Project HOPE Board of Directors – Diabetes Presentation

October, 2010 Project HOPE was kind enough to let me present some of my findings from A Journey for HOPE to the board. The following presentation depicted at a high-level, the purpose, process, and outcome of 5 months and 10 countries worth of research. Although there were substantial themes of findings that held consistent from one country to the next – I tried to convey the varied nature of the condition and vulnerability to cultural norms and perceptions.

I included what I called “the faces of diabetes” to help portray various archetypes of patients I met during my travels.

Below is a selected diagram that depicts the three frameworks I used throughout my research (another version included in the first blog post). What I’ve found is that taking a population based, or traditional public health, viewpoint alone is not sufficient for diabetes. Unlike infectious diseases, NCDs are constantly changing within the population and each individual (whether at risk, diagnosed, or managing the condition). A lifecycle approach is needed to understand the prevention required at the individual level as diabetes relief efforts help stop the progression across the spectrum of risk to compliance. The systemic perspective (what care is provided, where, and by whom) is vital to understand disruptive models in diabetes and chronic disease treatment that can creatively use resources available to produce the best outcome at both individual and population levels.

Finally, and most importantly, is Project HOPE’s role in providing global diabetes relief. I proposed Project HOPE serve as an unbiased intersection of public and private interests that works towards the betterment of patients and communities. I believe Project HOPE can maximize its impact by focusing on gaps in current public and private offerings and helping them align incentives to increase the overall value to the beneficiaries.

Funding this effort will require a broad portfolio of donors, many of which are non-traditional healthcare donors such as Pepsi, Nike, or Subway.

Since the completion of my field research with Project HOPE, I have been contacted by a number of physicians, nurses, dietitians, and experts worldwide. Thank you wholeheartedly for the immense dedication and passion you are pouring into your communities. The following are several articles and presentations resulting from this research this fall:

A Silent Epidemic - Southeast Asia Globe (PDF Version)

Deloitte’s Life Sciences & Health Care practice leverages externship program to deliver HOPE globally - DeloitteNet

Haas Healthcare Association Presentation – Project HOPE & Diabetes

The final findings and recommendations for Project HOPE will be shared when approved. I hope this research works to help and benefit all who work locally and globally for children, families, communities, and nations who struggle with diabetes.

The Africa Diabetes Leadership Forum: Johannesburg Sept 30-Oct 1, 2010

At the referral of several of my interviewees, Novo Nordisk and the World Diabetes Foundation graciously invited me to their Africa Diabetes Leadership Forum hosted in Johannesburg this September. The goal of the event was to bring light to critical needs and best practices on diabetes programs and policies in Africa. In addition, nearly every health Minister of Health of the African region was present to recognize the importance of diabetes in their national priorities and agenda.

 

One of the first speakers was the First Lady of the Republic of South Africa, Bongi Ngema. She first began with a personal story talking about lifestyle change. Cooking oil must be used in moderation. Gardens must be planted. People must change their behavior. She then continued to address her dedication to women with diabetes in their families and gestational diabetes as a priority for the country and region.

Professor Pierre Lefébvre later conducted a very moving speech that simplified many of the concepts and difficulties I had seen throughout my research. He compared diabetes to a tsunami. What we are seeing now is the very splashes of a wave that is going to rupture the health of our communities. He presented a model for thinking about success as it pertains to diabetes programs. E= MC² or Excellence = Money/Manpower X Committment². Commitment is critical to using the resources available to us to achieve our goal.

Lise Kingo, the Executive VP and Chief of Staff of Novo Nordisk went on to describe the corporate involvement in addressing diabetes needs through the World Diabetes Foundation (WDF). Novo Nordisk’s extensive work in diabetes since 1923 has proven that diabetes “hits the poorest countries the hardest.” It prevents children from going to school, disables parents and grandparents, and kills friends and neighbors through lack of detection and availability of treatment. Ms. Kingo described Novo Nordisk’s “triple bottom line” that measures overall company performance along three axes: financials, social responsibility, and environmental responsibility. Their programs through the WDF are funding a substantial portion of all diabetes programs globally addressing affordability, health system strengthening, the most vulnerable of patients, and advocacy/awareness campaigns at the country level.

The goal for the forum and outcome is to establish sustainable and LOCALLY owned programs and policies. The WDF has helped countries all over the world with leadership forums (NY, Moscow, Beijing, Johannesburg, Dubai) identify a holistic approach with partnerships and metrics to execute on a vision. She ended with a lovely African proverb, “if you want to walk fast, walk alone; if you want to walk far, walk together.”

Prof. Jean Claude Mbanya, President of the IDF, continued with some additional points specific to Africa. In his perspective, the young working population is the most vulnerable and likely to develop Type 2 at rates never before seen in Africa. The second are children with Type 1 diabetes – for them this is a death sentence without resources, education, and affordability. Jean Claude also described diabetes as an inherent threat to many current infectious disease efforts. This was an interesting take and was built on later by Knut Lönnroth and Frank Mwangemi who discussed TB at the World Health Organization and HIV/noncommunicable disease integration respectively. We also went through a detailed “lessons learned” from HIV in the region from Miriam Rabkin.

George Alleyne of PAHO (Pan American Health Organization) discussed “knocking on an open political door” and described what are traditionally referred to as noncommunicable diseases (NCDs) as the neglected chronic diseases (NCD) since they were originally neglected from the Millennium Development Goals. This “dual disease burden” of infectious disease and chronic disease must be addressed through scoped 1. Programs, 2. Funding, and 3. Impact (public health, financial, reach, etc.). Incentives MUST align to accomplish long-term goals. George reinforced the need to generate Activity with IMPACT vs. Activity with intention… a route which has been pursued by many who have fought to get the resources and programs on foot to date.

From what I could discern, each country would have to develop at a minimum (1) a public health and financial business case for diabetes and NCDs, (2) agreement and alignment of public-private incentives and goals, and (3) definitive goals and metrics to which success would be evaluated. Ideally, each country would also start with a clear baseline of data indicating the size, location, and areas of greatest need.

A pleasant surprise during the day was Derek Yach, the Director of Global Health Policy at Pepsi. A South African native having spent the majority of his career at the WHO, Derek is committed to reshaping Pepsi as a sign of hope for the future of humanity vs. a threat to humanity. “Every 30 seconds a limb is lost to diabetes,” he describes. His team is working with the company’s R&D to cut billions of calories in Pepsi’s food portfolio. The food industry has enormous power to shape how and what we eat – and this will benefit millions of people globally if they are able to successfully make healthy foods that people want to eat. Even starting with Pepsi Max in developing countries might help – diet sodas in general are very difficult to find and at times more expensive as the demand is low.

In the evening Tshepo Musese, a South African musician and actor with Type 1 diabetes, shared a moving performance that highlighted some of his experiences including: weight loss, fear of needles, family challenges, affordability. 

