The Impact of Amputation On Diabetic Patient In Fiji
Researcher: Ilaitia Delasau 5th Year MBChB, Otago Medical School. Supervisors: Prof A van Rij, Emeritus Professor Barbara Heslop, Dr Joji Malani Departments: Department of Surgery Medical and surgical Sciences, Department of Patholology Dunedin School of Medicine, Fiji School of Medicine Suva, Fiji Islands.
Lower limb amputation for diabetic gangrene is now the commonest surgical operation in Fiji. This reflects the very high (and rising) incidence of diabetes in the Pacific Islands. Following surgery most amputees return to villages to live in relatively primitive conditions, where the available health services are very limited. I spent 10 weeks of my summer vacation interviewing 34 diabetic amputees in their homes. This report describes how they got on after amputation, and illustrates the devastating impact of the disease on traditional Fijian live. Some suggestions are made for dealing with this enormous problem.
The Impact of Amputation on Diabetic Patients in Fiji
Type II diabetes is a major health problem in Fiji and other Pacific Islands, and the incidence is increasing. This is largely due to the adoption of a Western-style diet in preference to traditional Islands food together with a sedentary lifestyle. Amputation of the leg due to atherosclerotic vascular insufficiency, together with gangrene triggered by infection, is now the most common surgical operation in Fiji. Most amputees return from hospital to a fairly primitive life in the rural or suburban areas of the country.
Since the health service in Fiji is limited, I was interested to find out exactly what happened to diabetic amputees sent back to their homes after surgery.
Fiji has seen a massive rise in the prevalence of diabetes mellitus and impaired glucose tolerance since independence. The major changes in lifestyle that have occurred in this time appear to have exacerbated an underlying predisposition to developing this disease. The people are eating more Western-style diet in preference to traditional Islands food. For example, tinned NZ corned beef with high fat content, mutton flaps with 90% fat and canned fruit in heavy syrup, are poor substitutes for fresh fish, leaves and fruits.
The postulated "thrifty genotype" theory, which suggests that individuals from populations that have been repeatedly exposed to famine or starvation become selected for efficient carbohydrate metabolism and fat storage that allow them to better survive periods of deprivation. The same genes, however, predispose to diabetes in an environment with plentiful food. According to this theory, type II diabetes mellitus is seen as a genetic illness, which subsequent generations will inherit. According to this theory, the Fijians (and the Polynesians) who made the original long journey over the sea were probably genetically programmed to withstand a scanty diet. They might otherwise not have survived the journey. The same genes in their descendants could probably cope well with famine, but not with an abundant diet, nor with modem "junk food".
The majority of diabetics were brought up in villages and have moved from their villages in the rural areas to get jobs in town. In the villages they would mostly eat healthy food; lots of vegetables, fresh fish, fruit and very little "junk food". The shift to urban areas exposes them to varieties of different foods.
Accessing the subjects for this investigation
This caused more problems than I originally expected. I took 400 names of people who have had either forefoot, below knee or above knee amputation from the surgery department 1996-2000 record books. After obtaining their names with their date of birth, race, year of surgery and hospital number, I then visited the record room in the hospital to get each patient's folder and their contact phone numbers and home addresses. Once I had the phone numbers I then made phone calls, calling the patients or their relatives to try and arrange a visit at their homes.
Informations were collected by interviews and a questionnaire. Unfortunately at the record room, the majority of the 1996 and 1997 folders could not be found, as they kept only the last five years' records. Of the folders found, quite a number of the patients had no contact phone numbers, which made it a hard to get in touch with them. Some of the patients had changed their addresses without informing the hospital, and quite a number of them had returned to the outlying islands which were difficult to visit. A number of the patients had supplied their relatives or friends' work phone numbers as their contacts, and these people had change jobs or had moved somewhere else. Also quite a number of the patients with contacts were found to have passed away when I made contacts with the family.
The above highlights some of the limitations of this research and also the fact that there is no proper method of following up amputees in Fiji.
