Rural health success story, a glimpse from Zakiur’s team, Bangladesh

 

Dr. Md. Zakiur Rahman

Bangladesh is a sovereign country in South Asia, located at the apex of the Bay of Bengal. It has a 600 km coastline with the longest beach in the world and various islands, including a coral reef, home to 700 rivers, most of the world's largest mangrove forest and is one of the most densely populated countries (eighth) in the world. The predominant ethnic groups are Bengalis, along with numerous minorities, including Chakmas, Garos, Marmas, Tanchangyas, Bisnupriya Manipuris, Santhals, Biharis, Oraons, Tripuris, Mundas, Rakhines etc. The state religion and the majority is Islam, followed by Hinduism, Buddhism and Christianity.

Bangladesh

Though we are improving now as a low middle income country, we have a population of over 150 million and rural people comprise 77% and 60% live below the poverty line. Our healthcare infrastructure comprises of 3375 UHFWC, 82 types of district level hospitals and 83 recognized medical colleges. The total number of hospitals in Bangladesh is 1683, of these 678 are government hospitals , where doctor to population ratio is 1:43,660 and nurse to population ratio is 1:8,226. Bangladesh is one of the 6 countries of the IDF SEA region; 415 million people have diabetes in the world and 78 million people reside in the SEA Region; by 2040 this will rise to 140 million. In 2015, there were 7.1 million cases of diabetes in Bangladesh.

My 36 member team of Bangladesh Disease Research Institute ( BDRI) and I have successfully done 5217 diabetes screenings with the help of Novo Nordisk foundation and Biotrade on the occasion of World Health Day and service month of BDRI. My team members had taken so much pain to reach some places where no vehicle was available, even walking was very hard. In April 2016, we did several free health camps in and around Dhaka along with remote villages where the villagers never experienced free health camps; treatment of various diseases handled by family physicians with diabetes screening and limited free medicine provision.

I would like to share one experience of free health camp with the intention to encourage some of you to serve the under privileged and very poor rural people. Most of you will be hearing of Gopinagar for the first time, where we start our rural journey for diabetes screening. It’s about 160 km from the capital Dhaka in Bangladesh under Mymensingh district (to reach there we use bus, rickshaw and boat). People still enjoy radio as their recreation, as no electric supply there and TV is rare, run by battery. Mobile phone is very popular nowadays, almost every home has at least one with limited or no connection with internet. Their health seeking behavior is so poor that they still believe in kabiraj, ojha and quack (unprofessional, slightly educated and wrong learner). They think diabetes is a curse that is for sugar and carbohydrate restriction as he/she finished lifetime sugar and carbohydrate quota. They are not interested to diagnose as well. Although we offered free diabetes screening and consultation, some people did not allow their women for it. After meeting with the village leader and our motivational speech (as family physician) they agreed to help us. Finally we screened 232 people and found 47 in IGT (RBS=7.8-11.1mmol/l) and 12 diabetic (RBS=>11.1mmol/l); among them one DKA(our glucometer failed to read, later confirmed by HbA1C & OGTT). Patients were subsequently managed by endocrinologist in our diabetes center.

We didn’t know that the most memorable scenario still awaited. A 56 year old lady came to us on a handmade ambulance (no engine, rather shoulder of two people with the help of bamboo) where no engine oil is needed. For last two days she was semi conscious suffering from diarrhea and was newly detected diabetes case and on insulin. On quick examination we found GCS not satisfactory; pulse & BP suggested hypoglycemia. Without any hesitation we managed to start a channel for glucose that we had. After 30 minutes patient responded to pain stimulation and finally she communicated with us. This is usual for medical professionals but what a pleasant surprise for us that villagers thought we were second to God. One of the patient’s attendants told us that she was declared dead and prepared for funeral and they came here after hearing the health camp with intention to confirm the death.

That is the beauty of Family Medicine. When, where and how far we are was not important, we only needed love, hope and inspiration to serve mankind. We can see patients any way even in remotest places with limited facilities. Do love Family Medicine and Rural Health. Born out of desire of the villagers, we plan to visit monthly with the vision of rural satellite clinic and to set up rural community clinic in the future if opportunity arises.

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Dr. Md. Zakiur Rahman

Faculty of family medicine, Bangladesh College of general practitioners & Bangladesh Academy of family physicians, Dhaka. Consultant family physician, special interest on diabetology, BDRI. Professor of Microbiology, Monno Medical College, Manikganj. Chairman, Bangladesh Disease Research Institute (BDRI), Dhaka. National secretary, Spice Route Movement Bangladesh. Co-ordinator, Primary care forum Bangladesh. Email : profzakiur@gmail.com Facebook group : Primary Care Forum Bangladesh.

