Taking treatment to the people in EthiopiaBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7120.1472a (Published 29 November 1997) Cite this as: BMJ 1997;315:1472
Ethiopia is a huge country with a population of about 60 million, most of whom live in villages scattered far and wide in the dramatic mountainous landscape. Medical care is provided mainly in hospitals in the towns, with more limited facilities in rural health centres. Treatment for diabetes is available only in hospitals, which may be more than 200 kilometres from patients' homes.
Access to these hospitals is by foot or mule, or by bus if the fare can be paid, and some patients may travel up to five days in each direction to receive their treatment. Diabetic clinics in Gondar in the north and Jimma in the south each care for about 500 patients, but it seemed obvious to us that many, quite understandably, fail to attend, and if they are insulin dependent, must be presumed dead.
The Tropical Health and Education Trust, which is based in London, supports a project which aims to provide treatment for diabetes to the rural health centres which are nearer to patients' homes. The project trains nurses to become expert in diabetes care and provide a high quality service. There have been exchanges of diabetes specialist nurses and doctors between Britain and Ethiopia and the project is now well established in Gondar; the doctor there has already started to provide treatment in 10 rural health centres.
One health centre stands in an arid, isolated, burnt landscape, and is approached over a rough stone yard. The patients wait under the corrugated iron roof on benches, curled up on the ground wrapped in their white or brown shawls, or lying down emaciated and immobile. One young shepherd has walked for five days because he has no money and is remunerated only in kind; a young mother, daughter of a once rich farmer, has travelled for two days by mule; some have come by bus, spending much of their meagre savings. They have all come to see Dr Shitaye Alemu, the indefatigable doctor, who has brought them their lifeline—a supply of insulin.
They enter the cool room—the farmer, the shepherd, the mother of eight, the labourer—most with shoes, some without. Many had taken no insulin since their supply ran out the day before; one had tried traditional remedies for seven months but became ill and lost many kilograms in weight before restarting insulin. Some tried various means of eking out the insulin supply but on insulin free days they might feel weak and tired. Most are thin, some extremely wasted so that you wonder how insulin can be injected, but they demonstrate the ease with which they achieve their injections—a credit to their doctor. One small emaciated boy had developed two inches of fat hypertrophy on his arms, which seemed to be the only possible place for an injection.
A handsome woman of 46 enters the clinic. She had walked since dawn. She was a robust mother, who had survived 12 pregnancies with eight living children. Some had been large babies when compared with others in the village. She had been advised to have tubal ligation but had spurned this method of contraception. Divorce, so often witnessed here, was her contraceptive.
The patients continue to present—the emaciated 15 year old with sticks for legs and arms, and a pot belly, as well as an enlarged liver, a case of Mauriac syndrome, not seen in Britain for decades;the man with a useless hand and another with a deformed right knee; a child with unexplained proteinuria; and a student progressively losing weight with oral thrush and probably AIDS.
The tuberculosis clinic sees more than 2000 patients; we had seen 10 patients with diabetes. But this is one of the first diabetic clinics in a rural health centre—it represents an important achievement. The last patient enters—a cheerful, almost overweight (70 kg) 34 year old mother of eight children: at presentation of diabetes she weighed 35 kg and had almost died. She smiles at her doctor, “I was like a dried tree but you have given me life; my villagers say that I was reborn.”
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