COMPREHENSIVE TREATMENT OF KIDNEY FAILURE IN CARICOM: PUBLIC–PRIVATE PARTNERSHIP

1. COMPREHENSIVE TREATMENT OF KIDNEY FAILURE IN CARICOM: PUBLIC–PRIVATE PARTNERSHIP Overview of Guyana project. Options for CARICOM

2. DR. LESLIE RAMSAMMYMinister of Health “If all renal failure patients in Guyana were to be treated with hemodialysis, the recurrent costs could reach 68% of the total Ministry of Health budget, a situation which would be unacceptable.” Minister of Health from Guyana

3. NETWORKS MAKING A DIFFERENCE: MODEL FOR CARICOM

4. A FLYER LANDS IN QUEENS, NEW YORK CITY – DECEMBER 2007 • The story starts when Mr. George Subraj, a property developer, picks up a flyer soliciting funds for a young man dying of kidney failure in Guyana: LEELKUMARIE Mangal, 41, is appealing to the business community and the general public to help her son get a kidney transplant in India and dialysis treatment here. She said her son, MuneshMangal, 18, was diagnosed with “end stage renal failure” in August last year, after he became ill. His mother, a vendor of green vegetables, said she is willing to donate her kidney.

5. EXPLORATORY VISIT TO GEORGETOWN, GUAYANA SURPRISE VISIT TO THE MANGAL’S HOME A MOTHER PLEADS FOR HELP TO SAVE HER SON’S LIFE

6. ABOUT GUYANA • A Dutch colony in the 17th century, a British possession by 1915, achieved independence in 1966. • 80% is covered by rain forests. over 70% of the natural habitat remains pristine. • Ranks poorly on basic health indicators. Life expectancy is 63. • Water and sanitation sectors are poor service and quality. • Food or waterborne, and water contact diseases degree of risk is high. Guyana is slightly smaller than Idaho.

7. THE BURDEN OF CKD IN GUYANA • Absence of national reporting systems. • Rationing the available treatment capacity is politically challenging. • Competing healthcare concerns and a limited national healthcare budget. • Financial burden impacts entire families. • Unlike developed countries, the age of presentation is mostly before age 40. • Late presentation is the norm. • Inadequate dialysis frequency to save money. • Steroids and temporary catheters.

8. ESTIMATED NEED FOR KIDNEY TRANSPLANTS IN GUYANA • The population of Guyana is estimated to be approximately 1 million. • It would, therefore it reasonable to assume that approximately 200 new patients per year.

9. COST • $200-500 per dialysis session. • Annual per capita income is $1,219. compared to the US $43,562. • Renal Transplantation $ 150,000 in the US $ 60,000 in India

10. PREPARATIONS BEGIN FOR THE KIDNEY TRANSPLANT • Educating the local physicians. • Training the local nurses and OR staff. • Dealing with the press. • Dealing with the Minister of Health.

11. SKYPE CLINICS

12. LANDMARK KIDNEY TRANSPLANT OPERATION A RESOUNDING SUCCESS A SINGLE KIDNEY TRANSPLANT… “Raises the standards of medical care all around” Dr. Leslie Ramsammy, Minister of Health

13. REPORT OF THE FIRST PERITONEAL DIALYSIS PROGRAM IN GUYANA, SOUTH AMERICA • We placed 21 patients (15 [ESRD], 2 with acute kidney failure) on PD from July 2010 to present. • Of the 17 patients, 4 patients received living kidney transplants. • PD is a safe and cost effective option in Guyana and may be suitable for similar developing countries. In Guyana, PD was used as a bridge to a living kidney transplant. • In Press: Peritoneal Dialysis International

14. PUBLIC HEALTH PROJECT • A MINI-FRAMINGHAM TYPE longitudinal study in Guyana has been initiated to study the incidence and prevalence of diabetes, hypertension and CKD in Guyana. • Information will be collected and analyzed on sanitation, social interaction, quality of life, employment and immigration patterns and substance abuse over many years. • Will be helpful to policy makers.

15. PUBLIC HEALTH PROJECT • 7 students and 2 teachers have been identified. • They have been trained in basic sciences. • They have learned the use of BP and glucometer and survey techniques. • Work has started in 7 villages with 1000 adults.

16. TEACHING STUDENTS

17. RESULTS - COMPREHENSIVE RENAL REPLACEMENT THERAPY 2nd transplant • 14 Kidney transplants • 21 PD placements • 16 vascular procedures • 450 patients screened • Lectures • Press conferences • Changed health policy • Public health project initiated

18. PUBLICATIONS • Report of the first peritoneal dialysis program in Guyana, South America. In Press: Peritoneal Dialysis International. • Health policy for renal replacement therapy in developing countries. Journal of Healthcare, Sciences and Humanities 2011; 1: 41-54. • Ethical dilemmas in patient selection for a new kidney transplant program in Guyana, south America. In Press: Transplant Proceedings. • Prevalence of diabetic nephropathy in an underserved rural community. Indian Journal of Nephrology 2012;22:101-102.

19. SUCCESSFUL MODEL

20. STEPS TO REPLICATE THIS PROJECT • Each country needs to identify a suitable hospital for dialysis & kidney transplantation. • Identify lead physicians (Medical and Surgical). • Site visit to country and hospital. • Our team starts clinics • Identify suitable patients • Support from the Ministry of Health. • Point person for contact with US team

21. VARIOUS OPTIONS FOR CARICOM • Short-term • Send their patients to BSH, Guyana. • Long-term • Develop transplant program with our help. • Send physicians abroad for training. • Develop collaborations with academic centers.

22. CONCLUSION “You can never win a war against terror as long as there are conditions in the world that make people desperate –poverty, disease and ignorance” Archbishop Desmond Tutu, Nobel Peace Prize Laureate

23. Special Thanks to: Walter Reed NMMC • COL Ed Falta • CAPT Eric Elster • CAPT TG Patel • David Oliver Balwant Singh Hospital, Guyana Ministry of Health, Guyana Drexel University • Dr Steve Guy • Dr Alden Doyle Reserves • COL Art Womble Non-Medical Staff • OR staff, Tissue typing, coordinators, Luz Rodriguez, JaskaranPrasaud, Lake Persaud, Jay Mahendra