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dimanche 8 avril 2012

DIABETES CARE WITHOUT BORDERS: MOPOTSYO.ORG OF CAMBODIA


I have been very lucky to have become involved in International Health at an early stage of my Medial Career. It was not something that was encouraged or looked upon kindly by my peers or professors in Australia. The only International Medical activities known were those of Christian Missionaries or the AUSAID programme.
After the first year of service as a Junior Doctor we were allowed a very long holiday, during which time I was lucky to have been able to visit some remote parts of the South Pacific: Tuvalu, the coral atolls of Atafo, Nukanonou and Fakoafo(Tokelau,administered by New Zealand), Kiribati, the Micronesian islands of Nauru and Marshall Islands.
Every where one could see the misused kindness of the west: in Funafuti they had to construct a special air-conditioned room to house some of the newer medical equipments but there was no one in the atoll knowledgeable to use them!
The Lessons learned, and later reinforced by working with the Indigenous peoples :  Ask people what they would like and assist them achieve it rather than bring your model of health care and pharmaceutical care and impose it upon them.
In Jamaica, much to the amazement of the well dug in medical fraternity, Upper Class Ladies with time on their hands could be taught well to take care of unfortunate in their realm, mainly Diabetes and Hypertension. But there was no local interest in continuing such an idea, plus the medical hierarchy was not supportive. (Believe it or not, they even spread rumours that I was not a medical doctor, otherwise why should someone from Australia come to do volunteer work in Jamaica?)
It was evident to me, even at that time, that just a physiological approach to chronic medical care was insufficient and a chance meeting with a Medical Anthropologist, Dr Gretchen Lang, pointed out the way to Brunel University where I could get a good understanding of Medical Anthropology under Profs Cecil Helman and Ronnie Frankenberg.


MOPOTSYO.org which is an NGO based in Phnom Penh has been in existence over 8 years, directed by Maurits van Pelt, a dutch Lawyer who has spent all his professional life in International Health, begining with Mozambique, Rwanda and then Cambodia where he has been for 18 years. He speaks reads and writes Khmer . I have heard him speak English, Dutch, French and Spanish to boot!
The idea is very straightforward even though the work of instituting such a programme in the post war Cambodia was gargantuan!
Instead of paying lip service to EMPOWERMENT, actually hand over the power of looking after themselves to the patients. Facilitate that by removing barriers. These barriers are surprisingly put there by the Medical Establishment themselves: high consultation fees, lack of public health facilities, expensive medications, powerful drug companies who want to introduce a western model of drug regime. The society was weak, had suffered much during the vietnam war, covert operations of Air America and others and the horrible nightmare of Pol Pot. Poverty, lack of access and an unexplained higher than expected rate of Type 2 Diabetes, MODY and Hypertension in the population.

I met Maurits in 2008 and IMMEDIATELY knew that what he is doing is what is needed not only in Cambodia but also in many of the resource poor countries around the world that I was traveling through at that time: Myanmar was one such case and also even countries with a very poor record of diabetes care despite money spent, such as Malaysia and Singapour.

Please visit mopotsyo.org for more information about the organization. You may also wish to check out the videos, there are two of them detailing the work of the Peer to Peer Education, http://www.globalgiving.org/donate/11114/mopotsyo-patient-information-centre/

On my recent visit to Phnom Penh, i was able to witness a PEN get together in one of the slums of Phnom Penh. A resident Peer Educator, who has to go through rigorous education as well as pass the final examination, has opened the doors of her house and from 6 AM onwards a steady stream of persons come in, each clutching their Mopotsyo booklet to note the findings of the day. They are weighed, BP taken and a Blood sugar determination is made (fasting mostly but also random). The Peer Educator begins to address the results and concerns of the person: the nutrition chart, very different from the carbohydrate heavy chart of the west, is pasted on the wall. Most of the persons attending are lean, are older people who have Type 2 Diabetes. The audience of waiting persons also chime in with helpful advice. All this : occasional check ups in the laboratory, all the medications (average cost to the patient is four dollars a month, may be higher in a few with many medications), and twice yearly visits to the doctors contracted to check the medications, (2 dollars for two MEDICATION consultations) is financed in an ingenious manner, it is neither charity nor overburdening to the poor people, in a country where a visit to the doctor can cost 25% of their monthly income. The total cost per patient runs around 120 dollars per YEAR per PATIENT. (Per Year: average medicine cost 60 dollars, medication consultations 2 dollars, laboratory tests 4 dollars or 8 dollars if necessary to test more than once, glucose testing by the peer educator at least 4 times a year at 0.30 dollars, total  average cost to the patient is  67.20 dollars. Peer Educators are present in the communities for ongoing education throughout the year)
I could observe the following:
Solidarity of the persons who are suffering. ( Living and teaching in Cuba, I understand well the concept of Solidarity)
An administration which is not hierarchical that demands  RESULTS.
A sense of ownership of their health by the poorest of the poor in the society with no condescension by the medical personnel.
Relevant Education given in a manner that is RECEIVED by the patient. I was so reminded of my American Indian patients who repeatedly would say: we are given education but we dont receive it. MoPoTsyo patients, because of the peer network of education, do receive the relevant education and the incentive to make changes.
A nutritional plan which is relevant to Cambodians, not imported from Australia or France. This is not a Low Fat or Low Carbohydrate or Low Protein diet but nutrition which is available to them in which they can make meaningful changes which would improve their blood sugar. 
The COLLECTIVE counselling and interpersonal comforting brings great relief to the individual sufferer, he or she is not alone, surrounded as they are by poverty or poor resources.

Congratulations to all the Peer Educators of the MoPoTsyo for having Diabetes Control results better than most doctors in the west! see the results for yourself at mopotsyo.org

Merci Beaucoup, Maurits. Muchas Gracias..
http://www.ghf12.org/?p=1541 a precise of a presentation to Geneva Health Forum 2012.