Shifting Site of Care: Innovations in Health Technology & Delivery

When you visit a doctor, do you ever take the time to go through your bill line-by-line or request data on your quality of care? Do you make decisions around consuming medical services like you would, perhaps, food in a restaurant? The truth is very few people in the US ever see their healthcare bills in full and have minimal understanding of the detailed costs associated with healthcare services. In general, there are 3 main costs associated with a visit to any healthcare facility: (1) labor costs and expertise: physician / nurse / lab tech time, (2) space: waiting rooms, outpatient doctor’s offices, inpatient hospital rooms, and (3) resources: diagnostic / monitoring equipment, lab tests, and pharmaceuticals. Healthcare “consumerism” is a growing trend in the US, but in many ways has already shaped a number of health systems in developing nations – where patients have always paid “a la carte” for health services will full transparency into the incremental costs of products and services.

Consumerism improves the patient’s ability to make decisions around their care. When you decide to purchase a new TV, what are your criteria? Cost, quality, style? The more information you have to make educated choices the more competition there is to cater to your needs as a consumer. This is absolutely true for your health as well. Many corporations try to create “segments” of consumers based on patterns in purchasing behavior and decision-making (i.e. what are your priorities?). It is realistic to apply this same logic to health care services in developing regions. These countries’ decision-making processes and patterns are certainly different than the US, and often vary widely from each other. What is important to them as patients?

Information and Innovation!

It is believed that “competition drives innovation,” but in many ways information is king for consumer preferences. It affects how we perceive what is important and make decisions. Quality and cost are usually the two largest determinants for decision-making regardless of your nationality or economic status. New innovations that improve quality or patient outcomes usually come at higher costs than the previous offerings (e.g. Merck’s HPV vaccine). Innovations that improve cost usually involve shifts along the 3 cost sources mentioned above: (1) WHO provides the care, (2) WHERE the care is provided, and (3) WHAT resources are used to complete the visit. This is typically how a shift would occur:

WHO: Specialist (Endocrinologist) --> General Practitioner (Primary Care Physician) --> Healthcare Worker (Nurse, Dietitian, Psychologist) --> Peer Care --> Self Care

WHERE: Acute setting (Hospital) --> Specialized setting (Clinic) --> Community setting (Pharmacy) --> Point of care (Home)

WHAT: Medical devices (diagnostics / monitoring) with lab equipment and expert decision-making --> Medical devices without lab equipment or expert decision-making (usually reduced size and cost)

Often referred to as “shift in site of care” or “shift in provider of care,” technology is often a key enabler for the shift. This has countless applications in the Western markets, but especially in developing countries where cost is one of the main barriers for patients to access quality care.

Shifting to Simple, Fast, and Inexpensive (Not Cheap)

Shifting trends in the sites and providers of healthcare have been occurring for hundreds of years. With the goal to reduce cost to the patient – innovations must be more simple, fast, and inexpensive… but not cheap. Quality must be maintained or even improved to be considered successful.

One of the classic examples of shift in site and provider of care is the pregnancy test. Dating back to 1350 BC in Ancient Egypt, pregnancy was predicted through a variety of urine tests, evaluated by medical “experts” in a medical setting. A variety of mythical urine tests were used until the 1927 when the first high-quality test was developed: a bioassay of female urine was injected into a rat – if pregnant, the hCG present in her urine immediately induces ovulation from the animal. This was expensive and required many people and technological resources to perform. In 1960 an immunoassay was developed that allowed pregnancy tests to be conducted in a lab, without the use of live animals. This was cheaper and at times less accurate than the previous method of testing – and required a physician visit and waiting period for the lab tests. Finally in 1976, the FDA approved the first home pregnancy test (the e.p.t. kit). This shifted all 3 axes of cost – the test was now self-administered, at home, with one affordable, disposable device (now the only cost of the “procedure”).

This same trend has been occurring more and more with recent advancements in healthcare – largely with a focus on technology. But I would argue that you can produce shifts in care with innovations in health delivery processes and education, in addition to technology.

For example, the recent growth in “Minute Clinics” in pharmacies has taken simple technologies traditionally used in a doctor’s office and paired them with strict patient protocols (there is a reason you take a survey at the beginning to categorize your symptoms!) to allow a nurse practitioner to diagnose and prescribe treatment for an array of primary care needs. This improves affordability, access, and convenience of care (now only 15min of your time, and closer to home)!

Disruptive Behavior is Expected

In the business lens this is viewed as disruptive market behavior. Disruption is a form of innovation that produces a product that better suits the needs of the consumer: either through a less expensive substitute (low-end disruption) or shift in the basis of competition (new market disruption). Low-end solutions are especially appealing for developing countries. Here are quick examples of each:

Low-end:

• Amazon.com disrupted traditional bookstores with new and used books at a reduced price to what was available on the shelf
• Half.com disrupted university bookstores with a low-end market for used textbooks
• Netflix disrupted Blockbuster with a slower and cheaper service that favored consumer convenience and new process for ordering and billing

New market:

• iPods disrupted CD’s with a new market for electronic music purchasing, storage, and use
• eBay disrupted traditional online sellers with a new process for finding, purchasing and selling products online (it also opened doors for individual entrepreneurs to start online businesses)
• The Kindle reader has disrupted book purchases in stores and online – Amazon.com is demonstrating self-disruption with this invention!

Michael E. Raynor is a research fellow at Deloitte has spent years researching the importance of disruption in the corporate innovation process. He discusses his approaches in his books, The Innovator’s Solution and The Strategy Paradox, which are central to much of the work we’ve done with clients related to growth in emerging markets. From a product standpoint disruption can occur through advancements in technology (CD’s vs. cassette tapes), processes (Walmart’s supply chain), or changes in the larger environment (e.g. government policies, consumer perceptions, cultural values). Services can also be disrupted through technology (Kayak – online flight purchases), processes (iPhone apps vs. websites), and education/training that shifts the service provider (outsourcing / call centers). You could also argue that shifts in processes and service providers involve technology advancements as well – in many instances using technology that already exists in a new way.

Leapfrogging in Developing Countries

Developing countries are a playground for disruptive behavior. At Deloitte, I was able to work with pharma and medical device companies to understand future opportunities for disruption in emerging and domestic markets. Interestingly, innovation routes are sometimes more efficient in emerging markets: they leapfrog. A prime example is India’s expansion of phone service nationally; before landlines were ever installed in every home (very expensive, resource intensive), wireless cell phone towers were built to provide inexpensive, widespread coverage for cell phone users. As a result, individual cell phone plans in India are about $5-10/month with unlimited calling and data included. They never had to go through the heavy lifting of installing phone lines to the extent of many Western markets. This is now similarly true for the internet in a number of countries – many are wireless before wired.

