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vendredi 21 novembre 2008

Cambodia: A Delightful Month Past full of Rewards





Dear Friends:

The Last few weeks have been very rewarding since I have received recognition directly and indirectly for my work with the Indians of North and South America.

 

The Office of Faculty Development is pleased to announce that the audio of the SPAHP Distinguished Lecture  presented by Dr. Shaheb is available online at the url below: 

 http://winstream.creighton.edu/spahp/DLSeries/DrShaheb.wmv

 I visited Cambodia in the company of Dr Keuky, President of Cambodian Diabetes Association to which I am an International Consultant. Also present in our group for part or most of the time were:

Dar Buena Suerte Goodman RN , Outpatient nurse Director from the Yakama Tribe Indian Health Services Clinic in Washington State, USA

Mitexi Rosette Stabler and Maria lopez,both graduating doctoral students in Occupational Therapy at the Creighton University in Omaha Nebraska USA

Ron Raab, President of Insulin for life, a humanitarian aid organization based in Mebourne, Australia.

We did  teaching sessions and saw patients in various parts of the country. Mitexi was able to film some of the teaching sessions and they have been uploaded to youtube.

If you go to  www.youtube.com and type in Diabetes Cambodia you will get access to the 11 or so videoclips. It is in English and Khmer so it will be helpful to Khmer speaking patients. The teaching is done at the level of patients and peer to peer educators, so some people in the developed countries may find it too basic. But it is geared for Cambodia.

While I was in Cambodia, I gave a talk during the 5th Annual Diabetes Day at the Health Sciences University in Phnom Penh. Mitexi may upload the video of the lecture to youtube later. I met some delightful and dedicated people during that day, Maurits from MoPoTsyo NGO dedicated to Peer to Peer education; Dr Issakidis from Medicines sans Frontieres, who might stay on in Cambodia after MSF leaves Cambodia and Dr Jim LeGerfo , a wonderful doctor with years of cross cultural experience from the University of Washington in Seattle.

I will upload some of my thoughts on Diabetes and Cambodia on my blog

http://medicoanthropologist.blogspot.com/

 

There were numerous Cambodians who made our stay welcoming and fruitful: first and foremost Dr Keuky, the indefatigable President of the Cambodian Diabetes Federation; Drs Touch Khun and Sopharin, along with Theavy who belong to the CDA, Dr Cham Seam of the Kratie Province, Dr Witchouk from Mongkol Borei Hospital. Thanks also due to Miss MunChing Yong of Kuala Lumpur, Malaysia who played host to all of us at her home in KL and to Ko Maung Maung owner of Mandalay Inn (www.mandalayinn.com) in Siem Reap who was a gracious host to us all.

 

While I was visiting the HoCank tribe of Indians in NE Nebraska, I was interviewed for a video presentation the Transcendental Meditation University in Fairfield, Iowa is doing to assist the Indians incorporate Meditation as a form of complementary therapy for their high rates of Diabetes and Heart Disease.

I thank my dear friend Sandra in Melbourne for a wonderful time together in Melbourne, Australia and the pleasure of meeting MiHuSa there ..

Diabetes Cambodia: Personal Notes




 

Personal Notes

I had the great pleasure of seeing many patients with Diabetes . But the following four patients stood out in my memory

Group A

1.    Director of Health for a Province      STATUS

2.    Owner of a large, busy upscale restaurant   WEALTH

Neither WEALTH nor STATUS guarantees good diabetes care since none is available CONGRUOUS with the needs of the individual patient with diabetes.

Endocrinologists/Diabetologists/GPs with their offices in Bangkok Singapore will not add to the health care of Cambodian patients with Diabetes.

