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INTRODUCTION India is the second most populous country in the world, accounting for 15% of the world population (1). The population in India has grown from 273 million in 1931 to 685 million in 1982 (2), and to 746 million in 1984, as estimated by the Population Reference Bureau of Washington (3). According to the 1991 census in India, total Indian population was 846,302,688. Urban population was 217,611,012 and rural population 628,691,676. Hence, the large population of India poses a major challenge, as the number of diabetic patients would be very high even with a low prevalence rate. This is particularly true because a large number of individuals could have undetected diabetes. When infectious diseases come under better control, there will be a tremendous increase in the number of people with diabetes. India is predominantly an agricultural nation. A vast majority of cultivators are small farmers in villages; about 80% of total population live in rural areas (4). The literacy rate in India as a whole is still very low (about 36%). Shortage of trained personnel for teaching lay people regarding diabetes is yet another problem (4). Emergencies in diabetes can be fatal if not attended promptly. Moreover, successful treatment of patients with diabetes depends on regular contact with the caring physician. There are thousands of villages in India where people have to walk or travel by bullock cart for miles together to obtain even a simple medical aid. A more challenging problem is the scarcity in rural areas of lavatory facilities, which are essential for proper care of diabetes patients (3). In India, facilities for even ordinary clinical and biochemical investigations are available only in large towns and cities but not in small towns or villages. Remedies for diabetes prescribed by native medical men include neem tree leaves, bitter gourd juice, honey, etc. Some quacks have made fortunes selling wooden tumblers made from a particular tree, claiming that cold water kept in a tumbler for a few hours has an antidiabetic action (4). From the above description it is evident that there are many major problems and challenges in diabetic health care in India. Today, the position of India is unique in that it shares all health and economic problems of developing countries, and at the same time the incidence of diabetes, atherosclerosis and ischemic heart disease is not very low. A comprehensive approach is necessary for planning and implementing prevention and control programs for noncommunicable diseases including diabetes with common underlying risk factors (1,5). In 1994, there were 20 million diabetics in India; there will be more than 33 million in 2005, according to the World Health Organization estimates. One in four diabetics will be Indian. Diabetes was responsible for 102,000 deaths in 1998. Up to 75 per cent do not even 161 Diabetologia Croatica 31-3, 2002 1 Sono Scan Centre, Tadepalligudem, West Godavari Dist, Andhra Pradesh, India 2 Vuk Vrhovac Institute, University Clinic for Diabetes, Endocrinology and Metabolic Diseases, Dugi dol 4a, HR-10000 Zagreb, Croatia Review ORGANIZATION OF DIABETES HEALTH CARE IN INDIAN RURAL AREAS M. Bhaskara Rao 1 , Manja Prašek 2 , @eljko Metelko 2

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Page 1: ORGANIZATION OF DIABETES HEALTH CARE IN · PDF fileMetelko / ORGANIZATION OF DIABETES HEALTH CARE IN INDIAN ... Using an estimate of the prevalence of diabetes in India of 1.8

INTRODUCTION

India is the second most populous country in the world,accounting for 15% of the world population (1). Thepopulation in India has grown from 273 million in 1931to 685 million in 1982 (2), and to 746 million in 1984,as estimated by the Population Reference Bureau ofWashington (3). According to the 1991 census in India,total Indian population was 846,302,688. Urbanpopulation was 217,611,012 and rural population628,691,676. Hence, the large population of Indiaposes a major challenge, as the number of diabeticpatients would be very high even with a low prevalencerate. This is particularly true because a large number ofindividuals could have undetected diabetes. Wheninfectious diseases come under better control, therewill be a tremendous increase in the number of peoplewith diabetes.

India is predominantly an agricultural nation. A vastmajority of cultivators are small farmers in villages;about 80% of total population live in rural areas (4).The literacy rate in India as a whole is still very low(about 36%). Shortage of trained personnel forteaching lay people regarding diabetes is yet anotherproblem (4).

