Diabetes in India: A Sleeping Giant

Project HOPE India is located just a few minutes from the Rashtrapati Bhavan (President’s Palace) in New Delhi. The Program Manager for India, Dr. Sonia Kakar, has been working with the India team here to setup a capacity-building approach to help patients with diabetes across multiple cities in India. Their India Diabetes Educator Project (IDEP) started in 2008 as a four-year multi-partner collaborative initiative to combat the rapidly growing threat of diabetes in India. The 6 month course for experienced healthcare professionals (nurses, nutritionists, physical therapists, psychiatrists) is recognized by the International Diabetes Federation (IDF) and is the first large scale initiative to train and educate allied healthcare professionals in India on diabetes education, care and management (supported by BD, Lilly, and Bayer)¹.

India has about 40.9 million people living with diabetes, over 65% of which are not aware of their condition^2,3. By 2025, this is expected to nearly double to 69.9 million, representing the highest burden of diabetes in the world². This prevalence is concentrated in the wealthier socioeconomic groups and cities, with a 12% prevalence rate in urban areas. The shocking difference about diabetes prevalence in India is that the population has a higher propensity for the disease at a lower BMI and age-range than seen in the US. Of all Type 2 patients (99% of cases), only one third would be considered obese, 52-57% are in the normal weight range, and 10-15% would be considered underweight. In addition the average age for diagnosis is 20-30 years old (35-40% of which already have complications)³.

Why doesn’t India have a diabetes care program? The Indian Government still does not consider diabetes and other non communicable diseases as a priority area. India still has large public health needs related to infectious diseases and clean water / sanitation. These priorities are ultimately limited by India’s relatively narrow national budget for healthcare: 4.9% of GDP (0.9% of the government's budget) or the equivalent of about US$39 per person per year⁴. This is a very large contrast to the budgets seen in Brazil and Mexico where 7.5% and 6.2% of GDP are allocated to health, respectively. Additionally, an estimated 45% of India lives below the poverty line (US$1 per day) with the estimated average income around $42,000 rupees (around US$1016)^5,6.

Additionally 70% of people in India live in rural areas and there is an ongoing rural to urban shift in the population (if these statistics are right then that means 97% of all diabetes cases are in urban areas). The significant diversity among people living in rural, semi-urban and urban areas must be taken into account when designing a diabetes prevention and treatment program³. From a prevention standpoint, it’s important to think about where the future patients with diabetes will emerge. If they will grow mostly in urban areas as a result of the rural-urban shift, then a diabetes program in urban areas might be the best investment. On the contrary, if lifestyle habits from the cities start replicating themselves in more semi-urban and rural areas, a much larger comprehensive prevention program is needed to reach the mass population.

Cheena Malhotra, Program Associate for Project HOPE India, took me to visit several of Project HOPE’s eleven IDEP centers where they train healthcare professionals to diagnose and treat patients with diabetes. The 6 month course is very rigorous and is mostly a distance learning course with three in-person meetings (Induction, Workshop 1, and Workshop 2 & Final Exam). The program aims to train 3,000 diabetes educators by 2011 and generates awareness activities in the health facilities such as continuing education for General Practitioners.

It’s important to keep in mind that culturally, India is very “medically” oriented and prefers physicians to other healthcare workers or peer educators. This can make peer-education (or perhaps even just education) models slightly more challenging as it is usually the word of the physician that is respected at the end of the day. Traveling doctors are also very common in semi-rural and rural areas to help reach more patients where the needs are high, but infrastructure/funding is low; could these be a target for effective diabetes prevention programs? Communities here are also very family-based, and therefore working with family doctors may be another approach for reaching patients with preventive and screening efforts.

Project HOPE Diabetes Master Trainers, me and Cheena at Sitaram Bhartia in Delhi.

Next week we will be completing a number of site visits and interviews in Delhi and Bangalore! More exciting India findings to come soon…

Sources:

1. Project HOPE India Diabetes Educator Project

2. Diabetes Atlas 2007, WHO

3. National Diabetic Association of India http://www.diabetesindia.com/diabetes/itfdci.htm

4. World Health Organization (WHOSIS)

5. IMF 2008

6. India Survey for BPL Families http://www.pbplanning.gov.in/pdf/BPL16-3-07.pdf

Interview: Community Empowerment through Peer-Education

Courtney Guthreau is a diabetes educator. She is currently Program the Regional Director for the Americas for Project HOPE, based in Mexico.

Abraham Castañeda Chávez is a physician. He is also a diabetes educator and Medical Director for Project HOPE in Mexico.

What is the health environment like for someone with diabetes in Mexico?

