Diabetes management in the Third World

He is 32 year old male. He is a poor manual labourer ready to do any kind of job.He is also a Type 1 Diabetes patient for last 7 years.

He lived near the place I worked previously.He presented to me 7 years ago with sudden loss of weight and severe fatigue. His blood sugar was around 500mgs. He was treated with insulin and fluids and he became better.A trial of oral tablets for Diabetes was tried but did not work. He could not afford C peptide estimation or antibody estimation to prove that he is having Type 1 Diabetes. As he responded only to Insulin he was assumed as type 1 and treated with twice daily premixed Insulin.

As I moved out from that area I did not see him for few years. Last week he came to me again. He came for some relief to his severe unbearable ear ache. I asked him about his Diabetes.He reassuringly told me that he is taking Insulin injections regularly twice a day.He was not concerned about his Diabetes.He is having this ear ache and discharge for last few months. I examined him and saw that he had thick pus coming out of his right ear. He also had high blood pressure and severe numbness of his feet.
'When did you check your blood sugar?' I asked.
He was not very sure. 'May be 3 months ago', he replied.
What was the sugar value? I persisted
'May be around 300. It was always around that when i check'. He revealed.
'Do you keep your Insulin in refrigerator'? I enquired. I remembered that he used to keep his Insulin at a pharmacy nearby as he or his neighbours did not have a Fridge.
'No .I keep it in a plastic Mug filled with water'.
'Why not in the pharmacy'? I asked.
His explanation was like this. The pharmacy in which he used to keep his Insulin had closed few years ago.Also somebody had told him that Insulin if not kept in a Fridge, should be kept under water.
Here is a Type 1 Diabetes patient who is storing his Insulin improperly and thereby reducing its potency. He is taking this low potency Insulin and is checking his blood sugar rarely.His blood sugar is always high and now he is developing Diabetic nephropathy and neuropathy.Due to this poorly controlled blood sugar he had also developed acute ear infection about which only he is bothered.
What should I do?
I told him the importance of keeping the Insulin in a cool environment.I asked him to see anyone of his neighbours have a Fridge.If not I told him to buy an Earthen pot, put water and few pieces of ice in it and put the insulin in it so that it is submerged in water.I also gave him a week's course of antibiotics for his ear infection and few anti BP tablets. I refused his offer of consultation fee.
Should I have done more? Should I have donated a refrigerator to his house? Or should I have helped him in any other way?

I don't know.
There are thousands of such Type 1 Diabetes patients through out the third world. Only very fortunate few survive more than 10 years after diagnosis.
Let us hope the future will be bright for such patients. Let us work for more just world.

A strange interview

It happened some time ago. She is a 31 yr old Type 1 Diabetic patient of mine. She called me up one day saying a guy will come to see me asking about her health condition. He is her prospective bride groom. The families contacted through a matrimonial ad. He had met her and her family. Now he wants to know how healthy she is.

In India most of the time it is the family/parents who search and find partners for their sons and daughters.[Things are changing but slowly] The parents of my Type 1 patient were in search of a bridegroom for some years now. She had called me before also, saying a guy or his parents may come and ask about her. But nobody had come to me yet.She had a stable and well paying Govt job and this had attracted many suitors.Still her T1 status might have dissuaded her prospective grooms. As far as I know she had said no to one or two suitors too.

He called me 2 or 3 times on phone before fixing a suitable time to see me. He was a serious looking guy, little bald may be around 35 years. He introduced himself and mentioned the name of my patient[his proposed bride].
We were silent for sometime.Then I started interviewing him.He is only having a temporary job in a Company,but his family had some agricultural land and according to him are financially stable.
He did not knew how to start his questions.I helped him by asking what he want to know.
How serious is her Diabetes?
Will she need Insulin through out her life?
Can she become pregnant and deliver children?
Will the children inherit her Diabetes?

Some how I thought this Guy is nice and dependable. I wanted my patient to get a good partner.So the picture of her health status that I presented to him was very positive.

Yes, she needs Insulin through out her life.Her body is not producing Insulin,a hormone essential for Sugar metabolism. We are injecting it so that she can live normally.
She have no other defect.
She can become and pregnant deliver normal children.
Finally I also added that she is having the best blood sugar control among my Type 1 patients.

I had a feeling that he was satisfied and happy. She came the next day and wanted to know everything.I told her in detail.Then she asked me 'How you feel about him?' I said I felt he is nice and dependable. She looked at my face intently and I gave her a reassuring smile.