FIGURE When first contacted, Dr. David Dannenbaum couldn't understand why anyone would want to write about him. "I think you're barking up the wrong tree," he said from the Waskaganish Clinic on the eastern shore of James Bay. What about his pioneering work on tracking diabetes in the Cree? "Oh, that," he said.
It is fortunate that his wife and clinic partner, family physician Ingrid Kovitch, is as expansive about the diabetes registry they have created in northern Quebec as Dannenbaum is understated. In fact, she chose this fly-in community with the idea of doing this very work. "Diabetes is the single most important public health problem of the Cree right now. The number of people affected is astronomical. And what we're facing in the future is an increase. Yet it's something that's amenable to treatment and prevention."
Dannenbaum concurs. "When we got up here 4 years ago, diabetes was a huge problem and no one in the Cree nation was talking about it." One estimate puts the disease's prevalence at 17% among Ontario Cree older than 10.
This young duo is intent on tracking the incidence of type 2 diabetes mellitus in the James Bay Cree so that the community can be made aware of the magnitude of the problem and has access to reliable data. One study indicates that up to 42% of diabetes cases among the Cree remain undiagnosed. "We're basically using the diabetes registry to show people how serious the problem is," says Dannenbaum. "They have to feel that it's their problem as well."
After hammering out the registry's details, Dannenbaum and Kovitch sought approval to use it in 9 communities on the eastern side of James Bay, known to the 12 000 Cree as Eeyou Istchee. They got the nod from Billy Diamond, the chief of Waskaganish for 11 years. He praised the doctors' respectful approach and their active participation in community life. "Any time there's a community meeting, a talking circle or workshop, both doctors are there to discuss diabetes. People can talk about subjects they weren't able to talk about before, like the change of lifestyle in the Cree."
The initial chart review and data entry were done in 1996. With the registry, simple, standardized forms prompt health professionals to ask diabetes-related questions when taking a history. In addition to space for lab results, there are reminders to check blood pressure, activity levels, medications and weight, and to examine the patient's feet, vision and teeth. There are also columns to track follow-up visits so that changes are detected early.
One of the computerized registry's advantages is that it allows continuity of care in the face of rapid turnover of medical staff. Every year information is collected from the 9 participating villages and Dannenbaum crunches the data. The big picture is then made available to the community so that prevention and treatment options can be pursued. There has been a 10% increase each year in the number of cases being diagnosed, but Dannenbaum thinks this reflects the overall increase in incidence.
What is it like to spend 5 years living in a small, isolated coastal community with no roads? Dannenbaum and Kovitch, whose 3 sons are aged 4, 2 and 1, describe it as a paradise for young families. "You come home from work and take your kids fishing or go off into the bush together," says Dannenbaum. "The kids have an adventure every day."
Both doctors say the Cree culture is welcoming and child centred, and their family has been integrated into feasts and fishing expeditions. Recently they participated in a week-long whitefish celebration, where fish are scooped out of pools and the meat is smoked by the side of the river.
But living up North also involves adjustments. Initially both doctors observed the Jewish dietary laws and had kosher meat and supplies flown in. Now they are accustomed to local staples such as goose and beaver tails.
Practising family medicine in a contained town of 2000 has its rewards. The doctors know almost everyone by name and have been able to effect a transformation that would have been impossible for outsiders. That's why Billy Diamond doesn't hesitate when asked what kind of impact the doctors have had. "They made us look into the future," he says. "And they've become part of the community. Everyone considers them part of the family."