Abraham: Right now there is little understanding or promotion for the patient empowerment model in Mexico. The majority of patients with diabetes see a primary care physician, who may not understand the disease well enough to treat them appropriately – or worse, use insulin as a threat to control their symptoms. There are also occasional myths, such as, insulin causes blindness. Of course this isn’t the case and the opposite is true for a patient who needs insulin. This ends up causing a lot of issues with patient trust and compliance. Many doctors don’t feel comfortable using insulin.

A paradigm shift is required for a behavior change focused patient-physician relationship. There is a clear need to enroll physicians in the process both through training and exposure to our Project HOPE programs in Mexico. Project HOPE and SerBiem’s “traffic lights” have done a lot to provide basic standards of “healthy” levels to providers (and patients). A number of physicians have come a long way since we started working with them seven years ago, but there are many more that would need to be engaged for a larger or national program.

How did you decide to develop a community-based approach?

Courtney: Abraham and I started our work in rural Mexico doing TB and HIV/AIDs work.

Both of these programs have long accepted peer education models as a way to increase awareness and reduce prevalence in a community setting. When we started working with diabetes, we saw a huge opportunity for patient empowerment as a way to mobilize communities to focus on prevention and self-care.

Although diabetes is still viewed as a very clinic disease, it takes more than an army of physicians (or educators) to treat a community. “Diabetes is more than a disease, it’s a lifestyle” and requires peer support to overcome many of the emotional challenges that individuals face without role models and encouragement around them. The Art of Empowerment (Anderson & Funnell) has been an influential perspective as we worked to develop and refine our programs with diabetes over the years.

Do you view this as an extension of primary care for diabetes in Mexico?

Abraham: Physicians still must treat patients and monitor then on a routine basis. The only challenge is that they see a patient every 15 minutes on average. They will prescribe medication but do not have the time to do the educational component that is so important for changing a patient’s lifestyle. 5 Steps to Self Care, the "Educator de Pares" or Peer Educators, and elementary school programs have allowed us to reach dramatically more people in a powerful way.

Nurses have also said that they need 5 Steps to Self Care education to complement their knowledge, in addition to other trainings they receive, to understand all aspects of the disease (mental, physical, emotional). This is a real testament to the quality of education both from technical understanding to delivery.

What coordination do you have with public health programs at the municipal and federal levels?

Courtney: Our partnership with the local government secures the time required to train the healthcare workers through 5 Steps to Self Care. Since the program is 12 weeks long, this is a serious commitment for any professional or patient. They have seen our results in the community and are looking for more ways for us to work together to implement programs with a national focus.

Abraham: We hope to work with them more in the future to use 5 Steps to Self Care successful model and an example for a federal program. If we worked to certify health professionals, for example, we would want to show demonstrated results with patients after a certain period of time. What impact have they had on their patient populations? How many are in control? To what % have their A1c levels been reduced?

Right now Project HOPE is largely the “go to” organization in the community for physicians interested in diabetes education. If they need something new in their facility, they come to us first to see how we can help.

What results have you seen over the past 7 years?

Courtney: The impact on the communities has been profound. In order to effectively treat diabetes you have to also treat the families and communities. We have made a conscious effort to track the success of our programs with “real” outcomes. Although it is wonderful that all participants enjoy the 5 Steps to Self Care program, and patients return back to the Peer Educators – we want to know that we are having an impact on their personal and long-term health. “If you’re not impacting a patient’s A1c, then what are you doing?”

Abraham: We’ve also seen that patients often train others after the formal program is over, setting up a self-sustaining educational process. This is exactly what we would want to happen in the communities. Diabetes can be viewed as a normal progression in one’s life with age and weight gain. You may hear people say, "oh well, it's just diabetes." In addition, many people as they age see weight gain as a sign of “healthy reserves.” It takes a parent, brother, or daughter to intervene to support a community of healthy living.

Courtney: We’ve seen that A1c levels can drop quite a bit during the 5 Steps to Self Care program. 12 weeks is a standard interval for a check-up and around 40% of our patients with A1c 8% and above (many of which are much higher >12%) are able to move it down to 7% or below. In addition we use the WHO-5 as an indicator for emotional wellbeing and have seen significant reductions in depression, from 29% to only 6% of patients, in addition to a large increase in optimum scores (1% to 14%). We track A1c in the Peer Educators program and children’s eating and exercise habits with the elementary school programs. It’s important for us to provide education in the community, but we want to see tangible outcomes!

Thinking about outcomes for Project HOPE’s programs in Mexico reminds me of an excerpt from Nudge. Statistics have shown that you can have an impact on outcomes, often, just by measuring it in the first place. If each child is asked monthly about their eating, drinking, and exercise habits – would they not (1) think themselves about how they’re doing and (2) consciously or subconsciously try to give a better response each month? In some ways it’s similar to grades in school – if you have a test that is pass/fail, you are likely to get a different level of effort from the class than if it is graded on an A-F curve (or no curve at all!). This is why health metrics are so important to track in any system (whether by patient, facility, doctor, region, or country)!

