It was a great pleasure to be invited by PIMA and the Ministry of Health of Kiribati to meet with Dr. John Tekanene on Christmas Island to review diabetes.
My daughter Stefi accompanied me. She not only shared the adventure with me but was able to help a great deal too. The invitation was extended due to the very high prevalence of type 2 diabetes in Kiribati, which was noted in the recent WHO STEPS report of non-communicable diseases. The report indicated that in Tarawa the prevalence is about 30%.
Prior to my visit Dr. John outlined what he felt were priorities and we tried to address these during our visit.
Firstly, we brought in some supplies. The island was running very low on the standard medications metformin and glyburide, and was completely out of stock of insulin. All were put to good use during our stay. We were particularly pleased to establish a connection with the highly regarded international group “Insulin for Life” which not only provided the insulin for this visit at no cost but has offered tohelp establish a regular ongoing supply. We also brought test strips for the glucose meters and batteries to keep the meters running.
Secondly, I visited the 4 clinics on the island: London, Tabakea, Poland and Banana. Over the week we saw nearly 100 patients most of whom either had diabetes or wanted to make sure they didn’t. Visiting the clinics allowed me to talk to the patients directly and to start to hearabout their concerns and experience with diabetes. Dr John and I discussed current management practice and how this compares to that in the US. Major differences are that patients do not have their own glucose meters and non-hospitalized patients do not use insulin. Although we spent most of our time in the clinics we did help care for one hospitalized woman with very high glucose levels who I am sure benefited greatly from receiving round-the-clock insulin for a few days.
Thirdly, we did some informal teaching: for the nurses, with the patients one-on-one and memorably (for me!) a short talk in the village maneaba in Poland. We had brought some teaching materials with us which were distributed throughout the island. The staff reported that they would review the information and translate it and adapt it for use on Kiritimati.
Fourthly, we tried to gather some information to help guide further efforts. Stefi was given the task of visiting the community with one of the senior nurses to try to learn more about the local diet and if and how this has changed recently. The traditional local diet looked excellent: mostly fish and vegetables and coconut in various forms, but it is usually heavily supplemented with imported refined carbohydrates (white flour, rice and sugar) as well as other non-perishable foods such as canned meat and sodas.
Fishing and gathering the traditional diet was clearly hard work that would have prevented the build up of too many excess calories, which is not the case with the imported food. Interestingly the supply ship, Moa Moa, which had not been to the island for several months, arrived when we did. This was a cause for great excitement as we were repeatedly told that the island was out of supplies of rice and flour. We learnt that smoking is very common and a tradition on the islands. Besides this preliminary lifestyle assessment we also gathered information on many of the patients we saw regarding their age, gender, body mass index, duration of diabetes, major complications and current medication.
PIMA had sponsored the purchase of new disposable A1c meters. These allowed us to measure the average blood glucose level for the previous 3 months. This gave us a better idea of glucose control than the current random glucose measurement, which only measures 1 moment in time. The A1c test is widely used in the US but is not available in Kiribati. We are putting all this data together to enable to help us come up with further management suggestions.
Everyone we met was welcoming, courteous and generous. We hope that we were able to contribute in some small way to PIMA’s good work. I am now able to report back to friends and colleagues at the University of Southern California about what we might be able to offer to the islanders in the future and similarly the great rewards that they can experience by visiting. With the support of the Ministry of Health of Kiribati we plan to meet with the Institute of Global Health at USC to see if we can establish some ongoing projects with Kiritimati to further improve healthcare. I look forward to staying in touch with my new friends there and once again thank PIMA for the opportunity to visit.
By Dr. Elizabeth Beale