UAE Findings: Strength in Infrastructure

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

A Complex Infrastructure

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

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

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

Challenges in Talent Management

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

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

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

Prevention Needs Recognition

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

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

Cultural Perceptions and Care

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

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

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

Opportunities for Diabetes Solutions

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

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

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

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

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

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

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

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

Oman Findings: Big Need, Bigger Opportunity

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

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

A Hopeful System:

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

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

Training a Diabetes-Ready Healthcare Workforce:

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

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

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

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

How can Project HOPE Help?

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

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

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

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

Integrated Chronic Care for the Long-Term:

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

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

Traditional Medicine: Alive and Well

It’s impossible to discuss global health options for patients comprehensively without acknowledging traditional medicine and the important role it plays in the delivery of primary and family healthcare. The World Health Organization estimates that in some Asian and African countries, 80% of the population depends on traditional therapies for primary care (and in many cases all healthcare) needs.¹ While slivers of alternative medicine have emerged in the US, traditional medicine is very real and influences how many patients perceive and consume Western medicine. Having basic knowledge (and some first-hand experience) with varied approaches to traditional medicine has significantly helped in the process of understanding the full spectrum of healthcare in a number of countries. It has also been critical for communication with physicians in interviews to understand its role alongside Western delivery (and the challenges of delivering care) – as some physicians hesitate at first and look for recognition, “does she get it?”

Often referred to in the US as complementary and alternative medicine (CAM), the World Health Organization defines traditional medicine as follows:

"The health practices, approaches, knowledge and beliefs incorporating plant, animal and mineral-based medicines, spiritual therapies, manual techniques and exercises, applied singularly or in combination to treat, diagnose and prevent illnesses or maintain well-being."

While my knowledge about traditional medicine is by no means comprehensive, I was fortunate to research business opportunities in traditional medicine during my time at Deloitte. Within the first few hours of research, I was wholeheartedly intrigued. This is actually a very large industry: herbals are the dominant financial driver for traditional medicine brining in over US$14 billion in China alone (and an estimated US$5 billion in Western Europe). As the global mixing pot of the world, the US market for traditional medicine has been built over the years by those who have brought therapies with them from other countries. Their trusted remedies and brands are often available in bigger cities (although you would usually have to seek them out) and I think have the potential to grow dramatically in the general US market. Whole Foods is a good indication of this trend in recent years. Many of their health products might be considered traditional medicine, but packaged and marketed for quality – these are now “premium” items consumed by many households all over the states.

In addition, many Western companies have had to adapt their products to cater to traditional medical approaches or beliefs. For example, in India turmeric is often used ground and used as an ointment to stop bleeding for cuts and wounds. When Johnson & Johnson entered the Indian market with Band-Aids, their entry strategy was a failure at first because it was in direct competition with this free (and seemingly effective) solution. It wasn’t until they created a new product specific to the market, a turmeric-coated Band-Aid, that the product started selling as a trusted and effective remedy. Very interesting!

While there are many nuances among countries and regions on the method of traditional healthcare delivery, there are a few themes that I’ve seen cut across most of them.

1) Nature-based ingredients: herbals are the foundation of much of traditional medicine. Because all “medicines” are from natural plants, herbs, and occasionally animals – there is the belief that there are NO side effects. This has an impact on how they are consumed and perceived compared to Western medicine, which may be seen as “imperfect” or risky due to the apparent side effects.

2) Focus on self-strengthening: The healing approach for traditional medicine is, in some ways, the opposite of Western medicine: rather than kill the toxin, the goal is to strengthen the body’s natural resistance “from within”. Remedies are administered to enhance or stimulate disease-fighting agents from within through changes in diet, herbals, blood flow (e.g. yoga), often with a focus on specific organs or bodily functions. This is an important point because strong believers in traditional medicine see antibiotics’ removal of good AND bad bacteria as depleting the body of its natural defenses (and therefore harmful – this is why you are more prone to getting other illnesses while on strong antibiotics).

3) Holistic health solutions. Rather than focusing on treatment-only methods, traditional medicine usually involves changes in diet and exercise routines (also including meditation, sleeping requirements, tea “prescriptions,” and mental health recommendations) in addition to a prescribed medicinal regimen (in this case herbals). This is extremely interesting from a chronic disease standpoint where lifestyle changes (eating and exercising patterns) are central to care. It also acknowledges that health solutions treat the person, not the disease, acknowledging that activity throughout the day (especially what we consume) affects the body’s processes: stress levels, working energy, physiological chemistry, mental health, and on and on.

4) Age-old techniques. In every country and region, the methods developed have been tested and adjusted since the birth of the culture itself. This has a significant impact on the perception of the patients. I interviewed a number of patients in India and China with Deloitte and this point is what leads people to firmly believe that traditional health techniques really work. I had one interviewee that went as far as to say that Western medicine (since it hasn’t been tested as long) is merely a fleeting fad, developed by corporations to make money. While this may be extreme (I do believe that despite being for-profit organizations, healthcare companies truly want to help people), it was a radically fascinating point of view. Really? A fad? But, when looking at the side effects and antibacterial resistance stemming from many Western therapies, perhaps I too would believe the same if I’d grown up with a foundation in Eastern medicine.

There are countless variations of traditional medicine; however, I’d like to provide some general background on a few of the most prevalent below. This space is extremely interesting. The more I learn about alternative medical approaches, the more I want to learn. How did these techniques develop? How are they used today? Do they work – or is it placebo? What role does willpower / the mind play in healing? There are many questions I can’t answer, but like music or architecture, these are cultural developments that have shaped their societies’ perceptions, actions, and values over the years.