Seeing is believing:

Berta and Consuelo are examples of patient-leaders who provide hope to others through their own personal strength to control their diabetes. Both of these women have their diabetes 100% in control through nutrition and exercise – what an inspiration! Their determination to reach out to members in the community who are undiagnosed and/or struggling to control their diabetes is astounding. Consuelo holds outdoor exercise classes in the park for people interested in increasing their physical activity in their daily life. Berta is a loyal “educator de pares” and motivated each day by the ability to reach out to patients in the community and lower glucose levels for both pre-diabetic and diabetic cases.

They have diabetes. They are patients. They are peer-educators. They are empowered.

Visit the Mexico Country Profile and pictures!

Project HOPE Mexico: Educating Communities

Project HOPE Mexico provides something that every patient needs – a community. Led by Courtney Guthreau and Abraham Castañeda Chávez, Program Director and Medical Director team (y esposos), Project HOPE and their local partner SerBien are demonstrating the personal impact of diabetes educational programs in the community – and perhaps more importantly, real outcomes. Working with a larger team of dynamic professionals and volunteers, Project HOPE is making a difference in the lives of so many families struggling with diabetes in Mexico.

Diabetes is a serious health threat in Mexico; the lifestyle and “comida típica” or traditional eating habits in Mexico don’t help. Large consumption of fried foods, meat fats, dairy fats, and carbohydrates make almost 2 in every 3 Mexicans overweight or obese. As a result, diabetes affects nearly 12% of the population with growing prevalence among the youth. Unlike the proactive “Programa Saúde Familia” primary care teams in Brazil, little is done in the public health system in Mexico to reach out to patients to detect their diabetes before major complications arise.

Abraham describes his experience speaking with a primary care physician to demonstrate a sense of urgency. “How many patients do you have in your district?” he asks. The physician responds that the clinic is responsible for 35,000 patients. Conservatively, that means that at least 3,500 patients have diabetes. Then he asks, “how many patients do you have enrolled that you are treating for diabetes today?” The physician replies, “200 patients.” Where are those 3,300 patients? How far along have their conditions progressed? It is clear that the primary care and specialty care systems are not capable of scaling capacity (quickly and effectively) to address the needs of these patients.

Since 2003, Project HOPE Mexico has demonstrated a successful patient education model as a mechanism to (1) expand capacity for detecting and educating patients with diabetes and (2) PREVENT the progression of diabetes within communities. Working with a number of local partner physicians and providers, including Dr. Fernando (to the right), Project HOPE has benefited thousands of individuals in the Mexico City region. The current program portfolio includes a patient-centered approach with diabetes educator, peer-educator, and hybrid educator programs to achieve its goals.

Diabetes Education: Elementary School Approach

It’s never too early to start practicing healthy habits

Project HOPE currently works with a number of schools in and around Mexico City to educate students (and their families) that “3 Habits” are required for a healthy lifestyle: ear 4-5 servings of fruits and vegetables, drink 2 liters of water or “agua pura”, and exercise 60min each day. Through four “cuentos” or stories about the impact of overweight / obesity on long-term health, Project HOPE teaches children what they can’t control (race, heredity) and can control (food selection, sedentary inactivity).

The program is also careful with its messaging: this is a lifestyle aimed to revive the healthy person within each individual, not a “diet” program which implies a temporary or self-limiting process (and unattainable results). Project HOPE Mexico rewards children who achieve each of the 3 healthy habits by providing buttons for them to wear on their school uniforms to publicly pronounce their accomplishments. More amazing, Project HOPE collects and tracks information from each student on their progress over time and the outcomes associated with their BMI.

The impact? Children in the class I visited spoke up about talking with their families about these healthy habits and how everyone in the house should be eating healthy, exercising and drinking pure water (not soda). Project HOPE has empowered these children to pass on the education to their families. One testimony of a mother indicated that the “cuentos” empowered her to talk to her husband about healthy eating and justify serving salads instead of fat-rich meat or fried foods every meal.

Peer Education: Diabetes Promotores

Taking diabetes diagnosis and monitoring to the community

So how else do you reach those 3,200 patients not touched in the current health system? You literally, go out on the street and find them. Project HOPE’s diabetes education “promotores” are working magic one person at a time. Using a hand-held glucose monitor and test trips, they provide both diagnosis and monitoring services to the community in a surprisingly personal way. And, they’ve earned quite a reputation!