What’s next for healthcare? How can existing technologies be used to help improve quality, access, and affordability of care? Are there opportunities to leapfrog or shift the site of care from a hospital - to a community center - to the home?

E-Health and Telehealth: A Promising Model

At the end of the day, there is an unavoidable need for increased affordability and access in developing countries, often limited by the lack of human and technological resources. Telehealth has been a primary focus for promising innovations in these regions for a few years now. I interviewed the Health Affairs Journal’s Susan Dentzer, Editor in Chief, and Philip Musgrove, Deputy Editor for Global Content, to understand more about their priorities and insights on successful innovations in developing countries. Through a number of articles in the journal, they suggest that well-targeted information and communication technologies (ICT), especially PDA-based technologies can have a significant impact on patient care. In another article they stress the importance of cohesive national policies and investments to build a workforce for e-health, telehealth and telemedicine to be successful.

When I was in India I witnessed a different application for teleheath than traditional health information technologies or remote diagnostic/monitoring equipment. Dr. Thomas’ diabetes center in Vellore is using an educational “telesuite” to provide training to physicians and nurses all over the country. His lectures are taped and then broadcasted over the internet or available for watching at leisure by CD. Another interesting model is illustrated by Deloitte’s Center for Health Solutions: a new mobile diagnostic business model was developed by a dermatologist that allows patients to use their cell phone cameras to photograph skin conditions and send the images wirelessly to the physician’s office. The office then follows-up by email/phone with either a prescription (high confidence of condition) or a referral to another provider (with potential conditions and solutions).

Deloitte has also cited the importance of enabling technologies for home care, or the “medical home,” for controlling chronic disease populations specifically. Point of care diagnostics and monitoring devices have the potential to change how people access and pay for care – in many ways making health more retail.

NGO’s as Innovation Engines

What role do NGO’s play in innovation? In addition to corporations, NGO’s are well positioned leaders to pilot innovative concepts in delivering high quality and affordable health to the masses. Project HOPE and the IDF efforts to increase the number of diabetes educators in developing regions is a prime example of a disruptive model to provide patient education. As resources at the healthcare worker level are still limited, could diabetes peer-educators be the next innovative model to effectively and efficiently empower self-care in patients?

There is a large opportunity for non-profits to focus on technology and process enablers for new community-based and self care models (e.g. groups of rural patients using one “home care” kit). Cell phones in general are remarkable platforms for telehealth programs whether they are focused on education, diagnosis, treatment, monitoring, or compliance: all of which can improve quality and access of care at a reduced cost.

As NGO’s compare outcomes among several “trials” for health innovations in developing countries, they have a significant opportunity to engage national leaders in expanded implementation of successful models. Programs that are adopted by the government regionally and nationally represent the ultimate success for an NGO innovation engine. Whether technology, process, or educational improvements are involved – it is certain that care will continue to shift with respect to who, where, and how it’s provided over time. Non-profits should seek bold opportunities to act as innovation incubators by investing in new and creative models that, if successful, could become future platforms for national and international healthcare relief efforts worldwide.

Sources:

Deloitte Healthcare Consumerism Study http://www.deloitte.com/view/en_US/us/Insights/Browse-by-Content-Type/deloitte-review/46fba7d2770fb110VgnVCM100000ba42f00aRCRD.htm

NIH History of Pregnancy Tests http://history.nih.gov/exhibits/thinblueline/timeline.html

Global E-Health Policy: A Work In Progress, Health Affairs http://content.healthaffairs.org/cgi/reprint/29/2/237?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=telemedicine&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

E-Health Technologies Show Promise In Developing Countries http://content.healthaffairs.org/cgi/reprint/29/2/244?maxtoshow=&hits=10&RESULTFORMAT=&fulltext=telemedicine&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

Connected Care: Technology-enabled Care at Home,Deloitte Center for Health Solutions http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_chs_ConnectedCare_final_0308.pdf

China: Findings Full of Surprises

China surprised me in a number of ways during my Project HOPE meetings, interviews, and hospital visits in Shanghai, Beijing, and Hangzhou. What’s interesting is that the patient needs and priorities in China, as I’ve found, seem very different from a number of neighboring countries. This is a product of distinct cultural patterns, family lifestyles, eating habits and government healthcare policies – all of which are rapidly changing the healthcare needs of patients everywhere in China. In a number of countries so far, I’ve been able to walk down the street and pick out individuals who show clear signs as being high-risk for Type 2 diabetes and other chronic conditions. In China this wasn’t exactly the case.

Diabetes: China is #1

According to the latest research, a population-based study of 46,000 from the New England Journal of Medicine (NEJM), China has the highest prevalence of diabetes in the world with an estimated 92.4 million¹. This is almost double the WHO’s estimations of 43.2 million in October of 2009². Either way, this is enormous. To put this in perspective, the diabetes prevalence in China is 1.5-3X greater than the GLOBAL prevalence of HIV/AIDS today (32.9 million)³.

The NEJM article has actually stirred some issues with the Ministry of Health (MOH) in China who has rejected the NEJM figures entirely. The MOH also produces reports detailing health metrics in China and their data is quite different. I had Pan Chengrui, Project HOPE’s Program Officer for their chronic disease programs, actually walk me through every chart in the MOH’s 28 page chronic disease report from 2006 (only available in Mandarin). The impressive document is extremely detailed and went through virtually every disease state we could have researched for Project HOPE (note China does not have electronic medical records so I’m guessing this is also population based). According to the report, an estimated 6.07% of urban, 3.74% of suburban, and 1.83% of rural people in the country have diabetes. In comparison, this is about half the prevalence rates in India.

Project HOPE diabetes training in the Hangzhou

All things considered, I have hope for China and diabetes prevention. In interviewing physicians, diabetes educators, and patients, I found that although the current resources (primary care training, patient education materials) are limited, patients are fairly open to lifestyle change in general. When physicians tell them to eat differently, most of the time they do. This sounds easy, but it is REALLY very difficult – this is a permanent change to habits that have been developed and reinforced over years and years. I also noticed that unlike Mexico or India, I had a difficult time identifying people who appeared to be high-risk, for example people who are overweight or obese. While these rates are high, 28.1% for overweight and 9.8% for obesity in urban areas; this is about half that of the US or Mexico where over 60% of the population is overweight or obese.

