What happens to people with diabetes when the earth trembles? When a natural disaster hits, all focus goes into the immediate relief work and on saving lives. This is only natural and also how it should be. In such a situation, people with diabetes are particularly vulnerable because they are at increased risk of infections caused by injuries and most likely without access to medicine and hence in poor control. Therefore, while diabetes may not be at the top of the mind when a disaster hits, those who live with diabetes are doubly jeopardised. West Sumatra, September 2009 The Indonesian island of Sumatra is situated on the renowned "Pacific Ring of Fire", prone to high seismic activity and regular earthquakes. On 30 September 2009, a 7.9 magnitude earthquake struck off the coast of West Sumatra and caused vast damage to the provincial capital city of Padang. More than 1,000 people died and more than one million totally or partially lost their homes. A few months prior to the earthquake, Dr. Eva Decroli had commenced training to set up a diabetic foot clinic at Padang's public hospital, the M. Djamil Hospital as part of a project supported by the World Diabetes Foundation. By September last year, the hospital management had committed themselves to build a permanent diabetic foot clinic and Dr. Decroli had started providing services to the 31 registered patients. The M. Djamil Hospital, the largest medical facility in the area did not go untouched when the earthquake hit. As a consequence, emergency and basic health care services were conducted in a tent with only one big room for all out-patient services. The diabetic foot care clinic could easily have been forgotten, because who cares about the diabetic foot when the earth trembles and buildings crush? Besides, the equipment purchased for the foot care clinic had vanished among the rubble. Debris cause infections According to Dr. Decroli, one month after the earthquake people were still in deep trauma and they did not come to the hospital. "So a team of doctors and nurses went to the area worst affected by the earthquake to provide medical services. When we found patients who needed hospitalisation we sent them to the M. Djamil Hospital, parts of which still stood intact. We saw diabetes patients who were afraid to leave their houses. To encourage them to seek care, a fellow surgeon and I appeared on local television to give them the spirit and strength to stand up from the trauma of the earthquake," he says.   Teams of doctors and nurses doing outreach work in West Sumatra to reach diabetes patients who were still traumatised after the earthquake.   Due to sharp objects from the debris of damaged houses or buildings, many diabetes patients suffered injuries and severe foot infections including infected fractures. There were also cases of infection of newly amputated limbs because the patients could not come to the hospital for control. But already six weeks after the earthquake, a diabetic foot clinic was established in a temporary building at the hospital. - And because many private hospitals had closed, the demand at this temporary facility was even higher than before. According to project coordinator, Dr. Indah Widyahening one saving factor was that only the buildings were destroyed while most of the health workers survived. "Furthermore, medication was made available from many sources of funding, so the services could continue. Access to medical care was not dramatically affected, since many institutions sent health workers for relief. The difference was in terms of limitation of space and comfort," she says. Read about the project Haiti 12 January 2010 While preparing this article, another earthquake of immense magnitude hit the Caribbean island state of Haiti. The death toll is still unknown, but estimates already place it on the unappreciative top ten of worst earthquakes of all times. Among Haiti's 10 million inhabitants (1), an estimated 800,000 live with diabetes (2). According to Dr. Ammar Ibrahim, Director at the National Institute of Diabetes, Endocrinology and Nutrition (INDEN) in neighbouring Dominican Republic, the main problem is that the majority of these people remain undiagnosed. In the aftermath of the earthquake which destroyed most of Haiti's capital city Port au Prince, INDEN has stepped in to help the victims with diabetes in Haiti. As a consequence of circumstances, their strategy has two main areas: 1. Follow-up on already known diabetes patients and facilitate their access to medicine; and 2. Do a massive campaign to diagnose people who suffer from diabetes but who do not yet know it. Preparing teams for mobile clinics "The public health system in Haiti is very fragile but there are a few Haitian and international organisations which partially take care of diabetes patients. But faced with a disaster of this magnitude, many of the people with diabetes - particularly those with few resources - abandon their treatment because they cannot afford it or because they have other priorities. As a result, we expect to see patients with acute complications in the coming two to eight weeks. We therefore have to gather all efforts to help this group of patients," Dr. Ibrahim explains. INDEN in the Dominican Republic is preparing a team of doctors, paramedics and support personnel to set up mobile clinics to manage diabetes in Haiti. These clinics will work in the neighbourhoods for all people with diabetes to come to for medical attention and medicine. Long and short-term relief efforts According to Dr. Ibrahim, it is also important to work arduously to strengthen the Haitian diabetes organisations, donating medicine, glucometres etc. so that when the current relief work ceases, these organisations can follow-up on a long-term basis. The World Diabetes Foundation does not currently support any projects in Haiti, but this mainly rests on the fact that the Foundation is fully demand driven. "We know there is a dire need, but for our support to be sustainable, we depend on local organisations to seek our funding and lift and guide the work. Given our set-up we are not in a position to contribute to the immediate relief work needed for people with diabetes in Haiti. But we will welcome applications for supporting long-term efforts to build capacity within diabetes along the same principles we apply in other poor settings," says Dr. Anil Kapur, Managing Director of the World Diabetes Foundation.   References 1.  UN Population Division, 2010 medium variant, http://esa.un.org/unpp/ 2.  According to Dr. Ammar Ibrahim, Director at INDEN the prevalence is 8%. In comparison, the IDF Diabetes Atlas 2009 states 313,000 people to be living with diabetes in Haiti.

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