Berta and Consuelo uplift patients who don't know they have diabetes, have become hesitant of being associated with a medical facility or labeled as “not well” – and demonstrate exciting results. Berta shows me a card from a 25-year old patient who came in for the first time with a glucose level of 572 mg/dL only 8 days ago. Today his levels were down to 260 mg/dL (still high but a remarkable improvement!). She exclaims “and without a doctor!” It’s true, going through the basics of healthy living through nutrition and exercise can do a lot. While most of her clients see a physician on a regular basis, she inspires them through her own personal story. She has Type 2 diabetes, but through her own changes in nutrition and exercise has her A1c 100% in control with absolutely no medications. Since the far majority of diabetes cases in Mexico are Type 2 driven by heredity and obesity, a physician may treat their conditions, but Berta gives them hope.

I had my glucose tested to “experience” the impact of the community outreach myself. It was quick, easy, and painless!

Hybrid Education: “5 Pasos” or 5 Steps to Self-Care

Community mobilization in diabetes through clinical and peer-education

The “5 Pasos” experience was perhaps the most moving in Mexico; this is where the community impact really comes together in a beautiful way. Originating from the first Project HOPE assessment in 2001, J&J led the funding effort to design, test, and implement this progressive approach to diabetes care. Today the program has grown substantially and in some communities, is self-sustaining through continued donations, Project HOPE support, and volunteer staff.

Classrooms of mostly women and children with families affected by diabetes actively learn, re-learn, and then teach the physical, mental and emotional components of diabetes. This is true patient and community empowerment! The extensive course is 12 2-hour sessions with a final examination to receive a certification from Project HOPE for completing the 5 Steps to Self-Care. Course topics include evolution, decision-making, physiology, continuing education, self-care, nutrition, exercise, and health services. See below as a student describes to the group the physiology of Type 1 diabetes:

So how does education empower this community? It would be impossible to account for the testimonies of the 600+ certified students of this program. In the session I attended two were among the most powerful:

A young, thin, 22-year old woman came up at the end of the course to introduce herself; as she got closer it was easy to tell that she had substantial vision loss. Although she did not look like she should be screened, her family heredity made her a victim without many of the symptoms; most of her family had diabetes. As a result, her diabetes started affecting her microvascular function. Through 5 Pasos, she is working to control her A1c levels and preserve her vision.

Another woman described the emotional devastation that diabetes put on her and her family when she was diagnosed. At first, she wasn’t aware of her options. She had started visiting funeral homes because she believed her life would end until she realized, through the 5 Pasos community, that she could live a full and healthy life. She and many other women came up after the session to hug me and give me their thanks and blessings for my journey with Project HOPE to help those with diabetes globally.

Honestly, nothing could be more meaningful to me. These women will always be in my heart. This isn’t about theorizing a perfect system or protocol – this is about helping people. This is about changing lives. This is about empowering people to help themselves, their families, and their communities. This is Project HOPE Mexico!

Sources

Helping people help themselves in Mexico (DAWN Initiative Highlight)

Project HOPE Mexico: empowering people to care (IDF paper)

Project HOPE Global Diabetes Portfolio (presentation) – Courtney Guthreau

Navigating Healthcare in Brazil

As described in “Diabetes: A Platform for Chronic Disease,” using the patient care path is one of the most effective ways to understand how a patient moves from one state of health, and facility, to another. As Gabi and I discovered this week as well, it’s equally important to get a varied range of perspectives from healthcare theoricists (i.e. political / healthcare leadership), providers (primary, secondary , tertiary), and multiple patient groups to understand what really works and is needed in the system.

For a person with diabetes in Brazil it looks like your options, in general, would be pretty good.

One of the greatest challenges is that most patients are being detected for diabetes (both Type 1 and Type 2) when complications start to show or impact day-to-day life. The onset of complications implies that the diabetes has already progressed quite a bit, which results in an immediate treatment with pharmaceuticals, nutrition / exercise changes, and depending on the circumstance, hospitalization and daily doses of insulin. In addition, the current pre-diabetic population in Brazil is almost completely left out of the system lacking the educational or diagnostic infrastructure to help prevent the progression of the disease. This suggests that an increase in the capability and capacity for primary care to educate and diagnose patients with diabetic and pre-diabetic conditions is a HUGE opportunity.

Brazil’s progressive Programa Saúde Familia (PSF, or Family Health Program) is a unique “push” model that literally takes primary care to the homes of millions of Brazilians on a monthly basis. Teams of trained healthcare workers supported by a group of physicians and specialists, visit patients homes recording symptoms and conditions that may warrant a referral to a clinic or secondary healthcare facility. Chronic care (both hypertension and diabetes) has become a focus for this program.