Traditional Chinese Medicine (China):

Traditional Chinese Medicine or TCM by far is the best known among traditional medical techniques globally. TCM practices include such treatments as Chinese herbal medicine, acupuncture, dietary therapy, and both Tui na / Shiatsu massage (stress is predicted to cause 75% of all illnesses). What I didn’t know until recently is that modern TCM was systemized nationally in the 1950’s, pulling together what was until that point known as family medicine. Based on age old Taoist, Confucius and Buddhist principles, TCM approaches vary but aim to emphasize the individual’s intimate relationship with the environment on all levels.

Traditional Chinese medicine is largely based on the philosophical concept that the human body is a small universe with a set of complete and sophisticated interconnected systems, and that those systems usually work in balance to maintain the healthy function of the human body. The balance of yin and yang is considered with respect to qi ("breath", "life force", or "spiritual energy"), blood, jing (other bodily fluids), the Wu Xing (emotions), and the soul or spirit (shen). TCM has a unique model of the body, notably concerned with the meridian system. Unlike the Western anatomical model which divides the physical body into parts, the Chinese model is more concerned with function. Thus, the TCM spleen is not a piece of flesh, but an aspect of function related to transformation and transportation within the body… correlating to the mental functions of thinking and studying, for example.

Diagnosis with TCM usually involves patient observation. Some may also refer to the need to “have their pulse read” - I have heard that some TCM doctors can identify several diseases and even determine if a woman is pregnant by the pulse (rhythm, intensity, frequency). Herbal medicines are core to the treatment regimen for TCM, often in the form of herbs that are boiled for lengthy periods of time into a tea-like mixture. Acupuncture, meditation, cupping, breathing exercises, and massage are all other methods of treatment to restore balance in the body. I have been an advocate for TCM massages in the US focused on “acupressure” techniques, targeting specific pressure points along the spine and meridian system (they are also very inexpensive compared to spa-like massages). The goal is to stimulate the flow of the "chi,” or essential life-force that flows through the body to problem areas for healing.

TCM is the most widespread traditional medicine present in the world. For instance, in the Middle East, the majority of alternative therapies available are derived from Asian. In addition to herbals, TCM also incorporates a number of animal products that are believed to have healing effects on the body (e.g. bear bile, rhinoceros horn, and shark fin). However the therapeutic approach is holistic with food and exercise lifestyle interventions, similar to Ayurveda.

Ayurveda (India):

Balance is at the heart of Ayurvedic approaches to traditional medicine. As the basis for traditional medicine in India, ayurveda literally translates from Sanskrit as “science of life.” The technique is said to be grounded on the metaphysics of the five “great” elements that comprise the universe: earth, water, fire, air, and ether (no, not “heart” for you Captain Planet lovers). It is believed that each of us is composed of different ratios of the elements – when they are in balanced state, the body is healthy, and when imbalanced, the body has diseases.

What is fascinating to me is that ayurvedic techniques actually classify mental and physical personality types that are used as diagnostic/treatment “lenses” for ayurvedic doctors. The three areas or “doshas” are based on our dominant elements: vata (air & space), pitta (fire & water), and kapha (water & earth).² Identifying your dosha requires answering about 100 questions about bodily function and environmental preferences (e.g. Do you prefer hot or cold? What time of day do you have energy? How do you respond to stress?). There are many online “dosha” tests that will do this for you now (you can try one at What’s Your Dosha.com!).

According to the ancient practice, every individual has a mind, body, and spirit which must be cultivated respectively with mediation, ayurveda, and yoga. Ayurveda believes that building a healthy metabolic system, good digestion, and proper excretion leads to vitality in life. It’s focus on exercise, yoga, meditation, and massage reinforces the belief that the body, mind, and spirit/consciousness need to be addressed both individually and in unison for proper health management.

One of my favorite Ayurvedic techniques is known popularly in the Western world as the “neti” pot. Although I have never met a person in India who uses the neti pot, it is a great example of a traditional technique (in my opinion) with a high value proposition. It is simplistically a teapot that flushes out your sinuses with a saline solution – it sounds gross but it does work. One of the reasons I like it (as a chemical engineer) is that It uses both physical and chemical agents to address the health problem (vs. oral medication which is purely chemical). Additionally, the treatment if localized which increases efficiency and control in treatment. They do sell them at Whole Foods so you, too, can bring ancient Ayurveda therapies into your home!

Traditional African Medicine (Africa):

Traditional African medicine has a more “spiritual” approach to therapy than TCM or Ayurveda. It is considered a holistic discipline involving indigenous herbals and African spirituality, typically involving diviners, midwives, and herbalists. Practitioners of traditional African medicine claim to cure various and diverse conditions such as cancers, psychiatric disorders, high blood pressure, cholera, most venereal diseases, epilepsy, asthma, eczema, fever, anxiety, depression, benign prostatic hyperplasia, urinary tract infections, gout, and healing of wounds and burns.³

Diagnosis is reached through spiritual means and a treatment is prescribed, usually consisting of an herbal remedy that has not only healing abilities, but symbolic and spiritual significance. Traditional African medicine believes that illness is not derived from chance occurrences, but through spiritual or social imbalance. In the past, modern pharmaceuticals and medical procedures remain inaccessible to large numbers of African people due to their high cost and availability in urban areas. In recent years, this has improved substantially but African traditional techniques remain a strong part of the health culture.

Traditional practitioners use a wide variety of treatments ranging from "magic" to biomedical methods such as fasting and dieting, herbal therapies, bathing, massage, and surgical procedures. Migraines, coughs, abscesses, and pleurisy are often cured using the method of "bleed-cupping" and hot rubs are used after which an herbal ointment is applied with follow-up herbal drugs. Steam baths and induced-vomiting are used to cure some diseases, for example, raw beef is soaked in a steam drink of an alcoholic person to induce vomiting and nausea and cure alcoholism.⁴

I personally have very limited exposure and experience related to African traditional techniques, but look forward to learning more in a few months during my research with Project HOPE in Kenya and South Africa.

