RCGP International Newsletter

Bradford is a beautiful city          showed me how to test feet to            the Primary Care Training Centre      one day on action planning
standing on hills and                 detect any micro-vascular changes        in Bradford.                          with Dr Sheila Webb.
mountains. Since my                   due to diabetes, with patients              In the third week I was back at       In the UK flu vaccines are offered
graduation in 1975 it was my          reporting every 3-6 months for           Horton Park, and also nearby          to individuals over 65 and those
dream to one day see the British      check-ups. I was t a k e n t o           New Hey Surgery, observing            suffering from chronic diseases like
system of treating patients. In       B r a d f o r d R o y a l Infirmary to   practice. I visited the gum clinic,   diabetes and bronchial asthma. In
Bangladesh medical institutions,      meet Professor Donald                    met Dr Nelson, a sexual health        the UK I have not seen a
the British system is followed        Whitelaw, an endocrine medicine          specialist, and visited St Luke's     patient entering a doctor's office
and most medical books are            specialist, to whom patients with        Hospital with Alison Hunt, who        without permission. Even the
British, hence the dream. I had       diabetic complications are               presented a seminar on infection      hospital staff obey the same
been working as a general             referred. I also                         control about methicillin-            rules. This is how British people
practitioner in Shushasthya, an                                                                                      honour one's privacy. Hand
outdoor clinic for under-privileged                                                                                  washing with antiseptic and
people of Bashabo, Dhaka,                                                                                            running water after examining
seeing all types of patients inc-                                                                                    patients is compulsory. This is
luding diabetics.                                                                                                    how the spread of infection by
   I came to Horton Park Surgery                                                                                     medical p e r s o n n e l c a n b e
in Bradford on an International                                                                                      p r e v e n t e d and the use of
Travel Scholarship and started                                                                                       antibiotics minimised. Patient
working with my British coll-                                                                                        follow-up is very important and
eagues. I worked on 1 October                                                                                        observed. T h e c a l l a n d r e c a l l
2007 for about a month in                                                                                            s y s t e m should be introduced in
different clinics and hospitals.                                                                                     our country also.
British doctors and their staff                                                                                         Doctors in the UK have
were kind and very helpful to                                                                                        Internet facilities to
me, and I am amazed at their                                                                                         communicate with other doctors
hospitality. It was a wonderful                                                                                      regarding their patients, even
time in my life.                                                                                                     sitting in remote areas — a facility
   I was introduced to doctors,                                                                                      that enables them to overcome many
nurses and the staff of the                                                                                          problems in treating patients.
clinic, and spent the whole                                                                                          We should implement the
second day with a GP with                                                                                            system in our country when
special interests (GPwSI) in                                                                                         feasible.
diabetes, Dr Mike Lawson. Mrs                                                                                           I am very much grateful to Dr
Judith Webster, the dietician,                                                                                       Webb for her inspiration and
took me to observe her                                                                                               g u id a nc e f r om t h e b e gin ni n g
explaining to patients the imp-       Observing Or Ahmed's clinic in Dhaka
                                                                                                                     of my applying for the Intern-
ortance of diet therapy in                                                                                           ational Travel Scholarship till
keeping diabetes stable. Dr           visited the Diabetic Antenatal           resistant staphylococcus. Nurse       the end of my journey. She is a
Clare Connolly, the senior GP         Clinic in Bradford Royal Infirmary,      Julie Horsfield at Horton showed      good physician and an even
who last year visited Dhaka, was      where pregnant women with                me a steriliser and explained its     better teacher. I am much benefited
engaged in training new GPs           diabetes or gestational diabetes         functions and maintenance.            from my travel to Bradford and
and giving information on all the     are admitted. I observed how             The steriliser was donated to         hope my colleagues and my
latest developments in family         efficiently Professor Whitelaw           Shushasthya by the doctors of         patients will be too when I
planning. In the evening I            and his registrar, Dr Halima, manage     Horton Park Surgery and carried       implement in my clinic
visited Dr Chris Limbert, an eye      problem-laden cases.                     by Dr Lawson and Julie Horsfield      (Shushasthya) my experiences
specialist who takes phot-              I had completed a diploma              when they visited in November         and especially the latest
ographs of the retina of every        course (distance learning) in            2007.                                 developments I learnt in the
diabetic patient once a year, to      diabetes, with a GP from Horton            My final week was spent in          management of diabetes.
check on diabetic complications.      Park Surgery as my mentor. I had         the Family Planning Clinic at         Dr Moqbul Ahmed
   For the second week I visited      one day off from the busy visit          Horton Park Centre, where I           Shushasthya Clinic, Dhaka,
Allerton HC medical centre            schedule to prepare for my               observed many aspects of family       Bangladesh
where Mrs Rose Armitage               examination, which I took at             planning practice. I also spent

