He came to the Government clinic at Sedawatte, virtually under the Kelani bridge, laughing and joking after a function at home. The moment Registered Medical Officer (RMO), Dr. W.A. Gunawardene saw his swollen feet, checked his pressure and performed a random blood sugar test, she knew there was something seriously wrong, for both readings were [...]

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Diabetes: Taking the fight to the silent killer, head-on

By Kumudini Hettiarachchi
WHO funds NIROGI Lanka to build capacity and empower Central Dispensaries and Divisional Hospitals in awareness, prevention and control
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He came to the Government clinic at Sedawatte, virtually under the Kelani bridge, laughing and joking after a function at home. The moment Registered Medical Officer (RMO), Dr. W.A. Gunawardene saw his swollen feet, checked his pressure and performed a random blood sugar test, she knew there was something seriously wrong, for both readings were at dangerous levels.

Her advice was clear and urgent – “Go to hospital immediately.” He did just that, seeking admission to the National Hospital Colombo that day itself. He was fortunate, for when the heart attack came, expert medical attention was at hand, literally.
He not only lived to tell the tale to his relatives and friends in populous Sedawatte, but was also thankful to the staff at the Central Dispensary.

Showing the way: The Sedawatte clinic. Pic by M.A. Pushpa Kumara

What many people may not be aware is that, slowly and surely, over the past three years, select Central Dispensaries and Divisional Hospitals (earlier known as peripheral units) have been empowered and strengthened to check out the vulnerability of people to the silent killer of diabetes.

The person from Sedawatte is alive today because of the NIROGI Lanka Project, the Sunday Times understands.
Whereas earlier a Central Dispensary such as Sedawatte, catering to nearly 15,000 people from Sedawatte, Kotowila, Wennawatte, Weheragoda, Orugodawatte, Wadullawatte, Thotalanga and Peliyagoda would mainly deal with colds, coughs, fever and flu, now it is equipped to screen and also provide early care for diabetes.

The aim was diabetes prevention and control, as well as awareness, stresses NIROGI Lanka Chairperson Prof. Chandrika Wijeyaratne, Professor- Reproductive Medicine, Colombo Medical Faculty and Convenor- Diabetes Prevention Task Force.
Referring to the launch of NIROGI Lanka (National Initiative to Reinforce and Organise General Diabetes Care In Sri Lanka) three years ago, she explained that the Diabetes Prevention Task Force and the Sri Lanka Medical Association (SLMA), in collaboration with the Health Ministry, the Collaborative Research Group of the Colombo Medical Faculty, the Diabetes Association of Sri Lanka and the Healthy Life Diabetes Clinic joined hands to streamline diabetes care with the hope of controlling the disease.
With funding from the World Diabetes Foundation, NIROGI Lanka had on its drawing boards three components to achieve this goal. Component 1 was to train a new cadre of ‘Diabetes Educator Nursing Officers (DENO) to provide streamlined diabetes education and foot-care to patients who attend clinics in tertiary care and general hospitals throughout the country; Component 2 to establish a link between primary and tertiary care in diabetes; and Component 3 to deal with health promotion and prevention of diabetes by empowering the people.

Going into specifics, Prof. Wijeyaratne said that under Component 2, the aim was to provide quality diabetes care for people, by developing facilities in selected primary care centres in the Western Province, training primary care medical practitioners and improving laboratory services. With tertiary-care institutions being overcrowded, the aim was to provide day-to-day diabetes care at people’s doorstep, through easily accessible primary-care clinics.

It was here that the Sedawatte Central Dispensary came into the picture, along with Wellampitiya and Delkanda; the clinics at the Divisional Hospitals of Talangama and Piliyandala and the clinic at the Maligawatte District Hospital, making a total of six, the Sunday Times learns. Maligawatte has also been provided a brand new laboratory to undertake the necessary tests.
The idea has caught on so much that, of the six days every week that Sedawatte sees patients, while holding ante-natal, well baby, well woman and family planning clinics, now, every Friday is dedicated to diabetes care.