Homeopathy (Germany):

Homeopathy is a very interesting form of alternative medicine as it originated in the Western world. It was based on medieval principles developed in the 16^th century, but then fully developed by a German physician, Hahnemann, in the 18^th century. At that time, mainstream medicine employed such measures as bloodletting / purging and used laxatives and enemas which often worsened symptoms and sometimes proved fatal. Hahnemann rejected this approach as irrational and built a therapeutic discipline based on the concept that small doses of “what makes a man ill also cures him.” What is fascinating to me is this is the same principle used for developing vaccines. He favored the use of single drugs at lower doses and promoted an immaterial view of how living organisms function, believing that diseases have spiritual, as well as physical causes (similar to African medicine). Interestingly, Hahnemann also advocated various lifestyle improvements to his patients, including exercise, diet, and cleanliness.

According to homeopathy, illnesses are the result of disturbances in the life-force (similar to TCM), and believes the body has the ability to react and adapt to internal and external causes (referred to as the law of susceptibility). Again you see the strengthening from within as a pillar of this traditional approach. Any disturbance in the body, or miasm, is treated with natural remedies.

Today homeopathic medicine can be found in generally two forms: as either liquid solutions with (with an eye dropper) or very small pill-sized tablets that are melted in the mouth under the tongue. I have a number of friends and colleagues who are strong believers or use this as their “first-line” defense for treating illnesses like a cold or flu. There is a good chance you may have had your own experiences with homeopathy. Since its origins are scientific and less “mystical,” it is often easily blended with Western medicine in primary or preventive care.

Thoughts on Traditional Medicine:

As the US moves towards more preventive and holistic models for patient care, I’m curious to see if East-meets-West approaches become more of a reality over time. There are several leaders who have been working on this both in the US and Western world. In fact, my first encounter with homeopathic approaches was with a close friend’s mom, who practices both Western and homeopathic medicine. I visited her for my typical sinus infection in high school (product of lack of sleep and strenuous study / extracurricular schedule), and she prescribed an herbal medication for me. At first I was a little miffed. I paid to see a doctor and didn’t get a prescription – what? But, what I realized later is that I’d already started becoming fairly resistant to amoxicillin; at that point, I had no resistance whatsoever to the bacteria in my body. After some careful research (and developing a paper in college on antibacterial resistance), I stopped taking antibiotics unless I was desperately ill. The first year I had about 4-5 infections; the second 2; the remainder hardly any. Not to say that everyone should stop taking antibiotics as they’ve done wonders over the years, but there is something to be said about how and when they should be used – and what effect overconsumption can have on the body (and collective public / environmental health).

It’s also important to mention that few scientific studies or clinical trials have been conducted to thoroughly test many alternative therapies. Much of this has to do with the fact that they don’t need to be conducted for the remedies to be sold (and they would serve little purpose in regions where many are already 100% convinced they are effective). For Western countries to accept any herbal or alternative therapy, clinical testing is an imperative to drive adoption. Some “lifestyle” changes have already been acknowledged in studies like the DPP trials for diabetes (largest clinical trials conducted for diabetes), which has shown lifestyle changes to be almost twice as effective as any pharmaceutical remedy for Type 2 patients. Similar trials also exist for CVD and COPD which show that exercise and diet can reduce the risk factors and diseases that limit the quality and longevity of patients’ lives.

It’s unquestionable that traditional medicine plays an important role, to varied degrees, all over the world. Understanding its origins, uses, and impacts on perceptions and delivery of health is an imperative for gaining a full perspective on care for chronic diseases around the world. I’ve asked a number of times - could training traditional healers to advocate lifestyle changes for obesity, CVD, or diabetes could be an effective method to reach patients that are out of touch from the “mainstream” healthcare systems? So far, the responses haven’t been overly enthusiastic, but it’s another idea that could be explored potentially in rural areas. At least to some extent, I hope that my efforts to understand its role in each country have aided my ability to assess the current patient needs, program opportunities, and implementation challenges for Project HOPE.

Sources:

1. World Health Organization: Traditional Medicine Fact Sheet http://www.who.int/mediacentre/factsheets/fs134/en/

2. India Department of Ayurveda http://indianmedicine.nic.in/ayurveda.asp

3. Helwig, D. "Traditional African medicine", 2010.

4. Onwuanibe, pp. 25-27

Indonesia Findings: New Efforts, Strong Leaders

Arriving in Indonesia, I expected the healthcare environment to be somewhat similar (or perhaps a hybrid) of some others I’ve seen in Asia to date. Having done work with the BRIC countries (Brazil, Russia, India, and China) with Deloitte, Indonesia seems to be slightly under the radar despite the fact that, after the United States, Indonesia has the world’s fourth largest population (230 million, after China, India, and the US). Scattered across 33 provinces and 17,000 islands (that’s only 13,500 people per island on average), geographically Indonesia is one of the most challenging environments to implement top-down / national programs and policies. This may be why from a corporate perspective it hasn’t been as targeted as Brazil or Russia with smaller populations, but perhaps more affordability in some segments of society. From a development standpoint, especially related to healthcare, the need is clear and apparent in Indonesia.

Similar to the current state in Brazil, Project HOPE does not have any current diabetes or chronic-related programs in Indonesia. Dr. Nasar, Project HOPE’s country lead, was immediately supportive in identifying local and regional leaders to speak with about the current priorities in diabetes from government, corporate, and the health services perspective. I knew that a number of national efforts related to diabetes were still nascent, but blown away by our first day of interviews with the country’s leading experts in the field.