                                                                         Annual National Primary Care Conference 2008                    Royal College of
                                                                                                                                         General Practitioners

                                                                                                          2-4 October 2008
                                                                                                          Bournemouth International Centre

Page 4
                                                                                                                                     Summer 2008

   Primary care in Bradford and Bangladesh: Developing our links
Apart from the warm sunny weather, t h e
                                                                                                                                    heart disease,
first thing that hit me on arriving in
                                                                                                                                    chronic renal fail-
D h a k a i n N o v e m b e r 2 0 0 7 was the
                                                                                                                                    ure, hypertension,
number of people on the streets, teeming
                                                                                                                                    duodenal ulcer and
along the pavements in their thousands,
                                                                                                                                    asthma, in addition
matched only by the myriad of brightly
                                                                                                                                    to diabetes. Infectious
painted rickshaws zigzagging through the
                                                                                                                                    diseases were also
noisy traffic. It was a hive of activity, lined
                                                                                                                                    common, like otitis
by workshops and retailers of every
                                                                                                                                    media, respiratory tract
description: hundreds of small businesses,
with shops selling raw produce next to ones
                                                                                                                                    gastroenteritis, uri-
full of shiny electronic goods, a far cry from
                                                                                                                                    nary tract infec-
the British high street. My only previous trip
                                                                                                                                    tions, fungal skin
to the region, a visit to India in 1984,
                                                                                                                                    infections and sca-
seemed a long time ago as my senses were
                                                                                                                                    bies, tuberculosis and
bombarded by the noise and activity.
                                                                                                                                    worms (Ascaris). The
  I had come to Bangladesh as part of a                                                                                             only condition I hadn't
twinning project between my practice in
Bradford and Shushasthya clinic in Bashabo, a           A street in Bashabo, Dhaka, Bangladesh          seen before in Bradford was typhoid. The
slum district of Dhaka. One of my GP                    we vacated in 2001 ! The patients too           clinic had its own mini-laboratory, capable
colleagues, Clare Connolly, had visited the             seemed familiar though they spoke Bengali       of performing simple blood tests, also
year before, building on links set up by                rather than the Punjabi and Urdu that I was     Mantoux tests and urine microscopy, all
Sheila Webb, a local public health                      more used to in Bradford.                       included in the consultation fee. For complicated
consultant. I was to look at the provision of             Shushasthya is unusual in Dhaka, it is        tests the patients were referred to other
care for patients with diabetes. I was ac-              funded by Bangladeshi expatriate doctors        laboratories or clinics where the costs were
companied by Sheila, and Julie, a nurse from            in the USA. It is thus able to charge only a    high. We had brought my practice's
my practice. We had already met Dr Moqbul               nominal fee in contrast to the private          redundant autoclave, purchased a table and
Ahmed, the senior GP at the clinic, during a            health centres that charge over twenty          a voltage stabiliser to boost the clinic's
cold but productive October in Bradford,                times as m uch. This philoso p hy sat w ell     electricity supply and trained the staff to use
sponsored by the RCGP, observing at my                  with my NHS ethos, but most patients still      the autoclave, which was up and running
surgery. He had arranged for some of his                had to buy medicines as the clinic only pos-    before we left.
patients with diabetes to come in so we                 sessed small quantities for the really needy.      I organised a visit to the Bangladesh in-
could discuss their management together.                The doctors prescribed by brand name,           stitute of Research and Rehabilitation in Di-
  Before Shushasthya, I went on a two-day               rather than generically, as they believed lo-   abetes, Endocrine and Metabolic Disorders
visit to Sabalamby Unnayan Samity (SUS),                cally produced drugs are poor quality. This     (BIRDEM), home of the Diabetic Association
                                                        gave me an interesting insight into the pre-    of Bangladesh, a huge fifteen-storey
an NGO based at Ne-                                                                                     building with 550 beds, dedicated to the
                                                        scribing culture of some of the GPs in Brad-
trakona, a hundred                                                                                      treatment of patients with diabetes. My
miles north of Dhaka.                                                                                   NHS-based concept of specialist hospital
Away from the noise                                                                                     services treating disease and its complica-
and bustle of the capital, I                                                                            tions was confounded — here diabetes was
was surrounded by green                                                                                 merely the 'ticket' to accessing health care
fields full of half-grown                                                                               under one roof, from primary care of non-
rice, linked by lakes                                                                                   diabetic illness, through routine diabetes
and irrigation channels,                                                                                management to specialist services like sur-
interspersed by                                                                                         gery, maternity, CCU and renal dialysis.
numerous villages and                                                                                      Dr Latif, senior consultant and old class-
farms. The land was                                                                                     mate of Dr Moqbul, described the difficulty
as flat as a pancake,                                                                                   patients had paying for medicines. With
only broken up by                                                                                       imported insulin costing US$8 a vial, and the
forest or clumps of                                                                                     average patient needing 2-4 vials a month,
coconut palms and                                                                                       this drug in particular i s hard to fund for
banana trees.                                                                                           50% of BIRDEM's patients. Low income
   Back in Dhaka, I                                                                                     levels (average of $2 a day) result in
                                                                                                        p rioritising rather than full compliance with