Still, the warning signs are there. China’s food is heavy on meats with an array of traditional foods that with increased consumption will undoubtedly drive obesity rates and diabetes. China’s infrastructure is also very car friendly and as the family income increases, it’s very likely that in a few years you will see more sedentary lifestyles and fewer bicycles on the road.

Hypertension: A National Crisis

Learning about hypertension in China has been one of the most interesting experiences in my research to date. Hypertension is a huge need and serious health concern for Chinese citizens. This is partially due to genetic propensity, but largely to do with the Chinese diet. In Shanghai, we interviewed Dr. Ji-Guang Wang, the Vice Director of the Shanghai Institute of Hypertension and Professor at the Shanghai Jiaotong University School of Medicine. He is considered one of the top 3 hypertension specialists in China and had some extremely interesting insights to share with us:

• About 200 million people with hypertension in China
• Only 30% of the general population is aware of the dangers of high hypertension (and the need to be screened)
• Stroke is the #1 killer in China and have doubled in the past 10 years
• Chinese citizens ingest 2-3X (12-18g) the recommended salt intake per day (6g)
• Potassium deficiencies make some effective treatments for hypertension unusable for a large percentage of the population (and can also lead to an early onset of diabetes)

David, Lily and I interviewing the China CDC (far left) and leading experts / professors in hypertension (2nd from right) and stroke rehabilitation (far right)

What are the dangers of hypertension? Hypertension is a condition in which the blood pressure in the arteries is elevated. Over time, this basically wears our your blood vessels and is the leading risk factor for strokes, heart attacks, heart failure, and chronic kidney failure (kidneys are the highest in demand for transplants among that of any organ). Hypertension is usually asymptomatic, but if you read through the long list of potential symptoms – it’s basically anything you might experience with a cold or stressful work week: headache, drowsiness, confusion, vision disorders, nausea, and vomiting.

Improving hypertension rates involves significant awareness efforts and lifestyle changes: reduced salt consumption, reduced alcohol consumption, no smoking, increase physical activity, increase water intake. Dr. Wang has struggled with lifestyle changes with his patients with respect to salt in particular. Adjusting sugar or carbohydrates for diabetes is one thing, but no soy sauce? Dr. Wang has even proposed an innovative approach to helping with this problem: change the amount or type of available salts in the grocery store. Introducing potassium chloride (KCl) with sodium chloride (NaCl), for example, which would also eliminate the potassium deficiencies and help improve treatment options.

I spoke with a patient whose father died of stroke a few years prior. She was tall, thin, and seemed fairly physically active. I asked her about her hypertension experiences. She says that no matter how well she eats and how much she exercises, she cannot control her hypertension. She’s eliminated a number of salt sources but believes that her genetic propensity makes it “a lost battle” for her. The NIH currently has a sponsored study in progress to examine the impact of reduced salt intake on hypertension levels in China. Let’s hope this battle is not lost!

COPD, and Sleep Disorders: High Prevalence, Low Awareness

Smoking with obesity are the leading causes of Chronic Obstructive Pulmonary Disease, commonly referred to as COPD, in addition to a number of deadly sleep disorders (did you know sleeping can be deadly?)⁴. Smoking is a major concern in China. While only 3% of females smoke, 66% of all men smoke in the country. Although this is decreasing (both in prevalence and the quantity smoked per person), this is very “cultural” and reinforced in both work and personal settings, primarily for men. So why is smoking such an issue here? An estimated 8% of the population over 40 years old has COPD. In addition, lung cancer is the leading cause of cancer deaths in China (about 3.0 M) followed by prostate cancer (2.8 M) and stomach cancer (2.7 M).

Smoking risk-factors poster in Peking University Medical Center Hospital (PUMCH)

Awareness is very low for COPD and sleep disorders among patients globally. COPD is a long-lasting obstruction of the airways that occurs with chronic bronchitis, emphysema, or both. The primary cause is smoking and the airway blockages over time can have serious and sometimes deadly implications while sleeping. When the airway is blocked, the personal sleeping actually stops breathing for a period of time (sometimes several minutes!) and is subconsciously aroused, enough to disturb the REM cycles but not enough to fully wake the sleeper. Over time, the duration of breathlessness is extended and a person can actually suffocate in their sleep by the blocked airway.

Sleep lab in Peking University - the first sleep lab in China!

A major challenge is that the symptoms are often hard to identify– mostly tiredness or insomnia because patients are inhibited from getting a good night’s rest. A person has to go to a “sleep lab” to get diagnosed with a PSG test where their breathing is monitored overnight. In China the risk factors are very high and require more attention to encourage patients to seek help.

Treatment for COPD is another challenge – the CPAP. CPAPs are masks worn to bed that control the person’s breathing and prevent blockages form occurring. Often described as “Darth Vader masks,” patients have challenges with compliance because they can be cumbersome to wear and unattractive if you have a spouse or partner – but remind you, these are life saving devices. They are also fairly expensive in markets like China where personal devices are not covered and all paid out of pocket.

CAD and Osteoporosis: High Priorities

There are number of other high-priority chronic diseases in China that I would see as a focus with hypertension, COPD, and diabetes. Coronary artery disease (CAD) is caused my plaque blockages in the coronary arteries composed of fat, cholesterol, calcium, among other substances. This prevents oxygen-rich blood from getting to the heart, leadng to heart failure or heart attacks, and is the leading cause of death in the US. Coupled with stroke – CAD is a substantial cause of global deaths annually. China’s diet of heavy and fatty meats (a.k.a. bad cholesterol) contributes to the growth of high-risk populations and makes it a vital priority for the country to focus on prevention.

Another priority that surprised me during my interviews was osteoporosis. I honestly had never thought of this because it’s perceived in the US as a condition that mostly women encounter after menopause (and it’s not on the MOH priority list or radar in other developing countries). However, an orthopedic and rehabilitation specialist in Beijing urged me to think about the impact that osteoporosis has on the growing aging population. After doing some research, I found that in addition to post-menopausal women, people with high protein diets, vitamin D deficiencies, excess alcohol, or smoking habits are also at risk for osteoporosis. An estimated 1.2 million fractures per year are associated with osteoporosis in the US (700k vertebral, 250k wrist, and 250k hip fractures). In a society where multiple risk factors are hit by a large percentage of the population – this can have a huge impact on the aging health and lifestyle (especially with costs associated with orthopedic surgeries and rehabilitation).