Current Leaders in Diabetes

Dr. Rudijanto, President of the Indonesian Diabetes Association, and Dr. Aris Wibudi, President of the Indonesian Diabetes Educator Association, both met with Dr. Nasar and I to discuss their experiences and insights on the need for new programs in country. We met in the Rumah Sakit Pantai Indah Kapuk hospital which they are using as a pilot for some fairly innovative diabetes programs (focused on both community-level and healthcare worker-level interventions. In addition to the Society of Endocrinology in Indonesia – these two know probably more than anyone in the country about the needs and opportunities, and importantly, how Project HOPE can help.

Left to right: Me, Dr. Nasar, Dr. Rudijanto, and Dr. Aris Wibudi

One of the first pieces of information we discussed was by far the most shocking: there are only 54 endocrinologists in the entire country of Indonesia. Since there are an estimated 7 million people in Indonesia with diabetes, this would make each endocrinologist responsible for 130,000 patients! I asked a lot of questions around why this is the case. It seems as though a lot of it has to do with the medical education system – everyone is first trained as a General Practitioner (GP), then if they would like to become a specialist, pays out of pocket for the additional years of training (followed by residencies which I imagine would be limited in volume considering there are few established specialists to practice under).

What happens as a result is that the majority of diabetes care is delivered by GPs in the primary setting. This is very fascinating and changes the strategy for new diabetes programs quite a bit. For the Indonesian Diabetes Association, the current priorities are awareness – educating patients, families, and communities affected by diabetes. For the Diabetes Educator Association, the current programs are focused on a “train the trainer” model where GPs and nurses receive formal education (conducted once annually). Dr. Rudijanto is also in the process of developing a formal “diabetes nurse” role that would involve an extra 3 months of exclusive diabetes training provided in addition to the standard nursing curriculum.

As the Dr. Rudijanto and Dr. Aris Wibudi described the current state and opportunities it was impossible to overlook the passion and dedication these two have devoted to the field over the years. As more attention has been brought to diabetes over the past few years, they have committed themselves to aiding the Ministry of Health and others in helping patients with diabetes across Indonesia.

“Fun” and Diabetes with Dr. Roy

One of the most exciting parts of my visit to Indonesia was meeting Dr. Roy at the Rumah Sakit Pantai Indah Kapuk hospital. Probably the most enthusiastic and forward-thinking individuals in this space – I immediately fell in love with his vision for community-level efforts for diabetes in Indonesia. I was first escorted to their new pilot – the diabetes education center – a free space for education and screening including facilitated and self-study resources about diabetes risks, treatment, complications. As I sat down, the diabetes center honestly felt like I was in a coffee shop, not a hospital. What a great concept? Large windows, big chairs, neatly arranged materials made it an inviting space for anyone young or old. One of the stigmas around diabetes is that people don’t want to feel like a “patient” all the time – this center definitely did a great job at providing the technical capabilities without turning the space into a “medical” clinic.

Dr. Nasar, Me, Dr. Rudijanto, and Dr. Roy in the diabetes education center

A patient starts out with a free assessment and video on diabetes to give them background on the disease, risk factors, and progression over time. Patients can then sit for custom educational sessions on nutrition, exercise or diabetes management. Or, over coffee or tea, read through a number of materials provided for self-study. The staff that runs the center also does “roadshows” to elementary schools and once a year seminars to do patient education in a lively format. See the "diabetes kiosk" below for automatic risk assessments for visitors!

Dr. Roy’s goal is to “make diabetes education as fun as possible.” He sees diabetes education as the most essential part of diabetes promotion AND treatment. People in Indonesia are constrained from a resources standpoint, “everyone can’t afford to be put on insulin.” Lifestyle interventions are a must and he is determined to figure out how to make them work – and I wholeheartedly support his ambitious efforts to do so! Dr. Roy also believes that you have to go out and find people at risk vs. waiting for them to come to the hospital with signs of diabetes or worse, complications. He uses channels such as Agoyang Jakarta (meaning “shake Jakarta”) an exercise / dancing group in the city to do sessions on diabetes awareness. Similar to Dr. Roglic from WHO, Dr. Roy believes that access to healthy choices (e.g. walkways in public spaces) are critical to facilitating healthy lifestyles.

Tuesday exercise course - it turned into a potluck lunch celebration for Dr. Roy's recent birthday!

Every Tuesday and Thursday, Dr. Roy also holds exercise courses in the hospital (they have an open room with nurses who lead the program) followed by a 30min presentation on an aspect of diabetes and group Q&A. I really enjoyed watching the exercise course itself and was later excited to see Dr. Roy in action presenting on complications related to diabetes.

Now I understand what he means by fun! He used examples, images, and analogies that were catchy and related to “hot” topics that people were talking about in the community already – there was even a picture of Angelina Jolie in the presentation! What was fascinating to me is that this is a technique I’ve heard is used often in religious organizations through sermons – often relating to current events or topics that will help the message “stick” over time. Why not adopt similar techniques with diabetes education?

Dr. Roy and I also discussed the needs in Indonesia comparatively to the rest of Asia. The hereditary propensity is extremely high with prevalence rates are very similar to India in Jakarta (12%), but resembling China in other cities (7% urban, 5% rural). These numbers are growing and patients are getting younger. Still, Dr. Roy’s determination to bring diabetes to the lives of people in Indonesia is inspiring. As he joked relating to diabetic foot care, “why do people in the rural areas know more about Cristiano Ronaldo then they know about their own foot?” It’s a problem, but not one that can’t be tackled.

Indonesia’s Ministry of Health

Later in the week Dr. Nasar and I were able to meet with Dr. Tjandra Yoga Aditama, the Director General of the Ministry of Health of Indonesia (via introductions from Dr. Aris Wibudi). This was quite an honor and he brought in some of his leads for diabetes and noncommunicable diseases to make it an especially productive discussion.

