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.

DIABETES CARE WITHOUT BORDERS: THE REMARKABLE PEOPLE OF PHNOM PENH

These are some of the workers at mopotsyo.org an NGO which has success in empowering poor patients with Diabetes.
watch the following videos to get an extent of the good work they do in this country with a horrible past and a great future... these people are part of that future..

THE SLUMS OF PHNOM PENH, CAMBODIA AND WHAT IS A JEWISH ENDOCRINOLOGIST DOING THERE?

I am very lucky to be associated with Maurits and his tireless efforts through Mo Po Tsyo (mopotsyo.org) to control diabetes among the less served and very poor in the community in Cambodia.

This morning he was at my hotel at 6 30 and we traveled by tuk tuk as Phnom Penh was waking up to a Slum area of the city, where one of the Peer Educator of the Network lives. She likes most of the peer educators are from the community, has diabetes and or hypertension and usually has taken good care of themselves and undergone a three month educational course to be designated as a Peer Educator in their region. It was quite obvious that we were entering the deprived part of Phnom Penh, and soon welcomed into the house of the Peer Educator where a group of patients had already gathered and others were dropping in to check the Blood Pressure and Blood Sugar before going off to work. All of them have their medical records in which their efforts are recorded which they carry in plastic bags to protect it from the rain or dust. What is amazing is that, these people, poor by material standards exhibited a solidarity, helping one another, talking about things of common concern which was not just limited to Blood Sugar.. I was so happy to see that even in the slum with very limited resources, more than half of the patietns attending this morning session had good control of Blood Pressure and Blood sugar!  Congratulations to all the Peer Educators..

What is the Jewish Endocrinologist doing there this morning? He was remembering what he had been taught, not in the medical school but the jewish life which has taught to revere the saying of our fathers!

Shammai taught: "Say little and do much" (1:15).

Hillel taught: "Don't judge your fellowman until you are in his place . . . and don't say I will study when I have time, lest you never find the time" (2:4).

Hillel taught: "A person who is [too] shy [to ask questions] will never learn, and a teacher who is too strict cannot teach . . . and in a place where there are no men, strive to be a man" (2:5).

Rabbi Tarfon taught: "It is not your responsibility to finish the work [of perfecting the world], but you are not free to desist from it either" (2:16).

Ben Zoma taught: "Who is wise? He who learns from every man.... Who is a hero? He who controls his passions" (4:1).

OCCASIONAL PLEASURES OF INTERNATIONAL MEDICINE

International Medicine has its own rewards most of which are not quantifiable. The satisfaction of helping others and also abiding by the true nature of the human idea of sacrificing for others. and of course, there is a greater chance of meeting people of your own ilk, than in a medical society meeting in the country of your origin.

A friend of mine had given me some beluga caviar from Iran. i had hand carried it to Phnom Penh and it was resting in the freezer section of the refrigerator, as it should.

I suggested to Maurits that we have dinner at Le Rits and that he bring a nice bottle,which he did. a soft cabernet sauvignon. My country, Australia does not excel in too many things but it does in winemaking and oenology..

a very nice khmer french dinner

a bottle of wine from australia

caviar from Iran

and two like minded souls....

are there other things in life, how many are they?, with such sweetness?

Malacca to Phnom Penh: A Wandering Jewish Endocrinologist

The Wandering Jewish Endocrinologist, in anthropological parlance, The Other who has a Name.. in just a couple of days, so much happens, so much does happen in the course of the day..

The incredible hospitality of the Chinese Lady of Malacca and her gentle husband each with genealogy stretching for pages and who are so proud of their ancient Chinese connections.. regaling stories from the History of China and Asia..But her hospitality was so genuine...

Then on to Phnom Penh, Cambodia where another hero of our times, Maurits, is performing daily miracles. it is a pleasure to be with a person, who is intellectual, erudite and at the same time, more for others than for himself.. A selfish person has no story.. The Maurits Cambodian Model of educating Peer Educators is so successful and impressive..

You see me with Ren, the chief Peer Educator whose knowledge of Diabetes is on par with many of the Nurse Educators in the USA even though he was studying to be a tour Guide when Diabetes was diagnosed seven years ago in this young man..He is nothing short of superb in his knowledge, organization and communication. Maurits delegates authority well and at the same time demands the best of his co workers. Two sessions I attended were both inspiring.. 

Nga is an old friend from Vietnam and it was nice to see her to say Hello, she was on her way to Siem Reap with her family.. I became instant friends with her Niece..

In between all these there was a Secret Gift.. I shall share the bounties of that isolated country when Maurits brings a bottle of wine and we shall dine on Khmer-French cuisine..

It is nice to be part of this world in which so many humble and educated people are sacrificing themselves for the welfare of the downtrodden, oppressed and marginalized..

Food was not neglected during these exciting days, Malaysia as usual was excellent for food and Phnom Penh has not been disappointing either..

AU REVOIR, FRANCE.. I WANT TO GO HOME

This morning the sun has risen and a bright morning is in store..
Just exactly one week ago, around this time, in Toulouse, a father took his two children to school..
the following was written that morning ..


on that morning, whatever their intentions were, an email from Spain, alerted me about the news. Rabbi Sandler ( a french jew, murdered along with his two children, in front of the very same school which he had attended as a child).
I felt suddenly so alone! It was so difficult to get through the day in which I had to counsel my patients about their every day problems..
My two brothers wrote to share the grief. Most compassionate, counseling messages came from a country where there is hardly any computers .. Cuba!
Each of my friends wrote.. I felt so close to them..
There was a total silence from elsewhere..
A thought occurred to me, I need to go home..
But where was HOME? It certainly is not France. Not Malaysia, Not Miami. I exist in the hearts of my friends, my brothers in Portland..also among some in Miami. But most importantly my HOME is where I have compassionate friends, who comfroted me through this grief.. Cuba..
Au Revoir, France; Good Bye, Malaysia, I am going HOME, mi isla Rica, mi CUBA...

Traditional days of mourning is over and I shall concentrate more than ever in the humanitarian side of my work, in memory of Rabbi Sandler, a Jew..he was born and educated in a country where he was murdered also for being a Jew...

19 March 2012 Toulouse, France and I am suddenly so alone

During this day of immense sadness, what comes to my mind is a poem by Pablo Neruda

“It was half past eleven in autumn and I was waiting for someone or another. Time tired of being there with me, little by little left and left me all alone.”

“Never before or after did I feel so suddenly alone. It was waiting for someone that did it…”

Grieving is always lonely but it is sad to be lonely on this tragic day ..

I thought of our revered RASHI  Rabbi Shlomo ben Yitzhaki (Troyes, Fr 1105 of CE), the greatest commentator on the Talmud.

Such incongruities... 

Why do they hate us, asked a young Jacobo Timmerman (Argentina, author of Cell without a number, Prisoner without a name). His mother said: Because they do not understand us.

Night is falling here in the Indian Reservation and I am going to light the candle and say the Kaddish