Rehabilitation center in Beijing - focusing on orthopedic patients

China: A Nation in Flux

China has gone through a whirlwind of changes economically, culturally, structurally in the past 10 years. These changes all have dramatic effects on the lifestyle and choices each person makes – and subsequently personal health. Where do I live? What do I feed my family? How do I get to work?

From what I’ve witnessed over the past two weeks, the Ministry of Health in China has actually worked hard to change with the times and stay in touch with the needs of patients. Over the past three years, China’s government spend on healthcare has more than doubled and total expenditures have increased with a 15% CAGR⁵ since 2002. This is an astounding financial dedication to improving access and quality of care. For any health initiative in China, understanding the MOH’s priorities is an imperative, both for financial and relationship-management reasons.

In Shanghai I spoke with one of the leads for China’s Center for Disease Control and Prevention (referred to as the China CDC) who discussed their focus on improving capacity at the primary care levels and restructuring the referral system across China’s healthcare system (Tier 1, Tier 2, and Tier 3 hospitals). The government seems very transparent about its focuses in healthcare and strategic plans to help patients in both urban and rural areas. For example, the Town and Village Doctors in the rural areas (previously known as “barefoot doctors”) are a large focus for improving care and referral systems to patients with minimal resources compared to cities like Shanghai and Beijing.

Either way, working with the government and local champions in China is a must. It is nearly impossible to be successful going against the grain of the government, but that’s not to say there’s no place for advocacy here – it’s just much trickier. As China becomes a more and more developed (even first world) country, it will be interesting to see how this changes international development initiatives in the region and especially the urban areas. Shanghai and Beijing were in some ways much nicer than many cities in the US. Although China’s used to being a recipient country for these funds, my sense is that the funding will change (and should change) in quantity or program focus over the coming years. As the government steps in to do more vaccination programs, for example, non-profits have to re-think their role in helping patients in these communities. What gaps are left to fill?

For Project HOPE, I think supporting patient education efforts could be a huge impact. Having worked with the government leads over the past 12 years to train diabetes educators (physicians and nurses in Tier 3 and Tier 2 hospitals), they can better support them with tools and programs that work to effectively deliver messages to patients in addition to medically treating diseases. New programs focused on obesity/nutrition education (not a specific government focus) would help prevent hypertension, “diabetesity”, coronary artery disease, osteoporosis, and many COPD cases. Smoking cessation is already a large government focus – but what else can be done?

Health Information is Power

It is becoming more universally apparent to me that health information is power. China has been working on electronic medical record (EMR) and medical informatics solutions to track patients and deliver better care and corresponding outcomes. I spoke with Jianbo Lei, Director for Medical Informatics at Peking University Medical Center Hospital (PUMCH) who showed me some of the EMR solutions they are working on (so cool!). Technology in many ways has opportunities to improve access and quality of care, but the data that is developed also helps the MOH validate national priorities and stay in tune with the changes in the population. I watched as one of the physicians entered in several pages of hand-written notes into the EMR system (note – the physicians do this themselves, not nurses/administrators to avoid errors). This is an extremely time consuming process and will likely have to be streamlined before being rolled-out nationally.

Physician entering in patient data for the EMR system - look at all those files on the right!

I noticed during my time in China that many restaurants use PDA’s as a way for the waiters to electronically order food by table. As I request steamed bok choy, she is simultaneously penning the stylus on the PDA screen. Could this same technology be used for medical records in China? During the initial examination, could the physician record the patient’s height, weight, blood pressure, etc. into the PDA and upload it wirelessly to an integrated system? I found that in China the average cell phone user receives about 10 spam text messages per day, making it a less effective way to deliver health information to the masses. Mobile EMR platforms could be an interesting extension of China’s current health information efforts. But what other applications or technologies could be used to reach the masses? The answers could easily be found in Indonesia or Egypt... or solutions developed by completely unrelated industries (e.g. the restaurant industry). My eyes and ears will be open over the coming weeks!

For more information you can access the China Photo Album and all interview notes in the China Country Profile page.

Sources:

1. Prevalence of Diabetes among Men and Women in China (NEJM March 2010) http://content.nejm.org/cgi/content/short/362/12/1090

2. China overtakes India as diabetes capital http://timesofindia.indiatimes.com/india/China-overtakes-India-as-diabetes-capital/articleshow/5724579.cms

3. Kaiser Family Foundation http://www.globalhealthfacts.org/

4. China Chronic Disease Report 2006 (link does not work outside of China)

5. Ministry of Health, China; Ministry of Labor and Social Security, China

Deloitte AsiaPac & World Expo 2010!

It’s hard to feel away from home when surrounded by some of your closest friends and mentors. Last week I could not have expressed this sentiment enough. Feeling a bit like a family reunion, I was greeted by some of my closest work friends and colleagues this week for Deloitte’s AsiaPac Healthcare Meeting in Shanghai. Partners Pete Mooney and David Martin from the Project HOPE team joined with one of my long-time colleagues and friends Hui Cao (who was actually on vacation and came to some of my interviews “for fun” – what dedication)! With the European (Pete), the half-Chinese, half-Indian, half-American (David, long story), and Chinese MD/PhD (Hui) we were quite a team.

Deloitte colleagues enjoying lunch at the Expo: Ellen, Patsy, Pete, David, Hui, and I

Deloitte’s AsiaPac Heatlhcare Meeting is a way to bring together partners globally who are invested or interested in the firm’s healthcare capabilities in Asia. An impressive 40 partners or so were able to join for the event including previous teammates from a few of my emerging markets projects: Andrew Chen (also hosting the event), Sudeep Krishna, and Karel Bakkes from the China, India, and Netherlands practices. I also have to admit, that they were all very patient with me talking their ears off about Project HOPE, diabetes / chronic disease research, and my general enthusiasm for public-private interventions for global health. As some of my strongest mentors and allies through challenging client engagements, late nights, and energetic brainstorming sessions – I needed to borrow their brains for ideas and feedback!

The Deloitte AsiaPac team was fabulous at hosting and leading the event!