Dr. Nasar, me, Dr. Aditama (Dir Gen MOH), and diabetes leads

What was very interesting to me off the bat, was how new the recognized need for noncommunicable programs is in Indonesia. Only four years ago the office was 100% focused on infectious diseases. The change has required them to create new positions, restructure governance, and reallocate funding completely. Dr. Aditama and I discussed this evolution some and then his challenges with the fact that the majority of funding is still heavily on the infectious disease and environmental health sides (e.g. where USAID and the UN priorities are still focused). This has limited some of their efforts to institute new promotion and prevention programs associated with CVD or diabetes, for example. “The data shows that the need is there” (CVD is now the #1 killer in Indonesia like most Western countries) he pushed, but their priorities are still on communicable disease.

I also spent some time after our meeting with the diabetes lead directly, Hj. Titi Renawati. She and I had a “heart to heart” about her efforts building up the programs from scratch over the past few years. This was a significant undertaking! After our discussion it was apparent that few external resources had been available to her to help develop the strategic plan and actionable materials for implementation. She gave me books they'd developed on diabetes education for GPs (community centers / primary care) and showed me examples of very nice campaign materials (posters / pamphlets) that they were piloting in a few cities.

It is very clear that providing access to global best practices could be one of the best ways to help countries like Indonesia. Local leaders often know what is best for the country and how to best implement programs – what they need is a “menu” of things that have worked in other places so they can pick and choose what they think could help them best. For both developing countries and countries where the health policies / programs are still developing – this could be very powerful. Although Hj. Renawati’s funding may limit her from attending international conferences where such ideas are discussed – a mechanism must be put into place to help her access these resources.

Tertiary Care in Indonesia

Dr. Nasar and I also visited Rsud Kota Bekasi hospital in West Java to understand the current state of diabetes and chronic disease care in the hospital setting. Similar to India or China, there is no outpatient appointment system in Indonesia. Patients are referred from primary care centers to hospitals where they sit in a department-specific waiting area for their turn to see the physician (also about 5-8min visits per patient). For the poorest patient population, nearly 100% of care is covered by government insurance and 25-50% is covered for the second poorest patient group (all within their district). Traditional medicine is also very prevalent in Indonesia, but managed by “traditional healers” and separated entirely from the formal hospital-based healthcare system (unlike China where they have traditional hospitals and India where they have integrated East-West facilitates).

Wait times are fairly long in these outpatient centers – maybe 3-5 hours to be seen within one day (not unlike other countries in the region). Something that fascinated me though – was how this hospital in particular started to use these wait times for their advantage. The hospital gives some nurses part-time education roles and have them stand with a microphone (not kidding) to do sessions on prevention and awareness in the facility. Some of these are already focused on diabetes! I asked to speak with one of these nurses and learned more about how they selected topics and who the messages were directed towards and what I was really dying to know – have they seen any changes? More patients? I started brainstorming the potential for a non-healthcare worker screening advocate who would go to OP centers for women’s health, cardiology, pulmonology, and other specialties relating to chronic disease. Could they fill out a risk assessment card that they would take to their GPs for further assessment and referral?

Despite some coverage and improvements in screening, affordability is a major huge concern in Indonesia. I’m not really sure how to address this as it’s more of a systemic issue that would need to be addressed by policies in the MOH or laws regarding standards of care. Few qualify for government insurance and therefore all or most spending in health is by the patient – out of pocket. This means that many people don’t go to the doctor unless they are really sick, and well at that point, their expenses in the health facility are likely also high.

Brief Illustrations: Coverage and Affordability

Dr. Nasar relayed two stories to me that have stuck with me and indicate aspects of the system that are failing:

First is about corruption. A district leader in Indonesia publicly revealed that the sub-district chief for that area was registered as poor to receive healthcare coverage (in addition to a number of other benefits). Although this may be common among government officials to benefit from their own policies, in this instance it was taking away from those who deservedly needed the health coverage.

Second is about access to care. Dr. Nasar had an incident where a taxi driver of his indicated he’d been driving for 3 days straight to make money for an operation. As it turned out, his wife was pregnant and had gone into labor but required a surgery costing about US$500 to deliver the child. What happened to my shock and horror, was that his pregnant wife (in labor) was sent home because their family couldn’t afford the surgery. Dr. Nasar gave him all the money he had in his wallet and indicated to the driver that he could lose both this wife and unborn child if the operation didn’t take place in a timely manner. In the US it’s illegal to refuse care to someone in need, regardless whether they can pay or not. This may be commonplace in a number of countries, but is a true tragedy and representative of an array of issues that need to be addressed at a larger level.

A healthcare system is undoubtedly failing if it is killing healthy, unborn children. While this is just one example and not related to chronic diseases in any way – it must have implications for them. For example, what happens if I’m diabetic and need my foot amputated but can’t afford it? Do I eventually lose my whole leg, or life?

Primary Care: Where it All Happens

My last site visit in Indonesia was with Dr. Saraswati in a primary care community clinic in West Java. The facility was staffed with 3 physicians, one nutritionist, several pharmacists, and one chief manager to oversee operations. Centers like these are the “first –line center of health” in Indonesia and largely focused on women and children’s health, vaccinations, and referral mechanisms for patients to larger facilities. Diabetes care is also offered here with limited prescriptions available for Type 2 patients (insulin is only provided by hospitals). However as I learned, diabetes medication can only be prescribed and distributed 5 days at a time (extended from the 3 days at a time for other conditions) which is a huge barrier to facilitating patient compliance with treatment.

The good news was that many patients that come here are entering with earlier symptoms for diabetes: sweating, urination, numbness vs. severe complications (they usually go directly to the hospital). Most patients when diagnosed initially are between 200-300 mg/dL which could be worse, but is a relatively optimistic starting point to have good glucose management long-term. Dr. Saraswati spends about 30min with each patient the first visit to go over the disease and recommended treatment.

