Diabetes in Russia / Сахарный диабет в России

Welcome to my non-communicable diseases blog on Russia.

Russia is not renowned for its healthy diet... When it’s minus 30C outside your window, a deep-fried potato cake, generous dollop of sour cream and glass of sugary tea to finish, appeal infinitely more than a salad and mineral water. Oh, and that jog around the park will have to wait until May – there’s 2m of snow on the field at present…

In this first post on non-communicable disease in Russia, I’ll be considering the situation of diabetes within Russia including the opportunities and challenges facing its management.

So, what exactly is diabetes? Diabetes (also called diabetes mellitus) can be defined as an inability of the body to effectively get sugars, the body’s instant energy source, from the bloodstream into the cells. Normally, the body produces a hormone called insulin, which allows entry of sugar into the cells. The two most common types of diabetes relate to problems with insulin: diabetes type 1, where the body is unable to produce insulin; and diabetes type 2, where the cells of the body become less sensitive to the insulin that’s produced.   Without adequate treatment with either sugar controlling medications or insulin injections, diabetes will lead to major short and long-term health consequences. These include an increased risk of: heart attack, stroke, kidney disease, leg ulcers, loss of sensation, loss of vision, impotence and dementia. Unsurprisingly depression is also associated with diabetes. Whilst diabetes cannot currently be cured, it can be managed effectively, significantly reducing the likelihood of developing disease complications.

Russia has a population of around 140 million people. Around 2,8 million have an officially recorded diagnosis of diabetes [2008 estimate]. However, a health screening programme in 2006 involving 6 million Russian citizens found a diabetes prevalence of 5.5%, which if extrapolated suggests a national diabetes prevalence nearer to 8 million individuals. With an increasing in average age and level of obesity this figure is likely to rise still further. Significant under-diagnosis results in frequent late presentations – by this stage it’s often too late to reverse the disease consequences. As a result, 90% of the current health expenditure of diabetes is spent on limb amputations, heart disease, stroke complications, and kidney failure, with less than 10% being spent on insulin.

So, what are the major challenges facing diabetic care in Russia? 

1. Staffing: Until recently, little emphasis had been placed on primary care i.e. general practitioners looking out for diabetes risk factors like blood pressure, obesity, family history and raised cholesterol. The number of endocriniologists (hormone and diabetes specialists) is also low, with less than one per 50,000 population.

2. Standardisation: Until recently, there was very little in the way of official evidence based diabetes management policies, tailored towards the Russian population. Such guidelines have now been produced, however providing education for medical staff and changing deeply engrained management habits has faced some resistance. Some health facilities also possess outdated or ineffective equipment, further frustrating delivery best-practice.

3. Patient education: Many people simply aren’t aware of what diabetes is, what the risk factors and signs are, and how diabetes can be effectively managed.

4. Funding: Currently state funding only provides insulin for those registered disabled. All other diabetic medications and blood glucose monitoring equipment is provided by the regional health authorities. As the economic situation within the regions fluctuates, so too does the quality and continuity of medication and equipment supplied.

5. Geography:   Russia covers a ninth of the world landmass. Certain regions are incredibly sparsely populated and geographically isolated. Combined with extreme weather conditions, differing languages and ethnicities, and varying levels of education, providing effective on-going diabetes management is challenging to say the least.

However, things are now beginning to change. In 2002 the government of Russia embarked on ‘the federal target programme for diabetes mellitus’. The National Diabetes Institute and the Endocrinology Research Centre (ERC) were launched within the Russian Academy of Medical Sciences, Moscow. Within this, departmental subdivisions have been created focussing on each of the major complications of diabetes, with a specific department for diabetes education. Through these evidence based national guidelines and treatment algorithms have been produced and disseminated for the first time. A national register of patients with diabetes has been founded with the intention of accurately recording diabetes prevalence, incidence, disability, complications, mortality causes and rates, as well as provision of monitoring equipment.  Through the federal programme around: 150 diabetic foot units, 100 diabetic eye centres, 20 haemodialysis units and >1000 education centres have been designated as diabetes management units.  Data collected from 2003-2008 suggested an average decrease in measured HbA1c from 10.8 to 8.1 (HbA1c is a blood test measuring average blood sugar level over the past 3 months).