Results and Discussions
Summary of patients seen
Of the 400 names I got from records, after analysing on spreadsheets I came down to a total of 249 names. Out of the 249, I was only able to personally interviewed 34 due to the problems discussed above. I visited 32 patients at their homes and 2 were in the hospital at the time of the interview.
|Sample 249||Sample 34|
|Female||123 (49%)||16 (47%)|
|Male||126 (51%)||18 (53%)|
|Fijian||197 (79%)||28 (82%)|
|Indian||28 (15%)||5 (15%)|
|Others||14 (6%)||1 (3%)|
Table 1: Summary of patient
Figure 2: Gender Distribution in 249 patients
73% of my subjects were living in settlements on the outskirts of Suva, which I've called suburban (SU) area. 24% were out in the rural areas and only 3% in the Suva. (Figure 4)
Figure 1: Race distribution of amputees in 249 patient
Hospital stays before the amputation ranged from 1 day to 2 months and hospital stays after the operation ranged from 1 week to 5 months. (Figure 5)
Figure 4: Population distribution of amputees
50% of the amputees were not happy with the lead-up to their amputations. They were not very clear on why they needed an amputation and blamed the doctors for incompetency. In addition they thought the decisions regarding amputation were made too soon and they believed that their legs could have been saved if the doctors had involved the patient and other staff into the decision-making before the surgery.
|< 1 week||1-2 weeks||2-4 weeks||1-2 months||2-4 months||>4 months|
Figure 5: Length of hospital stay in 34 amputees
Figure 6: Type of support in 34 amputees
29% of my subjects had ABIs' greater than 1.2 but have no complaints of claudications or rest pain which is quite unusual. This could be explained by the fact that with chronic diabetes in addition to other complications, arteries get hardened i.e. arthrosderosis, and so the pressure that takes to compress them increases.
Figure 7: Ankle Brachial Index (ABI) measurements in 34 amputees
85% of the amputees I have interviewed have annual income of less than $10,000. Most of the native people from rural villages in Fiji have no steady source of income. Their main source of income is either selling 'Kava', coconuts or fish if they are close to the sea. The men plant 'Kava' which they have to look after and can harvest after 4-5 years. The roots are then dried and sold to the middleman in town. A kilogram cost about 10-12 dollars and the resulting income has to last the family for about 6-12 months.
Figure 3: Average annual income for 34 diabetic amputees
Prostheses in Fiji are not free; nor are they subsidised by the Government. A local man Mr X who had his prosthesis training in Brazil for two years makes prostheses locally in Suva. The materials are either imported or sourced locally. The Government provides the building facilities, but the business is owned by the Fiji Crippled Children's Society. Mr. X employs a few locals in the lab and makes about 45-50 BKA prosthesis a year and about 2-3 AKA ones. He reported that a lot of people in Fiji really need prosthesis but they can't afford them. He tries to help as much as he can with the costs, but he can't help much as the Government is not helping at all. Normally amputees give in their application and let him know how much they can pay, and if they are lucky, the Fiji Sixes Game (something similar to Lotto) pays the rest.
Amputees have to buy their own prosthesis, crutches or wheelchair. The cheapest below knee prosthesis cost $775 and if the materials are imported from overseas, it cost $970. An above knee one cost more than $1,000. That is a lot of money for someone who has no source of income, and has a family to support. One of the common answers to my question of why don't they have a prosthesis was "I couldn't afford it because it is too expensive. Where would I get the money from, the Social welfare won't help me pay for one." Other amputees said "I couldn't be bothered buying one because apart from the fact that it is too expensive a friend told me that it is "crap" anyway, its heavy and very uncomfortable."
