From smoke signals to satellites Long before the invention of phones or even mobile phones, smoke signals were used to communicate messages over a long distance. Story has it that African villagers used smoke signals to warn people to stay away from the village in case of serious disease. Modern technology has refined the communication over long distances – enabling the use of modern medicine in remote and poor areas.  When a mobile clinic moves to rural areas it minimizes the distance patients have to travel for health care. Oftentimes, the cost of transportation for the rural population is as big a hindrance as the cost of care itself. Therefore, bringing care literally to their doorstep is a tremendous advantage for these people. Since 2005, the World Diabetes Foundation has supported mobile diabetes care projects with the objective of bringing quality care to areas where most diabetes complications would otherwise go undetected and untreated. So far, 11 projects with mobile components have been granted support. The vast majority of these projects have been in India, the remaining are in Kenya, Sudan and Thailand. The mobile clinics supported by the World Diabetes Foundation fall within three categories: eye clinics, foot clinics and comprehensive diabetes clinics. Eye care through space Patients waiting outside the mobile eye care unit in Tamil Nadu's Kanyakumari district.   Aravind Eye Hospital in the state of Tamil Nadu was the first project to introduce a mobile screening unit by using a satellite connection to detect new cases of retinopathy. Since then, four other eye projects in Karnataka and Tamil Nadu have replicated the model and extended care to rural areas. They have conducted professional consultations and medical procedures in remote areas where no secondary and tertiary eye care services were previously available. Throughout all the mobile eye projects, close to 300,000 people have been screened for diabetes and almost 25,000 have been diagnosed with diabetic retinopathy. 21,856 of these have been given sight saving laser treatment. The original Aravind project had a fundus (retinal) camera in the mobile van to examine the eyes of diabetes patients. The camera was connected via satellite to the base hospital and sent the images directly to the ophthalmologist stationed at the base hospital. He could then diagnose and advise the patients on the next course of action before they left the mobile van. The same set up has been used in another project in the Kanyakumari district of Tamil Nadu as well as in the project run by the Sankara Nethralaya Vision Research Foundation in the state of Karnataka.   Eye care on shock absorbers The Nayana project run by Vittala International Institute of Ophthalmology uses a different mobile approach. In a specially constructed vehicle, they transport delicate equipment into rural areas and offer screening and laser treatment on site. In the three years which World Diabetes Foundation supported the Nayana project, the mobile van travelled through 13 districts in the state of Karnataka, covering more than 161,000 km and performing laser treatment on 7,744 persons. The long-term success of the project is that it has become a model for public and private non-communicable disease initiatives. Project responsible Dr. Praveen Murthy ascribes the success to the sound economic model: “It takes into account local ophthalmologists’ satisfaction, local patient compliance and professional satisfaction for all parties involved. Local ophthalmologists often do not have the resources to invest in advanced equipment, but when it is brought to them by van, they have an incentive to invest in their own training as well as in the van itself,” he explains. As part of the Nayana project, 107 ophthalmologists have undergone continued medical education on diabetic eye disease and 229 general practitioners have received general diabetes and diabetes related eye condition training.    Dr. Anil Kapur, Managing Director of the World Diabetes Foundation, has followed the retinopathy projects in India closely: “These projects all work on the principle that poor people may neither have the knowledge nor the means to go to hospitals for check up, thus by reaching out to the community, the most vulnerable sections of society get the opportunity to be screened for diabetes and one of its most serious complications,” he says. The Foundation has granted support to two new mobile eye projects: one in Uttar Pradesh in India and one in Thailand. The mobile eye clinic in Thailand was inaugurated on World Diabetes Day 14 November this year. The newly inaugurated mobile eye unit in Thailand. Foot care to rural areas The only mobile foot clinic currently supported by the World Diabetes Foundation is based on methods developed in the mobile eye care projects mentioned above and exemplifies how innovative ideas are replicated from project to project. The mobile foot clinic is equipped with the most advanced gear for screening and foot care treatment and manned by two or three nurses, a driver, a secretary and a ward boy, all trained in operating the equipment and patient counselling. When the Karnataka-based Padasamrakshane project started in 2006, Bangalore’s 7 million people only had one well-equipped foot care centre. Furthermore, the semi-urban and rural areas surrounding the city had no foot care centres. On average, people with diabetes living in remote rural areas are diagnosed four years later than people in urban areas. A consequence of the delayed diagnosis and poor access to care is higher rates of diabetes-related complications.   A patient's foot is examined inside the mobile foot care van using modern technology.   As mentioned, a mobile clinic is of particular importance for people in rural areas because it brings care which they would otherwise never have access to. The Padasamrakshane foot care project has trained health care professionals in diabetes foot care, assisted in establishing foot care centres across the state and established a mobile foot clinic to bring advanced foot care treatment and education to underserved rural areas. By the end of the project in May 2009, 10 foot care clinics had been set up across the state and more than 26,000 people had been provided screening, treatment and education on diabetes-related foot complications. Every month, the mobile unit makes 20-22 visits to rural areas within a 150 kilometre distance of Bangalore. Comprehensive rural care While the above-mentioned specialised mobile eye and foot care units address specific diabetes complications, the Chunampet Rural Diabetes Prevention Project in Tamil Nadu’s Kancheepuram district uses a more comprehensive approach to include primary, secondary and tertiary prevention. The mobile part of the project is the use of a fully equipped tele-medicine van which travels in the Chunampet cluster and screens people in rural areas for diabetes and related complications. To date, 24,018 people from 42 villages have been screened, especially for eye and foot complications. While the satellite on the mobile van is connected to an ophthalmologist in Chennai, the wider idea of the project is to establish a rural health centre focused on diabetes in Chunampet. The tele-medicine van in the Chunampet Rural Diabetes Prevention Project, Tamil Nadu.   By combining outreach via the tele-medicine van with a base health centre, the project aims at addressing prevention of diabetes in rural areas at all three levels - primary, secondary and tertiary. In practice, community health workers prevent diabetes (primary prevention) through health education to the rural population. Prevention of complications (secondary prevention) is done through patient education on diabetes management as well as conducting foot and eye care. Tertiary prevention (of further diabetes complications) is carried out by sight saving laser treatment on site. The holistic approach significantly improves access to care for the rural population, and as noted by the project responsible Dr. Mohan, “The improved accessibility enhances the frequency with which patients come for follow-up visits, which again affects their HbA1c-levels positively.”  A similar model is being replicated in Sudan where a mobile diabetes unit commenced operation in February 2009 from Dongola City in the Northern State. Monthly visits are scheduled at nine satellite diabetes clinics. Mobile diabetes clinics supported by the World Diabetes Foundation Mobile eye clinics Mobile diabetic retinopathy treatment (WDF05-110), Diabetes eye care I (WDF02-039), Eye/Tele-screening for diabetic retinopathy (WDF04-091), Eye/Diabetes eye care III (WDF05-148), Eye/Diabetic retinopathy integrated programme (DRIP) (WDF06-163). Upcoming: Mobile treatment for diabetic retinopathy (WDF09-487), Mobile eye care, Thailand (WDF08-395), MoH Mobile foot clinics Foot/Rural diabetic foot care (WDF05-142), Diabetic foot care Kenya (WDF07-302) Comprehensive mobile clinics Preventing diabetes and its complications in rural areas (WDF05-115), Mobile diabetes care delivery Sudan (WDF06-164)

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