Most people when asked to think about the disease affecting this part of the world might (rightly) come up with HIV, Malaria, and TB. And these abound, to be sure. But as some of these are brought into line, other patterns of illness emerge, particularly chronic diseases like diabetes and hypertension (high blood pressure.) These illnesses are less ‘charismastic’’ than infectious disease, but they have a huge impact on people’s quality of life and their ability to function in society. They are also increasingly the cause of death, accounting for 27% of deaths in Uganda even now. I’m a GP. I’m quite interested in these. Chronic disease management is our bread-and-butter. I’m also interested because I like thinking about systems. I think of the problem of disease control like this. If you want to control an infection, you probably need to find a good drug, or a good vaccine***. But to control a chronic disease, you really need a good system.
Once again, our hospital is at the cutting edge of thinking about this in a rural African context. Every adult patient who comes to the hospital has their blood pressure checked when they arrive at the out-patient’s department. People who have persistently high blood pressure or who are found to have diabetes are referred to the chronic care clinic. This clinic takes place once a week. A nurse and a medical officer review people’s blood pressure or diabetes, check their diet, check that they understand their medication, provide more tablets or make adjustments to the dose if the clinical parameters are not well controlled. There’s an digital template for entering all the data so that each person’s records can be followed from visit to visit.
There are some gaps, though. Some problems are with what we can do here at the hospital. For exampe, there is a really simple blood test for diabetes that can tell us how well a patient’s blood sugar has been controlled over a period of three months. It’s called HbA1c. It is cool because it is such a simple idea. It measures how many of a patient’s red blood cells have a sugar coating and gives the answer as a percent. As red blood cells last a long time, up to three months, it can tell us whether the patient’s blood has been a very sugary solution (poor control), or a nice slightly sweet one (good control). High blood sugar determines the negative outcomes (kidney failure, sight loss etc) in diabetes so this is critical information for the doctors. There are even near-patient test kits for this (that don’t need to be done in a lab, they can be done in a clinic) – but we don’t have these or even the lab test. Even if we had the machine, the consumables, like test strips can be exorbitantly expensive. So in our clinic we have to rely on measuring the patient’s blood sugar at the time they come to clinic. This might be low, because they haven’t eaten in the morning because of coming to clinic, or high (because they’ve had to wait to be seen, so they have just eaten a banana) – so making an assessment of whether someone’s diabetes is well controlled has an element of guess-work. There are other excellent (and simple) tests, like a little mono-filament which can be used to check the sensation in people’s feet. It would be great to have, but we don’t. Incidentally, foot care for diabetics is really important. Anywhere in the world, but importantly here. If diabetes is not well controlled then people loose the sensation in their feet. Here, where most people walk without shoes, having poor foot sensation is risky. If you step on a thorn and don’t notice, and then in some animal dung and a bit of mud, it is a recipe for an infection that can spread, and lead to gangrene (and then to amputation.) Taking care of all these things matters. Eyes are important too. Diabetics can get cataracts and damage to their retinas. Loss off sight means loss of independence, and has a direct impact on the patient and those who care for them. We don’t have enough eye care staff to test everyone who needs it.
Just as some of the problems are challenges for the facility, some of the challenges about chronic disease care are to do with what the patients can do. There may be little understanding of how diet can influence health, or people simply can’t afford or are too bound by habit to change their diets. Sometimes patients can’t come to the clinic when they are scheduled to do so. It can cost a lot to come from far in the district to reach the hospital. So they may only come once they have run out of tablets. And so we ask ourselves, is their high blood pressure because they haven’t had tablets for a few days, or is it because their tablets aren’t working? Sometimes patients have to pay so much to travel to the clinic that they have little left over to pay for their medication. THey collect enough supplies for a month because that is all they can afford, whereas if they had the funds, they could take three month’s worth home and not have to come to clinic again for a longer interval. Or they may not have enough money to pay for monitoring blood tests. Of their home may be in one of the more hard-to-reach areas in this already hard-to-reach district. The only transport available may be by boda-boda. And travelling by this means for an hour or two may not be feasible for a frail elderly person.
So, managing chronic care in this setting is fraught with lots of interesting challenges, both medical and practical. It makes it really interesting.
This is one of the things I have been thinking about during my time here. And after a careful review of the data from the clinic, a research study has been proposed to explore some of these issues in more detail. I hope that this might lead to some transformation of the service into the future. It would be so exciting to see care devolved from the hospital to the level of the community and from a centralised approach to one that is devolved outwards and truly patient-centred. But that is for others to do.
*** Yes, I know, control of infectious disease also needs public health systems…sorry, public health colleagues for a crass over-simplification