Helped out by a doctor who comes from the National Hospital and a nurse from the Maligawatte District Hospital, meticulous notes are maintained by RMO Dr. Gunawardene who, with pride, shows the books to the Sunday Times.
Weight, height, waist are recorded on the first visit, and the body mass index (BMI) calculated, case histories recorded, whether there is weight loss, undue thirst or frequent passing of urine at night, while basic tests are also carried out to assess the risk according to the World Health Organization’s Risk Chart, says Dr. Gunawardene, adding that the eyes and the feet the also checked.

“We advise them on diet and exercise,” she says, explaining that, on average, about 40 to 60 people are checked at Sedawatte on a Friday. “We tell them not to eat bread, but nadu or red rice, and throw in a large quantity of green leaves, vegetables and fruit if possible.”

The proof, of course, lies in the numbers, and when the Sunday Times visited Sedawatte, there were 322 diabetics, a majority of whom were women, on its books.

Coloured stickers mark the status of every patient, yellow indicating those with diabetes, blue hypertension, red ischaemic heart disease, green stroke and black other diseases. The patients with complications the dispensary cannot deal with are referred to the National Hospital and the Eye Hospital, it is learnt.

Under Component 2, 119 Medical Officers and 69 General Practitioners have been trained, while the strengthened city dispensaries and divisional hospitals have screened 27,986 people and detected 3,889 with diabetes.
Referring to Component 1, which was a novel concept of training nurses as DENOs and carers, Prof. Wijeyaratne said that NIROGI Lanka achieved tremendous success with 279 DENOs going back to 124 Government hospitals, in addition to 64 Diabetic Educators (DE) in private hospitals and 75 Health Educator Nursing Officers (HENO).

These nurses are working in diabetic and general medical clinics and wards of all teaching, provincial and base hospitals on a staggered basis, advising patients with regard to diabetes.

Implementing Component 3 of “enabling people to increase control over and improve their health”, the target settings had been Kotte and Kolonnawa, with 10 schools, 10 workplaces and 10 semi-urban communities being selected.
Cultural issues faced by women, such as what should be worn when exercising, which includes games such as volleyball, have been overcome. With housewives to the fore, there is evidence that dietary habits have changed. The elavalu henda (vegetable spoon) has been exchanged with the buth henda (rice spoon) so that more vegetables and less rice would be taken, points out Prof. Wijeyaratne.

Lamenting that, in some schools and workplace settings, the programme had not taken off as expected. She says that it is functional in 101 community settings, 14 workplaces and four schools.

Outreach programmes have also been conducted in Jaffna, Polonnaruwa, Ratnapura, Balangoda, Moratuwa, Nuwara Eliya, Katana, Kotahena, Chilaw, Peliyagoda, Kottawa and Gonapola, under Components 2 and 3.

Component 1 was headed by Prof. Wijeyaratne and coordinated by Consultant Diabetologist Dr. Kayathri Periasamy; Component 2 by Consultant Endocrinologist Dr. Noel Somasunderam; and Component 3 by Professor in Psychological Medicine, Prof. Diyanath Samarasinghe and Senior Lecturer in Community Medicine, Dr. Caarukshi Arambepola.

Beyond diabetes

With NIROGI Lanka Phase 1 and all three components being handed over to the Health Ministry recently, the hope is that this successful and low-cost model will not only be used for diabetes, but for all non-communicable diseases (NCD).
Commending NIROGI Lanka, the World Diabetes Foundation’s Programme Coordinator Hanne Strandgaard said, she sees Sri Lanka in the forefront of the battle against NCDs in Southeast Asia.

Having granted US$ 625,000 as “seed money” for Phase I of NIROGI Lanka, the Foundation is to grant US$ 500,000 for Phase II which will be carried out by the group headed by Prof. Chandrika Wijeyaratne.

In the next three years, the NIROGI Lanka Phase II will focus on vulnerable groups under ‘NIROGI Matha’ to tackle gestational diabetes; ‘NIROGI Pada’ for foot-care and ‘NIROGI Diviya’ to extend health promotional activities, it is learnt.
Meanwhile, the Foundation has granted US$ 850,000 to the Health Ministry to address additional capacity building at district and primary healthcare levels; deal with the co-morbidities of tuberculosis and diabetes; health promotion in schools; strengthen surveillance and monitoring systems for diabetes and other NCDs; and build stakeholder partnerships.




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