Dr. Saraswati and the community center managing chief

The bad news is that the physicians see increases in the patients’ glucose levels as time goes on (400-500 mg/dL) as compliance to therapies and lifestyle change is very poor. Additionally, everything that Dr. Saraswati knows about diabetes she indicated that she learned online. Lack of resources for GPs in the primary care setting is clearly an issue – she’d like to have better training and educational resources for patients. I mentioned to her the fact that many diabetes centers use group-facilitated sessions (typically once a week) to maximize healthcare resources but also empower patients with the opportunity to learn from each other. She thought this was fascinating. “Where could I find these resources?” she asked me. Even if she just had a handful of sample “curricula” that she could use with her patients she feels it would be enough. I mentioned that these evening education sessions are also difficult because they encroach on personal time – but that didn’t seem to concern her one bit. It was clear that helping patients first was her priority.

What’s promising to me is that providing access to resources and contacts who have already made strides in developing diabetes programs could be a huge help for Indonesia. The quality of local leadership in Indonesia makes me feel confident that their ability to execute and impact lives of patients is very high. The attitude of physicians here is very open and collaborative (vs. more competitive / resentful in China or independent / entrepreneurial in India) and makes a strong platform for team-based approaches to diabetes and chronic disease care. After a wonderful week of research I’m looking forward to staying in touch with a number of contacts here to see how I can help going forward. In reflecting on my experiences in country, the personal connections and relationships here have really made me feel like a part of the process for finding solutions that work in Indonesia. I sincerely hope my professional travels bring be back soon and am eager to stay in touch to support their efforts in the meantime.

Diabetes Interventions: Divergent Perspectives on a Common Cause

Starting Project HOPE’s research in April, I never anticipated how unbelievably fragmented the perspectives are on the future of diabetes care. At first, this really surprised me. Not only do approaches vary by physician role, geography, and level of experience, but the fundamental priorities and mechanisms for piloting interventions are also quite disparate.

I was first approached by Larry Ellingson in early April to help me understand and coordinate among the varied and established perspectives in the diabetes world. Larry Ellingson is the current CEO of Protemix Corporation and previous Chair of the American Diabetes Association (ADA) with years of experience working on the international task forces with the ADA and International Diabetes Federation (IDF). Larry is also a registered pharmacist and spent most of his career as a leader of global diabetes care for Eli Lilly. After being introduced by Dr. Howe, Project HOPE’s CEO, Larry kindly offered to speak with me and learn more about Project HOPE’s mission in diabetes and other chronic diseases. I was humbled by his offer. I will be the first to recognize that there is a steep learning curve here with many leaders who have been leading the way to address issues related to diabetes for many years. However, we had a pivotal discussion in terms of the fact that that, as he indicated (and encouraged), there is a lot left to be done.

One of my takeaways from our discussion is that fragmentation in the today’s global approaches creates potentially the largest challenge to coordinating among them. Some of this has to do with the fact that the needs, culture, healthcare environment, and policies are very different in every country. I can attest to this even within regions – they are far more dissimilar than I would have thought originally. However, Larry made a point that has stuck with me throughout my research, “the strategy is universal, but the implementation is local.” The IDF has been the communicating and coordinating body for diabetes, but for the larger chronic diseases there isn’t really any resource I could work with who has insights across multiple countries and regions.

Another key point (and something I’ve since seen with my own eyes) is that many of the current leaders in diabetes have been doing truly amazing things to help the patients in their communities. Their efforts are incredibly inspiring and undoubtedly leading the way for developing outcomes-based interventions that “work”. However, it’s important to point out that these efforts are largely focused on implementation vs. strategy – mostly because the patient needs are very urgent and require local and immediate action. My hypothesis is that this focus on local implementation, in many ways, has lead to the segmentation of thought for diabetes interventions globally.

Below are some selected perspectives from global thought-leaders in diabetes and chronic disease efforts provided through Dr. Ellingson and Project HOPE contacts.

Interview Excerpts: (click to read)

Dr. Richard Bergenstal – President Medicine & Science, American Diabetes Association and Executive Director of the International Diabetes Center

Dr. Gojka Roglic – Department of Chronic Diseases and Health Promotion, World Health Organization

Dr. K.M. Venkat Narayan – Hubert Professor of Global Health, and Professor of Medicine & Epidemiology

Dr. Shaukat Sadikot – a Vice-President of the International Diabetes Federation and President of DiabetesIndia

Eliana Tameirão – Senior Director Corporate Activities, Genzyme Brazil

Dr. Li,jianxin, Director of Cardiovascular Diseases Prevention Department, Shanghai Center for Disease Control and Prevention

Dr. Hj. Titi Renawati, Director Diabetes Programs, Ministry of Health of Indonesia

This is why umbrella organizations like IDF (for diabetes) and WHO (for multiple diseases) have such an important role. Larry stressed that for chronic diseases, it’s important to recognize the priorities that exist and work together to leverage assets in the community. It can't just be a diabetes solution, it has to be chronic disease solutions. Not only is it more efficient, but it can be more effective. I’ve noticed that health professionals working in diabetes already see a good cross-section of chronic diseases in their patients: diabetes is where many chronic conditions intersect. For example 95% of diabetes cases are Type 2, obesity-driven insulin resistance (note – this means a BMI just greater than 25 for most Asian countries). According to the IDF 50% of deaths annually are due to cardiovascular disease (CVD which include complications from hypertension, high blood pressure, and obesity. Sever clinical depression is also prevalent in about 15-20% of cases and a good portion have COPD either through obesity, genetics, smoking or all of the above. “This is where 1+1=3,” Larry mentioned. If we can collectively prevent the common causes (nutrition and exercise habits, obesity, smoking) the co-morbidities and mortalities will all go down.