Specialized Chronic Care Facilities or Centro de Olhos Hipertensão e Diabetes, have been set up around the country to help Brazil cope with the increasing prevalence of chronic disease in the communities. These include specialists like endocrinologists, cardiologists, nutritionists, psychologists, and ophthalmologists for treatment of the physical, emotional, and peripheral effects of the disease. A wider range of therapies is offered in these facilities, all of which are covered by the public healthcare system.

Which leads us to the second challenge with the system: capacity constraints in the specialized centers are increasing. We were told at the specialized centers that the wait to enter the facility was about 3-4 months; the PSF team on the other hand, indicated that they’ve had patients waiting up to year to have a visit scheduled. The goal is that these facilities would be 100% scalable because each patient once stabilized would be counter-referred to their primary physician. However, four barriers prevent this from occurring in reality:

1. Patients trust the specialists in the facility and don’t want to give them up, especially psychiatric services
2. Not all drugs (see right) provided in the facility are covered through primary care centers or pharmacies
3. Patient information is tracked paper via one health record per patient; when patients are counter-referred the primary care physicians do not have any history on the patient’s treatment
4. Finally, primary care physicians (as witnessed from our PSF interviews) do not necessarily have the skills or confidence to treat counter-referred patients from these facilities – which then reinforces point #1 with the patient…

This suggests that an increase in the capability and capacity for primary care to treat (in addition to educate and diagnose) patients with diabetic and pre-diabetic conditions is an URGENT need. The good news is that local and national health leadership in Brazil is already starting to do a lot to address these challenges (and in fact, this infrastructure is already proactively treating chronic diseases in a way that most countries are not). Teams of the chronic care experts are now starting to support the PSF groups and providing “real time” practical learning opportunities for them through weekly reviews of complex patient cases.

Claudio Duarte, Recife’s Secretary of Education and ex-National Ministry of Health lead on chronic disease, described other progressive programs such as “the city’s gym” which is hoping to focus on prevention through increase physical activity within the community.

In addition, training healthcare workers and patients are Project HOPE’s core capabilities! Discussions with the various stakeholders, physicians, patients, and leadership show that both a trainer-of-trainer (TOT) model for healthcare workers and peer-to-peer patient support groups for awareness, diagnosis, and compliance would greatly benefit Brazil’s patient population.

My last day in Brazil, a 12 year old girl asking for money on the street saw Gabi’s Guaraná Zero (Brazilian soda) and asked us “I have diabetes, can I have your Guaraná?” That blew me away. It’s clear that this is a real issue, and although we spent days seeking out diabetes in Brazil, in the end it, found us.

For a complete list of interviewees, notes, pictures, and videos please visit the Brazil Country Profile!

The Meira’s: Leading Healthcare in Brazil

This week was dedicated to uncovering Brazil’s greatest needs in diabetes prevention, diagnosis, and treatment. Gabriela Meira, a Deloitte consultant and dear friend, offered up a week of her time and energy to setup interviews and tours of countless influencers, deliverers, and recipients of both public and private healthcare in Brazil. Her family business Interne Home Care, founded and led by her mother Paula Meira, employs approximately 700 health professionals and is the largest home health company in the North / Northeast of Brazil. Together they are a dynamic duo (to say the least) and extremely generous for all they’ve done for Project HOPE this week!

Interne Home Care is based in Recife and started as a branch of Interim Home Health Care, a US-based home health company with provider (hospital) and health plan partnerships to deliver care. Eleven years ago, Paula invested in Interne as an independent venture that was best tailored to the needs of Brazilian health plans and patients. Now a larger organization with diverse home care offerings, Interne Home Care has created a unique model for diagnosing, treating, and preventing diseases in its region.

Their three lines of business CuraBem (Get Well), DurmaBem (Sleep Well), and FiqBem (Stay Well) address the treatment of diseases, specialties in COPD, and a dedication to chronic care prevention and treatment respectively. The latter is especially progressive in the Brazilian market. Although Interne focuses on the private sector, the business has been able to demonstrate the long-term cost savings in prevention and expanded to offer these services with coverage from many private plans in Recife. They treat countless people with diabetes and chronic care patients (typically older and with multiple chronic conditions).

In addition, Recife is known as the “silicon valley” of healthcare in Brazil with an entire district providing some of the best facilities and medical professionals in the country. The combination of public and private players in Recife made it a good target for research to understand the current state of diabetes and chronic disease in Brazil. Gabriela and Paula helped schedule a full itinerary of meetings for Project HOPE including national Minister of Health, state-level hospital, and local community health contacts. (Interview notes and insights will come soon!)

This research would not have been possible without the Meira’s. By the end of the visit they were strong supporters saying… “anything for Project HOPE!”

Gabi and Paula in front on an Interne poster: "Because you value life, and we value you."

