India: Diabetic foot care in the developing world
Diabetic foot ulcers, Infection | Susan Braid, Louise Stuart
A trip to India highlights the need for diabetic foot care assistants in developing countries.
In 2008, podiatrists from the University of Salford and from the North Manchester PCT visited Sri Ramachandra Hospital, a large university and teaching hospital in Chennai, India. The group’s mandate was to carry out a scoping exercise, on behalf of Scholl (SSL International, London, UK), for the establishment of a generalist foot clinic that it is hoped will bring podiatry knowledge and skills into the south Indian region.
The team investigated the types of foot problems that were commonly encountered in India, visiting hospital and outpatient clinics in wound care, dermatology, orthopaedics and diabetology. A number of relatively minor foot problems were encountered, yet the majority were the result of the complications of diabetes, most notably diabetic neuropathy, and these will be the focus of this editorial.
Diabetic foot care in India
Podiatry as a profession is non-existent in India; no institutions offer a university-level podiatry qualification, and management of foot problems is undertaken mainly by physicians, regardless of their specialty.
No dedicated space is available for the treatment of foot problems at the Sri Ramachandra Hospital, or for the coordination of care across related disciplines (i.e. the multidisciplinary foot care team).
The group found that the use of UK guidance (NICE, 2004) to identify people “at risk” of diabetic foot complications had severe limitations when applied to the Indian population. As there is no integrated community care, people present to hospitals with diabetic foot complications already in the acute stages. Consequently, the group observed high rates of amputation and surgical intervention, with all debridement being undertaken in theatre. Following such interventions, people were kept in hospital longer than medically necessary because no appropriate community-based care was available. The impact that this “fire fighting” approach to management has on resources is significant, precluding the possibility of risk management or early intervention.
Infection management and wound care
The management of infection witnessed by the group was problematic and, tellingly, meticillin-resistant Staphylococcus aureus infection rates were reported by clinic staff to be between 70% and 90%. In outpatient clinics visited by the group, there was variation in the level of infection control; in some areas, instruments were disinfected by cold sterilisation or boiling sterilisers. The wearing of gloves and masks did not appear to be commonplace.
Infection control was further impeded by limited access to appropriate antibiotic agents, which was dependent on a person’s ability to pay for the therapy. Access to appropriate wound care products was also extremely limited.
Cultural and economic factors
Cultural and economic realities in the Indian context put the vulnerable diabetic foot at further risk. It is considered disrespectful to enter a physician’s consulting room wearing footwear and the group observed people leaving their footwear outside the clinical area and walking bare foot into treatment rooms with an open ulcer.