Emergencies in diabetes can be fatal if not attendedpromptly. Moreover, successful treatment of patientswith diabetes depends on regular contact with thecaring physician. There are thousands of villages in

India where people have to walk or travel by bullockcart for miles together to obtain even a simple medicalaid. A more challenging problem is the scarcity in ruralareas of lavatory facilities, which are essential for propercare of diabetes patients (3). In India, facilities foreven ordinary clinical and biochemical investigationsare available only in large towns and cities but not insmall towns or villages. Remedies for diabetesprescribed by native medical men include neem treeleaves, bitter gourd juice, honey, etc. Some quacks havemade fortunes selling wooden tumblers made from aparticular tree, claiming that cold water kept in atumbler for a few hours has an antidiabetic action (4).

From the above description it is evident that there aremany major problems and challenges in diabetic healthcare in India. Today, the position of India is unique inthat it shares all health and economic problems ofdeveloping countries, and at the same time theincidence of diabetes, atherosclerosis and ischemicheart disease is not very low. A comprehensiveapproach is necessary for planning and implementingprevention and control programs for noncommunicablediseases including diabetes with common underlyingrisk factors (1,5).

In 1994, there were 20 million diabetics in India;there will be more than 33 million in 2005, according tothe World Health Organization estimates. One in fourdiabetics will be Indian. Diabetes was responsible for102,000 deaths in 1998. Up to 75 per cent do not even

161Diabetologia Croatica 31-3, 2002

1 Sono Scan Centre,Tadepalligudem, West Godavari Dist,Andhra Pradesh, India

2 Vuk Vrhovac Institute, University Clinic for Diabetes,Endocrinology and Metabolic Diseases,Dugi dol 4a, HR-10000 Zagreb, Croatia

Review

ORGANIZATION OF DIABETES HEALTH CARE IN INDIAN RURAL AREAS

M. Bhaskara Rao1, Manja Prašek2, @eljko Metelko2

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know they are diabetics. Studies over the last threedecades show a rising prevalence of non-insulindependent diabetes (NIDDM), which affects Indiansearlier than in the West. Diabetic retinopathy, the mostcommon cause of blindness in urban, middle-classIndians, is on the rise, although most of it ispreventable. Diabetes is also the most significant causeof end-stage kidney disease and of amputations inIndia. The costs of drugs for diabetes, already high forthe average Indian, are expected to go up in the nearfuture (5).

HEALTH CARE IN INDIA

The India’s healthcare sector has made impressivestrides in recent years. Major corporations such as theTatas, the Apollo Group, and many others have madesignificant investments in setting up state-of-the-artprivate hospitals in cities like Mumbai, New Delhi,Chennai and Hyderabad. Using the latest technicalequipment and the services of highly skilled medicalpersonnel, these hospitals are in a position to provide avariety of general as well as specialist services. Theseservices are available at extremely competitive prices,encouraging patients not only from developingcountries but even from a number of developed ones tocome to India for specialized treatment.

AIIMS – All India Institute of MedicalSciences

This institute from New Delhi is the leading medicaluniversity of the Asian subcontinent, which comprisesof the following member institutions:

• Apollo Hospitals

• Aravind Eye Hospitals

• Brahmaputra Hospitals Limited

• Lifeline Group of Hospitals

• Medwin Hospitals

• Nagarjuna Hospitals Ltd.

• Suyash Hospital Pvt. Ltd.

• MediCity Hospitals

• Hospitals in Chennai

• Hospitals in Delhi

• Hospitals in Pune

Basic health indicators

India has a multiplicity of treatment regimens. Theserange from the allopathic system to traditional healingand home remedies. The advantage of standardization,packing and storage, documentation and differentdispensing methods has ensured that the allopathicsystem is more acceptable.

The quality of life in relation to health can be gagedby morbidity information. The NCAER study revealsthat the short duration morbidity rate (diarrhea, coughand cold, and unspecified fevers) is 122 per 1000population. The major morbidity rate (epilepsy, heartdisease, hypertension, tuberculosis, diabetes, mentaldisorders, and leprosy) is found to be 46 per 1000population (1,2).

Short term morbidity and major morbidity aredisproportionately high among the vulnerablepopulation groups including wage earners and thosewith low levels of income. About 20 per 1000 childrenin the 0-4 age group and 29 per 1000 in the 5-12 agegroup suffer from physical disabilities such as Bitot’sspots, visual impairment, hearing impairment, speechimpairment and locomotor disability.

