“One sheriff and two deputies” approach to diabetes in SVG proposed

Fri July 26, 2013

Editor: Whilst at medical school, a friend’s father, a Texas Ranger, who was visiting, was rather interested in the local police uniforms and the network of police stations in Grenada. He noted the size of the island and the population and said to me; “One sheriff and two deputies control an area like this in Texas”.{{more}}

Diabetes is one of the world’s fastest growing public health concerns and in St Vincent and the Grenadines we are already seeing its toll on the public health system. The surgical ward at the hospital is practically a “garage” for the casualties of poor management of diabetes. The loss in productive hours, potential not attained due to amputations, expensive dialysis and kidney transplants and deaths are enough to set us back in the pre-vaccination era. Diabetes is no easy battle and hence I dislike the “Less sugar, Sweeter life” motto that has been used; it just does not address the real issues of life and death.

Diabetes is poorly managed by us. Though diabetes may have a lot to do with sugar, it is more than that, and thus we have to separate simple understanding from facts. The fact is that diabetes is a syndrome that affects the entire body and not simply an issue of consuming sugar or not. Too often, medical professionals give people misleading information while trying to simplify diabetes, thus giving the wrong and sometimes a confusing message. We still have persons believing that they cannot become a diabetic because they don’t “use sugar”. The truth is that persons in the best shape and who consume a proper diet can and do still develop diabetes.

The public health system is the chief manager of diabetes with its doctors, nurses and nutritionists. The truth is that it is inefficient and gets a failing grade. The problems we see with diabetes can be attributed significantly to the diabetics themselves, but the mechanism for the management of this crippling disease needs restructuring. The cost of diabetes to the country is far too significant to ignore, as that cost is on every citizen, diabetic or not. It therefore makes no sense to simply ignore the problem.

The District Medical Officer is normally thrown to the wolves, as this physician does not necessarily have any expertise in this area. If this doctor has faith in a specific medication that is available, he is free to use that course; thus there is a poor line of continuity of management if and when that physician is replaced. The time the doctor spends with the diabetic patient is short, as patients with other acute illnesses await service. With such a system, it is difficult to stem the flow of failing kidneys and legs requiring amputation.

A new-comer to SVG might be fooled into thinking that we have landmines in our country when you see the many amputees. The noted cry from many diabetics is that they don’t want to be sent to the hospital in fear of having their legs “chopped-off” and that is a practical fear. It is very easy to blame the hospital for the many amputations. The problem is far from poor hospital management. In my view the reduction of amputations can be achieved by proper diabetic patient management, rather than trying to save legs one at a time at the hospital.

It is true that ever-scarce resources do not allow us to have a specialized doctor for every medical district and thus the present mode of management maybe due to the limitation of the personnel, relative to the task of patient management. I have raised this issue not to simply make anyone angry by “washing our dirty linen in public” (I have learnt to expect it); but we have to address this issue of diabetes management publicly or it will kill us all secretly, one person at a time.

It is almost unbelievable that there is a structure and central management for HIV, but diabetes, which affects significantly more people and costs us more, does not even have a desk on its own in our health care system. Diabetes is a structured disease with predictable outcomes and we can use that to our advantage. We don’t require a battalion of doctors to manage diabetics. I suggest my principle of “One sheriff and two deputies” in the management of diabetes in St. Vincent and the Grenadines.

The “One sheriff and two deputies” principle will comprise a team headed by a specialist with the existing nurse practitioners, who in turn will each have two existing trained nurses who will receive further training in diabetes management. There are only a handful of medications, situations and possibilities with diabetes management which can be learnt over a four-week period by trained nurses. These “diabetic nurses” will be responsible for managing all diabetics in the community and will spend proper time with each patient. Specific “medical complication of diabetes” can be referred for review by the district medical officer. All patient data in view of medical regimen, blood pressure and blood sugar readings et cetera can be stored on an intranet for continuous assessment by the specialist and his team, ensuring proper protocol and management. The data can be used by central management, who can then deploy resources and monitor progress as seen necessary. Instead of having only one doctor managing the diabetic patients, there will be a team of four comprising of the DMO, nurse practitioner and two qualified nurses at the district level.

The cost of diabetes is significant at present and there will be no future reduction in that cost, especially if we sit and wait for some grant from the European Union, USAID or PAHO. We have to be proactive and solve this problem quickly by ourselves. It is embarrassing and makes no logical sense that we wait for international organizations to give us financing to do a survey on diseases that we already know are killing us. The time to act is now, or we will see our life expectancy drop to less than sixty years.

Dr Wayne Murray