I came across a 39-year-old diabetic lady who has had a BKA and an AKA and had 3 children, a 10-year-old, an 8 and a 5 year old. Her husband is unemployed and she sells packets of Kava, cigarettes, and lollies to make money for their daily needs. She has neither prosthesis, nor crutches. She reported that she wasn't given any financial help for no specific reason. She was fortunate enough to have a wheelchair donated by the Red Cross Society which at the time of the interview has had punctured tyres for a year, so she hasn't been using it during that time. They would have to pay $20 to get it repaired and they could not afford it. The Fiji Red Cross and the Fiji Six Games sometimes do help people with money to buy prosthesis and crutches. Quite a few of my subjects had their children who are working and helped them to pay for their prosthesis. Some of the patients I saw were retired civil servants and receiving pensions, while others were getting some money from the army whose husbands were army officers. These patients could afford their prosthesis
Social Welfare $30/week was available for some.
Mr X reported that at the moment he is the only one in the country who is qualified in making prostheses. He is overworked and couldn't really accommodate the demand of the whole country. He suggested that the country needs another qualified prosthesis expert to look after the western side of the island and two qualified technicians.
Education and help in getting used to appliances.
The responses to my question on whether the patient had any form of help after the amputation were similar: that there was little, if any help available. "They only know you while you are in the hospital, once you're out you're a total stranger". The average hospital stay after the operation is 2-112 to 4 months. They usually spend a few days to a week at the physiotherapy department to help with the walking with crutches that they have to pay $20 dollars for. They are then told to go home and take things easy and if they want to, they can apply for a prosthesis at the rehabilitation department. On asking if there was any help at home, 99% said none, only family help.
Once home, the patients can arrange for a prosthesis if they can afford it with the man who makes it at the rehab department in Suva. The rehab department is in another part of Suva and patients after spending a few months at home have to try and get to this address. After they had the artificial leg fitted they practiced for a few days and then were sent home, told that they will get used to it. Normally they are told to come back in three month's time for a clinic. This is quite difficult if patients are in villages far from Suva or in the islands where transport is a problem. A number of my subjects reported that they were not told to come back if they had any problem. Some of my subjects with prosthesis are not using it anymore because it is either to heavy or too uncomfortable to wear. I understand from most of the subjects interviewed that the follow up for amputees with prostheses in Fiji is very disappointing and poorly monitored.
Other reasons for the poor follow up included:
The rehabilitation department is privately owned and the government is not doing much to change it, there is only one prosthesis expert for the whole country. He is really stressed out by the volume of work, the lack of funding, poor resources, and lack of other trained staff.
Social Implications of Lower Amputation
It must be appreciated that these are only some of the major social implications of lower limp amputations among the people of Fiji.
- A lot of suffering and pain to the amputee and his/her immediate members of the family. Especially if the patient used to be a very active, outgoing person which family and friends looked up to. Losing a leg brings on emotional and physical suffering due to not being able to carry out what they were formerly capable of doing.
- Most experienced with the loss of employment a gradual loss of self-esteem, confidence and hope for better future. Most of my subjects had lost jobs that involved walking and climbing and after the amputation could not see themselves doing the job safely anymore. Some lost their jobs after being declared medically unfit as a result of other complications of diabetes. As there are no support systems in place for these amputees in Fiji to help them cope with their loss, most of them gradually lose their confidence and self esteem and are totally confined to their homes doing nothing but sitting around all day.
- Amputation meant disruption in the family budget due to medical expenses. Diabetic patients get all their medication from the hospital which helps a lot, but since most of the amputees cannot travel to the hospital by bus, they have to go by taxi every time they go in for a check-up. This can be quite expensive for a family with school kids and relatives all living in the same house.
- Additional family responsibilities in caring/nursing for the amputee and providing welfare. A number of my patients were being looked after by their children (who had to leave school) because their partner was working.
- There was a loss of responsibilities and respect especially if amputee holds the post of traditional chief, "turaga ni vanua". By his/her non-compliance of traditional obligations this will inevitably cause directly or indirectly social structure breakdown, and a diminished appreciation of Fijian values and traditions. All these lead to break down of law and order together with urban drift in some cases. A few of my patients hold important positions in their settlements and for them losing a leg means they cannot participate as much as they wanted to and this causes a lot of frustration. Immobility and non-participation in community work could give rise to resentment and gossip in the village. This would be stressful and psychologically destructive on the amputee.