The second day of the forum was dedicated to best practices sharing which included a number of my previous interviewees including Dr. Eva Njenga, Atieno Jalango, Dr. Maina, Mrs. Eva Muchemi, Dr. Francois Bonnici, and Professor Rheeder. Segments included examples of programs or policies across the following:

• General awareness education
• Exercise
• Nutrition
• Training healthcare workers
• Early detection / screening
• Treatment protocol / coordination
• Patient empowerment / compliance
• Quality of resources / data
• Complications prevention and management

At the end of the forum the general consensus was that the event was enormously successful. Africa is on its way to developing national and a larger regional strategy for diabetes and other NCDs (both noncommunicable diseases and previously neglected chronic diseases).

IDF has published a Summary Report for the forum online.

South Africa Findings: A Dual-Burden of Disease

South Africa hosts a number of Africa’s leading experts on diabetes care in Cape Town, Johannesburg, and many dispersed in the less-urban centers of the country. Compared to Kenya, South Africa has far more resources for diabetes patients including more health coverage, system infrastructure, academic research, and a very established national Diabetes Association South Africa (Diabetes ZA). What I would learn is that my first stop, Johannesburg, would soon be the diabetes focus point for the African region with an upcoming IDF/WDF supported Africa Diabetes Leadership Forum in September 2010.

The Diabetes ZA Executive Manager, Leigh-Ann Bailie, cites that diabetes kills as many people annually as HIV/AIDS in South Africa. A country with eleven national languages and even more used in practice creates challenges for national efforts. With only about 2 physicians per 10,000 patients, resource constraints are a large concern. Additionally, the dichotomy of the “have” and “have-nots” in South Africa create two sub-groups of communities with diabetes. The programs and mechanisms used to reach, educate, and treat them maybe dramatically different. Despite considerable changes in the South African society over the past 20 years, racial tension and segregation must still be considered delicately.

Stefan Lawson, Project HOPE’s country lead in South Africa, took some time to update me on their efforts more broadly and current concepts in diabetes. Establishing a community-based clinic or hub for various activities – education, detection, treatment, etc. would be a potential program to get started. Similar to Kenya, many low-income families believe vegetables or fruits are out of reach. A garden or cooking classes could help empower women in the communities to change the way they think about providing affordable meals for their families. Stefan also cited the need for fitness opportunities in urban areas – where safety is largely a concern and gyms are reserved for the middle/upper classes.

Diet Remains a Challenge

Professor Rheeder of the University of Pretoria took some time with Stefan and I to lay out a number of issues, the first and foremost – diet. Similar to Kenya, the traditional low-income diet in South Africa is porridge or cornmeal “pop”. Dietary awareness programs are few and with even fewer examples of success to replicate more broadly. However, he notes, general awareness about diabetes and the link to obesity is “ok”. The growth of fastfood chains like KFC and others have been steady in the past 10 years. Still, the choices are limited and many lack access to patient education programs to help them make healthy decisions.

Access to Detection & Treatment Limited

In the short-term, curative medicine is the single greatest need for patients with or at risk of developing diabetes. Most patients also pay out of pocket and cannot afford either medication, glucose monitoring or both. Prof. Rheeder emphasized the importance of focusing on the curative capability with respect to the peripheral areas (i.e. complications) associated with longer-term cases.

However, in order to address the right population further programs need to be established to detect those with and at high risk for diabetes. The University of Pretoria, under Prof. Rheeder’s leadership, has established a mobile diabetes diagnostic bus to “share” resources and medical expertise across regions. This is very similar to Project HOPE’s partnership with United Healthcare in New Mexico. The South African bus spends about 3 weeks in a given location, either hospital parking lot or corporate area) to increase access and awareness for diabetes diagnosis.

Diabetes ZA is also heavily involved in doing discounted testing for patients in need. However, they don’t get enough donations to do free testing for low-income or unmotivated individuals. Some corporate efforts will sponsor nurses for a few hours a day, but these barely make enough money to cover the cost of strips – about 300 Rand (US $43) per 50 pack.

One of my favorite tools that they are testing, however, is the “patient passport.” Assuming the patient is literate, the patient passport could be a powerful mechanism to empower patients and promote them to take charge of their diabetes. Each passport has educational pieces up front (e.g. two pages on physiology), information on short-term and long-term complications, a checklist of what you should have performed in a clinic, and custom pages dedicated to “my story”. Similar to Mexico, these personalized pages document progress using the stop-light red, yellow, green methodology.

Healthcare Expertise & Capacity Issues

Healthcare expertise and capacity to treat populations with diabetes is undoubtedly better than most regions of Africa. However, South Africa has significant potential to develop and demonstrate success with capacity expansion efforts that could be translated to the rest of the region.

Professor Willie Mollentze of the University Free Sate in Bloemfontein, ZA describes his experience working in the second poorest province in the country. With a population of 2.6 million, Bloemfontein has about 98,000 people with diabetes, 48,000 of which were registered just this past year. In addition to this surprising growth, clinics dedicated for diabetes patients are overwhelmed with workload. He sees 80-100 patients a day and has been working to creatively identify ways to reach more patients with even the fewest resources (people, medications, and diagnostic/monitoring technologies) available.

Dr. Francois Bonnici has been a driving force behind capacity expansion efforts focusing on children with Type 1 diabetes at the Red Cross Children’s Hospital in Cape Town. As one of the most eminent global leaders in diabetes, Dr. Bonnici has also worked to establish a number of the diabetes associations and national programs and policies all over Africa.

Serving now as the only wholly dedicated children’s diabetes center in the southern hemisphere, the Red Cross Children’s Hospital treats about 750 active patients under the leadership of Lyn Starck, a diabetes educator and pediatric nurse. Over the years she notes an increase in children with Type 2 diabetes and the sentiment that the onset of Type 1 diabetes is occurring younger and younger in their community. Lyn reflects on a number of familiar challenges:  glucose monitoring strips are too expensive, nurses “waste” time spent on admin responsibilities and paperwork, language barriers for patients in various regions, and lack of skilled healthcare professionals. She also mentioned a number of national efforts to improve healthcare infrastructure in South Africa – primary care rebuilt only at the expense of tertiary care. These shortcomings unfortunately have huge implications for diabetes patients who rely on nearly all levels of the healthcare system and infrastructure.

Dr. Bonnici and Lyn stress, “you have to empower the nurses.” Working with groups like DESSA (Diabetes Education Society of South Africa) to establish a curriculum to train diabetes educators in South Africa is critical. More importantly for the long-term, getting this role acknowledged by the government medical system will create a pipeline and legitimate career path nurses can pursue focused on diabetes. It seems that despite years of work to create this role and curriculum, there are more politics behind the scene that need to be addressed.

Creating a Vision for Diabetes Care in South Africa

I was profoundly moved by my time spent with Dr. Bonnici in Cape Town. After decades of working in this space, his perspective and experience is incomparable. First, he emphasizes, we need a vision. In business terms, the return-on-investment (ROI) will be different for the short and long terms. In the short-term we need to focus on complications of diabetes such as footcare and eye care to prevent amputation, blindness, and dialysis. These will help prevent expensive and life-deteriorating conditions for millions of patients in South Africa. In the long term, prevention is the key focus.  Early detection, awareness campaigns, and elementary school healthy habits programs are all strong candidates for prevention, but only time will tell how effective they can be.

