FootAid Trip to Kiritimati

Julie M. Chatigny, DPM, AACFAS

I arrived in Honolulu on 3/13/2017 and met up with Dr. Michael Goran and one of his former students, Skylar Steinberg, to discuss our plans and goals of our week in Kiritimati. I, being a foot and ankle physician and surgeon with a clinical emphasis on diabetes, and Dr. Goran, being a well-published, highly respected researcher in the field of pediatric obesity and diabetes found that we had very similar interests and goals, as well as, many questions. First and foremost, what is contributing to the high incidence and prevalence of type 2 diabetes mellitus? 

We left Honolulu on 3/14/2017 just after noon, had a three-hour flight, and arrived in Kiritimati on 3/15/2017 as we had crossed the international dateline. Our travel companions included about twelve fly fishermen from the United States seeking a week-long catch-and-release adventure fishing for bone fish, giant trevally, and trigger fish. 

Upon arriving at the Cassidy International Airport, we were greeted in the airport’s VIP lounge by Dr. Teraira Bangao, several members of the Ministry of Health, and staff with a beautiful flower headpiece and cold coconut milk. We were provided a rental car and followed Dr. Teraira to our accommodations at The Villages. 

As it was evening when we arrived to The Villages, we were not going to start work until the following day. We took a walk along the main road from The Villages toward London. We stopped to watch kids and young adults playing soccer, saw many people walking along the road carrying bags of rice and coconuts, people riding bicycles and motor scooters, and people at their homes getting ready for the evening. What struck me the most was that nearly every person we encountered was not wearing shoes. Even walking along the asphalt road and riding bicycles, people were barefoot. 

Over the next several days, I spent time at the London Hospital where I worked with Dr. Teraira Bangao, Dr. John Tekanene, and their incredible staff of nurses, pharmacists, and a midwife. Together, this group of people treat everything from congestive heart failure to pneumonia to diabetic foot infections as well as have a maternity ward. At the hospital, I helped Dr. John debride a diabetic foot and leg ulceration and infection, drained a heel abscess that had extended proximally along the tarsal tunnel jeopardizing a woman’s leg, and diagnosed a tendinitis due to a flatfoot deformity. Dr. John and I attempted to perform a below-the-knee amputation on a non-diabetic man with Buerger’s disease (thromboangiitis obliterans) which had resulted in infection and gangrene from smoking, but he and his wife continued to refuse the amputation.

Although Dr. Elizabeth Beale was unfortunately unable to accompany us to the island, she was paramount in organizing medical items to donate to the hospital and clinics. She developed a foot exam form and her daughters put together medical illustrations and folders to provide to the hospital and clinic staff. When I brought in the items and folders, the medical staff was greatly appreciative, but a bit overwhelmed. I met with the nurses and Dr. John individually to explain the folders and how to go about a diabetic foot exam. Again, it seemed a bit overwhelming and the nursing staff did not seem to understand the importance.
I decided to take a different approach and learn as much as I could about what people ate and drank, did for entertainment, why they presented to the hospital and clinics, and better understand the culture so I could figure out a better plan to educate the health providers and staff.
Also, as Dr. Goran and Skylar collected their data, they identified several children under the age of 18 years old who had a HgbA1c > 6. As I was located at the hospital while they were out at the schools, one of the nurses drove the identified children to the hospital where I interviewed them and collected information on their diets and knowledge about their parents and diabetes. 
The following is a summary of what I learned over the week I was visiting the island: 
Food:

• Fish Raw, salted / canned Mackerel, fried White Rice
• Canned Spam
• Canned Ham
• Crackers
• Cookies
• Bread Fruit
• Bread with frosting-type spread Pumpkin
• Uncooked Top Roman noodles 

Drink:

• Sugar water 3 large spoons (ladle-size) of sugar in 1 Liter of water. Soda, non-diet
• Coconut water
• Toddy
• No regular, plain water 

It’s rude to offer a guest of your home a drink of water. You need to offer a sugary beverage. People often seek the medical aid of a “healer” before they will seek medical help from a doctor. Average life expectancy is 55 years old.
High infant mortality rate.
People often have > 4 children. 

People do not recognize the correlation of consuming sugar and having diabetes. For example, a husband and wife came to me to learn how to read their glucometer. They kept stating that the Metformin was causing their sugar to be high. It took several attempts and several different descriptions for them to finally understand that the sugar they ate and drank was causing the high blood sugar and that the medication was helping them, not hurting them.
I now have a much better understanding of what needs to be accomplished as far as education and assisting with intervention. It will definitely take time and a multidisciplinary team of dedicated individuals to set realistic short-term goals with the long-term goal of helping the people of Kiritimati live a longer, healthier life.
The people of Kiritimati were warm and welcoming. I appreciate their patience with me asking all of my questions. I am especially thankful to Dr. John as we were able to spend many hours together learning from each other. Thank you to Carlton Smith for this incredible opportunity; Dr. Elizabeth Beale for seeking me out, your help and organization; Dr. Beale’s daughters Alexis who has an incredible talent for medical illustrations and Stefi (and her boyfriend Eric) who put supplies together and met me half way to deliver them; Dr. Teraira for helping make our journey so comfortable and successful; Dr. Lydia Lam for your insight and recommendations; and thank you to everyone that helped make this organization a success. 

Author

Dr. Chatigny received her Bachelor of Science degree in Biological Sciences from CSU, Sacramento. She spent the next 12 years working in the fields of Molecular & Cellular Biology as well as Genomics & Genetics in multiple research laboratories in Utah and Arizona studying brain, breast, and ovarian cancer as well as Valley Fever and tuberculosis. Dr. Chatigny was a private contractor / consultant for the Southern Arizona VA Healthcare System’s VA Biorepository Trust in Tucson, AZ, the Warm Autopsy Program at Sun Health Research Institute in Phoenix, AZ, and the Molecular Profiling Research Institute – now Caris Life Sciences, in Phoenix, AZ.
Dr. Chatigny earned her doctorate in podiatric medicine from Midwestern University in Glendale, AZ, and went on to complete a three-year surgical residency program at Kaiser Santa Clara in California, where she received training emphasizing elective and traumatic foot and ankle surgery, pediatric foot deformities, diabetic foot deformities and wound healing, biomechanics, and medicine. The third year of training focused on rearfoot pathology and surgery including reconstructive procedures, trauma, rearfoot fusions, foot and ankle arthroscopy, and total ankle replacements.
During residency training, Dr. Chatigny was fortunate to travel to DaNang, Vietnam with Kaiser Permanente’s Global Health Program to perform foot and ankle surgery at the DaNang Orthopedic & Rehabilitation Hospital. She currently is the podiatric physician and surgeon in a multi-specialty group of volunteer physicians working with PIMA (Pacific Island Medical Aid) and collaborating with FootAid to educate and promote foot health as well as foot and leg preservation on Christmas (Kiritimati) island – one of the poorest island nations in the world with the highest prevalence of type 2 diabetes mellitus.