With the World Expo having opened just a two week prior, we were scheduled Thursday morning to explore the famed Expo for a few hours – how exciting! I had never been to an Expo, nor did I at the time really understand the purpose (anyone?). I decided to do some research and discovered that the World Expo, then called the "Great Exhibition of the Works of Industry of All Nations,” started in London in 1851 as an “international exhibition of manufactured products” – an information sharing fair that would stimulate the development of several aspects of society including art and design, education, international trade and relations, technologies, and tourism. Today re-branded as the World Expo, it is a tourist attraction of its own – especially with how much China has invested in the event infrastructure.

With the World Expo in town it’s impossible to escape one thing: Haibao. Haibao is the mascot of the Expo and present ALL OVER Shanghai (in an unbelievable way): Haibao posters, shrubs, lights, stuffed animals, public art, food and jewelry! HaiBao was even in the Shanghai Children's Medical Center!

For some reason I had imagined that the Expo was a huge tent with “booths” for each country (all of which I had heard had long lines). What I discovered was that each country had enormous pavilions (NOT booth), which were possibly the most elaborate temporary structures I have seen to date. I hope they reuse a lot of the decorations for some modern restaurants and hotels in 6 months! The lines were indeed very long for the most popular pavilions (anywhere from 2-4 hours) so we prioritized seeing more of the Expo grounds and went in only the pavilions with the shortest lines (we liked Cambodia the best!).

Our last stop was by far the largest and most dramatic pavilion, China! This was clearly a permanent structure that was impressive in every aspect of the design and execution. You actually have to arrive early in the morning to reserve a special ticket for this pavilion, but I’m hoping this will be around for a few years after the Expo leaves China as an ongoing tourist attraction. The design was especially impressive; even the escalators beneath the structure reinforced the lines/design of the building.

Friday was spent in a full-day meeting with many of Deloitte’s AsiaPac partners in Healthcare. I was brought in as a presenter to speak on our relationship with Project HOPE and some of the strategy we are working on this summer with respect to chronic disease. The response from the group was very encouraging! While I did do a small “pitch” for why chronic diseases are important in developing countries, I felt that there was a strong validation of the importance and relevant implications for our clients. We are all working towards the same goal of helping patients either through corporations, governments, or non-profits – it has been only beneficial to work across each stakeholder to understand (1) what the needs are (2) how to coordinate so that efforts are streamlined, not duplicated and most importantly (3) so we can achieve these goals collectively!

Before leaving Shanghai on Sunday, I was thankful to have some quality time for sightseeing in the city. On Saturday morning, I met up with a group of Berkeley MBA admits for brunch (a ladies brunch!) along with a Deloitte colleague from the Shanghai office. Emma (far left) then took me to the fabric markets which was indescribably impressive - sadly no room in my carry-on for a coat, suit, dress, and custom-tailored work shirts. David and Patsy Buldoc took me shopping for "Cartier" watches – quite an experience and somewhat reminiscent of Chinatown New York (but way more selection and in Mandarin!). My last night in Shanghai, Hui took me out for a traditional “hot pot” dinner and iced tea. The rice-pumpkin puffs and Chinese eggplant were amazing!

Thanks to some needed down-time, I’m rapidly gaining an appreciation for the country’s diversity in culture, food, history, customs, and traditions. In addition to an extremely productive first week with Project HOPE China, I’m so grateful for all those that made this a memorable and adventurous experience!

Shanghai Children’s Medical Center

Ni hao! Last week I spent in Shanghai learning from the very experienced Project HOPE team in China. The China office celebrated the 25^th Anniversary of Project HOPE’s presence in Shanghai in 2008 – a HUGE accomplishment. As one of the first non-profits to enter China, Project HOPE is still one of the only foreign foundations formally registered with the Chinese government and it took almost 20 years to gain this status (there are only 13 total, 5 in the healthcare space including the Gates Foundation, Clinton Foundation, Merck HIV/AIDs initiative, and a French TB-focused NGO).

Project HOPE was brought in for its technical expertise to help build the Shanghai Children’s Medical Center (SCMC)in 1998 – and still remains an active partner for the facility as it continues to grow over the years. Performing more pediatric cardiology procedures than any facility perhaps in all of Asia, their Heart Center has become a regional destination center for high quality care. SCMC was the only hospital in China to receive a USAID grant and has invested it with a number of well-known, global donors to transform a radish field (literally this entire area was a radish field) into a hospital nicer than many I’ve seen in the US at an affordable price. In addition to helping with the physical and technical infrastructure design, Project HOPE also provided resources to train a large contingency of the hospital staff during its first opening.

I was able to get a special perspective of SCMC this week as a resident in the hospital guesthouse! It was extremely convenient to be on-site but also privileges as the rooms are very comfortable.

My first tour of the center I did with one of Project HOPE’s nutritionists, focusing in the weight management and obesity center, in addition to a few of the patient wards. We focused on some of the educational materials available to patients and their families in the center. Was it “practical” enough for patients to understand (i.e. not overly technical)? Families in general don’t have the same communication challenges as you might see in India where the language and level of literacy changes from one town to another. We asked one of the children’s father in the ward if the posters were easy to understand – he said that one with example meal schedules was very helpful, but another detailing out amounts of different nutrients was confusing, “what does potassium such and such mean,” he said.

On Wednesday, Pete, David, and Hui from Deloitte US came to greet me in Shanghai and attend a number of my meetings, interviews and tours.

We took a comprehensive tour of the SCMC facility (including the range of patient wards) and learned all about how patients receive and pay for treatment in a facility like SCMC. One of the most interesting things we learned (news to me!) was that many patients with sick children want treatment immediately, and the preferred method for pharmaceutical administration is by IV.

Patients are admitted for part of the day to one of the IV rooms seen below to quickly treat patients without the need to wait for a pharmacy to receive prescription medication. They mentioned the “one child per family” as actually having some impact here on how care and medication are delivered in the pediatric center (so interesting!).

It’s hard to describe how beautiful the facility really is in person. They’ve done a lot to make this an exemplary hospital for other cities and regions in China. I hope that Project HOPE can be a part of helping patients in the extended community in the future as well!

During lunch we interviewed Jia Yun, a diabetes educator from Shanghai Ton University. There she provides individual consultations and group workshops for about 10 patients at a time. In addition, they do free classes for up to 30 patients at a time to diabetes patients, 97% of which are Type 2, older patients.

In 2008 the hospital decided it needed a formal diabetes educator role and sent Jia Yun to Denmark, Japan, and Sweden to understand the operational model used in countries with developed programs. Since then, her passion for treating patients with diabetes is inspiring to say the least. In addition to visiting with countless patients during the day (and performing some administrative roles, as “patient educator” doesn't fit in with the current Chinese hiring model), Jia spends many of her evenings preparing general and tailored educational materials for her patients.