I do believe that Project HOPE can serve as an “innovation engine,” as I described previously, for piloting and tracking outcomes to identify successful and replicable interventions. I met earlier this week with the Director General of the Ministry of Health in Indonesia. As the highest official governing all health programs and policies, he described to me an interesting evolution of their office. Just three years ago they created their division for non-communicable diseases (in addition to the infectious disease and environmental health divisions). They have a lead on diabetes and have spent countless hours developing physician guidelines, educational materials, and health promotion tools. Indicating the level of effort, I asked them who they worked with over the past two years to develop these materials. To my surprise, these were all insular activities or performed “organically” to put it in business terms. I was shocked. To me this is like building a car without consulting an engineering manual – how would you know it’s going to work?

It is clear that a global cohesive strategy is very much needed. Although not necessarily in scope for our research and strategy-setting with Project HOPE, I am hopeful that we can help work with larger umbrella organizations to create, embrace, and fund efforts that are coordinated and communicated globally. In the case of Indonesia’s MOH, they desperately would have wanted some guidance in developing their diabetes programs. I mentioned the opportunity to share “best practices” or a “menu” of programs across countries so they could at least have access to information and contacts on what others are doing. Their eyes lit up. They assumed that because they couldn’t afford to travel and attend international conferences that they wouldn’t have access to this information. They are asking me for help.

Countries can learn a lot from each other regardless of how “developed” their healthcare programs or policies. This week I was elated to find an article in Jakarta newspaper about the US looking to Iraq for innovative ways to provide primary care (see article here). This is wonderful! I am an advocate for breaking away from traditional health models (especially when they are clearly not working) and looking for solutions in unlikely places. Health programs in many resource-constrained areas are perhaps the most interesting, and if they generate strong outcomes can be applied to health systems in a number of countries to reduce the increasing cost and consumption of healthcare resources. This reinforces the point that idea-sharing across borders can be extremely mutually beneficial for both developing and developed countries. In addition, 90% of all chronic disease care (and diabetes care) is provided in the primary care setting. 90%! This creates a lot of room for disruptive models in care that can revolutionize the people, processes, and technologies used to deliver chronic care globally.

As one can infer, the debates surrounding chronic care and diabetes efforts are remarkably complex. For me, Dr. Roglic’s point further explains the reason for the diversity of perspectives here: there is no “tried and true” method. This is extremely frustrating. As emphasized by Dr. Venkat, outcomes are critical to moving forward with any global effort. So what do you do when there aren’t any? Would you risk developing and hedging your bets on strategies that are directionally correct, but potentially incomplete or inaccurate? If the outcomes are good, how do you know they are replicable? Could diabetes educators or peer educators produce better outcomes than the current physician-based systems in many countries? Are physicians’ outcomes being measured in the first place? As Dr. Bergenstal reinforced, if you have $1, how do you prioritize controlling the current population vs. focusing on prevention efforts? Which is more effective?

As we work towards establishing global strategies for chronic care prevention and treatment, it’s imperative to keep a close eye on which programs and policies are working and more importantly, which are not working. This requires a portfolio management that is strategic by nature, but flexible enough to pick-up and drive successful models and quickly adapt less effective models – all based on outcomes. Which outcomes are important is an entirely separate matter. I asked Dr. Roglic about this during our discussion, and she was very clear that there is not one example of interventions that show convincing outcomes. My understanding is that these are still in development and debate globally. At some point we will have to get the right people in the same room to align and drive towards these outcomes. This will facilitate the “strategy” we need to guide global portfolios in chronic disease care!

Interview Excerpts: Diabetes Interventions

Below are a few snapshots of interviews that portray a range of current perspectives on priorities in diabetes interventions. Some are global, national, and community-level leads, but all have extensive and relevant experience which I’ve tried to illustrate through the following excerpts:

Priority #1: Control the Current Patient Population

Dr. Richard Bergenstal – President Medicine & Science, American Diabetes Association and Executive Director of the International Diabetes Center

Dr. Bergenstal is the current President of the American Diabetes Association and International Diabetes Center. He and I had a very lively discussion on their current efforts with the ADA and global initiatives to expand the capacity and quality of diabetes offerings globally. Their programs are centered on “teaming” approaches for delivering diabetes care – among endocrinologists, primary care physicians, nurses, diabetes educators, families, and patients. Since 90% of care is performed in the primary care setting – expanding the awareness and skill sets of general practitioners is very important (both for referrals, early detection and long-term care). Team care, he believes, is also a critical factor for patient empowerment – which I found extremely interesting. He also reiterated Dr. Ellingson’s points around the need to engage local leadership in country and the need for the “process of customization” in implementing programs.

We spoke openly about his perspectives on priorities for investments in diabetes care. His sentiments are that it is better to address a broken system first to control the current population and then establish long-term systems for prevention. And he has a point. If WHO projects the prevalence rates are going to double, prevention is only addressing half the problem and addressing current needs may best help the group with the most opportunity for change: the high-risk or pre-diabetic population. Increasing patient empowerment and quality of care for the current population also has the ability to increase awareness among high-risk and healthy individuals. Would this accomplish some of the prevention goals as well?

Dr. Bergenstal also mentioned that his daughter is working in public health and debates with him often on this point. From what I hear she leans towards the prevention side on the issue (as many “pure” public health thought leaders would agree). But this just goes to show that in a healthy environment, it’s ok to discuss the pro’s, con’s, and potential intersections of both. Generations later, public health will undoubtedly win on prevention, but focusing on the current population and systemic needs can be an enabler and improve the quality of life of millions in the process.

