Challenges for management of the diabetic foot in Africa: doing more with less.

Diabetes mellitus reached epidemic proportions in much of the less-developed world over a decade ago. In Africa, incidence and prevalence rates of diabetes are increasing and foot complications are rising in parallel. The predominant risk factor for foot complications is underlying peripheral neuropathy, although there is a body of evidence that confirm the increasing role of peripheral vascular disease. Gangrene and infections are two of the more serious sequelae of diabetic foot ulcer disease that cause long-standing disability, loss of income, amputation or death. Unfortunately, diabetes imposes a heavy burden on the health services in many African countries, where resources are already scarce or cut back. Reasons for poor outcomes of foot complications in various less-developed countries include the following: lack of awareness of foot care issues among patients and health care providers alike; very few professionals with an interest in the diabetic foot or trained to provide specialist treatment; non existent podiatry services; long distances for patients to travel to the clinic; delays among patients in seeking timely medical care, or among untrained health care providers in referring patients with serious complications for specialist opinion; lack of the concept of a team approach; absence of training programs for health care professionals; and finally lack of surveillance activities. There are ways of improving diabetic foot disease outcomes that do not require an exorbitant outlay of financial resources. These include implementation of sustainable training programmes for health care professionals, focusing on the management of the complicated diabetic foot and educational programmes that include dissemination of information to other health care professionals and patients; sustenance of working environments that inculcate commitment by individual physicians and nurses through self growth; rational optimal use of existing microbiology facilities and prescribing through epidemiologically directed empiricism, where appropriate; and using sentinel hospitals for surveillance activities. Allied with the golden rules of prevention (i.e. maintenance of glycaemic control to prevent peripheral neuropathy, regular feet inspection, making an effort not to walk barefooted or cut foot callosities with razors or knives at home and avoidance of delays in presenting to hospital at the earliest onset of a foot lesion), reductions in the occurrence of adverse events associated with the diabetic foot is feasible in less-developed settings.