Almost 80% of the diseases in India are waterborne orare caused by water organisms, i.e. cholera, diarrhea,typhoid, hepatitis A, malaria, and filaria. It is primarilythe poor who are most affected. About half of allvillages in India do not have any source of protecteddrinking water. Clearly, the quality of life from thehealth standpoint is far from satisfactory.

Guiding principles of health care according toBhore Committee, 1946

In 1946, the Bhore Committee established theguiding principles for provision of health care to thecitizens of India. They run as follows:

• That no individual should fail to secure adequatemedical care because of inability to pay for it.

• The health program must, from the very beginning,lay special emphasis on preventive work withconsequential development of environmentalhygiene.

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• The health services should be placed as close to the

people as possible in order to ensure the maximumbenefit to the communities to be served.

• The doctor – the leader of the health team, should

be a social physician who should combine remedialand preventive measures as to confer the maximumbenefit on the community, and the future doctorsshould be trained to equip them for all such duties(2).

Health for all

In Alma Ata (in the erstwhile USSR), a globalinitiative towards health-related research and actionwas held in 1978. All the participants, including India,affirmed to ensure health for all by the year 2000, withprimary health care as their top priority. However, after22 years, we are far from from achieving this goal (1).

Status of health care in India

India has worked continuously to improve its healthcare system in the last several decades, andconsiderable progress has been made in expanding thepublic health system and reducing the burden ofdisease. Other notable achievements include theestablishment of an extensive network of governmenthealth care facilities both in the rural and urban areas,and determined efforts to upgrade the skills of healthcare workers, particularly in rural areas (1).

In just over five decades, life expectancy in India hasdoubled, and the infant mortality rate halved. However,during the same period the India’s birth rate hasdeclined by only 25% (1).

Nevertheless, its performance requires muchimprovement in comparison with other emergingeconomies, including most comparable nations in theregion. Deficiencies persist with respect to access,affordability, efficiency, quality and effectiveness,despite the high level of overall private and publicexpenditure on health.

Performance on selected health indicators

The India’s life expectancy was 49.1 years in 1970 andhas increased to 62.6 years by 1997. The infantmortality rate (per 1000 livebirths) has decreased from130 in 1970 to 71 in 1997.

Trends for demand in health care

The burden of disease is the cost a society bears, asmeasured in death and disability, from illness anddisease (3). The health care system must anticipateand respond to this changing burden of disease, ideallythrough preventive as well as curative measures (4).The demand for health care will be driven primarily bydemographic changes and changes in epidemiologicprofile (3,5).

The population of India is currently around onebillion and is still experiencing high population growthrates, at 1.3% per annum, which is high compared tomost emerging nations.

DIABETES HEALTH CARE IN INDIA

The practical management of diabetes in developingcountries is often made difficult by the scarcity ofhealth care personnel, monitoring equipment and evendrugs, especially in more remote areas (2). Poor gene-ral awareness of the disease due to inadequate or evenabsent diabetes education undoubtedly contributes todelayed presentation and missed diagnosis (5).

The development of diabetic complications is closelyrelated to glycemic control, to accessibility to patientcare, and to patient compliance with a rigid dietaryregimen and lifestyle. These can be influenced by anumber of factors (including age, comorbidity,socioeconomic status, and social health care support).Hence the risk of development of longterm compli-cations could be avoided by improving the quality ofdiabetes care for patients by establishment of publichealth care system (2).

Diabetes is a lifelong disease, thus increasing themorbidity and mortality, and decreasing the quality oflife. At the same time, the disease and its complicationscause a heavy economic burden for the diabetics, theirfamilies, and the society.

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Data for India suggest gross inequities in theavailability of care for people with diabetes (4).Ramachandran et al. have estimated that the annualcost of care for one insulin treated patient attendingtheir diabetic center in Madras (in 1996) was 350 USD.For a person treated with oral hypoglycemic agents ordietary modification alone, this figure was 70 USD.Using an estimate of the prevalence of diabetes inIndia of 1.8%, they calculated that 17.3 million peoplehave diabetes, of whom around 20% (3.5 million)require insulin (4). Multiplying the Madras estimatefor the cost of care by this prevalence of insulin treatedand non-insulin treated diabetes produces a sum of 2.2billion USD theoretically required to treat diabetes forthe whole India. Given that the entire health carebudget for the country in that year was only 720million USD, something is obviously either away inthese estimates or there is considerable imbalance inthe care of diabetes in India.