The billion-dollar question is still on the table - is lifestyle change an attainable goal? For the future of South Africa and larger global health - we truly hope so. Dr. Bonnici’s comments around lifestyle change reminded me of my conversation with Dr. Ashraf Ismail from Joint Commission International in Dubai relating to safety – “safety is a product of culture, not processes.” Lifestyle change will happen when eating healthy is “smart” and cultural norms refuse to accept other behavior. This is very similar to the evolution seen with smoking in the US over the past 20 years.

So how do we get here? Targeting obesity and multiple risk factors is a start. Improving opportunities for biking and physical activity in public (similar to the city gyms in Brazil or China) is another. However, Dr. Bonnici stresses that the true key to lifestyle change and the future of diabetes is women empowerment. Empowering female heads of households and nurses to educate and shift norms of daily living is critical to the long-term success of any diabetes program.

Dr. Silver Bahandeka, VP of the International Diabetes Federation for Africa, describes his vision of programs as three-fold in order of priority:

1. Patient-focused diabetes education: nutrition, exercise, screening, management, compliance with complications
2. Juvenile diabetes programs: access to insulin, education programs for family and educator. 
3. Medical capacity building: physician education, diabetes educator nurse training programs

Interestingly these focus first on patient/individual, then community/collective, then systemic/infrastructure needs in that order. As the champion for the Africa Diabetes Leadership Forum in September, Dr. Bahandeka has been a strong driver in promoting diabetes programs and policies at a national level. Working with Ministers of Health across the region, he has advocated for increased funding for diabetes despite many ministries small or previously allocated budgets.

In this journey, many will be looking for leaders in the region as role models for replicable efforts. South Africa and Cameroon, in Dr. Bahandeka’s opinion, have made great advances in their diabetes efforts with both strong programs and policies. Several interviewees in South Africa agreed that the national policies are very good but have been poor in implementation.

Translating vision to reality is going to be the largest challenge for countries in the African region. Top-down efforts may be a harder model for success - many noteworthy programs are led by one, very dedicated leader who has built it from the ground up. Incentives (financial or otherwise) that align with the national vision but promote ownership and self-starter initiatives may prove most successful in the coming years. Looking farther ahead, succession planning of these efforts will be critical to make them sustainable (and ideally self-sustainable) over time.

In the meantime, the Africa Diabetes Leadership Forum will be an invigorating impetus to getting a foothold on the right path. 

Kenya Findings: Africa's Shocking Glimpse of Diabetes

My gut reaction when asked to go to Africa for diabetes work was that this would resemble the earlier stages of what I had seen progressing in the Middle East, Americas, or most likely Asia. I was shocked by how wrong I was. Nairobi presented to me a reminder of how varied the needs in diabetes are among regions, communities, and lifestyles globally. Africa is developing a different breed of diabetes I have seen in other regions, largely due to significant differences in diet and cultural perceptions than the rest of the world. The rates for diabetes, especially Type 2, were much higher than I had anticipated and growing quite rapidly with little education and healthcare infrastructure to treat non-infectious diseases.

About 3.5% of Kenya’s population has diabetes – totaling about 520,000 patients in 2010. While the needs for Type 1 patients in Africa did resemble that noted in many other countries, although with much fewer resources, the largest surprise in Africa was the demographic of the typical Type 2 patient. Many Type 2 patients are triggered by familiar issues: adoption of Western lifestyles, poor diet, and lack of exercise. 

However, many Type 2 patients in Kenya are NOT overweight, but underweight and simultaneously malnourished. The first clinic that cited this finding literally made me almost fall off of my chair in both shock and fear. This will require (1) significant locally-based research into why this is the case (there has been none to date due to lack of funding) and (2) custom programs in awareness and screening efforts that will be dramatically different from other regions globally. I dedicated myself to try and understand the medical perceptions for why this is the case, despite the lack of research, and have outlined a few hypotheses below based on the interviews.

HIV/AIDS and Africa

It is difficult to relate to health development in Africa without recognizing the role HIV/AIDS development work and efforts have had on individual communities and the larger region. The first thing that was apparent is the disproportionate amount of healthcare funding devoted to HIV in Africa. Tents for testing and ongoing treatment were evident at nearly every hospital and many community centers. Many interviews I conducted discussed the “overfunding” of HIV in the region and sometimes unethical use of funds or programs to use up assigned budgets. This was indeed surprising, but important to hear reiterated from varied government, corporate, and non-profit voices. Based on population alone, Africa receives significantly more health development funding than any other region. It is imperative that the purpose and use of these funds are re-evaluated to maximize impact to the community and its health.

While many HIV/AIDS programs have been very successful in terms of increasing awareness and diagnosis rates, it has not addressed a lot of the personal/family embarrassment issues, not to mention the need to balance both privacy and community openness. Everyone is aware of the “signs” for someone who has HIV and it seems on the lookout for family, friends, neighbors. For example, weight loss is typically a flag for the diagnosis of HIV or use of antiretrovirals. Historically, weight has been a sign of wealth, status and stability in most regions in Africa. This has significant implications for individuals with both Type 1 and Type 2 diabetes: Type 1 showing loss of weight at the onset of diabetes and Type 2 losing weight to control his/her symptoms, both of which could be perceived by onlookers as HIV. Therefore, many resist losing weight under any circumstances and ingest low-cost, high-calorie diets that are often very low in nutrients.

Additionally, many of the HIV efforts having succeeded in their purpose fail to dis-incentivize individuals from contracting HIV/AIDS. Although extensive prevention and educational programs exist, management is the main focus of HIV efforts. In Africa, HIV/AIDS is addressed essentially like a chronic disease. What was hopeful to me, is there could be a million “lessons learned” from HIV programs in Africa over the years that could be translated to traditional chronic diseases – like diabetes. Despite a number of models that have worked well (community diagnosis/monitoring, local women initiatives, country-wide annual testing campaigns), programs have not quite figured out the prevention side, where the long-term return-on-investment lies. One of the largest challenges results from lack of financial incentives: if you contract HIV in much of Africa, there are virtually no financial consequences. This is contrasted with the now growing diabetes rates – causing significant trauma on family and household economics. One of the very common quotes to hear from newly diagnosed patients is “I’d rather have HIV than have diabetes” referring to the lack of diabetes support in comparison to plentiful HIV relief efforts that make it easy to cope with the disease.

“I’d rather have HIV than have diabetes” – a common patient perspective in Kenya

Finally, there is a growing intersection of diabetes, HIV, and TB in Africa. The co-morbidity of HIV and Type 2 diabetes is seen as a long-term side-effect of many of the antiretroviral treatments. Wearing down the metabolic system over time, antiretroviral regimens are hypothesized to contribute to increased rates of diabetes regardless of weight, diet, and exercise lifestyle considerations. TB/diabetes co-morbidities are also noticed in Africa where TB has shown to put patients at higher risk for developing Type 2 diabetes. I believe that the large majority of development funds focused on diabetes in Africa will begin in the next 2-3 years with joint HIV/TB programs that either already exist or use existing funding. While this may address some of the problem, funding focus will have to evolve to include a new portfolio for diabetes in the coming years to address urgent needs for Type 1, gestational diabetes, and the emerging Type 2.