Maternal health in rural Uganda

A desperate pregnant woman carrying her toddler on her back struggles, walking alone from a remote village to our hospital. She is hemorrhaging as she slowly trudges through the Bwindi Impenetrable Forest. Just as she exits the forest she collapses. A passing motorcyclist notices her lifeless form by the roadside, straps her to the seat, and transports her to our hospital.

  Many members of the medical staff of the Bwindi Community Hospital are celebrating at a party for a medical student from England, Danny, who has finished his rotation. He will soon to return to the UK so they have prepared a gala affair that comprises a roasted goat, dancing, and much good cheer. Our revelry is interrupted by the cries from a breathless hospital nurse: “ija, juba, juba!!” or “come quickly!”

We race down to the obstetrics unit. It has already been an  exhausting day, having delivered 12 infants—four by cesarean section. I glance at the OB ward, again filled with mothers in labor. The nursing staff’s attention is focused on the motionless, exceedingly pale woman lying on the exam table who has been trudging through the forest; we don’t know her name or who she is. She is in shock from massive blood loss. She has no recordable blood pressure but she does have a thready pulse. Venous access is gained through a jugular vein and blood arrives. Two nurses are assigned to manually squeeze the lifesaving liquid into her listless body. Soon her pulse becomes stronger, but an absent blood pressure persists; her only hope for survival is an operation to repair her ruptured uterus.

Not so many years ago this type of surgery would have been unimaginable in this area of rural Uganda. I had come to southwestern Uganda in 2001 to assist with the Batwa pygmies who had been evicted from the Bwindi Impenetrable Forest several years earlier when it was gazetted as a World Heritage Site to protect the endangered mountain gorillas. The Batwa had received no compensation and had become conservation refugees.

Estimates in 2000 were that the maternal mortality rate in the rural southwestern region of Uganda was 880 maternal deaths per 100,000 live births. For every 113 births, a mother had a tendency to die in pregnancy. Over the last decade, a 120-bed hospital has been constructed that includes a maternal health unit and operating theatres. The Bwindi Community Hospital’s chief focus is on improving maternal and child health.

One of the predisposing causes of this high maternal mortality rate is the long distance a mother may be required to walk to access medical care as this region of sub-Saharan Africa has no paved roads and lacks public transportation. If a laboring mother has had a previous caesarian section or has problems with the current pregnancy and begins the one- to two-day journey to seek medical care, then both the mother’s and child’s lives will potentially be in jeopardy. To address this problem, the Bwindi Community Hospital has a 40-bed Waiting Mother’s Hostel on campus, where pregnant mothers can sojourn until delivery. For a small fee of $1.25, a mother may remain at the hostel for days, weeks, or even months. Here the mother is provided a bed, access to a communal kitchen, and laundry and bathing facilities. Additionally the mothers are offered maternal education, daily rounds by hospital staff, and immediate availability to vaginal delivery or caesarian section. As a result of the Waiting Mother’s Hostel and access to quality obstetrical care, the maternal death rate has been reduced by over 60 percent.

It is fortunate that this pregnant, hemorrhaging mother has found our facility, but sadly her unborn baby is dead.  At surgery, a macerated infant is delivered through the rent in the ruptured uterus. Despite ergometrine, uterine massage, and over-sewing of the uterus, the uterus remains atonic and the bleeding continues unabated. A decision is made to perform a section-hysterectomy. The medical student assistant and I pray for surgical skills and wisdom, and then we begin the difficult surgery. After another hour, the bleeding has ceased and the mother has an adequate blood pressure.

I return to the guest house at 2:00 a.m., the stars above sub-Saharan Africa shining brightly. The Southern Cross and Alpha Centari seem to point the way home. As I approach the guest house, I am surprised by the sounds of music; Danny’s party is still in full swing. Everyone is elated that the woman has survived the operation, and the dancing continues until the wee hours of the morning.

The next day, the woman emerges from her coma and relates her story. On her difficult, lonely two-day trek through the forest, carrying her only child on her back, she knows that she is dying. Her hope is that she can make it to the hospital, and then everything goes dark. She wonders if she is dreaming when needles are being poked in her and prayers are being made for her survival. When she awakes with her toddler lying next to her, she sheds tears of happiness, rejoicing that her son still has a mother who can raise and love him.

Her name we learn, appropriately, is Victoria.