The government is unable to provide proper healthcare, so most of the people depend on private hospitalsfor better care. There are a number of voluntaryorganizations and private clinics and outpatientservices to pay the individual attention, patienteducation towards diabetes.

DIABETIC ASSOCIATION OF INDIA

Diabetic association of India was founded in Mumbaiin 1955 with joint efforts of Dr. R.V. Sathe and S.S.Ajgaonkar (2). The aims and objectives of theAssociation are as follows:

• Study of the causes and treatment of diabetes

• Promoting of patient education through various

media such as lectures, discussions and publicationof books (2,3)

• Promoting plans for early detection of diabetes

There are about 25 branches distributed all overIndia. In South India, Madras association has beenaffiliated to the International Diabetes Federation(IDF) since 1955 (5). The Association also works incoordination with WHO. The Association takes activepart in international congresses on diabetes, andorganizes national congress on diabetes every threeyears (4).

There are a number of private and public trusthospitals. In South India, there is a diabetes researchcenter in Madras, founded by Dr. M. Viswanathan in1954 (6) and in school of diabetology at NIIMS inHyderabad, headed by Dr. P.V. Rao.

PRESENT SITUATION OF DIABETES ININDIA

Indians are more prone to diabetes than almost anyother population in the world. Since very long, webelieved that diabetes and heart disease are exclusiveto the affluent societies. So, Indian health care policiesemphasized prevention of infectious diseases only (6).

However, as the living conditions in India improved,we are increasingly following western dietary habitsunsuited for our environs, adopting sedentary lifestyle,and are exposed to psychosocial stress. This hasresulted in an unprecedented rise of diabetes toepidemic proportions during the last few decades inour country.

The only national study to date on diabetescompleted in 1989 was coordinated by Prof. M.M.S.Ahuja from the All India Institute of Medical Sciences,and Dr. P.V. Rao, who is presently at the Nizam’sInstitute of Medical Sciences. About 2% of the 12,000people surveyed in Indian villages were found to bediabetic, and more alarming observation was that halfof them did not know that they had diabetes. Thisinfers that there are at least 20 million diabetics inIndia, which is the highest ever reported number fromanywhere in the world.

Further, Indians tend to be diabetic at a relativelyyoung age of 45 years, which is by about 10 years earlierthan in the West. The life expectancy in a diabetic isjust about 8 years after the onset of the disease, as theysuccumb to kidney as well as heart disease more oftenthan others. This is very alarming indeed.

Another important consideration in this regard is thestatus of diabetes among migrant Indians living all overthe world. There are several millions of Indians livingoutside India, either as recent migrants to Westerncountries such as England and United States, or asdescendants of the ’coolies’ indentured by the Britishto South Africa, Mauritius, Malaya, Fiji and to theCaribbean countries like Trinidad, Guyana and

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Surinam. It is now well known that diabetes is morecommon in these migrant Indians than in the local hostpopulations of these countries (6).

In a recent study concluded in 1992 and sponsored byWHO, Dr. P.V. Rao screened populations of Indianorigin living in London, Malaysia, and British Guyanafor diabetes and heart disease. Among these migrantIndians diabetes was at least four times more commonthan in Indians living in India. One of seven migrantIndians above 25 years of age was diabetic.Furthermore, more Indian women than men wereaffected with diabetes among immigrants, which wasnot the case within India. These higher rates fordiabetes among migrant Indians, and in specific amongwomen are attributed to the quality rather thanquantity of dietary intake, lifestyle and social stress.

Indians eat less, weigh less, and work more thanEuropeans. But why are they more prone to diabetesthan Europeans?

’Thrifty genotype’ is the answer. It is a hypothesis ongenetic inheritance, put forward way back in 1956 byJames Neel, a geneticist. Prof. M.M.S. Ahuja hasadapted this to the Indian context, and Dr. P.V. Rao hastested this hypothesis over the last five years in theframe of international research among Indians livingwithin India and abroad (6).