Diabetes: A Platform for Chronic Disease

Now that you have a sense for the global burden and need for chronic care programs and treatment, it will be easy to ground yourself in Project HOPE’s chronic disease approach and programs. Managing a chronic disease (and as important, keeping people well) requires a very different model than traditional acute care. It demands different products and services in addition to varied physician skill-sets to develop a personal trust and empower patients to want to make changes in their lives.

Some of these chronic vs. acute differences include¹:

• Clinical, Education & Communication skills
• Patient – centered care
• Peer support
• Lifestyle modifications
• Community mobilization

Project HOPE’s approach to public health is “helping people help themselves” or empowering patients to have the will and capability to help advocate for and manage their own conditions. This involves strengthening the local infrastructure, increasing capacity for quantity and quality of care, and educating patients when and how to seek help. Their approach for chronic disease is specific to each country’s environment and needs. This requires an initial public health assessment to identify the greatest needs to generate the largest impact for the program investments. Project HOPE’s current diabetes programs (Type 1 and 2) can be seen below – each of which uniquely addresses the gaps and environment in the communities it addresses².

Working with providers (hospitals, clinics, physicians, nurses, public health workers), health officials (local and national government), corporations (pharma, med device, technology), health management and insurance organizations, educational systems (elementary through medical universities), existing non-profit organizations, and (last but not least) patients is essential to providing a universal understanding of systemic needs and opportunities across the patient care path. I will spend my time “in the field” interviewing, observing, and working directly with these stakeholders to recommend the best “fit” program from their portfolio (including new ideas and best practices across communities).

Project HOPE’s approach works to build healthcare capacity FIRST – training health professionals to increase the scale and quality of care in the community. This is a truly sustainable approach in alignment with their goal to help communities help themselves (i.e. teaching the communities how to fish rather than feeding them for a period of time). Not only is this valuable from an investment standpoint, but it is also more successful. Outcomes in development programs³ show that initiatives have a much higher rate of success when local leadership empowers the community. When capacity is scalable, patient awareness (top-down and bottom-up) efforts help drive prevention and early diagnosis (here’s where the real ROI is) in addition to compliance efforts to manage patients’ care across the continuum.

Project HOPE’s strategy will expand from a strong foothold in diabetes to other disease states such as cardiovascular disease and cancer (usually in this order). Not it’s time to see how theory plays out in the field – and the journey begins!

Sources:

1. Project HOPE Global Diabetes Portfolio (presentation) – Courtney Guthreau
2. PROJECT HOPE, UNITEDHEALTH GROUP LAUNCH CONNECTED CARE TELEHEATH PROGRAM TO EXPAND HEALTH CARE ACCESS IN NEW MEXICO
3. Positive Deviance / Hearth: A Resource Guide for Sustainably Rehabilitating Malnourished Children – The CORE Group

Use Your Resources!

In preparation for visiting public health programs in country, Stuart Myers, Project HOPE’s Senior Vice President overseeing all global health programs, has initiated my educational journey with an array of extremely helpful and relevant resources on public health, chronic disease, and HOPE’s current programs. As he pointed out, this will also be a wonderful way to help me get back into the student mindset after a few years in consulting (Google only goes so far!). I also did some research on so called, “bibles” in the field and came up with a few good reads as well to best enable me to hit the ground running my first few weeks.

I’m including below a list of these resources (some of which may pop up later in more detail) and brief summaries of some of the most insightful primers.

Nudge

Richard Thayler and Cass Sunstein team up to describe how people make decisions (what factors influence them, what psychological thought processes prevail) and how these decisions impact health, wealth, and personal / collective happiness. They classify people in two categories: Econs, those thinking with a delayed-gratification or long-term economic lens, and Humans, i.e. everyone else. Two of the most powerful takeaways here are that (#1) you can influence how people make decisions without eliminating their choices and (#2) 90% of the battle is providing a good default. In examining everything from Medicare Part D, social security, and mortgages, they provide case after case that helps Humans everywhere learn the joys of choice architecture and being an Econ (fortunately I was trained by one for many years). My favorite example that demonstrates Point #1 is a representation of “shock design” – where a director of food services for a school system experimented whether placing healthy foods first made a difference as to what meals were purchased by students. Her experiment demonstrated a 25% increase in healthier foods then arranged first or at eye level compared to junk/snack/sweet foods. Unbelievable! Just a warning - the authors also take at least one chance (usually more) per chapter to take a jab at MBA graduates.

