When my patient Ramchandrappa (name changed) showed a blood sugar reading of 456gm/dl he was as clueless as me! Him because he did not know what diabetes meant and me because I could not understand how a heavy worker like him who toiled the whole day in the fields can develop diabetes in the first place. This was several years ago, when I freshly graduated from medical school. Now it’s a common place occurrence for me to have farmers and daily wage labourers attend the Non Communicable disease clinic at our rural health center where i get a sense of rural diabetes problem.

If diabetes and hypertension were lifestyle diseases and were earlier touted to be the ‘albatross around the necks of the rich folk’ it is no longer so anymore. I see people from all walks of life— the heavy farm workers, those who barely eat two meals a day, those with a BMI of less than 20kg/m2 suffering from these lifestyle diseases. What makes it even difficult is that we are unable to pin point a single causative factor as to why they develop the disease. In this background the advice that I tell the rural folk vastly varies from what I ask my urban patients to do. Most of the standard practices to be followed by a diabetic feels almost futile in this context of rural diabetes.

Barriers faced by rural diabetic patients in India

The barriers that our rural folk face are very unique and the “one size fits all’ approach that we provide for diabetic management cannot help here. Some of the most common examples are listed below:


1) Walking and other forms of exercise– doctors often tend to mention exercise and the WHO recommended 30 minutes of brisk walking a day for a diabetic. But how practical is this advice to a farmer or a cattle grazer who is spending his entire day walking around the village with his animals?.

2) Junk food– I asked an old lady once to cut down on her junk food consumption. I told her no bakery goods, no sweets and fruit juices and no eating fried items. Her reply startled me, she told that all “I eat day in and day out is ragi balls with vegetable curry”. What further dietary restriction can I advice for a person following such low dietary diversity?

3) Consumption of 3-5 servings of fruits and vegetables– it seems almost ironic to note that there is a total absence of any shops selling fruits or vegetables in a rural area. Every household bulk purchases a few vegetables during the village market day or the “Santhe” held around once a week to fortnightly. Fruits do not extend beyond the occasional bananas. In this context from where are the farmers supposed to source their vegetables?

4) Weight reduction– most of my rural patients with diabetes have a BMI averaging between 18.5-21kg/m2. Sometimes even lower rarely higher than 25. They are mostly lean and lack any muscle mass. In such a scenario what more weight reduction and exercise can we advice?

5) Adherence to medication– Once I had prescribed a drug which needs to be taken thrice daily after meals and to my surprise and slight irritation my patient had returned back the next month with even higher blood sugar readings despite the optimum medication dose. On simple probing I found that he only has two meals a day so did not consume the afternoon dosage of the drug! Prescription pattern thus should be reflective of the cultural context that we are in.

6) Festivals and feasting– if the clinics are held just after any major festival like Deepavali or Sankranthi then rest assured that everyone’s sugars and blood pressure readings will hit through the roof. This is a universal phenomenon which cannot be questioned but only worked around. In a country like ours where every month there is either a harvest festival, a village fair or a relative’s wedding, feasting on sugary treats is almost a given. What then should be the advice to give such patients.

7) Dilemma of insulin– when finally deciding upon starting insulin injections for their diabetic control the rural folk are at a great disadvantage compared to their urban counterparts. Who will give them the injections everyday? They are not comfortable with pricking themselves. Also, how will they store the insulin? Most rural households do not have a refrigerator. Finally, how will they dispose of the needles? There is no door to door garbage collection at the villages. Most of these needles will ultimately just find itself in a landfill or on the village roads posing huge environmental concerns.

8) Follow up– in any OPD visit at a tertiary hospital in the city there is a fixed time where patients can walk in, however this does not hold good for the villages. Here, women come to the clinic after carrying out all their chores and cooking for the day. Men come as and when they are freed from their farming responsibilities. We as doctors need to become accommodative of their difficulties in accessing health care. I have several patients who travel more than 30 miles to reach the health centre and their arrival and departure is solely dependant upon the bus that reaches their remote village. Asking such patients to make this journey every month and sometimes even twice in a month for their blood investigations and checkup seems very insensitive. Patient follow up is often quiet difficult to achieve in such settings.

Please click here to know about diabetic foot care in my blog.

Written above is only a handful of the experiences that we face on a day to day basis dealing with lifestyle diseases among the rural folk. As physicians trying to ensure their well-being, we are to weigh in their cultural and socioeconomic context before prescribing them therapy. This thought will never cross the mind of a doctor sitting in the tertiary care hospital in the cities.
Though the barriers faced to access quality and affordable care in rural areas are aplenty, what remains is the will to make a positive change.

Indigenous low-cost solutions to the barriers of rural diabetes

Some of the unique solutions to this rural problems that our patients face includes:

  • Buddy walking system- encouraging our patients to create a buddy system in their villages where they can either walk or do other forms of exercise in groups. When we exercise as a group it makes for excellent time to socialise as well as shall seem less like a chore and more of an enjoyable activity.
  • Encouraging the concept of kitchen garden in every household. Instead of relying solely on the once weekly ‘Santhe’ day to purchase their vegetables, farmers can grow their own vegetables at home on a small patch of land and help meet their daily requirements. They neither lack land nor expertise unlike in urban areas.
  • Colour coding our glucose values- in the rural OPDs we note down the patients sugar readings on a chart which is marked by three colours, red (>200mg/dl), yellow(150-199mg/dl) and green(<150mg/dl). Even if our patients do not understand values and cutoffs they do comprehend that red means ‘danger’ for developing complications and green is well controlled sugars. This chart also when plotted every visit can show how far along they have come in their diabetic journey.
  • Cost of the medications have been substantially reduced by writing our prescriptions in the generic format which are then purchased at the government pharmacy dispensing these drugs at subsidised rates. This is a win-win situation for our patients and a good example of public-private partnership. Availability of quality consultation from the private sector and affordable cost of medications from the government makes compliance much better in case of rural diabetes treatments.
  • The problem of follow up can be solved by employing women from the villages and training them in basic health care like measuring blood sugars and recording blood pressures. She can act as a link between the doctor and the patient. She can be a depot holder for common medications and can quickly alert the health system in case of any misdemeanours. This way we are empowering the rural women by paying her a nominal honorarium and also making sure our patients needs are met. Such a system exists in the government but every rural health centre of private hospitals can also build on it for reaching out to all the vulnerable.
  • From asking our patients on insulin to store it inside their earthen pots or ‘matkas’ to keep them cool to teaching them to do weight strengthening exercises of the arms using discarded cola bottles filled with sand, our solutions to these seemingly rural problems are unique and often innovative. Even if our patients do not know the names of the drugs they are taking they can describe it beautifully using colours and shapes (‘2 blue colour tablets before food and one orange colour big tablet after meals at night’).

Take home message

There might be many of you who are thinking of starting your medical practice in peri-urban/ rural areas,many might be doing bond in underserved areas, some might even be care-givers of rural patients but let distance and limited resources not become a challenge to you in your practice. Blanket advice about exercising and following a healthy diet or reducing junk food consumption is not helping in any way. Look around you, the solution to every problem is right there. Their issues are very unique and as a rural physician our suggestions should be tailor made for them.
Coming back to the first question as to why our rural folk are developing these diseases in the first place? Changing lifestyle and increasing stress partly due to failing monsoons and poor crop returns, better availability of screening facilities for earlier detection of diabetes and ultimately the ‘Asian Indian Phenotype’ may all be reasons contributing towards rural diabetes.

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