- Working hours of employed members of a family are reduced when urgent needs of amputee are attended to. This give rise to poor economic returns for an employer.
- Early retirement of amputee is a skill-manpower loss. This could lead to reduction in financial benefits in terms of pension and insurance where these are available.
- Child bearing and motherhood may be a be source of embarrassment in the village or rural life A number of female patients were still having babies and reported that sometimes they felt that they have been the talk of the village.
Suggested remedial actions
The following would be the work of a lot of people over more than one way things look at present.
- First of all an immediate improvement in the recording of statistics related to all lifetime the aspects of diabetic patients treatment.
- A national survey to be carried out covering the period that records are available for of recent, past and current amputations on diabetic patients, to determine statistics on number of amputees, gender, age group etc, to provide basis for future national health strategies and actions to alleviate suffering and improve quality of life. It should also investigate the proper clinical diagnosis of prospective amputees before surgery. Most of the amputees interviewed complained," I should not have been amputated" or "it was too early, I came in tonight, the next morning my leg has gone" and blame doctors for incompetence.
- The Ministry of Health should liaise on with other relevant government ministries such as Ministry of Social Welfare, Ministry of Women and Culture, Ministry of Education and other organisations if need be in providing Government Assistance for amputees. Such assistance may be in the form of continuing education for diabetics and amputees, provision of wheelchairs and artificial limbs, employment, health education and counseling in rural areas and villages.
- Improved Public conveniences and facilities to cater for amputees as well as other handicapped people and intensify promotions of causes, risk factors, complications, prevention and treatment of diabetes in villages. Present strategies and programmes are inadequate. Diabetes educational programme be included in school curriculum and workplaces in light of dramatic increase in diabetes nation-wide.
- Lastly but not the least, the Ministry of Health should look into sending more suitable health professional abroad to get training on Diabetes control, amputation and especially prosthesis making and fittings. I'd concentrate on this section, because a good "diabetic nurse instructor" who liaised with the appliance suppliers could make a great difference. I am sure that suitable people could be trained in NZ at not too great an expense. (People who go to conferences overseas with enormous expenses and don't do much else except sit in offices planning the next conference are absolutely useless.)
Points raised by amputees
- Doctors need to spend a bit more time talking to the patients before "laying the saw on their limbs". Diagnoses are made too fast and a lot of the legs could be saved if more questions were asked. Most of the patients are complaining about surgeons "too eager to chop their legs" without looking at the impact of their loss.
- Doctors and nurses need to instill SELF-CONFIDENCE into patients. Patients need to be told that doctors cannot make them better if they do not want to get better themselves. The will to live is paramount in the recovery/rehabilitation process.
- Diabetics need to be told that they can live a normal live if they strictly follow instructions by the doctors.
- Amputee's quality of life is very poor if they are immobile and home bound, hence the need for prosthesis, wheel chairs and crutches. The problem is that most of them could not afford prosthesis because they are too expensive. The Government should look into the problem and provide assistance to all amputated patient.
I thank the following for making this project possible:
- The Otago Diabetes Research Trust for funding the research scholarship
- Dunedin Basic Medical Sciences Course Trust - for air fare and grant towards the cost of living in Suva. 40 Health Research Council- for $500 supplement to studentship
- My supervisors: Prof Barbara and John Heslop, Prof Andre Van Rij, Dr Joji Malani, Dr Eddie MacCaig
- Records staff at CWM Hospital for the tremendous help with getting folders etc. 40 Sister Kaitani and the operating theatre staff who really helped me with the surgical records.
- The Fiji School of Medicine accommodation staff.(for looking after me during my 10 weeks' stay.) I would also like to thank the following people for all their personal help:
- Dr Mere Vosaki, Fiji National Diabetic Centre
- Jenny Hurley
- Malcolm Gould
- Asena Tikina
- Mr Beni Naiveli
- My class computer wizard-Frank
- All my subjects (amputated diabetics) and their family
- Not forgetting my own family for their support.