Steps for the future

Currently the National Diabetes Institute is pushing for greater diabetes screening and increased numbers of endocrinologists to allow more rapid referral. They are also arguing for an improved staffing ratio in rural areas to account for the distances involved.  Concerns regarding federal funding for insulin provision (independent of disability) and the continuation of the diabetes register (currently staffed by volunteers) are on-going. It is hoped that media campaigns will improve public awareness and data collected showing the cost-benefit ratio of close diabetes monitoring and so prevention of complications will build support for further improvements and thus put pressure on authorities regional and national to build upon the positive progress achieved over the past decade.

 

References

Novonordisk (2008) Diabetes in Russia: Problems and Solutions. [online] Available at: http://www.novonordisk.com/images/about_us/changing-diabetes/PDF/Leadership%20forum%20pdfs/Briefing%20Books/Russia%20II.pdf [Accessed: 22 Apr 2013].

Diabetes Voice (2013) 1 1 H e a l t h d e l i v e r y National and regional organization: the key to effective diabetes care in Moscow . [online] Available at: http://www.idf.org/sites/default/files/attachments/article_475_en.pdf [Accessed: 22 Apr 2013].

Young TK, Schraer CD, Shubnikoff EV, Szathmary EJ, Nikitin YP. Prevalence of diagnosed diabetes in circumpolar indigenous populations. Int J Epidemiol. 1992 Aug;21(4):730-6

Picture taken from: http://health.passion.ru/novosti-zdorovya/sobytiya/besplatnye-proverki-na-diabet-po-vsei-rossii.htm

Chronic Disease within Russia

How healthy is Russia?

As part of my masters coursework, I've been asked to write a weekly blog focussing on different aspects of non-communicable disease within Russia. Over the coming weeks I'll be considering diabetes, breathing disorders, heart disease, cancer, mental health and more!  Whilst it's only week two, it's been fascinating to see the different approaches, unique challenges and potential opportunites in providing heathcare to the largest country on earth.  

Any thoughts, comments and questions would be very very useful to me - either comment beneath, via facebook or email.  I'm eager to learn as much as I can from the project!

Belief in Russia

The fall of communism hailed a period of religious openness within Russia.  Sadly those times seem to be fading, with increasingly tight controls on anything not perceived to be in line with government policy.  Where is Russia going?  The economist held a recent interview discussing the role of religion within Russia and the russian political sphere.  Makes for interesting viewing.  Your thoughts as comments would be most appreciated!

Eastern Europe language learning

The excitement of discovering a lonely planet store in Manchester was further compounded by the realisation they sell a pocket-sized phrasebook/dictionary for eastern european languages. It covers Russian, Romanian, Hungarian, Polish, Czech and five more. Very exciting. Further preparation/procrastination ahoy me thinks!

PS ahoy is the Czech word for hello :-)

Places that don't exist

Have also been watching a really fascinating TV series called "Places that don't exist".  Three of the nations are in the sphere of the Former Soviet Union (including Trans-Dneister, Ossetia/Abkhazia/Ajara and Armenia/Azerbaijan).  Russia still has close involvement in each.  Again, a very informative series with a unique insight into different mindsets, the role of conflict and the potential future direction of the FSU.

Slow progress?

Ever find that time is moving on, that organisating things is perpetual and that little of substance is being achieved?  It's been about 5 weeks since my trip to Germany.  I seem to have been on-call often, with my sleep-wake cycle being sent into disarray.  When opportunites come emails are sent, phone calls are made, answers are few...  Progress with paperwork has been at times frustrating.  It's also been four months since I was last in Eastern Europe.  Masters studies have been squeezed into free time, however, each week seems to run into the next.  Where has the time gone?

Where are things going, what am I achieving?

Stop.  Reflect.  Perspective check.  I think I sometime struggle due to defining personal success (and thus to some degree self-worth) in terms of achievement and overt productivity.  The outworkings of such a philosophy can be quite dangerous.  If I 'fail' to achieve, does my worth diminish?  Do patience, planning, contemplation and relationship building have no worth?  Does God's love for me change depending on how 'productive' I am (or what I would personally deem as productive)? 

