equipment maintenance professionals. In this blog I want to share with you some of my experiences on what it means to be in what the ‘International Development’ world calls a ‘low resourced country’.

Training to become a Biomedical Technician is quite an expensive undertaking. The college is over 90% funded by the fees from students. The main fee is about 300 USD per term (900 USD/year).  On top of that come examination fees (100 USD/year) and housing fees (60 USD/term), for which you have a bed in a small room with two-four co-students plus some facilities. Altogether, that is quite a lot of money in a country where 60% of the population lives below the poverty line and 42% are considered to be in extreme poverty.

Chris Mol lecturing to BMET students.

Our BMET students are usually funded by their family. This includes not only parents, but also uncles, aunts and older brothers and sisters. It is very difficult for ‘older brothers’ with a reasonable income to save money or purchase a house while their (many) younger siblings still require education. These contributions are not considered a loan and won’t be paid back. Money is spent in the family where it is needed.

On top of family funding, many of our students have to work to earn money during their school terms as well as in between terms. The work they do is what they call piece work: washing cars, helping in building works, and whatever else they can find. The salary for this, as for gardeners and house maids, is in the order of 40 cents/hour, if you can find the work!

Students take notes during a lecture.

In this context it is not surprising that many students have little money left for anything that is not an absolute must. Most students do not have a computer and if they do, are dependent on the overloaded network at the college to get internet access. However, most of them do have a mobile phone which is frequently used. The cost of talking is about 10 cents per minute, but many schemes give cheaper access under certain conditions. Also, special offers for ongoing Facebook access are popular. 

Coming from a high resource country, it at first appears to be a good idea to help students by offering them loans to finance their studies or a computer, something that is currently not done by the government. But this becomes less attractive considering the near certainty that such loans will not be paid back, simply because students would not feel this as a strong moral obligation.  And a problem of gifts is to define where to begin and where to end and how to do this in a way that appears fair and does enable you to continue to be related to your environment in a ‘normal’ way.  The advice I am currently following is not to interfere in these matters and consider my teaching of the BMET course and the long-term improvements to healthcare graduates will make as the best contribution I can make.

Your comments are welcome at: chrisr.mol@gmail.com