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A global health pediatrics team provides one Ugandan hospital with the basic resources it needs to make childhood diabetes manageable

Toni Moran, M.D., wasn’t sure what to expect when she went to visit Mulago Hospital in Kampala, Uganda, two years ago. What she found haunted her: a disease that is manageable in the United States causing untold preventable deaths for lack of basic medical resources. “Our diabetes work here [in the States] is so high-tech and cutting-edge,” says Moran, division chief of pediatric endocrinology and diabetes at the University of Minnesota. “In my career here in Minnesota, I hardly ever see children die.”

But in Uganda—a largely rural country where health care focuses primarily on acute care for infectious diseases like malaria and AIDS—type I diabetes is often fatal. When she went to visit Mulago Hospital’s pediatric diabetes clinic, then run by Ugandan pediatrician Grace Buwule, M.D., Moran was struck by the unmet rudimentary needs.

Toni Moran, M.D.

‘Hurdles at multiple levels’

“I hadn’t expected the disparities I found there,” says Moran. “There are hurdles at multiple levels. For one, 80 percent of the population is rural,” making access to any health care difficult. “And most clinics can’t even diagnose diabetes because they don’t have the ability to measure blood sugar. Many children die without anyone ever knowing they were diabetic,” she says.

If a Ugandan child is diagnosed with diabetes, families have no way to monitor dangerous blood sugar fluctuations and often no insulin to treat the disease. (Though some companies that produce insulin are willing to donate it, government bureaucracy—and sometimes, corruption—disrupt distribution.)

“Grace was a good pediatrician, but she had no training in diabetes—and no nurses, no team, no infrastructure,” Moran says. “What she needed were really basic things.”

Moran vividly recalls one 2-year-old patient from her 2007 visit. “They were sure he would die,” she remembers. And the overwhelmed, under-resourced staff kept making errors in his care. “There was one mistake after another; they used the wrong size syringes and different size syringes with different doses of insulin.” Making matters worse, the child’s parents—who wanted to take charge of his home care&—were misdirected.

“They had been sold some expensive and completely worthless tablets to treat low blood sugar reactions,” Moran says. “Instead, I taught them to use honey, which is inexpensive and widely available. They were also told he shouldn’t eat any carbohydrates, which besides being inaccurate is impossible, since their diet is based on carbohydrates.”

Ties to the U

The University’s deepening relationship with Mulago Hospital was initiated by two Department of Pediatrics faculty members, Cindy Howard, M.D., and Chandy John, M.D., in 2005 as part of the Medical School’s Center for Global Pediatrics. (Howard, who coordinated an educational exchange between Makerere University in Kampala and her former employer, the University of Maryland, is the Global Pediatrics Program’s associate director; John is its director.)

A few months after her first visit to Kampala, Moran brought Buwule to Minneapolis to offer her more training in diabetes care. Together they developed a protocol, and Moran helped teach Buwule how to work with a team and how to empower patients and their families to participate in their care—unfamiliar concepts in Uganda’s British colonial medical system.

Moran also helped Buwule assemble a local medical team at Mulago Hospital: two nurses, a junior physician, a nutritionist, and a pharmacist. And in January 2008, Moran sent two fellows, Melena Bellin, M.D., and Lynda Polgreen, M.D., and pediatric nurse Trish Grover from the University of Minnesota to Uganda to work with Buwule for three weeks.

Pediatrics resident Geoffrey Oburu, M.D. (right), talks with a Ugandan teenager about managing her type 1 diabetes. (Photo courtesy of Toni Moran, M.D.)

Signs of hope

When Moran paid her second visit to Kampala last summer, she observed tremendous change. The first good sign: The little boy she remembered from her first visit was “doing great!” Moran says. Other signs pointed to systemwide change as well. “There was a huge amount of progress,” says Moran, who found that Uganda’s health-care system had moved beyond exclusively managing acute illness. “It’s a step forward that they’re now dealing with chronic illness.”

Howard agrees that the move away from constant “crisis mode” is encouraging. “That’s very new, and it’s very exciting,” she says. “It’s heading in the right direction.”

Unfortunately, Buwule left Uganda, for personal and political reasons, soon after Moran’s last visit. But in spite of her absence, the team is moving forward with remarkable resilience. “Even now, without a lead physician, those two nurses are doing an incredible job,” says Moran, who is in close touch with a pediatrics resident from Uganda who’s working with the team and hopes to take the helm in the next few months. Meanwhile, residents and students working in Uganda through the University’s Center for Global Pediatrics continue to bring insulin and other vital diabetes supplies to Kampala.

As for Moran, her experiences in Uganda have led to other explorations—she recently traveled to India with others from the University’s Academic Health Center to lay groundwork for a collaboration related to clinical care and research—and they have altered her perspective at home. “Here, we take so many things for granted,” she says. “I take less for granted now.”

By Susan Maas

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