Indians have lived through several centuries of famineand starvation, and largely survived on sustenancefoods. Over generations, they evolved a ’thriftygenotype’, which made them resistant to prolongedperiods of starvation. We tend to store a part of ourenergy intake simultaneously while ’burning’ it.Apparently this may be the reason for a ’big belly’ on asmall body frame among Indians.

The findings of the multinational study by Dr. P.V.Rao were that body fat around waist is the culprit fordiabetes and heart disease among Indians. Overall bodyweight was not always high among Indians with ’bigbellies’. This meant that total amount of food intake inan Indian was not high although the contents havechanged over centuries from vegetable sources to ’fatrich’ animal sources. Even the vegetable oils used forcooking such as coconut oil, which is widely used inKerala, Malaysia and Guyana, are strongly related to thehigh rise in diabetes rates among the populationsscreened from these areas.

There is a need for a concerted effort from allconcerned to first of all know that we Indians are moreprone to diabetes and heart disease. It is also importantto understand that dietary restrictions we followblindly based on Western literature do not apply to theIndian context. It is not how much a diabetic eats northe amount of ’sugar’ one takes but what matters is theamount and nature of the ’fat’ in food. This warrants anurgent reconsideration of the traditional understandingof diabetic diets; “no rice, no sugar in coffee, no fruitsor no potatoes” just does not mean anything. “No oils,no fats, no food fats’ must be the first dietary advice fora diabetic, especially in India” (6).

Measure the waist and not just the body weight toknow the progress of the disease. Warn those prone toavoid paunch, not just obesity. This requires betterunderstanding among physiotherapists and ’weight-watchers’ alike of the causes of diabetes and heartdisease.

Who will be a diabetic? Now it is possible to make areasonable ’guess’. If one is over 45, with a ’big belly’and a family background of diabetes, it is almost certainthat he or she is going to be a diabetic. Then it may bepossible to stop the disease process even before itappears.

Understanding diabetes, living with diabetes, andpreventing further complications are the majorconcerns of the health education programs beingdeveloped at the Nizam’s Institute of MedicalSciences in Hyderabad.

Prescribing drugs and restricting diets are not theright answer for the emerging important problem ofdiabetes, but understanding the disease in our contextand following specific measures against it are now morethan ever urgently required (6).

PROBLEMS OF DIABETES IN RURALINDIA

In Andhra Pradesh, a house to house survey wasundertaken in a defined rural area of Eluru. The crudeprevalence of diabetes was 1.6% (1.9% in males and1.4% in females). In all subjects aged ≥40 years theprevalence of diabetes was 13.3% (6). The results aresurprising because of the poor socioeconomicconditions, low health awareness, and limited access tomedical facilities in the study population. In these

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circumstances, diabetes is often diagnosed with theonset of vascular complications and potential morbidityfrom retinal, renal and arterial disease associated withdiabetes.

The implications for the provision of health carecenters throughout the Indian subcontinent are clearlyenormous (5,6). Economic realities have to be takeninto consideration. These include both the finances tomake comprehensive and acceptable diabetes careservices available to the people, and more importantly,the capacity of the people to afford these services. TheIndian government spends around 1.2% of its annualbudget on health. As communicable disease preventionand management is still an important aspect of healthin India, the money routinely allocated tononcommunicable diseases, and especially diabetes, issparse (7,8).

PLANNING OF DIABETES HEALTHCARE IN RURAL INDIA

The practical management of diabetes in developingcountries is often made difficult by the scarcity ofhealthcare personnel, monitoring equipment and evendrugs, especially in poor remote areas. Poor generalawareness of the disease due to inadequate or evenabsent diabetes education undoubtedly contributes todelayed presentation and missed diagnosis (9).

The development of diabetic complications is closelyrelated to the glycemic control, as indicated by theresults of the Diabetes Control and ComplicationsTrial (DCCT) on accessibility to patient care, patientcompliance with a rigid dietary regimen and lifestyle(10). These can be influenced by a number of factors(including age, comorbidity, socioeconomic status andsocial health care support).