She has also created what she calls a “volunteering model” to perform peer-educational roles. This was extremely interesting to me after witnessing the success of Project HOPE’s peer-education programs in Mexico. The model has 24 volunteers with diabetes that have been hand selected to do education for patients – each one offering a different role based on their capabilities (one is better at explaining pharmaceuticals and the other at carb counting for example). She says the largest challenge she has is that many patients don’t believe they can manage their condition – “this is the only way we could fix that.” In addition to knowledge and skills to perform self-management, she also stressed that affordability is an issue. She sees hope in specialized diabetes centers (as seen in other countries, like Brazil’s Hypertension and Diabetes Centers) that provide integrated education and treatment.

Lily and Pete discussing the transparency of costs in SCMC (the board behind them lists out the services and associated prices).

Like anything in China, an effort of this scale (or any scale) would require substantial support from the government for both execution and political reasons. And although each healthcare facility is technically public, the government requires that each be financially independent (break even). Interestingly, this creates similar profit-focused issues as seen in many private healthcare systems like the US. Is care altered to drive profitability? Well, not exactly. But it does make it harder to increase non-revenue generating activities such as education vs. investments in surgical capabilities which both patients are willing to pay and the majority of services are reimbursed by the government. In general, patients don’t necessarily want or feel like they need education – let alone the motivation to pay for it! I doubt many people in the US or other developed countries would pay money for an education-only visit (you might ask, “Wait no prescription? Why did I pay to come to the doctor?”). Our Deloitte and Project HOPE teams probed a lot on these issues to uncover any barriers that would need full acknowledgement in developing a new chronic disease program in China.

India: A Few Findings & Themes

After two wonderful weeks in India, I’ve started identifying several themes that I’ve heard reinforced among a number of interviews, hospital tours, and program site visits. Chronic diseases and diabetes in India have progressed in a very unique way. Largely influenced by the competitive family culture, fragmented primary care system, academic mindset, and lack of government priority in chronic diseases, India is now positioned to rapidly explode with accelerating chronic diseases related to poor lifestyle choices and obesity.

Common Misconceptions

For 95% of the diabetes cases in India (Type 2), it is 100% preventable. Conversations with patients, health care workers, and friends in India revealed that the population already has the message, loud and clear, that the disease is hereditary (unlike Type 1). However, what hasn’t been communicated is that it is preventable. YOU have control! Only in rare cases can you develop Type 2 diabetes without a high concentration of abdominal fat (i.e. you have to gain mid-section weight to trigger the insulin resistance). If you control your weight, you should be able to life a long, healthy, diabetes-free life.

Another misconception is literally lost in translation. The Hindi term for diabetes literally means “sugar” or the sugar disease. This association is made because blood sugar is used to diagnose the disease. This creates two main problems; (1) patients believe that only sugar contributes to the progression of their disease – while oil/fats is what triggers insulin resistance for pre-diabetic cases and (2) many patients cut only sugar out of their diet and believe that will control their blood sugar – ignoring breads, carbs, and starch which breakdown into simple sugars and really escalate glucose concentrations.

Lifestyle change is not easy in India. There is a lot of guilt associated with changing a family’s routine. And, people love their d­­āl, chapatti, and rich sauces (as do I!). One diabetes educator told me that there is one place where most patients compromise by far – food. Changes in nutrition are SO important and “slacking” here on a routine basis is arming a silent enemy. Also, a slight heavyset weight is traditionally viewed as “healthy” from a time when food was more scarce. Increased family incomes AND bad meal choices leads to bigger bellies. Period. Exercise is also not easy accessible as many cities don’t facilitate public spaces for walking, jogging, and other activities. Could Brazil’s “city gym” concept work here?

Finally when I ask about prevention, I hear the same response over and over. In a discussion with Dr. Sadikot, President of DiabetesIndia and VP of the International Diabetes Federation (IDF), he stated firmly, “Start with children. Start young, very young.” Educating elementary school children is a wonderful way to reach an entire family (and train the next generation). I believe that chronic disease prevention must become the “global warming” of the future. The diabetes educators could be valuable resources that could be used to help conduct these school session. What child hasn't been taught about the dangers of global warming in school? They go home, they ask their parents about it and challenge the previously accepted family norm. How long has it taken for more environmentally friendly lifestyles to take hold? Might this provide some insights for health lifestyle interventions as well?

Capacity Building in Primary Care

There is a large opportunity for building capacity for awareness, education, and early detection in the primary care setting in India. Training “family physicians” and other primary care contacts may help them recognize signs that they see in patients day after day. Building an effective referral path to specialists and diabetes educators would be essential. My perception is that working with primary care physicians with whom patients feel comfortable (or have seen years and years) may also help with the community support to support families and manage the multifaceted (e.g. emotional) aspects of diabetes. Diabetes educators could also serve as a resource to help conduct information sessions or trainings – or there may be an opportunity to craft some creative peer-education models?

Gurgaon Max Healthcare diabetes educator initiation

Today, the diabetes educator model only works when patients are referred into an outpatient / inpatient secondary or tertiary clinical setting. Diabetes educators serve an incredibly vital role in the treatment and compliance of the disease, but this is not enough. Patients have to be identified before they have visible signs or worse, complications.

Practical Messaging for Patient Education

Dr. Sadikot, VP of the International Diabetes Federation and President of DiabetesIndia could not stress this point enough. Messages like “use only 15g of oil per day” have virtually no impact on a patient. Messages for patients have to be practical and ACTIONABLE. It is far better to make prescriptive suggestions such as “don’t reuse oil in the kitchen to reduce transfats” or “use half the oil, it will taste the same and be twice as good for you.”

One of the diabetes educators in St. Thomas Hospital in Bangalore relayed a story to me that reinforced this message. When asked if they were compliant with how much oil they consume daily, the patients responded “TK of course, of course.” When shown then that 15g of oil is the equivalent to 3 teaspoons, the patient nearly fell to the floor – “but that’s how much I use in one roti!”

Acknowledging a Medically-Focused Culture

Indian culture has a reverence for academics. Doctors and engineers especially are viewed as a different academic “class” if you will. I think this is why professional development opportunities, such as the India Diabetes Educator Project, have been SO successful. Also, doctors in India are fairly entrepreneurial and constantly looking for ways to operate as a more effective business of one. Independent consultant physicians (or healthcare workers like nutritionists) are very common.

