vendredi 28 décembre 2012

PEER TO PEER EDUCATION IN DIABETES: MOPOTSYO OF CAMBODIA


In Praise of Peer to Peer Education Network in Cambodia and its director Maurits van Pelt

 (on the third month of treatment, the blood sugar has become normalized!) Consistency, welcoming and caring approach, solidarity with the patient, lack of hierarchy all contribute to the success)



 (which Doctor in the western world wouldnt like a patient like this: Blood Sugars during one month: 93, 110, 96, 126 mg/dl taken around the same time of the morning; Blood Pressure of 95/66, 118/83, 123/78, 133/89. These are actual patients under treatment)
 (yet another popular Peer Education session in place, the time is 7 AM!)

In Praise of Peer to Peer Education Network in Cambodia and its director Maurits van der Pelt

(medications charted in the personal log)
When I was living in Jamaica, running rural clinics targeting poor people with Diabetes and Hypertension, I became aware of the “ politics of International Aid” and the local actors, who were truly actors in professional clothing, benefitted most.  Attending conferences and training workshop saw them filling the First Class sections of Air Jamaica flights.
I decided to investigate a Swedish grant of sizable amount, to empower women in the countryside, and tracked the expenses and the outcome. I came across a group of people, with no great expertise in that field but chose to attend conferences in Budapest and Alabama and had invited “foreign experts from Sweden” (which is usually a part of the aid deal) who had produced some glossy publication. It was difficult to find what happened to that grant, but with the help of some conscientious civil servants, I found out that the final result of those thousands of dollars was this: Two families were helped to become independent by making bammies. Bammies are a Jamaican cassava bread of indigenous origin, the making of which is a common knowledge among the rural people.
Erudite scholars of International Relations, from Argentina to Germany to Sweden, had cried out against the Elite to Elite transfer of technology, knowledge and cash which was later used against the poor to whom the aid was intended
UKAID Department for International Development  DFID had stated that governance is important in delivering of the aid effectively.
Evidence shows that in order to deliver sustainable international development we must be able to understand and work with its politics.
SOMETHING VERY SIMILAR IS HAPPENING IN THE FIELD OF DELIVERING CARE FOR PATIENTS WITH TYPE 2 DIABETES AROUND THE WORLD, ESPECIALLY THE DEVELOPING NATIONS, WHETHER RICHER AS IN MALAYSIA OR POORER AS IN JAMAICA.
Humble entrance to the poor area and the home where the MOPOTSYO peer education is held
 Cambodia is a poor country, so may not have the latest technology. No technology can replace human warmth and concern.
 Maurits with some of the participants at the MoPoTsyo Peer Education Network
 A Happy Peer Educator in front of her home... Patients arrive at 6 am and by 8 30 am they have all left for work! so that she can rest and reflect on that morning's work and plan.

Those professors from the West and their cronies, these charlatans, aggrandized themselves collecting information like a child does stamps and proudly displaying them in multitudes of articles. What has happened to Nauru (known through their publications to have the highest rate of Diabetes Type 2), but the locals are left to suffer after the charlatans have left with their tents and red carpets. A new breed of locally grown began making appearances benefiting because of their acquaintance with the Gang of Charlatans at International Meetings in their well-pressed suits. They too began writing publishing grandiose plans to save the planet of the “impending epidemic” of obesity, Diabetes etc. Their initial papers were received with thunderous applause by the likeminded, but what happened to these programmes, which were touted as the cure for this “epidemic”?
I became interested in the Peer-to-Peer Education Programme after listening to Maurits van der Pelt, its director at a meeting in Phnom Penh, Cambodia in 2008. From the beginning I had the intuition that here is a method of providing Humanitarian Medical Care in a responsible, culturally sensitive fashion without embellishing ones own curriculum or pockets.
There were many articles throughout the world, talking about the Peer Education programmes, most of which was modelled after the Biomedical paradigm, as a an auxiliary to feed into the existing system, rather than an independent system which would co exist with the current approach (which has failed the patient both in the west and the east if we are to go by the rates of Diabetes Control around the world!).
All had glorious intention, and promised a great deal and within a year or two they all fizzled out but they did get a paper or two published.
Why is the Peer Education Network MoPoTsyo of Cambodia important?
You can follow the track record of the PEN and you can see that it is
Producing good results (in fact comparable to the practices in the west) at an incredible affordable price, less than about 120 dollars per year per patient
And Expanding to other provinces than its origin and increasing the services provided to hundreds more of the poor.
You can read the highlights at

The relevance of MoPoTsyo has never before been acute as it is now. Within two days I read two publications, one from the USA and another from Malaysia:
1.   Primary Care Providers are not capable or have interest to provide counselling in the prevention and treatment of Obesity and thus Type 2 Diabetes as well. This study from the USA.
Bleich SN,Bennett WL, Gudzune KA, et al. National survey of US primary care physicians’perspectives about causes of obesity and solutions to improve care. BMJ Open 2012;2:e001871.doi:10.1136/bmjopen-2012-

001871
2.   High percentages of  medical encounters at the Public Health Clinics in Malaysia are bound to end up in errors dangerous enough for the patient. Most of these errors are preventable.
Results
The majority of patient encounters (81%) were with medical assistants. Diagnostic errors were present in 3.6% (95% CI: 2.2, 5.0) of medical records and management errors in 53.2% (95% CI: 46.3, 60.2). For management errors, medication errors were present in 41.1% (95% CI: 35.8, 46.4) of records, investigation errors in 21.7% (95% CI: 16.5, 26.8) and decision making errors in 14.5% (95% CI: 10.8, 18.2). A total of 39.9% (95% CI: 33.1, 46.7) of these errors had the potential to cause serious harm. Problems of documentation including illegible handwriting were found in 98.0% (95% CI: 97.0, 99.1) of records. Nearly all errors (93.5%) detected were considered preventable.
Conclusions
The occurrence of medical errors was high in primary care clinics particularly with documentation and medication errors. Nearly all were preventable. Remedial intervention addressing completeness of documentation and prescriptions are likely to yield reduction of errors.
Research article
Medical errors in primary care clinics -- a cross sectional study
Khoo E, Lee W, Sararaks S, Abdul Samad A, Liew S, Cheong A, Ibrahim M, Su SH, Mohd Hanafiah A, Maskon K, Ismail R, Hamid MA
BMC Family Practice 2012, 13:127 (26 December 2012)


In light of these things, one admires MoPoTsyo and its Peer Educators (many of whom I know personally and have observed them at work) more. A group of interested citizens of Sentul City, West Jawa is interested in establishing a Peer Education Network, at a very small scale at first to look at and aid in the prevention of Obesity (BMI of over 22 Kg/M2), Diabetes and Hypertension. Mo Po Tsyo would certainly be our model.

It is good to keep in mind that, those of us who have seen it first hand, that the private medical care in the low and middle income countries are not in better shape!

Studies evaluated in this systematic review do not support the claim that the private sector is usually more efficient, accountable, or medically effective than the public sector; however, the public sector appears frequently to lack timeliness and hospitality towards patients.

 Basu S, Andrews J, Kishore S, Panjabi R, Stuckler D (2012) Comparative Performance of Private and Public Healthcare Systems in Low- and Middle-Income Countries: A Systematic Review. PLoS Med 9(6): e1001244. doi:10.1371/journal.pmed.1001244
 The friendly accomodating Chief Peer Educator of Cambodia 
One observation which is important: can you tell the Peer Educators from the patients?  This solidarity accounts partly for the success of the programme. Ignore the two foreigners!