India has the largest number of diabetics in the world,with nearly 30,000,000 at present, which is likely totouch the 60,000,000 mark by 2025, the doctor said.

The ever increasing number of diabetics alarminglystretch the disease burden beyond the limits of healthcare provisions. A primary care clinician with certainexpertise in diabetes can barely look after some 30persons with diabetes in a day by spending 10 minuteswith each, and provide minimal care to one thousandpersons with diabetes in a month.

Setting up diabetes health centers in rural areas ofIndia is necessary as most of the people are illiterate,poor, and live in rural areas. To meet the diabeticpatients’ requirements and ensure easy approach tothe health center, it has to be set up in the center ofthe chosen place to reach the patients from theperiphery and to allow for transportation of patients byambulance to regional diabetes health center forfurther management (11).

Hence the risk of development or progression oflongterm complications could be avoided by improvingthe quality of diabetes care for patients byestablishment of a public health care system.

Diabetes is a lifelong disease. It increases themorbidity and mortality, and decreases the quality oflife. At the same time, the disease and its complicationscause a heavy economic burden for the diabeticpatients themselves, their families and the society. Thefoundation of a diabetes health care system is the coreof public health care for diabetics. However, this willnot occur unless the government and public healthplanners are aware of the potential problem.

PRIMARY HEALTH CARE FORDIABETICS

The health care for diabetics provides an excellentexample of a chronic disease where primary health caremust play a key role. The personnel involved at localand referral levels are physicians, nurses and midwives,auxiliaries and community workers, who should ideallywork as a team. After a period of training, communityhealth workers have a valuable part to play in the healthcare team. Their training should enable them to detectnew cases, to test urine for glucose, to identify specificproblems, to give advice, and to know when and whereto seek advice themselves. They should also be able toprescribe follow-up care and to provide accurateinformation to the patient and his family relevant tothe patient’s needs.

The primary health center should be staffed by aphysician, a nurse, and some health auxiliaries. Inaddition to its health functions, it serves as aneducational institution for both the staff and patients,as a center for dissemination of printed informationsuch as diet sheets, and as a place where patientrecords are kept (12). It aims to offer continuous,comprehensive and coordinated care (13). Diabetic

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health centers in rural areas should have an OPdepartment, inpatient ward, ICU and hospitaladministrative wing to manage the hospital.

Staff required for the hospital

Staff requirements include: diabetologist, staff nurses(well trained in diabetology), health educator,dietitian, physiotherapist, ophthalmologist (consul-tant), dentist (consultant), podiatrist, laboratory tech-nician, etc. (14).

Diabetes health care team

“We need a caring physician but also a dietitian and acaring educator. Today, diabetes treatment means teamwork and we need health care team that understandnot only diabetes as a disorder but diabetes as a way oflife. Physician and other health professsionals shouldunderstand the need they have for one another. Eachindividual in the diabetes care team has his ownparticular knowledge that is required for the success ofthe treatment and the care the person with diabetesrequires and deserves” (15).

Diabetologist

The work of the physician (diabetologist) is verydifferent in the two models. In an acute emergencysituation the physician directs the treatment; heintervenes and controls it directly. To passing from thisrole to that of an indirect actor by delegating themanagement of the treatment to the patient is achange, a difficulty of which the doctor is not oftenappreciated. This role change poses the problems ofrisk and responsibility for both the physician and thepatient. Clear-cut in acute situations, what risks andresponsibilities is the physician prepared to accept inthe disease being treated outpatiently? It is under-standable that the acute model, with directresponsibility rather than indirect support in chronicillness, should more readily shape the identity of thedoctor.

In the acute model health personnel have learned tosuppress their emotions; they gradually tend todevelop a shell which may protect them but which mayalso have unfortunate consequences in theirrelationships with patients. In chronic cases, on the

other hand, there cannot be prolonged care withoutinvolvement of the doctor to encourage, to guide and tolisten to the patient. In urgent cases the physician’sprofessional attention is mobilized by an externalstimulus, the crisis (16-18). Inversely, in chronicsituations longterm care requires a will, an internalmotivation of the physician. This could explain why,paradoxically, a tired physician might be more efficientin an emergency case than when dealing with a chronicpatient, where he or she would have to draw upon allavailable energy and attention to respond to thesituation. Visibility of the medical act is also verydifferent; attention getting in emergency medicine ismuch more humble and withdrawn in longterm care(19,20).