Doctors must be engaged in every aspect of an expanded diabetes program, especially if it relates to challenging the current status quo. They must be convinced that any new programs benefit their practice and the health of their patients. Some physicians and specialists may feel threatened as if their patients are being “taken away” from them by educators. This is absolutely not the case. Physicians will never have time to administer education to patients (especially if this can be done more cheaply by a less expensive and more available resource).

Diabetes is also a strange beast in countries with traditional medicine. When patients think of self-care, they think of ayurveda or homeopathic medicine. When they think of pharmaceuticals, they think of Western medicine. So where does diabetes and most chronic disease fall on this scale? In between. This requires patients and physicians to think differently about care, mentally and in practice.

I also doubt whether the peer-education model (as seen in Mexico) could be successful in India. With such a focus and trust in physicians, I’m not sure patients would trust peers to conduct any level of care or education. The best opportunity I could see now, is that the diabetes educators could identify “peer leaders” that could help educate other patients. I think it would have to be triggered from a medical angle to be successful (at least initially, this too may change!).

Government Partnerships for Long Term Development

Currently, the government provides little to no level of basic care to patients. The federal, state, and municipal facilities all run differently with varied costs to the patients. Government facilities have strong talent because many new residents are rotated though or trained in public facilities. However, MOST shocking to me was that insulin dependent children who could not afford insulin, do not have any standard system to get their medications. This made me quite speechless. “What do these children do?” I asked. I received a wide range of answers – these poor families. I would love to encourage donations from insulin manufacturers to help these children, but at some point the government has to step in here. There has to be at least a quota of free vials they could provide hospitals to help these patients. India’s healthcare budget for the public sector is shockingly low (0.8% of the government budget) and there is more that can be done.

It’s clear to me that Project HOPE’s involvement with government facilities is a must. Proving that a pilot system impacts outcomes may warrant larger government adoption and support for chronic initiatives. Hospital leads could attest to the need and benefit may become champions for expanded public coverage of treatments.

Dr. Agarwala, AIIMS

I interviewed Dr. Jain and Dr. Agarwala, a pediatric endocrinologist and dietitian in the All India Institute of Medical Sciences (AIIMS), one of the largest and most famous public hospitals in India. They reiterated that affordability is a huge issue. Almost half of their patients travel hundreds of kilometers from rural areas for better treatment in Delhi. The hospital has many wonderful resources, but many of these can’t be accessed by low-income patients because of the cost.

In the inpatient ward I saw many mothers lying in the hospital beds with their children; waiting for care, waiting for treatment, waiting for hope.

Rural Outreach

Briefly, rural outreach is going to be extremely important. Lifestyle changes in rural areas are going to trigger more obesity-related conditions and require new models for addressing patient needs. When interviewing mDhil, a health information text messaging service in India, I learned that many rural families share one cell phone (either one to family or several families). Could the same principle work with glucose meters or blood pressure monitors? If affordability limits personal access, could it enable collective access?

Additionally, pictorial educational materials will become more important for rural programs in India. Where “every kilometer the water, food, and language changes” using simple tools to convey health messages effectively are a must (no technical jargon or figures either). This would help prevent very sad cases such as a scenario described to me in Bangalore: a number of rural Type 1 patients were pulled out of school at a young age - their parents (incorrectly) thought diabetes was contagious and would endanger other children. Wow. There are many other implications for rural health initiatives in India and I wish I could have spent more time to really understand this community. This will have to be incorporated into my next visit!

An Afterthought…

Our India team’s last day together we stopped by one of the larger malls in Bangalore on our way to the airport. I looked around and saw overweight men and women right and left – was I in the US? Not only were these malls some of the largest I’ve seen in any country, but the high-calorie, high-fat foods were definitely a favorite. Most of the women over 40 definitely looked like they could be in a pre-diabetic state. Audrey Finkelstein from the J&J Diabetes Institute also mentioned to me during one of our discussion that “you have to go where people get their information.” Where do people spend their time? If it’s church, you go to church. If it’s at the market, you go to the market.

Crowded Cinnabon in a large mall in Delhi

During my time in India I learned that malls have become a favorite destination for families and young couples (in addition to visiting other family homes or friends on the weekends). Perhaps shopping malls could be a target for outreach education, prevention, or early diagnosis? As I go through my notes from India again and again, I will keep probing new ideas. We must reach these people BEFORE they become patients. Remember for many chronic conditions, prevention is better (and cheaper) than a cure!

For more information you can access the India Photo Album and all interview notes on the India Country Profile.

Interview: J&J Diabetes Institute

Non-profits like Project HOPE aren’t the only entities trying to make a difference in patients’ lives around the globe: associations, corporations, governments, providers, local communities, and individuals all work together to make change a reality. Corporations can play an interesting role in changing the way we think about healthcare delivery. Technology is a HUGE enabler, especially in developing countries, to help facilitate shift in site of care or caregiver to expand capacity, reduce costs, and often… improve treatment.

Globally, the Johnson & Johnson Diabetes Institutes provide healthcare professionals with education, training and a space for collaboration with the aim of enhancing the understanding of diabetes and helping to improve patient outcomes. Each Institute (typically a partner hospital or Center of Excellence) aims to ensure that diabetes specialists are able to receive skills training and education customized to reflect the needs of local patients and providers. Their slogan “transforming diabetes care through education” is strongly aligned with HOPE’s current programs, and as a partner, I thought it would be interesting to see what they’ve learned from investing in emerging markets for diabetes care globally.

Audrey Finkelstein is the Worldwide VP Advocacy and Professional Relations - Global Strategic Affairs at LifeScan Corporation, a Johnson & Johnson operating company that specializes in home glucose monitoring and devices. She has agreed to be a part of my Advisory Board for researching potential chronic disease programs and partnerships for HOPE this summer. Audrey also works with J&J’s Diabetes Institute and generously has shared some of her thoughts on the needs of patients and their communities globally.

What do you think are the greatest needs of diabetes patients globally?

After a patient with diabetes has been diagnosed, the most important goal is to make them as self sufficient as possible. Finding a physician that has extraordinary relationship-building skills is a bare minimum. “Diabetes is a disease, not only of numbers, but of the heart and the soul.” In order to treat the physical, mental, and emotional needs of a patient, you have to nourish the whole person and empower them.

“Diabetes is a disease, not only of numbers, but of the heart and the soul.”

How do physicians build that relationship? Is that something you can teach?