“Pop” and Tribal Mindset: Diet in Kenya

Few families are able to afford a regularly healthy diet in Kenya. Unlike much of Asia, the Middle East, or South America, healthy foods can be scarce and financially out of reach for many households. The Kenyan diet is traditionally comprised of “pop,” a cornmeal based porridge consumed as the main meal daily in the late afternoon (e.g. around 4pm). Githi Theuri, a Nairobi based nutritionist in a cardiologist office, described the diet as a resemblance of the earlier “tribal” mindset. Many tribes ate only one meal a day in the late afternoon with game meat about once a week. Fruits? Vegetables? These were not perceived as important factors in a traditional diet and, many believe, a root cause of the growing Type 2 diabetes prevalence.

I spent my weekend in Kenya on the border of Kenya and Tanzania with a Maasai tribe learning about their lifestyle and perceptions as one of the regions only preserved tribal cultures. Similar to what Githi illustrated, they eat one meal a day of grains and kill one cow a week to feed their living community: about 25-30 people. Cows are the only currency used by Maasai and almost anything that is produced by them is reused for food or shelter including blood, milk, meat, hides, bones, etc. Dairy milk with fresh cow’s blood is considered the equivalent to a Maasai energy drink, if you will. In recent years the government has encouraged Maasai to adopt “modern” technologies such as currency or bank accounts, but the community has largely refused.

Despite the vast and fertile land available in this region, farming is not pursued due to lack of agriculture education and irrigation technologies.  In addition to confirming what I had learned in Nairobi about Kenyan diet, the Maasai helped me understand what I heard repeated in interviews as the “tribal mindset” to which affects urban perceptions on family, money, and priorities. This could not be more opposite than the Western consumer-driven culture; tribal mindset incorporates a desire to only work as hard as needed to survive. Not much value is placed on surpluses of “things” or money, and there may be little trust in the longevity of both.

Therefore, few families have a lot of extra income to spare and the concept of setting aside finances for healthcare is unknown. Diabetes will sink a boat in tribal mindset – both resulting from diet and financial impact. Simultaneously, the modern or urbanized form of a tribal diet is a large plate of French fries smothered in ketchup, mayonnaise, or your condiment of choice. I became a loyal client of the Java Coffee house near the hospital district in Nairobi and witnessed this with even their highest-end of customers. French fries! Kenyan diet has evolved but remains a mainly carbohydrate and protein-based diet with few variety in food and nutrients.

Challenges for Diabetes in Kenya

The primary and most urgent challenge for diabetes in Kenya is the need to increase resources for children with Type 1 diabetes. Similar to India, lack of resources for families with Type 1 children is a death sentence. Insulin and community-based educational programs for families and educators are essential. The Kenya Diabetes Management and Information Center (DMI) in Nairobi has been a leader in addressing this need with funding primarily from Novo Nordisk’s World Diabetes Foundation. The financial burden of Type 1 diabetes is not manageable for most Kenyans and the center focuses now on sponsoring insulin and monitoring for 90 children and a youth camp which was attended this year by 70 or so patients and family members.

Although they are the first to acknowledge this is a drop in the bucket. I met with Mrs. Eva Muchemi, the head of DMI, who described the challenges in securing this funding on an ongoing basis and future plans to expand to training of healthcare workers throughout the healthcare system in Kenya. 80% of Kenya’s population is rural creating significant infrastructure and resource challenges for patients in non-urban areas. Through their persistence, DMI’s efforts and coordination with the emerging Diabetes Association in the region are admirably leading the way for patients in Africa.

Gestational diabetes has been explored as a focus due to its higher rates than seen in other countries. This could result from diet during pregnancy and is often overlooked by both pregnant mothers and health professionals if untested. One of the largest issues with gestational diabetes is that without treatment the impact – a significantly larger baby – is often celebrated as a good and healthy outcome considering traditional perceptions of health and weight. Later resurgence of Type 2 diabetes is not prevented or addressed and can create a number of health risks for the mother and child years later. A recent initiative from the MOH has required all pregnant mothers to be tested for gestational diabetes, however successful implementation of this effort is still pending. Despite a positive push in the right directly, many hospitals don’t have the equipment, processes, or expertise to execute standardized testing.

Type 2 diabetes is growing quite rapidly in urban, but also rural areas. I met with Dr. Rene Kiamba and Jotham Nkonge, the J&J Manager Sub-Saharan Africa and LifeScan Sales Manager  to learn more about their programs in diabetes management. J&J has demonstrated substantial leadership in training health professionals and increasing educational programs for patients with diabetes globally. They described financial limitations as the largest inhibitor to effective treatment – as all care for diabetes is out of pocket. They also illustrated the emergency of a “new” Type 2 diabetes seen in underweight or malnourished patients. This creates more challenges as health professionals struggle to standardize risk signs for testing and diagnosis with limited resources.

Africa & the Skinny Type 2 Diabetic

How are patients developing non-obesity driven Type 2 diabetes in Africa? All research indicates that abdominal fat, diet, and exercise are the key contributors to the progression of Type 2 diabetes. Dr. Eva Njenga, one of the founding members of DMI and currently the lead of their board of directors, described her experience treating patients with diabetes for decades in Nairobi and the Kenyan region. Her hypothesis, and a common perception among leading physicians in Kenya, is the carbohydrate-rich diet essentially wears out the pancreas and triggers insulin resistance. Of course, there is no research to validate this making it difficult to stand behind any prevention-based effort.

Jean Suren, an American diabetes care and training nurse in Nairobi, has reiterated Dr. Njenga’s sentiments with the need to focus on training and capacity building in physicians, but also nurses in the region. Disagreements over the training curriculum that should be adopted in Kenya, due to lack of research and its unique challenges and limitations, have slowed the progress for nation-wide objectives and programs. DMI and the Diabetes Association in development have focused on this as a critical first-step in fighting diabetes in Kenya. Still, the “new” skinny Type 2 diabetic continues to perplex health professionals and contributes to the total growth of diabetes in the region.

Community-Based Efforts

In addition to children-focused programs at DMI, educational campaigns to the community for both awareness are screening are critical and in development. Dr. Maina, the Noncommunicable Disease head for the Ministry of Health of Kenya, described this as the focal point of their effort in the ministry of health. How they plan to achieve this is by targeting the district hospital level in Kenya for training of healthcare professionals and distribution of posters raising awareness on diabetes in 12 of the most common languages. Similar to India, Kenya has 50-100 languages creating another layer of challenges for nationwide programs.

I also see a great potential for agriculture-based programs at the community level. Anything that supports families or communities in producing healthy food options economically will help prevent Type 2 diabetes. Also basic education on cooking affordable but healthy meals with available resources would boost family eating habits without impacting finances. However, many families are simply concerned about getting enough food so efforts should be focused primarily on increasing resources in addition to learning how to use existing ones better.

Finally, national surveys and research that provide accurate data on the disease burden, contributing risk factors, and effective treatments are essential, but costly. A reoccurring challenge in many countries, these efforts are vital to establish metrics and objectives for programs but are hard to fund as they compete with programs that directly impact patients (such as insulin relief and healthcare worker training).

