We measure something called HbA1c in blood to get an idea of long-term blood sugar control in patients with diabetes. Lower the HbA1c better is diabetes control. Having sugar under good control reduces the risks of having complications such as blindness, kidney disease, nerve problems and heart disease from diabetes. Typically, we aim for HbA1c below 7%.
I was positively surprised when one patient after another who came to our diabetes clinic had HbA1c consistently below 7%. In North America, I was used to seeing it above 8% most of the times; perhaps it was because we dealt with only referred cases of diabetes who failed treatment in primary care settings. Still, having HbA1cs in so good ranges is rare even in primary care settings as I recall from my residency days. Then why is this difference? Are we doctors doing a phenomenal job at this public hospital?
Before we reach that conclusion, we should look at who these patients are and what they undergo before they reach our office table.
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This is a picture taken in the morning where people are lined up in several parallel lines to get a ticket for visit to a doctor. This is just a small segment of the crowd; the total length of the line is much longer. People start queuing up from 4am. Ticketing counter opens at 8am and closes at 11am. After they receive this master ticket, they then go to their assigned clinics, submit the ticket and are assigned another number. Depending on the number, they may be seen in the morning or it may be late during the day. So, for many of these patients it is a whole day deal. It's not just the time, you should be committed to put up with the push and pull, sniffling, spitting, coughing, body odor, loud cellphone conversations, crying children, rude people, rude counter staff, rude and dictatorial doctors.
In summary, anyone who comes back to see a doctor by going through all this is a very highly motivated patient concerned about her health. We know that the common type of diabetes is a disease of lifestyle and a motivated person can make a huge difference to diabetes control just by simple lifestyle changes and compliance with medications. It is hardly the doctors, but most likely patients themselves who are making the difference. Just our clinic set up is giving a skewed snapshot which when taken in proper context tells us a more complex story.
But what is worrisome is what's happening with the non-motivated ones? Those are the ones who actually need doctors: just to push a little bit in each visit. Diabetes does not cause pain and disability immediately. You can go along with the disease without having much discomfort until complications start developing. The whole goal of treatment is prevention of those complications. This should be happening in the clinics. But exact same patients are missing from our clinics. There are plenty of these patients in our hospital wards who are admitted with complications from diabetes. Our clinics are clearly not targeting the ones who need us the most. And this is a problem if we look at the changing pattern of diseases in our country and the subcontinent.
Even in 2008, WHO estimates attributed 50% of total deaths in Nepal to non-communicable diseases (Source: http://www.who.int/nmh/countries/npl_en.pdf). Most of it related to cardiovascular diseases (CVD), for which a major contributor is diabetes, although diabetes on its own is responsible for a small number of deaths. This pattern of deaths is a change from historical pattern which was primarily of communicable diseases. And this is expected to grow exponentially over the coming years.
The way our clinics run currently are definitely not set up to address the changing disease dynamics. The change is urgent.
I was positively surprised when one patient after another who came to our diabetes clinic had HbA1c consistently below 7%. In North America, I was used to seeing it above 8% most of the times; perhaps it was because we dealt with only referred cases of diabetes who failed treatment in primary care settings. Still, having HbA1cs in so good ranges is rare even in primary care settings as I recall from my residency days. Then why is this difference? Are we doctors doing a phenomenal job at this public hospital?
Before we reach that conclusion, we should look at who these patients are and what they undergo before they reach our office table.
.JPG)
In summary, anyone who comes back to see a doctor by going through all this is a very highly motivated patient concerned about her health. We know that the common type of diabetes is a disease of lifestyle and a motivated person can make a huge difference to diabetes control just by simple lifestyle changes and compliance with medications. It is hardly the doctors, but most likely patients themselves who are making the difference. Just our clinic set up is giving a skewed snapshot which when taken in proper context tells us a more complex story.
But what is worrisome is what's happening with the non-motivated ones? Those are the ones who actually need doctors: just to push a little bit in each visit. Diabetes does not cause pain and disability immediately. You can go along with the disease without having much discomfort until complications start developing. The whole goal of treatment is prevention of those complications. This should be happening in the clinics. But exact same patients are missing from our clinics. There are plenty of these patients in our hospital wards who are admitted with complications from diabetes. Our clinics are clearly not targeting the ones who need us the most. And this is a problem if we look at the changing pattern of diseases in our country and the subcontinent.
The way our clinics run currently are definitely not set up to address the changing disease dynamics. The change is urgent.
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