This requires a heightened level of empathy and compassion in medicine that maybe overlooked in the priorities of the medical education systems globally. Physicians must reach out to their patients and build open, honest relationships, especially with diabetes. Many patients will come back for their A1c checkups and have filled in glucose numbers that aren’t real or eaten well just a few days before their visit. The best doctors like Dr. Edelman, an endocrinologist from UCSD and founder of Taking Control of Your Diabetes, view themselves as a “life coach”. Only then can you treat the whole person and build the trust that transcends the doctor’s office, empowers the individual, AND improves patient care.

How do you address diabetes in a community: prevention, detection, treatment?

“It takes a village to treat a person with diabetes. If a person has diabetes, then the family has diabetes, and the community has diabetes.” If I could, I would adopt a village and bombard them with prevention and awareness messages from the elementary schools, to their temples, to their primary care settings, and at every level of the healthcare system. Behavior change (e.g. nutrition and exercise) in an individual is tough – you need your family and your friends to be all on board. Right now, there is not enough awareness or seriousness around the need for increased chronic disease prevention and control. We need global and local leaders to adopt villages one-by-one to make an impact.

“It takes a village to treat a person with diabetes. If a person has diabetes, then the family has diabetes, and the community has diabetes.”

In my research with care givers and patients this is 100% accurate. Without family support to change daily routines, especially food!!, the individual will usually compromise on his/her needs. This very common with a “woman of the house” as well who feels obligated or uncomfortable changing the family’s meal schedules for her sake.

Poster from CMC Vellore in southern India.

What has been your experience working with diabetes in developing and underdeveloped countries vs. the US?

Diabetes is not the same around the world. What is frightening in Asia, especially, is that populations are becoming diabetic at significantly lower BMI’s. Globalization has had a significant change on their lifestyle (i.e. they are less active) in addition to worsening eating habits and growing popularity in fast foods (and local, cheap fast foods). As you know, building capacity in the healthcare systems is not enough. You’ve seen the lines of patients waiting all day in the hospitals (and yes, I have) and know that that will never be enough. Joe Solowiejczyk, who works for Life Scan at J&J, has done a lot of work training diabetes educators in India. There he’s “treated the heart and soul” of patients with diabetes and really understands what the patients need, what works, and what is currently failing them in the system.

As a result of my conversation with Audrey (we also discussed some of my preliminary analyses from the field), I wanted to take some time to talk with Joe to understand his experiences in India – especially while I am still in country and can build off of his insights.

Joe Solowiejczyk is Manager of Diabetes Counseling & Training for LifeScan Corporation, a Johnson and Johnson Company. Joe has also lived with Type 1 diabetes for over 40 years, and is extremely passionate about translating his personal experiences into patient care. As a nurse, diabetes educator and family therapist, he specializes in assessing how family dynamics impact the management of diabetes and designs interventions that result in more effective coping and optimal metabolic control. He is a full-time faculty member of the Johnson & Johnson Diabetes Institute and is on the faculty of Children with Diabetes.

What do you think is the largest challenge for patients with diabetes in India?

Patients lack resources: access to people, access to medications, access to testing their own glucose levels to know how and if they are improving on a daily or weekly basis. As a person with diabetes for over 40 years, I know how important access to resources is for a person to receive quality care and effectively administer self-care. Nurses get paid more abroad (as do many doctors) and attrition of healthcare workers abroad is a serious concern in developing countries.

Additionally, patients often can’t afford all the regimens of care they require. If they are (1) taking oral medication, (2) insulin dependent, and (3) testing their glucose on a regular basis – all three of these activities have a cost associated with them. Type 1 patients often prioritize the insulin and Type 2 the oral medication with little or infrequent glucose testing.

Is lifestyle intervention possible in developing countries like India?

Lifestyle changes in India are very apparent in urban and rapidly growing in rural areas (note – I’ve seen this too and this is not only shocking, but VERY scary!!). As a family’s salary goes up, they move less, and eat more. But still, the answer is YES! This requires intense work with patients and their care givers and family members. You have to work with them to come up with a plan focused on behavior change.

“Love and compassion are most important for healing.”

Dr. Nihal Thomas, from CMC Vellore, describing health in urban and rural India.

Although very loyal to their “family doctors”, patients in India will often shop around for specialists that suit them. If a physician tells them to test 3 times a week and they think that is too much (which by the way, it is hardly helpful because you never understand the daily highs/lows!), they will find another doctor that tells them 2 times a week is ok.

I had a couple who kept coming back again and again, but there were no changes in their numbers. They needed to have the emotional component of their disease addressed, but this has a very poor social stigma in India, in general. Culturally, it is embarrassing for individuals (and their families) to see psychologists.

Psychologists are love/hate in many countries I’ve noticed: how would you suggest reaching patients emotionally in India?

I think that there is a larger role for dietitians to take on some of the counseling roles for patients in India. From my experience, they would be open to talking to a dietitian with strong coaching and counseling skills. India has a very didactic culture, and they can use this to their advantage (rather than disadvantage) to help the patients overcome mental hurdles they may not be willing to accept in the first place.

I talked to a diabetes educator in Bangalore yesterday about this and her response overwhelmingly confirmed this perception. Each patient usually sees a psychologist once to test the “stress” levels of the patient. If the patient is deemed stressed, then they are required to come back for more sessions. What happens is that patients view this is a test and a HUGE disappointment if they “fail,” which in my opinion, likely worsens any emotional issues they are already dealing with. I think Joe is on to something here with his suggestion…

What is your perspective on effective prevention in India?

Prevention has to be delivered at the same time as efforts for health capacity building and improved care. ”It is not enough to have a slogan in a newspaper.” You have to deliver “doable,” practical messaging that patients understand. We need public health messages like HIV and TB. We need to work “hand in hand” with primary care doctors to understand the disease and refer patients before or after being tested for their glucose levels.

”It is not enough to have a slogan in a newspaper.”

Working with doctors within and across countries can be a highly political environment. It’s important to engage everyone in this journey and encourage peer-training (e.g. physicians training physicians, diabetes educators training diabetes educators – as in Project HOPE’s model!).

Me with the St. John's Hospital diabetes educator team in Bangalore.

So that’s what I’m trying to do!! This week was full of interviews with providers and stakeholders in the diabetes and chronic disease world globally and in India. It’s exciting to start pulling together the pieces within and across borders – person to person, village to village, country to country, and region to region, and each to the global community.