The Right Foundation

What initially began as a semester abroad during undergrad ballooned into a long term commitment for Dylan Bush MD’27 and Solomon Islanders.

Now, nearly seven years after his first visit to the Solomon Islands, Bush’s research into diabetic amputations has provided a springboard for the creation of a national strategy to manage diabetic limb infections by the country’s Ministry of Health, and in partnership with the World Health Organization. 

While an undergraduate at UC Berkeley, Bush studied abroad in the Solomon Islands and met doctors at the nation’s only tertiary care center. The topic of diabetic amputations came up frequently, as well as an uncertainty about outcomes, access, and rehabilitation services.

“There was a clear data gap. Although physicians knew what they were seeing day-to-day, no one could share accurate numbers in terms of diabetic infections or amputations,” Bush says. “I knew this data would be critical to drawing attention to the issue.”

Bush visited the Solomon Islands again as a Fulbright scholar, when he began his research into diabetes-associated amputations, and a third time last summer. Nearly one in every five adults in the Solomon Islands has diabetes, with limited access to regular medical care. Without that access, complications like diabetic ulcers can progress to sepsis and ultimately amputation. 

Quantifying the impact of such amputations was a demanding task—80 percent of the patient population lives in rural areas, where there exists little to no infrastructure or public utilities, and there were also challenges with reviewing medical records.

“We literally had to comb through thousands of paper medical charts in order to find the data we needed,” Bush says. “In some cases, surgical logbooks were missing, so we had to get creative to find the data we needed.”

Aside from reviewing records, Bush says he made sure to understand the local situation by spending time with surgical teams and visiting people in rural villages across the country who had undergone diabetes-associated amputations. He learned Pidgin, the local language, and made the extra effort to integrate himself into the local surgical team.

“Eventually, they became comfortable enough to share their real thoughts and frustrations with me, which helped shape my understanding of the issues,” Bush says. 

Patients not only face challenges with surgical access, but medical professionals also face shortages of basic supplies like antibiotics. Bush says there’s no insulin available outside of the major hospitals because many rural areas, where most of the population lives, lack electricity and therefore can’t refrigerate the lifesaving medication. Patients and physicians must cross dense wilderness or unforgiving seas by boat to reach each other, with surgical sites a mean distance of 33.3 miles from patients’ homes.

“It doesn’t sound like a lot, but a mile here in Providence is far different from a mile in the Solomon Islands,” Bush says. “It’s very common for patients to die en route to the hospital.”

There were also cultural considerations. Kastom medicine—traditional medicine carried out by cultural figures like healers—offers patients more easily accessible and culturally acceptable treatments, potentially delaying health care that can save both life and limb. Bush says that pervasive beliefs, like treating wounds with herbs or drinking fruit juices, contributes to these challenges. Some also live in fear, having watched friends or relatives venture to the hospital and have a limb amputated, or die.

“Local surgeons are operating in very challenging circumstances and given the commonality of delayed presentation and supply shortages, good outcomes are rare,” he says.

Bush uncovered some sobering statistics: nearly 80 percent of patients waited longer than seven days before seeking medical care from the onset of symptoms, and almost a third of patients waited more than 30 days. Even after arriving at a health center, 96 percent of patients experienced further delays prior to surgery.

The data he collected was used by the World Health Organization and the Solomon Islands' Ministry of Health and Medical Services to develop a national plan to address these challenges. The organizations aim to upscale facilities and improve early intervention and less invasive techniques to manage infections. This includes training nurses to recognize the signs of deep tissue infection, creating an improved communications system between hospitals and provinces, and an outreach program to educate the population on the importance of managing their conditions.

Since returning to Rhode Island, Bush has continued to support the advancement of the Solomon Islands health care system. He recently helped Stallone Kohia, MMed, a Solomon Islands surgeon, to apply for the Mammadi Soudavar Fellowship, a fully funded training observation program at the Memorial Sloan Kettering Cancer Center for surgeons from low- and middle-income countries. Kohia, who will arrive in September, will be the first Solomon Islands surgeon to train at a US-based hospital. 

Bush still receives updates from the surgeons on the islands, and says he is happy to be a resource for them.

“I hope that during my fourth year I can potentially go back, but in the meantime I’m looking forward to continuing my involvement with the local team,” Bush says.