As the MOH works to increase capacity for diabetes awareness, detection, and treatment nationally – it will benefit from the strengthening of organizations like the Kenya Diabetes Association and International Diabetes Association’s presence in Africa. Recognition of the unique challenges from the patient, physician, clinic, and larger community-wide perspectives will help Kenya develop more programs to better address the needs of diabetes patients going forward. 

DMI Office in Nairobi

Egypt Findings: Targeting & Coordinating Efforts

Egypt was by far one of the most interesting visits due to the variety of diabetes efforts and quality of interviewees ranging from the regional World Health Organization, International Diabetes Federation, Cairo Diabetes Institute, Egyptian Society for Diabetes, and multiple contacts within the national Ministry of Health. Egypt is a country of about 70 million, of which 4.8 million patients are estimated to have diabetes. Similar to the Gulf region and Asia, a high propensity for abdominal weight gain is a huge risk factor for aging individuals in Egypt – and every year the high risk population grows younger (more like 20-30 years old). Almost 30% of the entire country’s population resides in Cairo (about 20 million), perpetuating the “urban” lifestyle lacking exercise and healthy eating habits. In addition, the city is fairly hectic and doesn’t facilitate any form of transportation other than motor vehicles – as I experienced firsthand by attempting to walk around the neighborhood near my hotel (street crossing is dangerous as well!).

Project HOPE has had a presence in Egypt for 35 years (based in Cairo since 1975) and Dr. Reda is the current country director managing a number of primarily maternal and child health (MCH) and infectious / rare disease programs. As a pediatrician herself with master’s education in NGO studies she has a lot to offer between her personal network and experiences over the years. I have to admit, she was also very willing and flexible to accommodate an intense interview schedule and never missed a beat from one to the next. Additionally to my surprise and delight, my colleague Gabi Meira (from the Brazil Findings post) joined me in Egypt as a fellow volunteer to support the interview process and help me think through solutions at a broader systemic level.

Us all at lunch

Access without Affordability:

Within the first two interviews it was clear what the largest issues were in Egypt for diabetes care and in many instances, healthcare in general. Egypt has a very strong healthcare infrastructure with capable hospitals and clinics and well-trained physicians and nurses. The single largest issue that affects how patients seek and receive care is affordability. We heard the public health insurance system described as everything from “minimal” to “non-existent.” Patients almost always pay out of pocket for healthcare services whether in a public or private facility. In addition, the availability for theoretically covered treatments for poor patients (e.g. insulin) is often limited or only available in certain facilities at different times (so you may have to try a few before you can get the treatment you would need for free). Similar to the UAE, without an insured primary health system patients often wait until they are fairly ill to seek treatment. At that time their cost of care is likely more expensive – so this is really a self-defeating process for most patients.

Dr. Reda, Dr. Khaled Ahmed Nasr, and me in the primary care division of the MOH

I also heard some horror stories similar to that in Indonesia where patients in the greatest need can be refused treatment due to their lack of affordability. For example, I was told that it is not uncommon for a surgeon to come out of the operating room half way through and validate with the family members that they can pay for the cost of the procedure – note this is before sewing the patient back up. I would hope this doesn’t happen in some of the larger or well respected facilities but you can imagine it definitely shapes patients’ perceptions and willingness to seek treatment unless needed.

My first interview was with Dr. Hassan El Kalla who used to work as the first undersecretary with the Ministry of Health and now manages his own business that focuses on investments related to healthcare, real estate, technology, education and the intersection of all of the above (how fascinating!). I’ve never heard of anything quite like his role but it is clear he has worn many hats over the years and his passion has driven him to develop new ways to benefit the larger communities in Egypt. “You can’t just focus on one” he said, because a lot of health, education, technology investments are interrelated and require coordination for effective implementation. In addition to setting the stage on the health needs in Egypt, Dr. Hassan also connected me with Health Care International (an Egypt-based consulting company) and MOH contacts to better understand the current state of efforts and needs in Egypt.

Today’s Efforts – Treatment and Patient Empowerment:

It is impossible to discuss diabetes in Egypt without recognizing the work of the Diabetes Institute in Cairo with Dr. Ibrahim El Ebrashy who has led the vision in addition to a number of national planning efforts related to diabetes treatment. The Diabetes Institute has 350 beds and sees about 30,000 patients per month, of which 95% are Type 2 cases. In addition to podiatrist, optomologist, dental, and vascular surgery specialties, the center aims to provide comprehensive diabetes care for the condition and complications over time. Dr. Ibrahim believes strongly in early detection as a way to prevent the progression of diabetes among his patients. He also stressed that patient empowerment is the only answer to challenges related to lifestyle change. Patient education efforts are there, but still young in development. In addition, patients that come from rural areas often do not read or write and would require educational materials that are more illustrative (similar to India).

Diabetes Institute outpatient clinic waiting area

Although a successful model, the Diabetes Institute reaches only a regional selection of patients – not even a large contingency of Cairo. With efforts focused primarily on patient treatment and empowerment within their community it will be imperative to track outcomes related to their efforts to see how they can be replicated (and affordably!) in other parts of the country.

I also had the privilege of meeting with Dr. Azza Shaltoot from the Egyptian Society for Diabetes who has been working since 2000 to implement effective programs related to treatment and patient education for primarily Type 1 patients. Their programs were based off of the work of a French model with in the International Diabetes Federation community. They translated a 20 hour course from French to Arabic with a series of educational books for children and their parents to drive patient empowerment among the communities in Cairo. They also developed their own introductory video which featured two children acting out some of the main concepts discussed in the books with songs to remember certain content (similar to a children’s TV show – it was great!). What was interesting to me is this is very similar to our 5 Steps for Self Care program in Mexico working with mainly Type 2 adults (although could be targeted towards any age group since both Type 1 and 2 are discussed). They conduct the training sessions in hospitals where they have partnerships through a teaming approach among healthcare workers or in their own educational room and clinic within their workspace.

Dr. Shaltoot expressed their interest in expanding to Type 2 efforts since that represented the larger affected population. What fascinated me was the solution they developed – unlike anything I’ve seen in any other country: they created a hotline for patients with diabetes! In 2008 they launched the system run by an educated counselor (not nurse or diabetes educator) who has access to a diabetes database full of thousands of questions and answers related to diabetes. They developed the software in collaboration with the prime minister (all Q&A resources were provided by the Parma University in Italy) and since it has operated 12 hours daily and served over 33,000 calls. They also record and track each call in the system by phone number to keep data on the needs of the patients calling in and how the cases are being managed. She also described a phone-based diabetes monitoring program that called patients based on their level of control: good (monthly), moderate (weekly), and poor (daily). I don’t believe there are outcomes tied to these efforts and how they’ve impacted patients’ glucose levels and incidence of complications long-term, but helping establish metrics for tracking will make or break the case for replicating their work in a larger scale.

Diabetes Hotline poster created by the Egyptian Society for Diabetes

In David Bornstein’s book on social entrepreneurship, How to Change the World, there were several case studies on the effectiveness of hotlines to provide resources to the masses and manage social needs in a very accessible (and convenient) way. I had wondered if this could work for diabetes as well and was delighted to learn more about their program. I see a lot of opportunity for Project HOPE to collaborate with the Egyptian Society for Diabetes to help expand their capacity for their call centers and patient education efforts. One of the largest challenges they’ve had is promoting the services they offer (e.g. marketing) and working with the MOH and national healthcare leads may help grow their investments to benefit a larger patient population in Egypt, the region, and globally as well.