Diabetes nurse

Diabetes nurses play an important role in the publichealth systems. They work as assistants to dia-betologists to give patients more detailed informationand instructions about diabetes (21). As everyoneknows, diabetes is a lifelong disease, hence diabeticpatients have to deal with special problems every day,including how to plan their meals with various foods, dodifferent kinds of exercises, wash their feet, choosespecial shoes and socks, seek doctor’s help, deal withhypoglycemic events, and so on. Usually thediabetologist just gives some general information to thepatients on visiting them, while the nurse can makegeneral information more and more detailed andconcrete to fit the patient’s daily life. The diabetesnurse also works as a diabetes educator to give somelectures on diabetes for patients (17).

Diabetes educator

The need of a comprehensive plan for diabeticeducation has long been felt. Its relevance cannot beneglected when one recalls that diabetes is a disease forwhich no cure has so far been found. A person oncediagnosed as a diabetic has to live his whole life withthe disease. All the more, this disease affects severalaspects of the victim’s life, such as diet, lifestyle,physical well-being, mental state, economic condi-tions, sexual and marital life, etc. (22). So, in anydiscussion regarding diabetes, not only the patient butalso his family should take active part. Once a diabeticis started on treatment and in-between something goes

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wrong, naturally his relatives will be worried and willquestion how and why it happened. Here arises theneed for a diabetic education program (23,24).

The educational plan should go through three phasesin parallel with the course of the disease (25). Thesephases are:

• primary or initial education

• secondary or indepth education

• tertiary or continuing education

Dietitian

The patient’s diet and the diet of his family should beanalyzed. While prescribing the diet it is ensured thatthe diet is not very much different from that of thefamily. Every diabetic is given an individulized dietsheet using the charts, wax models and actual display offood items. Patient is educated about the type andquantity of food to be taken (26). Note that in India,some people take only vegetarian foods. So, balancedand required calorie diet and diet schedule aresuggested to the patient (26).

Physiotherapist

Yoga and diabetes

The science of yoga is an ancient one. It has a richheritage, it is part of Indian culture. It has become asubject of modern scientific evolution resulting in therecognition of some of its influences on the humanbody and metabolism. Several old books make amention of the usefulness of yoga in the treatment ofcertain diseases such as hypertension, diabetes, obesity,asthma, etc. (27).

The practice of Pranayama produces significant fall inthe fasting blood sugar and postprandial blood sugar.Yoga programs which train large muscle groups result inan increase in maximal oxygen uptake, decrement ofsubmaximal heart rate, and augmentation of the strokevolume. They also result in metabolic changes such asreduction in blood lipid levels and decrease in bloodlactate concentration during submaximal work. On theother hand, reports of the influence of yoga on bodyfunctions are very few and several of these have yieldedonly controversial observations. A favorable effect ofyogic excercises on cardiovascular, endocrine, metabolicand respiratory functions have been observed. There

are specific yogic practices for the control of diabetes:Pranayama, Dhanuraasana, Arthamatsendraasana,Pachimotanasana, Halasana, and Vajrasana.Dhanuraasana is individually most effective. These arepracticed on an empty stomach for 30 min followed byShavasana for 10-15 min (28).

Intensive care unit (ICU)

Diabetes health care centers have to be situated inrural areas where all critical cases can be managedsuccessfully in health care center, as critical patientscannot reach regional hospitals within the requiredperiod of time (29,30). So, ICU has to be set up withall necessary equipment such as ventilator, cardiacmonitor, pulse oxymeter, IV-fluids, IV-sets andcannulas, self-retaining urinary catheters, urobags,Ryle’s tubes, etc. (29).

Outpatient care

After examining the patient, the physician has to referhim to laboratory for necessary investigations. By thetime investigations are completed, the first phase ofhealth education has to be given, e.g., teaching thepatient on the technique of insulin injection if it isrequired. He should be taught the ways to monitorurine and blood glucose periodically, prediction ofhypoglycemic symptoms and immediate care to betaken, sick-day rules, etc. (31). The patient comesback to the physician with laboratory reports aspreviously advised. The physician advises thenecessary treatment and care that has to be taken.