Taking Control of Your Diabetes

Dr. Steven Edelman, MD is an inspiring physician for patients and doctors everywhere and has lived with Type 1 diabetes for 39 years. His book Taking Control of Your Diabetes is a book to live by (literally) for anyone who has diabetes and takes a unique approach of motivating self-advocacy and personal ownership by tackling the physical and emotional issues of the disease. Please note, this book is also a great read! Not only does Dr. Edelman hope to empower people with diabetes everywhere to be their own best advocate, he embraces the “real” day-to-day challenges with a compassion and understanding that instills a patient-physician trust lacking in so many doctors offices. In addition to giving me an in-depth background on diabetes prevention and management (YES it is preventable!), this book has given me hope that we will have more physicians with the passion and determination of Dr. Edelman.

Rx for Survival

Philips Hilts starts out by giving us an eerie history of health threats to humankind as documented over time; the Bubonic Plague in the middle ages, the Spanish Flu early 20^th Century, and more recently the West Nile virus, Avian Flu, and HIV/AIDS prevalence today. Throughout his book he takes a journey to Nepal, India, and Botswana to illustrate examples of our public health needs globally, building a case for why investing now is so important. After sanitation and basic antibiotics extended the average human life from a life span of 25, to 40, to now the upper 70’s, he claims we are for the first time at risk for reversing that trend with a new generation of complex, massive epidemics. Global support for an investment in health interventions (many of which are simple vaccinations and treatments) he claims will save $200-500B annually in lost economic productivity and direct costs. Whether this is precisely accurate, it is clear that there is a large financial return for health investments in any country, and through his examples, low/middle income communities especially.

India Diabetes Educator Training Manual

Project HOPE’s joint partnership in developing a course on diabetes education in India with the International Diabetes Federation (IDF) has produced an extensive program and long-distance educational course that pairs traditional diabetes concepts with guidance on mentoring and cultural sensitivities critical to the success of the effort. Through this program, Project HOPE trains nurses and other healthcare professionals to educate, diagnose, and treat patients with diabetes in India. With a focus on prevention (nutrition, exercise, early diagnosis), this has been a very successful program to build capacity and diabetes diagnostic infrastructure in India. Interestingly, Indians (as well as other Asians) tend to develop Type II diabetes at a much lower BMI making them more susceptible to complications down the line (since they are less likely to heave received an early screening). Verbal and visual cues such as the “Zimbabwe hand jive” and behavioral-change models such as SMART goal setting focuses on empowering the individual to become a self-advocate for his/her personal health. We could use some of this in the US as well!

See a list of Project Resources used to date…

Dr. Edelman would agree that TCOYD is a great read!

Why Chronic Disease?

Current State:

Global health and health development efforts typically focus on “traditional” medical relief programs such as infectious disease, women and children’s health (child survival, nutrition, and now microfinance), and water purification / sanitation programs. And why not? There is a huge need and tese programs are especially desirable because the majority of cases they involve a known prevention or treatment that can have the largest “bang for the buck” with dramatic public health outcomes for the investment. This is why USAID, the Gates Foundation, and large health-focused donors have made significant investments over the years to TB, malaria, and HIV programs over the years. Of the roughly $12.9B¹ donated for international health relief efforts annually from the US, 99% of funding is aimed towards these conditions.

What’s Changing?

So why chronic disease? For anyone who has read The Bottom of the Pyramid or The World is Flat, you may be aware that times are changing (or have changed already) for a number of developing countries around the world. What impact does this have on health in these countries? With rapidly growing middle and middle-upper classes, especially in urban and suburban areas, these communities are starting to see a shift in “disease demographics” that will require a multi-tiered and multidisciplinary approach to slow the development of emerging diseases as a whole.

The World Health Organization (WHO) has been a strong leader in raising global awareness and a much needed sense of urgency around chronic disease. I promise, the numbers will blow you away. The developing world accounts for 80% of the global death burden for chronic diseases today. This is not just attributed to the populations in these countries; cardiovascular disease (CVD), diabetes, chronic obstructive pulmonary disease (COPD), and cancer are already the leading killers in the majority of developing countries in Africa and Asia, as they unquestionably are in the Western world.

WHO Statistics²:

• 80% of people with diabetes live in low and middle income countries
• Chronic disease currently accounts for 60% of global deaths but is expected to rise to 73% by 2020
• Diabetes estimates alone indicate a projected 200%+ increase from 180 million to 366 million by 2030 (90% of which is Type II diabetes and preventable)
• Most people with diabetes in low and middle income countries are middle-aged (45-64), not elderly (65+)

Please note, like many infectious diseases, chronic diseases among the poor are often PREVENTABLE and TREATABLE with known, proven prevention approaches and solutions. Without proper prevention and treatment, these productive members of society will often go blind, be placed on dialysis, or lose limbs (diabetes); require permanent oxygen dependency and/or physical handicap (COPD); or suffer from stroke, heart attack and death (CVD).