Dr. Reda, me, and Dr. Mona El Samahy from Aim Shams University clinic for Type 1 diabetes

Increasing Patient Awareness:

One of the first things Dr. Hassan El Kalla mentioned was the need for a baseline. Where does Egypt really stand with respect to diabetes prevalence nationally? Although the IDF has statistics for the rates in country, few trust these numbers and believe that a larger survey has to be executed to get to a more accurate estimate. “Without a good starting point, it’s impossible to know who you’re targeting and what impact you’re having on the population with your investments.”

This was reinforced by Dr. Ibtihal, the Middle East regional director for non-communicable diseases for the World Health Organization. She stressed that public promotion and prevention were top priorities for Egypt and the larger region. Project HOPE’s experience in educating patients through early detection programs (such as the Promotores or “peer educators” in Mexico) could be a huge help. When I asked about where people congregate or get their information in Egypt – I was told again that shopping malls and TV were possibly the most effective mechanisms for reaching patients. For example, many traditional medicine therapies (based on Chinese or Asian techniques) are advertised as being able to treat or cure diabetes. This is dangerous as many patients avoid the formal health system and seek substitutes without outcomes or proof of effectiveness.

Dr. Sami Gad Allah of Health Care International (HCI) also reiterated this need to increase early diagnosis and those who seek proper treatment. As a part of their investment in insurance agencies in the private sector, they are currently prioritizing diabetes and other chronic conditions with a new focus on homecare. With the opportunity to reduce costs and improve quality of care, this would be the first homecare effort in the entire Middle Eastern region to his knowledge. As he describes it “diabetes is not a disease, it’s a condition and needs to be managed with the patient’s lifestyle daily.” If he can demonstrate outcomes and reduced costs in the private sector, this could be a model that would benefit public patients as well.

Primary Care Promotion:

One of the best ways to increase public awareness in a targeted way is to work through the primary care health system. Dr. Ibtihal was a strong advocate for this approach as well as a sustainable investment for training primary care physicians and nurses, similar to Project HOPE’s model in China. She recommended we speak with the MOH leads for primary care to better understand their priorities and efforts to date.

Dr. Nasr El-Sayed is the Minister’s Assistant for Primary Care and provided a one of the most interesting interviews of our visit in Egypt. The MOH sees primary care as essential for the early detection / screening and long-term care components with the opportunity to target multiple risk factors vs. focusing primarily on the specialty treatment with endocrinologists. He discussed a lot of the lifestyle changes in the patient population over the past 20 years that he believes have been the primary cause of obesity, CVD, and other conditions increasing in prevalence dramatically.

Dr. Ibrahim El Ebrashy from the Diabetes Institute added that there are a number of diabetes clinics within hospitals that serve to provide similar functions as diabetes-educated primary care physicians.

Educating the Future of Egypt:

This is not a new concept, but one that continues to come up as I probe for ways to prevent obesity and chronic disease that stem from lifestyle conditions. The MOH Assistant for Primary Care could not have stressed this enough “our students are the future of Egypt.” Working to help provide them healthy options and the fact-base to make healthful decisions is critical for educating tomorrow’s population and their families. From what we can tell, Project HOPE’s school education programs in Mexico are a strong fit for the system in Egypt.

This also aligns with the WHO’s goal to educate patients directly long-term. Training healthcare workers is one step in the right direction, but at the end of the day it only matters if the information reaches the patient as well. Patient empowerment ideally starts before the disease has progressed to a stage of complications. As Dr. El Ebrashy mentioned, it’s critical to tailor these messages to the language and culture in a very specific way. The materials need to be in Arabic, but not Gulf Arabic – specifically Egyptian Arabic. These subtle differences make a large difference as to how the materials are received and the impact it has on the patient.

Coordination is an Imperative for Success:

One of my last interviews in Egypt was over breakfast with Dr. Adel El-Sayed, an International Diabetes Federation lead for the Middle East region. In addition to validating the previously mentioned findings, we spent some time discussing how important coordination of efforts are for investments in diabetes and chronic conditions in Egypt. I am impressed by how many efforts and leaders have already done to make a difference in the communities in Cairo and beyond, but few are coordinated and looking at the larger system. The MOH and Diabetes Institute efforts with the national diabetes strategy have only recently reached out to him for input from the larger IDF perspective. For example, scoring systems that are used to classify groups of patients at risk could be used to segment strategies for diabetes prevention, intervention, and treatment long-term. I loved this concept as a way to prioritize resources and tailor care in a systematic way. Dr. Adel El-Sayed has had years of experience in Egypt and the larger region and provided the most comprehensive view across stakeholders and initiators of efforts in the Middle East.

Closing Thoughts…

Unlike the UAE and Indonesia where national diabetes efforts are just being initiated, Egypt has a number of efforts that need to be understood and mapped against the care continuum to pinpoint where Project HOPE can have an impact. For example, if the Diabetes Institute is heavily focused on treatment – what can Project HOPE do to increase early detection to channel patients into their facilities? Additionally, MOH priorities are essential for a non-profit to align with the “vision” of the ministry and become a team player in facilitating and coordinating change across a number of stakeholders. Over time, I’d like to see Project HOPE become trusted advisors in a number of countries where they can offer their experience and expertise from working in other countries and regions.

The last day of interviews in Cairo was one for celebration as we’d now completed over 100 interviews (102 to be exact) in over 8 countries since starting in early April (12 countries if you include Cuba, Saudi Arabia, Nepal, and the US by phone). This was for me a huge accomplishment and I’m so thankful to everyone globally who has supported this effort to date by donating their time and experience or recommending referrals to contribute. I have the next two weeks out of the field to start processing information and prepare for the last assessments in Kenya and South Africa – both of which promise to provide unique and exciting research related to patient needs and opportunities for Project HOPE!

UAE Findings: Strength in Infrastructure

The UAE has one of the most interesting health provider and insurance systems I’ve seen to date. Based on the complexity of the patient population and varied forms of insurance, the health system here has unique challenges and opportunities for new diabetes programs. One of the most important influences on the system is the Expat population in the UAE: about 80% of the population is comprised of Expats (non-citizens) who do not benefit from the government healthcare programs. Not only does this mean the population is very diverse (Dubai and Abu Dhabi are considered two of the most international cities around the world) but only 20% of the population relies on government programs (and funding) for healthcare.

A Complex Infrastructure

So how does this impact care as a whole? The vast majority of health in the UAE is private: privately insured and privately provided. The result has been a significant investment in health infrastructure from both private and public funding to support the larger patient population (and in theory that of some of the region as well). In Dubai, the “Healthcare City” is a mini-city of some of the nicest healthcare facilities I have seen anywhere with top-of-the line technology, equipment, and information systems. However, this can be seen all over the UAE with a number of exemplary hospitals and clinics, many of which are international chains that have been “imported” to treat a specific patient population or affordability level. For example Mubadala, Abu Dhabi’s investment arm, is currently in the process of establishing a Cleveland Clinic in Abu Dhabi. The Expat population is comprised of several classes of patients: the low-class labor workforce (e.g. construction workers), the low/middle working class (e.g. taxi drivers), and high-end businessman (e.g. real estate / finance). This adds to the complexity of the health care and insurance needs / affordability of the patient segments.

