How Embwangeni got its diabetes clinic

Malawi. At the hospital diabetes was rarely talked about during the morning reports. When digging deeper the assessments showed that the hospital had no structured way of managing people living with diabetes in an outpatient setting. Furthermore, the community was not aware of the signs and symptoms of diabetes, and the clinical staff was uncomfortable managing people living with diabetes. Finally, knowledge of diet and lifestyle was not well disseminated. That was why no one talked about diabetes.

Many had family members with diabetes
But the verbal absence didn’t mean that diabetes was absent. “When I would speak to people in the community or even hospital workers about diabetes I was surprised at how many people had family members with diabetes or that had died from diabetes. A lot of them were people that I knew well. Four of our own staff members had diabetes,” says Andrea Thompson, the nurse behind the assessment.

“I talked to one man with diabetes about diet, lifestyle and complications related to diabetes and he had tears in his eyes because he was so happy to learn about the disease and how he could do something about it,” she says.

11 health workers trained
The establishment of the diabetes clinic began with the initial training of one clinical officer and two nurses. One was Mr Fiskani Nyasulu who is now Chief Nurse at the NCD/Diabetes Clinic; the other was Ms Andrea Thompson, a US Peace Corps volunteer. They attended a two-day training in basic diabetes care at Mzuzu Central Hospital which was put together by Dr Theresa Allain of College of Medicine in Blantyre, the Ministry of Health and the Diabetes Association of Malawi. ”From that training I was able to get Dr Allain’s presentation and other information presented so that we could train others at our facility,” says Andrea Thompson. “The three of us trained an additional 4 nurses, 2 medical assistants, 2 clinical officers and 1 patient attendant.” The result is a local team consisting of 11 Malawian health workers now trained to provide basic diabetes care.

Watch: Take a tour of the Embangweni NCD/Diabetes Clinic

Uncontrolled diabetes treated
According to clinical guidelines, it is advisable to diagnose diabetes at an early stage, so that the patient can control and manage his or her diabetes and avoid complications. However, the reality in Embangweni is a different one. “I saw that we were not managing diabetics at all but rather treating them as they came in for complications or acute stages of illness,” says Andrea Thompson. According to Chief Nurse of NCDs & diabetes, Fiskani Nyasulu, this is already changing. “The change I have witnessed since I started working with diabetes here is that people now know about diabetes. They control their diet and the medication they take and they know how to act if they experience hyper- or hypoglycaemia,” he says.

WDF’s support to Malawi includes capacity building and so far more than 600 health care providers have been trained and 22 diabetes clinics strengthened or established. ”Among many challenges related to preventing and treating diabetes in Malawi, first and foremost we should focus on strengthening diabetes care at primary care level. It is essential that the individual living with diabetes can learn to manage blood glucose levels, change diet and lifestyle in order to avoid disabling complications from diabetes,” says Mr Bent Lautrup-Nielsen who is responsible for the Malawi projects.

Biggest challenge in treatment and prevention
While the establishment of a diabetes clinic is crucial to provide a minimum of service to people living with diabetes, many challenges lie ahead. A WHO STEPS Survey for NCDs from 2009 estimated that 5.6% of the population (corresponding to 352,000 people) in Malawi aged 25-64 years are living with diabetes but most of them they are not aware. “According to a survey conducted by the Diabetes Association of Malawi in all 28 districts only 10,000 to 15,000 is receiving treatment in either public or private hospitals which is far below the estimated number of people living with diabetes in the country,“ says Timothy Ntambalika, President of the Diabetes Association of Malawi.

The figures from Embangweni confirm this gap. According to the Malawian Health Surveillance Assistance Office the catchment population covered by the Embangweni Mission Hospital is approximately 33,000 people. Following the estimated 5,6% prevalence, in the hospital’s catchment population there would be around 1,100 people above 25 years of age living with diabetes.* However, at present only 31 patients are registered at the NCD/Diabetes Clinic corresponding to less than 3% of the catchment population. In other words, the 31 patients currently known at the NCD/Diabetes Clinic merely show a tiny bit of the top of the iceberg of NCDs and diabetes.

“Treating diabetes is extremely challenging,” says Chief Nurse of the NCD/Diabetes Clinic, Fiskani Nyasulu. “While struggling for excellence we have problems finding glucometers and sticks, materials for assessing visual acuity, chemistry analysers and anti-diabetic drugs.” Embangweni is a mission hospital and not a government hospital which means that patients have to pay for their medications. This prevents a lot of people from accessing treatment or even being diagnosed until they are very sick.

Nationwide Walk on 14 November
Prevention includes lifestyle changes that are difficult to implement. Poverty and issues of food security make it difficult to maintain a diabetic friendly diet. Furthermore, to be overweight is seen as a sign of wealth. So changing the culture surrounding lifestyle changes and diet is very difficult.

On 10 November the Diabetes Association of Malawi is organising a nationwide diabetes awareness walk “to let the whole country know of the Global Diabetes Awareness Month and World Diabetes Day 14 November throughout Malawi” says Timothy Ntambalika.

*We assume that 60% of the catchment population is aged 20-79, totalling 19,800. 1,100 equals 5,6% of this age group. 

FACTS
Estimated prevalence rate of diabetes in Malawi is 5,6% (WHO STEPS Survey 2009)
352,300 people live with diabetes in Malawi (IDF, Diabetes Atlas 2012)
10,000-15,000 people receive treatment (Diabetes Association of Malawi)
Embangweni Mission Hospital (EMH) has 142 beds
Staff situation at EMH: out of 238 hospital staff there are 0 doctors, 6 clinical officers and 30 nurses