A wealthy woman from western provinces of Cambodia flies to see her Diabetologist in Singapore. Her consultation lasts just over half an hour, comes back always with one prescription or more and more lab tests ordered, with very little education and only BIOMEDICAL and PHARMACEUTICAL follow up is carried out. This is PARTIAL care of the patient and has to be complemented by time, education and knowledge which can be done only in Cambodia in case of Cambodian patients. (then we might even have Cambodian patients from Melbourne and Seattle coming for service!)

Total cost of the visit to Singapore to see the doctor, around 1000 USD.

Kuala Lumpur or easily reached HoChiMinh Ville in Vietnam are no substitutes either for more than just clinical competency.

This pattern cannot be encouraged. ( reminds me very much of the University of Miami School of Medicine, my Endocrine Alma Mater wanting to attract the rich from south American countries to come to Miami! Technical rather than human medicine!)

An alternative would be a TEAM available in Siem Reap

Consisting of

A volunteer doctor from abroad complemented by a Khmer Doctor. The voluntary doctor has to be deeply interested in other cultures (otherwise would they volunteer?) and we can look towards Australia, Europe and USA. Australians and French seem natural choices.

It would be good if they can donate two weeks to four weeks at a time, so that a roster could be drawn for one year at a time.

A NURSE DIABETES EDUCATOR ( Michele Smith RN CDE from the Indian Health Services now serving with UmonHon Nation would be my role model for the position. She has more than twenty years of experience managing diabetes programmes and her recent stint was in North Dakota managing four outlying diabetes clinics, with the help of peer to peer educators, assistant physicians, in an area larger than siem reap province, under difficult weather conditions)( she plans to donate her time in the future, she may be enticed to become a Consultant to the Cambodian Diabetes Association)

Visiting Podiatrist, who would do continuing care of the patients as well as involve in patient as well as educate health care providers in the region

There is a strong role for the model of peer to peer educators ( one per hundred patients a la MoPoTsyo model in Phnom Penh). If the Peer Educator is provided with Internet connections, Dr Yehuda Kovesh would be available constantly and consistently to provide help when needed over the internet or through the CDA website. ( the Indian Health Service Peer to Peer service provides Laptop and internet connection to the educators )

 

IT IS FAR MORE COST EFFECTIVE- FOR THE RICH, POWERFUL AS WELL AS THE POOR- TO PROVIDE CULTURALLY RELEVANT, MEDICALLY APPROPRIATE THERAPY IN CAMBODIA THAN SENDING PATIENTS FOR SHORT MEDICAL VISITS ABROAD OR SENDING PROVIDERS FOR INTENSE EDUCATION IN OTHER COUNTRIES AT SEMINARS.

B.

TWO OTHER PATIENTS STAND OUT CLEARLY IN MEMORY, I SHALL WRITE CASE HISTORIES ABOUT THEM SEPARATELY.

1.    A 19 YEAR OLD PATIENT AT KOSSAMACK HOSPITAL DIAGNOSED AS TYPE 1 DIABETES NOW WEIGHING LESS THAN 30 KILOGRAMS WITHOUT CONTINUAL ACCESS TO INSULIN.

2.    WE SAW THIS PATIENT, A 29 YEAR OLD IN KAMPONG CHAM, WHO WAS DIAGNOSED AS TYPE 1 DIABETES AND BLOOD SUGAR LEVELS UNRECORDABLE BY GLUCOMETERS WITHOUT ACCESS TO INSULIN THERAPY

Fortunately for both of us, they didn’t develop Ketosis. In patient no 2, urine testing for Ketones showed negative results, making me think of Ketosis Resistant Diabetes. We would follow such patients and try to delineate the aetiology of this condition. It is Diabetes, but Ketosis Resistant, such as patients I have seen and cared for in Jamaica as well as numerous American Indian patients who present with Hyperglycemia and ketone negative urine, who are young , in their mid twenties at the time of diagnosis and have other social or chemical factors inducing their insulin resistance. We will follow these two patients in the first instance.

This is the end of my report to Dr Keuky on this eventful visit to Cambodia. I am writing this from Cochin in India.