Inpatient care

If the patient has been advised admission, the staffnurse has to take care of the patient and she has to playa role of diabetes educator as well. Patient should betaught about the medication, diet, foot care, etc. Alldiabetics should be taught how to identify acutecomplications of diabetes and to guard againstlongterm complications (32).

If the general condition is fair, he may be discharged.The patient can be advised for review and follow-up.An identity card along with o.p. card has to be provided(18).

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Ambulant patients

As most patients in the rural area are illiterate, theyhave to be admitted as ambulant patients for a shortstay which should serve a dual purpose of the control ofdiabetes and intensive diabetic education (22).

Diabetes education and treatment camps

These camps are conducted in periphery in differentareas once or twice in a month with social organizationslike Lions Club, Rotary Club, etc. to screen diabeticpatients. Some days before the camps wide publicityand propaganda are organized in nearby villages. Thelocal village heads, prominent people like schoolteachers, postal department, employees and voluntaryorganizers should be involved (31,32). Camps areusually conducted in a public place like a school.Sunday is a preferable day for such camps, so that mostof the people can participate (33). Local newspapers,pamphlets, etc. can be used as a mode of publicity. It isa good teamwork with health care professionals such asdiabetologist, educator, dietitian and laboratorytechnician and staff nurse. The camp has to beconducted in the morning so that fasting blood sugarand urine analysis can be done appropriately.

The diabetics in the camp should receivecomprehensive treatment including education, dietmodification, exercise, medications. Several lectures ondiabetes are delivered on different aspects of diabetes,with displays of cooked foods and modules. A dietexhibition should also be organized (34). The patientsrequiring additional investigations or intensive care areadmitted to the ward for detailed evaluation andtreatment (35-37).

To deal with the great challenge of the global increasein the prevalence of diabetes, a governmentalexecutive intervention is essential. A diabetic healthcare delivery system is potentially important and has tobe shifted gradually into the community basis.Implementation of regular and nationwide educationprograms will make the public health care system moreeffective in developing countries (38,39).

FUTURE STRATEGIES

If we wish to approach the problem of diabetes with aview to prevent and control it, an appropriate diabeteshealth care program should be planned out (9,40,41).The following suggestions are worth considering:

Planning of health care for diabetics

Every state should plan out its own program givingconsideration to local conditions, food habits andcustoms. Epidemiological studies related to theprevalence of diabetes, clinical features andcomplications should be carried out. This will give abaseline regarding total number of diabetics,requirements of drugs and insulin, presence ofcomplications, and plans for rehabilitation anddisability reduction. Depending on the results, furtherplans should be implemented (9,41).

Education

A countrywide patient education program should bestarted utilizing available resources in cooperation withsocial organizations, especially Diabetic Association ofIndia through its various branches. This programshould also stress other known risk factors such assmoking, alcohol, obesity and nutrition (9,42).

Training of medical staff

In this regard, the All India Institute of Diabetes hasalready started postgraduate course in diabetes foryoung doctors and refresher courses for generalpractitioners.

Supply of drugs

Fortunately oral antidiabetic drugs are available inIndia at an affordable rate. However, the government ofIndia should make it a policy to include insulin as a lifesaving drug available to all at an affordable rate.

International cooperation

It should be developed amongst developing countriesand also between developing and developed countries.This will encourage global exchange of thoughts andknowledge. The WHO should extend favorableattitude towards such an action in the world byfacilitating the exchange of expertise, technology andinformation through promotion of technical coop-eration amongst developing countries (43,44).

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Evaluation and supervision

It is necessary to have periodical evaluation of anynewly implemented health care program to rectify themistakes and for execution of alternative steps (45). Itis natural for such a huge populous country with nu-merous languages, scripts, ethnic groups and cultures

to have socioeconomic and concurrently other healthproblems. However, this excuse can never pull us out ofa viscious circle of poverty, population growth andhealth hazards. If we wish to achieve the goal ofpositive health we should plan out new strategies tofight on all fronts as far as health is concerned (46).

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