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