Diabetes in the Developing World

Exam room
A nurse educator, Dr. Varine Menh and Dr. Hudson gather in the exam room that served as the diabetes clinic.

Margo Hudson, MD, of BWH Endocrinology, contributes this piece about her global health work in Cambodia.

“Is there diabetes in Cambodia?” was a frequent question posed to me when I told my BWH colleagues that I was heading to Phnom Penh this summer to help a small hospital launch a new outpatient diabetes program.

The hospital is the Sihanouk Hospital Center of HOPE which, like most Cambodian health facilities, is heavily sponsored by charitable organizations, in this case the global charity HOPE Worldwide. It has a 30-bed acute inpatient facility, as well as a large outpatient facility and maintains 2 emergency rooms.

It draws patients from a wide area, including many rural villages, and it has an active residency program taking seven general internal medicine residents each year. The outpatient clinic sees

Hospital
Sihanouk Hospital Center of HOPE

approximately 300 patients a day with 20% of patients carrying a diagnosis of diabetes. Since May,  two nurse educators and Dr .Varine Menh  have been forging a diabetes program focusing on improved patient education and management through visits held jointly with the MD and RN present. Dr. Menh has been practicing internal medicine for more than 20 years, but recently spent a month at the well-known diabetes clinic, the Barbara Davis Center, in Colorado. On her return to Cambodia, she was determined to improve the care provided to the center’s patients with diabetes.

Health Volunteers Overseas is a large umbrella organization that helps pair physicians with needy programs around the world. The philosophy of HVO is that the primary purpose of sending volunteers is to provide training to local physicians rather than providing the services themselves, allowing the programs to eventually become more independent and capable. HVO has been helping place physicians with varied specialties for short term visits (2-4 weeks) at the Sihanouk Hospital for many years.

How did I fit into this? It is truly partly serendipity and partly intentional. Late in spring of 2013 ,I realized that I could take an extended “vacation” from my BWH responsibilities over the summer. Having spent several years helping with diabetes programs at IHS hospitals through BWOP, I thought, why not go global? I googled “Healthcare volunteering” and found several organizations offering matches. HVO happened to have a site in Cambodia that  posted a need for help with the new adult diabetes program. The U.S. physician liaison for HVO, Dr. Victoria Seligman, happened to be just finishing her degree here at the Harvard School of Public Health and was able to speak to me about HVO and the connection with the Sihanouk Hospital. I then went off to the American Diabetes Association meeting in early June, and the award for international diabetes care went to the Australian physician, Dr Graham Ogle, who had started the pediatric diabetes program at, of all places, the Sihanouk Hospital Center of HOPE. Well, as he said when I met him after the award ceremony, it was “providential,” and I knew I should go.

I was there from mid-July to early August. While hot, the hospital and hotel were air-conditioned, and it was hotter here in Boston at that time. Once I settled in, I had a lovely routine. The hospital would send a driver to my hotel every morning to pick me up so I did not have to confront the challenging city traffic at rush hour. On arrival at the hospital, I would give the housestaff and junior attendings an informal lecture on various topics focusing on basic physiology such as insulin secretion and insulin signalling. Then I would spend the rest of the morning observing direct patient care with attendings and housestaff, offering my suggestions on management.  For lunch, the hopsital arranged to have a woman prepare me true Cambodian meals which were wonderful. The afternoon was spent in outpatient clinic again and then, at the end of the day, I gave a more formal PowerPoint-type lecture, most of which came from lectures I have previously given but some were “donated” by my colleagues in the endocrine division.  Much to my surprise, all medical records are written in English, so I had no trouble reading or writing in the charts. Cases were not limited to diabetes, and I saw remarkable instances of valvular heart disease for example since cardiac surgery is not easily available. I was most excited with my diagnosis of a patient with unrecognized hypokalemic periodic paralysis. 

This was definitely not an “all work and no play” trip. I had time every day to go for a swim back at my hotel, and I saw all the major tourist  sites, including a trip to Siem Reap to see the famous Angkor Wat. While in Phnom Penh, I saw museums and Cambodian opera. I was there long enough to make many new friends, both staff and guests at my hotel, as well as staff and physicians at the hospital. During my stay,  the country held its first truly contested national election which, while marred by election irregularities, did represent a real step forward for democracy in Cambodia.

While financial support for this type of mission is quite limited, I would recommend it for anyone with time, interest, and ability to  travel as a truly satisfying and enjoyable endeavor which can lead to long term friendships and collaborations.

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