Tuesday, April 24, 2012

Medicine “Off the Map”: Hypertension and Diabetes

     Last spring, I spent an hour each week watching the ABC show “Off the Map.”  The premise of the show was that three American residents came to the jungles of South America to work in a clinic in the mountains. Written by the same writers who gave us Grey’s Anatomy, the show was full of drama, love triangles and rare “exotic” illnesses. The first episode, a giant sea ray imbedded his tail into a man’s leg. Several episodes later, a young man came in with an allergy to coca leaves..…
     Amidst all the “tropical disease” and “exotic illness” there was no mention of hypertension or diabetes. As my attending once  told me hypertension, diabetes are the everyday constants in our service, the “petit dejeuner or breakfast” he said.

      Real Medicine "Off the map" per ABC.     
     The truth is that, in 6 weeks, I haven’t seen any dengue, no typhoid fever, no injuries sustained during a elephant stampede. There are rare illnesses here, fascinating cases I would never see in the states. But the truth is a sizeable part of our service consists of Diabetes and Hypertension.
     In fact, Gabon is experiencing an epidemic of diabetes, hypertension and obesity. Gabon differs from its Central African neighbors in that the gabonese people are relatively well off. One Senegalese friend of mine referred to Gabon as the “Las Vegas” of Central Africa. The country has many natural resources, the most important being oil.  Money flows into the country and although it doesn’t reach all the way down, most Gabonese people live well. I have yet to see a case of malnutrition, no kwashiorkor and every child I have seen, no matter how small, has shoes. (Shoes are my very not objective measure of wealth)
   For this reason, Gabonese people have access to a wide variety of imported foods: starchy, carb rich, sweets and juices. The Gabonese traditional diet contributes to the problem, consisting of mostly tubercules like manioc, taro root and  starchy foods like plantains and rice, as well as a healthy appreciation for locally-produced vin de palme or palm wine. 

Ogooue Distribution, a supermarket in town, is full of imported goodies from the Middle east, Cameroon and Europe, like potato chips and Perrier. .
      In addition, culturally, a bit of extra weight around the middle is not at all a bad thing. It is desirable and even attractive in certain circles. All of these factors come together to create a situation where diabetes mellitus type II, hypertension and obesity are becoming increasingly more common.

       Gabonese dietary staples: Plantains and Manioc (wrapped in banana leaves).
    The adult medicine service has made several important strides in this area. With the help of American public health fellows they have developed tools to educate patients and some are quite popular. My personal favorite is the “Fiche de la Regime Diabetique.” It is a handout outlining the Diabetic Diet, with culturally appropriate dietary options such as river fish, manioc, plantains, taro root, papayas, wild game and mangos. It divides food into three categories: A volonte (unlimited), En quantite limite (in limited quantities), interdit (Forbidden).   
        Dr. Kombila does the best job of explaining the diet to patients.  He, like Dr. Justin, is Gabonese and understands the culture and eating habits of people here very well. He also has a pretty comical way of describing the diet. I have to fight to keep a strait face once he gets started.
     When he describes how much manioc a patient is allowed to eat per day, he extends his arm dramatically, to represent a baton of manioc. Then he uses his other hand to symbolize a machete and says:
“ You take the machete and cut the baton  in TWO. You eat one for you and the other half you give to your grandchildren and the kids in the village.”

   Then when he tells patients where they can find diabetic sugar at the local market. In Gabon, regular sugar is sold only in cubes. Diabetic sugar, which is imported, is loose sugar.
“Maman, the diabetic sugar is in the form of little little little cubes of sugar.” He says, using his fingers to demonstrate. “They taste like sweet but are not sugar.”
   When he gets to the section discussing food in the “interdit” category, he leans forward and speaks emphatically.
    “Candies, cakes, palm wine, you absolutely cannot eat,” Then he adds. “If you even see people eating it, you should go the opposite direction.”
     In contrast, his discussion of food in the “a volonte” category is much more accepting.
   “You can eat ALL the carp in the Ogouue and there is no problem.”

  Several river eels a patient's family caught for lunch.

    His creative delivery makes me laugh at times, but patients respond to his approach. He explains the diet in a way that patients can understand and emphasizes the important points.  
    In addition to this handout, Dr. Justin holds a Diabetes class for newly diagnosed patients twice a month. I found out about the course when a former student of his was admitted to the Kopp for an episode of hypoglycemia. Dr. Justin walked in and immediately called out to the patient: “YOU are the patient?! How could you forget what we talked about in class. Hypoglycemia KILLS.” 
    Diabetes management, in terms of medications, is similar to the US and the main tools in the arsenal here are Daonil (sulphonylurea oral med), Glucophage and Mixtard (insulin). Because of the cost and limited availability of syringes in rural Gabon, my attendings manage some patients on only Daonil and Glucophage, even if they feel they would be better served by injectable insulin.  As always, many factors contribute to decisions about patient management.

     The foods that can be eaten "a volonte" (unlimited) according to the Diabetic Diet handout. A dried fish from the Ogooue River and eggs.

    Most homes in rural Gabon have small tin bowls or wooden baskets that the family chicken can lay eggs in . 
(Pretty great picture of a chicken if I say so myself!)

       Hypertension is a different problem, because the service is ill-equipped to provide comprehensive education. There are no handouts, and no courses. However, I think that the consequences of uncontrolled hypertension are heartbreaking here.
    I remember one patient we saw several weeks ago. She had been living independently in one of the fishing villages on the river. She stopped taking her medication, Adalat (Nefedipine) and Esidrex (thiazide diuretic) several years earlier and was lost to follow up. Her stroke left her paralyzed, unable to fish, unable to collect taro root and plantains. Her family moved her to the city so that they could provide the round the clock care she needed.  It was the first time she had lived anywhere other than the village in which she was born and raised and in which her parents and grandparents lived and fished before her.
      A stroke can be devastating no matter where you live, but I think that there are unique challenges here. There is no rehab in our province (only one service in the capital) and very limited access for those with a disability. The only handicapped-accessible ramps I have seen in the country have been in the hospital and the modest facility is far from being handicapped-accessible. Small aids like adult diapers and mattresses designed to prevent pressure ulcers are not available here.
       My attendings try to provide some education on how patient’s families can rehabilitate their loved ones. They show  families simple exercises to do at home. However the reality is that patient families are ill- equipped to provide 24 hour care, as well as physical and occupational rehab. As a result, many patients permanently lose much of their function and never again approach their baseline function. 

The 2012 Albert Schweitzer Lambarene Fellows.
From the right: Brandis Belt (Public Health Fellow: Yale), Ayesha Rabbani (Pediatric Fellow: BU), Molly Ryan (Public Health Fellow: BU), and ME!
     The current public health fellows (my roommates Brandis Belt from Yale & Molly Ryan from BU) are working to assist the hospital in developing newer educational materials. They are working on a few ideas and strategies to address both illnesses, as well as working on a new adolescent health campaign. Their hope is that if they can educate young people about their health, they can begin to respond to the epidemic by educating the next generation of Gabonese people.

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