                               Green fields around Netrakona, Bangladesh                                protocols. Another major difficulty for
had been forewarned about the cramped                   ford, including my registrars, who trained      patients with chronic diseases is the frag-
conditions and the evening power cuts, with             in the Indian subcontinent.                     mentation of care by multiple private
everyone sitting patiently waiting in the                  Sitting in with Dr Moclbul, I saw patients   providers. The Diabetic Association of Bangladesh
dark for the back-up generator to start. It             with chronic conditions commonly seen in        tackles this by disseminating
reminded me of our old surgery, which                   Britain, like arthritis, anaemia, ischaemic                                  Continued on page 8

                                                                                                                                                Page 5
   Continued from page 5

   Primary care in Bradford and Bangladesh:
   developing our links

Visitor to Bashabo, Dhaka, Bangladesh

protocols to other doctors        I returned to Bradford, after   of chronic disease manage-
through training courses,       a stormy night when Cyclone       ment and building on my
and by using patient-held       Sadr hit Dhaka, getting home      practice's link with
records. With a 5.6%            24 hours late after our           Shushasthya.
prevalence and rising, dia-     departure was delayed. Two          In future I hope that the
betes is a serious health       weeks had not been long,          experience I gained from this
issue in Bangladesh. The di-    but in that time I'd learned a    exchange will be of benefit to
abetic patients I saw were      lot about Bangladesh and its      my patients in Bradford,
not obese as we would de-       health service, about local       particularly those from the
fine them in the UK; I          patterns of disease and the       Indian subcontinent and
learned that the correlation    drugs and treatments              other developing countries.
between weight and dia-         available, particularly with
betes still holds in            respect to diabetes. My           Dr Mike Lawson
Bangladesh if a BMI of 23 is    contribution seemed small         email:
taken as the upper limit of     by comparison, sharing my
normal.                         experience

      Page 8

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