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Author - Dr. Scott Kellermann

Adolescent health challenge - Type 1 DM

Dr.Smruti Mandar Nikumbh –Haval

About a young boy and his journey with diabetes mellitus type 1

One evening when I was busy in writing for my next publication my father in law called me when is my next OPD day.He was dealing with a young 17 year old boy who approached him for his complaints of weight loss (8 kg in 3 months),polyuria,polydypsia,hair fall,easy fatigue and vague abdominal discomfort.He advised relevant investigations and to his surprise his random blood glucose was on higher side 456 mg/dl. Now that was alarming as we were about to diagnose a type 1 DM patient who was a adolescent boy.

Adolescence or teen age its a age of weird ideas,dreams,ambition of career ,sports, unpredictable twists and turns .But this was a life changing twist.

 That high value of blood glucose alert us to investigate him for diabetic ketoacidosis though he was clinically stable.To our relief kidney function was normal but the fasting and post postprandial values were high and HbA1C was 14.2 with glycosuria. He was having UTI and urine ketones were 3 +.

 Now the next step was encounter with the family and most importantly patient himself.As expected the boy was anxious,irritated and nervous about the whole thing.The emotion was clear on his face Why me?

  He was also feeling sad that now he has to give up his favourite sports.But on other side parents were worried that why there son only got this.Both of them are not so far known diabetic neither any close family relatives were  diabetic.

 It was quite challenging for me to handle so many emotions at the same time as a young physician with little experience in this. I set my conversation priorities and told parents that let us thank God that in spite of such a hight sugar he is not in severe DKA. But now we know the root cause of his symptoms now its time for us to work as team and create a strong path for his dreams and a healthy life.

  Parents were feeling sorry that they did not stopped him from drinking excessive sugar cane juice or eating lots of sapata. I told them not to feel sorry as its not the food gave him this stage but its his genetic body that lacks insulin to maintain normal homoeostasis of blood glucose.We can achieve this now with insulin only as OHAs wont work in his case keeping a strong future for him in mind.Slowly as they were understanding the base of the disease and the way they are suppose to tackle  their anxiety was reducing.

Now the next step was fright of daily insulin therapy and pain associated with it.I gave them pen device advice but they chose conventional one.The boy was very anxious as he was feeling like a gunnie pig.Not to forget he was a science student.:P. But this problem to got solved with my Favourite finger rules.That demo reduced there fear of insulin therapy and now one more hurdle crossed.

  This entire process was easy as he was a science student and parents were really co operative and receptive.We gave him lifestyle modification,relevant pharmacological advice.

I know I should have admitted him but his exams were going on hence admission intracath would have increased his stress followed by sugars.So we took challenge and told them warning signs.If any of them appears  to contact us.

 I reviewed him after 5 days.As I always like my patient coming back to me with a big smile.He was from that cadre. Reports were fine,sugars were improving.Most importantly he was feeling much better and his symptoms has reduced .He was trying to learn the art of insulin administration. This was just a beginning. Long way to go. I know I should have done investigations like C peptide level, GAD Antibodies etc but I have some resource limitations. But will get them done soon.

  This case thought me a lot about adolescent patient's psychology, there challenges.

Thank you Almighty for helping us diagnosing him in time and save one life from falling in trap of intensive care.thank you.

Finger rule: 3 finger, 4 finger, 5 finger rule

While taking insulin over arm patient should keep 3 fingers over biceps and triceps, then remaining area is ideal for insulin administration. They can take it laterally when arm is put in supine position .This helped us to overcome the misconception of injection site-“for any injection is deltoid”. Over abdomen, we asked patient to leave 4 finger area from umbilicus. This leads to sparing of rectus sheath and facilitates administration of insulin more subcutaneously. So here patient can rotate sites easily. Over thigh we used 5 finger rule so patient spared quadriceps and hamstrings. Patient can take insulin over tenser fascia lata or adductor compartment. But here chances of absorption via intramuscular route are higher. Hence it’s not an ideal site.

Conclusion

This case thought me a lot about adolescent patient's psychology, there challenges.

Suggestions for strengthening rural healthcare.

To create database or educational materials which will help primary care physician in rural area all over the world in awareness of diabetes type 1 and its complications. Can arrange awareness and screening camps in schools and colleges.

