SAN JUAN DEL SUR, NICARAGUA – It all starts for me with a sign on a downtown building in Tacoma. The sign says DAVITA. This is the name of a well-known and successful company that provides dialysis to patients who suffer with kidney failure.
I have an intense reaction whenever I see the sign. It has a powerful message about our health care system here in the United States, and this all connects to my life in Nicaragua.
After 15 years as the director of the Tacoma-Pierce County Health Department, I retired three years ago and moved with my wife to a farm in southern Nicaragua. Both of us were ready for a set of new challenges. We had always wanted to live abroad and grow our own food. And we both wanted to be involved in health issues in a setting that was less bureaucratic than what we experienced in Tacoma.
Our move was an adventure as we began to learn about a new country. Getting things done in a different culture, where little English is spoken and time moves at a different pace – with monkeys on our roof, a boa constrictor in the swimming pool, large hairy spiders the size of salad plates on our walls, ant invasions and insects, insects and more insects – all were part of the learning curve for us.
After about six months we felt ready to look into our health project. We chose as our focus the prevention and care of diabetes. The choice was simple, as the community here urged us to take this on. Its importance was brought home to me after an experience I had walking in our local village.
I met a man sitting in front of his house. He was an amputee. I just assumed that his missing leg was from the war. He was the right age, and there had been many casualties in the local fighting. I asked him about his war injury. He corrected me.
“No, this was not from the fighting,” he said. “I have diabetes.”
His situation said it all. There are many diabetics in Nicaragua, and most do not receive the care they need to avoid the horrible complications of uncontrolled diabetes that an amputation represents. Nicaragua is a poor country, but its major health problems are not due to infectious diseases like malaria and tuberculosis. As in the United States, the three main causes of death in Nicaragua are due to chronic diseases: heart attacks, strokes and diabetes (with diabetes being a major contributor to both strokes and heart attacks).
Two years ago we began a program with services for those who already have diabetes and those who are at risk for the disease. Women are at the center of our groups. We use a curriculum that focuses on better nutrition for the family and improving weight control.
Over the last two years we have held clinics and prevention groups in schools, churches, private homes and government health centers. I am often asked by visiting students and volunteers if our experiences here apply to what is happening in the U.S. with its out-of-control diabetes/obesity epidemic. There has been much talk about our poor national diet and an increasingly sedentary lifestyle.
Though many doubt the relevance of our experience down here because of the dramatically different living conditions, the answer is very straightforward: The situations are directly comparable. People are people. Lifestyle decisions are lifestyle decisions, and diabetes is diabetes no matter where you live.
People here eat too much fried and carbohydrate-rich foods and add too much sugar to what they eat and drink. Also, people are moving from the countryside to towns and cities and a more sedentary lifestyle.
Even though the people here have little access to health resources, we’ve learned that diabetes can be managed here. Sneaking through all of the differences between our countries is the realization that we can control this horrible disease in a very resource-poor setting.
We do not have a large budget or access to high-tech medicine. We always work in a group setting and use community volunteers to get our message across. We have directly seen that diabetes is preventable through a good diet and weight control.
Likewise, if you have the disease, we’ve seen that its complications are preventable. We do it with a steady message of a better diet, a focus on weight control, a careful use of medications and, importantly, social support. And it doesn’t have to cost much. We spend $12 a month per diabetic for their care.
What we practice in Nicaragua is common knowledge in the U.S., but we have fallen into the trap of focusing on the back end of the disease and not on the front end of prevention. We wait until the disease develops, then throw resources at it. But this does not solve the problem.
This is where my reaction to the Davita sign comes in. Renal failure is a late complication of diabetes. Dialysis is very expensive, can greatly affect the quality of life and does not cure the disease.
No matter the country you live in, controlling diabetes is difficult. But, as we are learning in Nicaragua, a return to basics through a focus on prevention with patient education and support does not have to be expensive. It just gives us the best hope of saving lives and lessening the suffering of this terrible disease.
Federico Cruz-Uribe is a former director of the Tacoma-Pierce County Health Department. He now lives in Nicaragua.
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