I was able to meet with the Health Authorities of Abu Dhabi and Dubai to understand their perspectives on the system and needs for chronic care programs. In Abu Dhabi all residents are required to have insurance through their employers and in Dubai about 80% of the population is covered. All Emirati are 100% covered for all health services public or private through the government. I was extremely impressed by the quality of data from Abu Dhabi (as all people are covered the health data is tracked via insurance reimbursements) and we discussed the progression of diabetes in the population.

The graph below was one of the most frightening I’ve seen and demonstrates the “boom” of diabetes growth the population is destined to see without serious action.

Challenges in Talent Management

The UAE’s biggest challenge in healthcare is recruiting and retaining quality health care talent. One of the most interesting interviews I conducted was with Dr. Ashraf Ismail from Joint Commission International (JCI). He highlighted this issue and the impact it has on the quality of care at a systemic level. Although the country has some of the best facilities in the world, they require highly educated and coordinated health professionals to execute healthcare that is safe and effective. He stressed that safety is a culture that needs to be nurtured over time. This is difficult when the average physician and nurse stays in country for about 2 years before moving to higher-paying positions in other countries. In fact, many recruited healthcare workers view the UAE as a stepping stone to moving to countries in Europe or the US. This is a huge issue. Hospitals are constantly in the process of onboarding and training professionals and in most cases, the concept of “teaming” approaches to healthcare are lost entirely.

Another impact of this transient healthcare environment is that the general patient population (including Emirati) doubts the quality of care, despite the impressive infrastructure. Taken to the extreme, many patients travel internationally for healthcare services, especially larger procedures. Typically Expats return to their home countries (e.g. UK, India, Germany) for treatment. The Emirati are known for medical tourism outside the region as all of their health services are 100% covered if in a private facility (regardless of country). This is challenging on a number of levels because the lack of faith in the system creates a Catch 22 of lacking investment in the system.

It is also worth pointing out that the UAE is unlike many healthcare systems where the providers are consistent and the insurers change every few years. Instead it is quite the opposite, the insurers are primarily constant and the health providers are changing and varied.

Prevention Needs Recognition

For the majority of privately-covered patients (e.g. Expats) primary care is not covered or recognized as a needed investment. The purpose of health coverage is treatment and the majority of patients often wait until they are sick to seek treatment as a result. For diabetes specifically, early detection is varied among the community. The general awareness among nationals is very high for diabetes but few seek treatment early in the progression of their condition. Additionally, many expats from India, Pakistan and Western countries bring their propensity for the disease into the system as well.

I met with Zulekha Hospital in Dubai who is working to engage the community in awareness and education efforts for a variety of conditions it sees as high priorities in their patients. For example, their “healthy kidney” campaign has involved posters and providing free water bottles to all incoming patients to drive awareness. They expressed diabetes as an important area and gave suggestions on ways to reach patients in a community setting – mostly through the malls or festivals in country.

Cultural Perceptions and Care

For regional and national patients, a number of cultural perceptions significantly affect how healthcare is perceived. Patients’ conditions as well as motivation to seek help and treatment can be significantly affected. Mubadala is Abu Dhabi’s investment arm (you may have seen some ads for them during the World Cup?) and their lead for the healthcare sector expressed his experience with patient perceptions. The majority of patients with an Islamic background, for example, seemed to have a cultural acceptance of many diseases or conditions as if sent from God. With a belief that many events in life are fate-driven, it’s even more challenging to motivate patients to make changes in their lifestyle and health habits. I spoke with an internal medicine specialist and diabetes nurse at the International Modern Hospital that treats the largest number of Emirati patients outside in the private system. They stressed that it is difficult to get patients in the door and “even the concept of taking a pill” is a huge challenge for some. In an effort to reach patients more effectively, they tested some homecare concepts that failed completely, as many patients cancelled appointments last minute or were not home when the physician team was scheduled to arrive.

Additionally, the Dubai Health Authority spoke a lot about options for people to practice healthy habits such as exercise. Public spaces for walking, running, and playing are very important and already prioritized within the government / MOH efforts. However, over and over again I heard many challenges with respect to the weather (humidity and temperature) of the region. When I was in Dubai it was almost 50^oC and humid which can be almost dangerous conditions for any exercise. So how do you deal with this? They are piloting concepts that open health clubs for nationals to have exercise facilities that are included in their health coverage so this maybe an interesting (and replicable) solution if it works!

As I’ve mentioned before, having healthy options is a significant component of empowering patients to change their lifestyles. However, the culture must support the decision process that chooses these options over the status quo of inactivity (watching TV, sitting at the computer) and poor food choices (as it was described to me, “Krispy Kream is making a killing” in the UAE).

Opportunities for Diabetes Solutions

There is a lot to be hopeful for with respect to diabetes care in the UAE. It is already recognized as a national priority and once a strategy is in place, the funding and willpower is there to make it happen. I spoke with Dr. Ali Shakar, the previous Director General of the Ministry of Health for the UAE who spent a lot of time discussing past efforts and opportunities for the country (and what Project HOPE can do to help). He was interested in collaborating to develop a larger GCC effort that focused on patient empowerment and prevention efforts through Project HOPE’s “5 Steps to Self Care” and “Healthy Lifestyles” educational programs: one targeting the affected patient population and the other elementary students that represent the “future of the nation.”

Mubadala also emphasized their impressive investments in diabetes care to date – as well as plans to expand. Their work in the Diabetes Institute in the Empirical College, led by Dr. Maha Barakat, had been recognized internationally for its vision and success with execution. The center has driven so much volume that they are opening another facility in Al Ain, where 35% of their patients are commuting from for care. The facility provides all diabetes care and specialists in house (including lab and pharmacy services) with a range of specialty care including podiatrist, cardiologist, and weight management services.

I was also able to visit the Joslin Diabetes Center in Dubai which is a branch of a US-based chain that delivers top of the line care. I met with two diabetes educators there and the founder of the center who described the learning s they’ve had in the past 13 months since its opening. In the first year the facility was reserved exclusively for nationals and demonstrated the ability to reduce patients A1c levels in 3 months through treatment, lifestyle change, and close monitoring. The diabetes nurse walked me through their educational and treatment model.

She mentioned that they provide each patient a glucometer and strips for free and electronically “download” all glucose readings from the meters with each visit. This was fascinating to me as I’m not sure it’s a standard practice in the US. What happened was that patients actually started testing their glucose regularly and noticing changes based on their diet and medication (this also means patients can’t fake their glucose readings which can be a common issue otherwise).

They also highlighted a few challenges in the first year of care for the community. One, there are huge challenges finding nurses that have the technical skills and LANGUAGE skills to work with patients. This is not something that had occurred to me before. Because many healthcare workers are imported, many are not as proficient (or at all proficient) in Arabic. Could you imagine trying to talk about your emotional challenges with diabetes with someone who doesn’t even speak your language?