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Dr Smruti Mandar Haval  (Dr. Smruti Subhash Nikumbh)
 M.B.B.S.D.N.B. (Family Med),M.N.A.M.S.,P.G.D. Diabetology  & Geriatric Med.
Certified International Diabetic Educator by Project Hope & International Diabetes Federation (IDF) USA
Consulting Physician in Family medicine, Diabetology, Preventive Cardiology, Thyroid disorders  & Geriatric Medicine
C.E.O. Sukarmayogi Publishers, Sankeshwar Dist: Belgaum, Karnataka
Assistant Professor, Department Family Medicine, USM-KLE IMP,Belgaum
Blog: drsmrutihaval@blogspot.com
          drsmrutimhaval.blogspot.com
Area of practice- Sankeshwar, Dist – Belgaum ,Karnataka

Epidemiology of your area in brief:  It’s an semi rural area covering more than 50 km radius including many villages. Its USP is it’s an border area connecting borders of Maharashtra and Karnataka which makes it an multiethnic area. Common chronic health diseases are diabetes,hypertension,asthma ,hypothyroidism etc.

Good news isn’t something you often hear in the Bush

Floods batter Emerald

Dr Ewen McPhee

 
The popular perception is of barren landscapes, withered communities limping along on hope and prayer. The image of a hard life, of privation and lack of attraction to the young, an acceptance that to live in the country is to be second-rate, a lifestyle choice! Lately my town has been doing it tough, drought, floods, unemployment and mine downturns. One would think there was no good news to be had in this place.

Yet I have been on a 4-year journey with some innovative, visionary people nurturing a new enthusiasm for one aspect of rural life, that of medicine and the delivery of healthcare that is equal too anywhere in this great land.

Some amazing things have happened in those four years.

Within 200 kilometres of my town, should you or your loved one suffer a stroke, a team of paramedics, doctors and nurses could provide you with clot busting drugs that could save your life and reverse severe disability that would have been your future.

If your car rolled over or you were trapped in a ditch experienced doctors would be in that trench, or at the roadside to help keep you alive as “firies” and “ambos” rescued you from a horrible fate.

Queensland Ambulance

For many with severe mental illness access to care in the Bush is fraught, the nearest psychiatrist hundreds of kilometres away, and urgent care often involving long trips. Those same doctors above and their colleagues now worked with Psychiatric Nurses, Psychologists and Social Workers to ensure that you could get the best care under the guidance of remote specialists through telemedicine.

Four years ago midwives and birthing mothers couldn’t guarantee that they would know who would be there to support them. A fly in fly out workforce of itinerate doctors was the accepted standard.

Now you could know your doctor, as you could your midwife, as three young female doctors joined the team to provide expert care for women. No longer was the prospect of giving birth to twins too early a cause for anxiety as these young doctors and their nursing colleagues provided expert care the equal of anywhere in the country.

 

Emerald Hospital Central Queensland

I have been on a journey with over thirteen doctors on creating a resilient, supportive learning community. A group where the care of our community, keeping people as close to home as possible during their recovery, is the main game. I have been humbled by their commitment.

What bought about this change? The answer is simple, yet incredibly complex in its facilitation.

Part of the solution involved many conversations, commitment by Government (Federal and State), Universities and Professional colleges to invest in a vision.

The vision enabled and reinvigorated an enthusiasm for rural practice in young medical students, often those who had grown up in country towns. That vision saw those young students supported and mentored through specialist training in the skills needed to repopulate the Bush with highly trained professionals.

The Rural Generalist Program has been a success for its promise and commitment to rural communities and the passion of its leaders and educators. Yet few would know that the program exists, fewer still understand the importance that it has had in creating a new breed of primary care clinicians (General Practitioners) with the skills necessary to delivery quality, safe and sustainable care to the country.

Another facet has been the relationship between general practice and the generalists, between the training organisations and GP educators. From this core has grown a connectedness with the wider health community in education, training for nurses, ambulance, and allied health.

I have leant the value of a good administrator, and strong medial leaders, of respect for my nursing and allied clinicians knowledge and expertise. None of what has happened, occurred in isolation, rural teams thrive where everyone pulls together and at its centre has been a commitment to the care of my community.

Senator Nash visits Emerald Medical group

You don’t hear good stories often, yet I’ve been part of one, lets hope that it continues to grow, to be valued and respected.

Thanks everyone….

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Dr Ewen McPhee- Rural General practitioner and GP Obstetrician. President Rural Doctors Association of Australia.

Area of practice: Emerald Central Queensland Australia

Epidemiology of the area: Central Queensland 1000klms from the Capital Brisbane and 300klms from the Coastal city and Tertiary Hospital in Rockhampton.  With a three pillar economy of Coal Mining, Agriculture and Cattle, Emerald has a population of 15,000 people serving a district of 50,000. The Hospital sees 350 confinements a year and is the centre for Accident, Emergency and Surgical care for the district. Emerald is served by the Royal Flying Doctor Retrieval Services.