The look in your eyes

Years of untreated diabetes left Ms Julia Torobio blind, unable to work for a living and unable to see her children grow up. Like every third citizen in Bolivia, she lives on less than USD 2 a day (1).  But being poor is no guarantee for not developing diabetes; in fact, every tenth citizen in Cochabamba lives with diabetes (2). 

Disruption and losses

Ms. Toribio was diagnosed with type 2 diabetes already in her mid twenties after having been heavily overweight in her youth. At that time she and her husband lived and worked as farmers in their native area, Potosí. But dreams of a better life drew them to the urban area of the City of Cochabamba ten years ago. Her husband worked in the construction business while she was fully occupied taking care of their six children. Treatment and medication was covered by the husband’s health insurance, so she was able to live relatively well with diabetes.

But life changed dramatically for Ms. Toribio and her six children the day five years ago when her husband was killed in an accident. Not only did she lose her husband; she also lost the income the family lived from – and the health insurance which had hitherto enabled her to live with diabetes.

As a consequence, she stopped taking her insulin. The lack of medicine deteriorated her health so critically that she became invalidated and dependent on her children because she could not move due to pain in her hands and feet. One and a half year ago she lost her eye sight.

With a little help – and a lot of solidarity

At this very critical moment, Ms. Toribio heard about the Vivir Con Diabetes Centre through a distant relative. The Centre is Bolivia’s first of its kind for integrated diabetes care and attention. Since 2003, when the Centre acquired its first physical space, it has grown from only offering diabetes education to now offering specialised treatment for patients with diabetes complications. Two smaller branches were recently opened in La Paz and Santa Cruz with financial support from a World Diabetes Foundation fundraiser project and the Vivir Con Diabetes Centre is gradually extending its reach to become a national reference point for diabetes.

Because the Centre operates with principles of solidarity, there are five different pricing categories depending on a social assessment carried out by the Centre’s social worker. Due to this principle, Ms. Toribio was able to break the vicious cycle which her untreated diabetes had turned into. When she first came to the Centre she had a medical, nutritional and ophthalmologic consultation after which she resumed treatment with insulin given for free through the programme Insulin For Life. Shortly after, she had a cataract operation free of cost thanks to the Centre’s PRE VISIÓN programme with the catchy slogan “Don’t loose the look in your eyes”.

But this did not end her woes as it was discovered that she also had diabetic retinopathy that needed laser therapy. Fortunately for Ms. Toribo, the World Diabetes Foundation has funded the acquisition of a retinal camera and laser unit under the PREVISIÓN programme. As a result of the laser treatment she has now regained her sight by 70% and is able to work again and earn a minimum income to sustain her five children. 

Gradual capacity building in the Andes Valleys

For poor people, diabetes may seem like a death sentence – not an immediate one, but one which slowly weakens the body and kills the person piecemeal. The name “Vivir Con Diabetes” resonates the opposite, namely “Living with Diabetes”. And this is exactly the objective of the Centre: to enable people with diabetes to live.

According to one of the founders of the centre, Executive Director Dr. Elizabeth Duarte, “Before we started Vivir Con Diabetes in the late 1990’s, Bolivia had specialised endocrinologists, but there was no place for people with diabetes to go and get information about how to live with the disease. So we started to apply for funding internationally and with support substantial support from the World Diabetes Foundation, as well as others the Centre Vivir Con Diabetes has now been established in Cochabamba with two outreach points in La Paz and Santa Cruz.”

There are currently around 4,300 diabetes patients registered at the Centre which is manned by 28 staff members in total. With the support from the World Diabetes Foundation, more than 600 individuals have been trained as diabetes educators and under the Foundation’s peer-to-peer programme, one diabetic foot specialist has been trained in India. Upon return he has set up the country’s first diabetic foot specialist point at the Centre in Cochabamba.   

No pierdas la luz de tu mirada

The aforementioned PRE VISIÓN programme with the Spanish slogan “No pierdas la luz de tu mirada” (Don’t lose the look in your eyes) was initiated in June 2008 and planned to run for two years. The objective was to prevent blindness due to diabetic retinopathy in the Department of Cochabamba. With the procurement of the most necessary ophthalmic equipment including a digital retinal camera and a laser machine, the Centre has established an ophthalmic clinic for screening and treating diabetes patients with eye complications. The digital camera is presently the only of its kind in Bolivia.

The ophthalmic clinic is currently financially self sustainable in terms of consumables and staff salaries. Part of the explanation is to be found in the patients’ fee strategy: 70% of the patients attending the Centre pay full service fee and this covers the 30% of the patients who cannot afford to pay the full service fee but pay according to their individual financial capabilities. A laser treatment at the Centre’s ophthalmologic clinic costs around USD 20 for each sitting. According to Dr. Duarte this is very cheap compared to the private clinics in town which charge around USD 500. The price paid at the Centre mainly covers the salary for the retina specialist who conducts the laser treatment.

Since she got her eye sight back again, Ms. Toribio has been working in the street selling sweets (golosinas). This gives her a daily income of around 10 Bolivianos (USD 1.50) which barely pays the rent for the room where she and her four children and one grand child live. Fortunately, she lives among good-hearted people, so some neighbours gather small amounts to pay the total cost for rent, water and electricity. Thanks to an NGO, her children are able to attend school close to home. Following the diet of a person with diabetes is not a luxury which Ms. Toribio can afford – her concern is about getting enough food for herself and her children. But at least, the vegetables she collects for free at the nearby rural district probably do no harm to her involuntary meagre diet. 

Fewer acute patients

Although Ms. Toribio cannot afford to choose a varied and healthy diet, the services offered at the Centre has still helped her getting back on track – resuming medication and regaining her eye sight. On an overall level, the services rendered at the Centre also seem to have a positive effect on people with diabetes. “At the Centre as well as in private clinics we now see far less acute diabetes patients coming in with for example ketoacidosis,” says Dr. Duarte.

“Hopefully, the important work carried out by the Vivir con Diabetes Centres will catch the attention of the Bolivian Ministry of Health in order to secure that chronic conditions like diabetes are integrated into the country’s health priorities – acknowledging that it also affects the country’s considerable poor population,” says Dr. Anil Kapur, Managing Director of the World Diabetes Foundation, who visited the Centre in late March this year. 

References

1. 65.2% of Bolivia’s population live below the national poverty line (http://hdrstats.undp.org/en/indicators/104.html). 19.6% live on less than 1.25$ a day (http://hdrstats.undp.org/en/indicators/102.html). 30.3% live on less than US$ 2 a day (http://hdrstats.undp.org/en/indicators/103.html).
2. The exact prevalence rate is 9.4% according to Centro Vivir con Diabetes.