There is also a large economic case for a focus on chronic disease globally. The crippling rise in the cost of healthcare in the US is largely attributed to the burden of chronic disease prevalence, management, and treatment. At the same time, lost economic productivity due to chronic disease is already a reality for developing countries. The BRIC countries alone demonstrated a $1.15 trillion economic income loss in 2005³ (Brazil - $49.2B, Russia - $303.2B, India - $236.6B, China - $555.7B). The real ROI here is in prevention – both delaying and preventing the onset of disease all together.

A Call to Action:

It is clear that dynamic changes in patient needs and disease states create opportunities for both commercial and non-profit organizations to have a significant impact. A focus on prevention, early diagnosis, and sustainable treatment mechanisms are critical to addressing the needs of a population and vary dramatically based on specific environmental, physical, and cultural factors and trends.

Project HOPE and its partners have been strong leaders in this space. And while I’m not an expert in this field, I plan on using my emerging markets, healthcare, and consulting lenses to identify some new opportunities and solutions to address the community need in a number of countries around the world. Working with Project HOPE’s global and regional leads, local partners, subject matter advisors, and Deloitte we will aim to proactively anticipate these trends and aggregate organizations that invest as “first movers” in regions and countries where patient needs are urgent and growing.

Inaction is Your Choice:

Perhaps many in the Western world has “come to terms” with chronic disease or views it as a natural progression of society in a number of ways. I urge you to think differently. These issues require urgency in the US and Europe, in addition to emerging countries around the world where their resources and infrastructure aren’t targeted towards these conditions (largely focused on acute disease). These issues require massive education both for health professionals and communities, infrastructure and capacity building, and most importantly fundamental changes in lifestyle, behavior and mindset for patients and families everywhere.

Footnotes:

1. Conference Board; Non-Profit Quarterly, 2009; USAID Budget 2007; Foundation Center 2009

2. World Health Organization – Chronic Disease Report 2005

3. World Health Organization – Working Paper 2006, An estimation of the economic impact of chronic noncommunicable diseases in selected countries

Welcome to a Journey for HOPE!

After several tremendous years with Deloitte Consulting, I am taking a leave from work to pursue a four month “externship” with Project HOPE, working internationally in the field with local, national, and global leads to grow the organization’s current niche in chronic disease (now focused on diabetes). At the conclusion of this effort I will transition from being a student “in the field” to a student at UC Berkeley as a part of the integrated MBA/MPH program (through Fall 2012). Although, from what I hear of the Berkeley experience, I suppose some of my lessons in the field may serve me well during this transition!

About Project HOPE:
Founded in 1958, Project HOPE, Health Opportunities for People Everywhere, is dedicated to providing lasting solutions to health problems with the mission of helping people to help themselves.

Identifiable to many by the SS HOPE, the world’s first peacetime hospital ship donated to the organization by President Eisenhower, Project HOPE now provides medical training and health education, as well as conducts humanitarian assistance programs in more than 35 countries.

This work includes educating health professionals and community health workers, strengthening health facilities, fighting diseases such as TB, HIV/AIDS and diabetes and providing humanitarian assistance through donated medicines, medical supplies and volunteer medical help. In addition, HOPE works to develop strong relationships with the local Ministers of Health (MOH) in every country it operates, acknowledging that collaborating with local leadership is essential to delivering a sustained impact for the long term. Health Affairs, the leading US journal of health policy thought and research, began and is still published today under the leadership of Project HOPE.

Learn about all the wonderful commitments HOPE has made to communities around the world!

www.projecthope.org

My Mission:
I will be working with Project HOPE over the next four months to identify a global chronic disease development strategy that builds on the organization’s current diabetes programs in Mexico, India, and China. While the majority of current global and public health programs focus on infectious diseases or women and children’s health, HOPE’s current work in diabetes is an innovative foothold that addresses a health need where prevalence (and subsequent economic burdens) are exponentially increasing globally, but especially in a number of developing communities.

With this in mind, the goal of this effort is to understand what the future of chronic disease care could look like for an organization like Project HOPE. What interventions are working in the existing diabetes programs? What are the gaps and opportunities for addressing unmet needs in the community? How do environmental and cultural factors impact behavior-change and health management across the continuum of care?

Join the Mission!
This blog documents the journey to identify the needs, best practices, and opportunities for chronic disease relief with the support of Project HOPE's leadership, global health and clinical experts, and patient communities across Asia, the Middle East, Africa, and South America. Of course, I will also include personal stories, perspectives, and experiences throughout my travels and lessons in the field. And as a disclaimer, I am still (and always will be) an engineer at heart so apologies ahead of time if my excitement around problem solving and/or logical structuring is coming through along the way!

I couldn’t be more excited to start working as a full-time HOPE volunteer next week. And to you, thank you for your support and joining me on the journey!