Comforting to know however, is that God's plans will come to fruition regardless of my efforts.  He has saved my be his grace, not through my own worth.  Even if I were infirm and immobile, God's grace and love shown to me (and thus my worth in his eyes) would not change.  Jesus' death and resurrection has made this certain.  All work and service for Him should be as an outpouring of thanks, not as a definer of self-worth.  The funny thing is, things seem to happen when you entrust the efforts to God.  The results are often different to expected, yet more praiseworthy in hindsight.  Afterall, he is creater and sustainer of all.  Reflection makes it plain that it is far better this way - just need to be daily reminding myself of this!

So, planning and preparation over the last two months:
- Further discussion with the medical council of Saarland, list of required documents formalised
- Teaching schedule for the Eastern European Congress of Christian Medics provisionally written
- Key note speech offered to PRIME at said conference
- Provisional offer to teach medical communication skills at a medical school in Ukraine in May
- Potential for a further trip to Romania to teach medical communication skills to medical students later in the year
- Masters coursework on epidemiology (part one) completed [means a 1/6th of the course is done now!]
- Medical rota for next rotation finally obtained (many swaps will be required however...)
- Getting to know people better at church.  Feeling that fellowship and being able to encourage others is improving as a result! 

Lets see what the next few months hold!

Return to Saarland

So, this is it, the return to Saarland.

After a somewhat eventful and prolonged journey; DHL lost my train tickets; my plane was cancelled at short notice; booked online tickets with Eurostar / TGV / Deutsch Bahn whilst on my way to London; telephoned and booked a hotel room in Paris; I can greet you from Germany.  Highlight of the journey was definitely the TGV driver appologising that the train could only manage 280km/h due to the icy weather and then deciding to travel at 310km/h anyway!

I've come back to Saarland (south west Germany) for several reasons.

Firstly, I made some really great friends here back in spring 2011, when I had the opportunity to complete an exchange semester here.  This was a truelly blessed and influential time, and I am extremely grateful for it.  It's been fantastic to be able to catch up with some of these including those from church (instant warm welcome and lunch invitation - love it!), friends from work, and friends from halls ('gudd Gess' has been shared!). 

Secondly, I've had a job interview here.  The interview was for the department of Nephrology (kidney medicine), one of the departments I studied within whilst here on placement.  I sent off an application a few weeks back and they said that they were interested in hearing more - hence my determination to get here!  Thankfully, the interview went really well and I've been accepted!  The head of department was approachable and open, telling me more of what to expect and the challenges and opportunities ahead.  My previous supervisor also came and put in a good word for me (I have retrospectively rewarded him with fine scotish whisky and M+S shortbread).  So, I've got a few formalities to sort out with the administration, however once that's sorted I'll be able to receive the contract.  Unexpectedly, my second year of the UK foundation programme may also count towards my speciality training, shortening the process by a year and letting me enter at a higher pay-grade (score!).

Thirdly, I needed to figure out the German equivalent of the General Medical Council.  This has proven to be the challenge of the trip so far...  They required 13 legal documents, after a lengthy discussion I managed to persuade the administration to accept 2 of the documents I had brought with me.  Turns out I need to become good friends with a notarist in order to legally recognise and translate my certificates, scripts and legal forms into a legislatively acceptable format.  I think there may also have been further miscommuncation during the meeting, as I had to spend several minutes persuading them that I was infact a real practicing doctor inspite of not having an MD.  Definite character building experience!!!  (although nothing that a combination of pray with coffee + german cake can't fix).  I have admin lady's email address and will be in further contact.  I seems possible to get everything together, it'll just involve quite a bit of hassle, time and expense.

So, it's great to be back in Germany.  Job is set and the language skills are coming back.  Sadly, lots of the students are away or in exams at the moment.  Encouragingly my church pastor tells me that quite a few new christian medics have started this year.  A christian medical group has also recently been founded.  Also, incredibly excitingly, I have discovered that a russian speaking congregation have started to meet in the town - Mega Awesomah!!!  Looks like there will be plenty of opportunies for Christian medical fellowship and improving my russian language skills!

In summary - I'm seeing many opportunities as to how I can serve here in Germany.  There will be many opportunities to learn more about people, my strengths and waekness, langauge(s) and cultures.  The present frustrations are useful to me as they will prepare me for what is to come.  It's also a great humbling experience and will allow me to serve others much better and to learn to rely on and work hard to honour God.  Just need to remember this when they say in the administration tells me in their direct manner - Nein, das ist unmoeglich!