They also expressed some challenges with the “fate-centric” culture but that after time they were fairly compliant with care. Finally, I was shocked to discover that all of the model foods for carbohydrate counting and food-portion education were Western foods (e.g. green beans, rolls of bread). There was no hummus, falafel, pita, or anything that resembled what the majority of the patients consumed on a daily basis. This is a HUGE area for improvement – it’s not enough just to translate materials but the content of the education needs to be adapted to the culture itself. If patients don’t know that falafel has tons of carbs they are going to worsen the progression of their disease.

The UAE was by far one of my most productive visits with the majority of the interviews initiated from previous interviewees that supported the cause with the belief that Project HOPE can help. Influential interviews with Dr. Ashraf Ismail, Dr. Ali Shakar, Mubadala, and the health authorities of Dubai and Abu Dhabi provided a diverse perspective of the in-country priorities from a variety of stakeholders. The UAE’s unique location in the Middle East also makes them a strategic target for regionally-collaborated efforts that include the larger GCC region with similar patient needs. Additionally, the availability for national funding for pilots that could be successful in the region considering the national GDP per capita is larger in the UAE than the US (and almost double the US’ in Qatar).

I look forward to seeing what comes of Project HOPE’s work in this region as they focus on primarily government partnerships to facilitate program development and implementation, leveraging their expertise and experience with global diabetes efforts to date.

Oman Findings: Big Need, Bigger Opportunity

Oman has one of the highest prevalence rates for diabetes of any country globally. Although a country of only 2.8M, an estimated 12-16% of the entire population is affected with even higher prevalence rates for hypertension and CVD. The need for diabetes and chronic disease interventions is unquestionable. I met with Dr. Mohammed Lamki, head of the Oman Diabetes Society in Muscat and was amazed and impressed by the awareness of this need and current efforts to strategically address the population across the spectrum of prevention, early detection, treatment, and compliance.

Much of this has to do with the fact that diabetes has been on the radar for Oman since 1991. Almost 20 years ago a survey was published in Diabetes Medicine that revealed a 9.8% prevalence rate among a sample size of patients in Oman. At that time, these rates were not tracked in this region and provided an awakening around the unusually high hereditary propensity for diabetes.

A Hopeful System:

Currently the majority of diabetes patients are detected in Oman when they develop complications such as loss of vision, foot numbness, and kidney problems (it is estimated that 50% of patients on dialysis have diabetes). This indicates that these patients’ conditions have already progressed to a point of no return, but there is still hope that they can slow down the progression of the disease. This is fairly common among most of the countries I have visited, with only a few select communities that have succeeded in pushing patients into the diagnosis / treatment process before complications appear. What does this mean? HUGE opportunities for early detection and prevention for the onset of diabetes.

What is even hopeful to me, is the healthcare system itself. Oman covers all healthcare for patients through the government system, including insulin, glucose monitors and oral medications for diabetes, such as metformin. This relieves a large barrier of affordability present in most countries. Patients can, of course, pay out of pocket for more expensive brands or products such as fast-acting insulin or insulin pumps. In addition, the average GDP per capita is much higher than a number of other countries I’ve visited to date reducing the barriers for more expensive therapies.

Training a Diabetes-Ready Healthcare Workforce:

Dr. Lamki’s vision is to prepare Oman for high-quality, large-scale diabetes care. Formally launching his diabetes educator program and website this week (June 22^nd) he has been working to build a state-of-the-art Diabetes Institute in the Royal Hospital in Muscat as a comprehensive care and teaching facility for the country.

His approach is similar to that of some of Project HOPE’s programs in India and China. With a focus on building capacity within the nursing community as diabetes educators, the new training program will enhance the access and quality of care in secondary and primary care centers in both urban and rural areas. What was very apparent was his strong belief in the role nurses (not physicians) play in diabetes treatment. “I believe in nurses, not doctors.”

Working with a educationalist in the MOH, John Kelly, they developed a curriculum for an 8 week diabetes education program: 2 weeks of instruction, 6 weeks of practical experience. The need for “practical” education was a high priority as well. Diabetes is a complicated disease – it can’t just be taught theoretically – this program gives nurses the opportunity to train under experienced nurses to see how it’s done: learn, see, do. The goal is to standardize some of the tools available to health facilities around the country as well and provide easy access to experts through a national center of excellence.

I spoke with the Director of Nursing Programs in Oman’s MOH later to discuss his perspective on the program. With areas like foot care as a large need (there is a huge shortage of podiatrists in the region), he expressed the ministry’s interest in expanding homecare efforts where inpatient capacity is constrained. I also learned that they have a post-graduate training for nurses and GPs to provide chronic care in the community. The 1.5 year educational program includes instruction and practical experience (similar to the diabetes model) focusing on a multidisciplinary approach to treating multiple risk factors. These are all noteworthy initiatives to help patients with diabetes (and other chronic diseases) in the region.

How can Project HOPE Help?

Going through the actual diabetes training curriculum with Mr. Kelly, we discussed several opportunities for how Project HOPE could bring its expertise and experience to benefit the current efforts in country. I had limited previous knowledge of an educationalist’s role in healthcare, but Mr. Kelly explained his “patient journey” or care path approach to designing educational programs for a variety of health programs. The training structure is planned by starting with the capabilities required of the healthcare worker - what skills are needed from the moment the patient enters a health facility.

What I noticed is that the proposed curriculum is very similar to Project HOPE’s current training programs in India and China related to diabetes. Although Oman’s MOH has developed the curriculum, they have yet to fund and develop the actual content to deliver the course. This could be an opportunity for Project HOPE to partner with Oman’s Diabetes Society to leverage its strengths and experiences in other regions to reduce the time and resources needed to execute Oman’s goals for the training institute.

Additionally, Dr. Lamki expressed an interest in learning more from Project HOPE about actually running a diabetes education program on a day-to-day basis. Technical expertise and management experience could greatly benefit Oman as they start-up and refine their program over time. Outcomes could also be a promising sub-focus within the project management. As Project HOPE has started conducting outcomes research on patients who benefit from diabetes education – outcomes research could be implemented to evaluate success within Oman’s Diabetes Institute. Good results could also set the stage for an exemplary model and standards of outcomes for the region.

Project HOPE also worked with the International Diabetes Federation in India to acknowledge the diabetes educator program as compliant with global standards. This process could be facilitated in Oman with Project HOPE’s experience and understanding of IDF’s requirements and program goals.

Integrated Chronic Care for the Long-Term:

Educating GPs and patients may be a long-term strategy for chronic care in Oman. Because the disease prevalence is integrated across chronic conditions, chronic care educators may be the future model to address multiple risk factors, early detection, treatment, lifestyle change, and patient empowerment across the continuum of care. With nurses as the soldiers of healthcare fueling the educational systems in health, it is difficult to pull patients into the system without increasing awareness among the primary healthcare system and patient communities.

That being said, you have to start somewhere! I applaud Oman’s current efforts and look forward to seeing the impact over the coming years. Whether in an advisory role or implementer of programs, Project HOPE has an opportunity to assist and contribute to success throughout the journey…