Priority #2: Promote Public Awareness for Prevention

Dr. Gojka Roglic – Department of Chronic Diseases and Health Promotion, World Health Organization

Dr. Roglic was kind enough to take some time to speak with me about the World Health Organization’s perspective on new programs in diabetes and chronic diseases more largely. Before our discussion, she made it clear that the WHO is more interested in efforts that address government policies and public programs within the country vs. corporate objectives in market. As Project HOPE is primarily funded by corporate giving, I wanted to make it clear that the current diabetes/chronic disease effort is driven by a comprehensive needs assessment that will first set a strategy based on needs, then find funding to fill gaps not met by current government and corporate sectors. Currently (as I’ve mentioned before), 99% of funding for public health programs are focused on infectious disease, women and children, and environmental health causes – which is largely why Project HOPE has mostly corporate funds to work with at the moment.

Within the first 2 minutes of our discussion Dr. Roglic conveyed to me WHO’s priorities very clearly, “prevention.” New programs, new policies, new solutions should all focus on targeting the healthy and at-risk populations. These conditions are ”perceived as diseases of affluence,” but they’re not. It’s time to advocate for education, awareness, and early screening. The right messages have not been communicated in country, for example, many people have no idea that diabetes is preventable (and I’ve seen this over and over again).

She broke down primary prevention into three segments of programs and policies: urban planning, transportation, and food. Dr. Roglic believes that solutions in public health are largely contingent on the options patients have available for food (cheap fruits, vegetables), exercise (parks, sidewalks), and transportation (can they walk or ride a bike safely?). I agree with her entirely on the importance of these topics and discussed the “city gym” and “adult playground” concepts in Brazil and China respectively. Philip’s latest efforts on certifying healthy cities may also be an interesting step in the right direction, although corporate driven. I asked her about Dr. Venkat’s perspective on the fact that clinical trials suggest it is better to focus on high-risk populations vs. the general public. She responded that there are no clinical trials present in obese or overweight populations to demonstrate otherwise. Fair point. I will have to do some research as well and compare what is really available, but even then outcomes that are “significant” are also debatable (as are the study approach, selected population, trial protocol/variables, and methods for statistical analysis).

The key question I had towards the end of our discussion was around lifestyle change. What do you do when people have access to cheap healthy foods, but choose to eat junk food instead? I recalled my experience in India with the popularity of fast food restaurants like McDonald’s and Cinnabon – fruits and vegetables are very cheap and accessible here but many overweight (children especially!) can be seen waiting in line for the more expensive, greasy alternative. In the US many cities have options for facilitated exercise, yet we have one of the highest obesity rates in the world. Is it just about providing choices or do you have to influence how people make decisions?

This may be where the public promotion and prevention efforts come in (coupled with good options) to help change decision-making at the individual, family, and community level. Still, she made it clear that there are no strong examples of lifestyle intervention with convincing outcomes. “It has to be something self-sustaining; conditions that can be replicated.”

Priority #3: Model Interventions Based on Clinical Trial Outcomes

Dr. K.M. Venkat Narayan – Hubert Professor of Global Health, and Professor of Medicine & Epidemiology at Emory University, Previous Chief of the Diabetes Epidemiology, US Centers for Disease Control and Prevention (CDC)

Dr. Narayan and I had a brief initial discussion, but his perspective is worth noting here because of his expertise working with the CDC and experience in the US and Indian healthcare systems. Dr. Narayan has been involved in a number of large-scale diabetes efforts including the Diabetes Prevention Program (DPP), which is probably the largest and most impactful clinical trial in diabetes to date.

His perspective is that clinical trials demonstrate that diabetes and lifestyle interventions are most effective when a person has been screened for either being diabetic or high-risk for diabetes. Therefore, as priorities are concerned screening for early detection and following lifestyle interventions should be the prime focus for investments. These interventions must also have the sufficient intensity (several months) to have a long-term impact; one or two or several touch points are not enough. I mentioned Project HOPE’s programs in Mexico with a 3 month patient education course to get his feedback on that model or intervention.

Dr. Narayan and I are planning another discussion to dive deeper into his experiences with the CDC, DPP, and programs in India in more detail. I’m curious to learn more on his perspectives for increasing the screening rates (e.g. training PCPs, community outreach?), which medical / lifestyle interventions he believes are most successful (how they can be adapted to resource-constrained healthcare systems?), and what outcomes are most valuable in his eyes as a physician-leader in diabetes care globally.

National Leaders & Priorities:

Dr. Shaukat Sadikot – a Vice-President of the International Diabetes Federation and President of DiabetesIndia

Dr. Sadikot has done some inspiring work in India to help increase awareness and empower physicians for better detection and treatment of patients with diabetes. I’ve referenced our discussion earlier, but with respect to investment priorities we also discussed the tradeoffs involved with deciding where to invest educational efforts: patients or healthcare workers? His effort is multi-tiered. DiabetesIndia, of which he is president, focuses on educating healthcare through a network of about 10,000-20,000 physicians. They also perform preventive programs through elementary school efforts. Dr. Sadikot illustrated the need in the medical profession for diabetes training: six years ago he did a conference on diabetes and received 73,000 emails as follow-up.

He also emphasized the importance of bringing together global thought leaders in diabetes to discuss best practices and solutions that could be replicable for multiple regions. Although I have only five countries’ perspectives at his point, sharing ideas across borders could be extremely beneficial to the countries (vs. expensive trial and error methods) and the patients in their respective communities.

Eliana Tameirão – Senior Director Corporate Activities, Genzyme Brazil

Eliana is extremely passionate about improving diabetes options for patients in Brazil. Relaying stories to us about her father who has Type 2 diabetes and her grandmother who passed away from its complications (blindness and then amputation), she describes this cause as one that is very “close to her heart.” Eliana spoke about patient empowerments as a key to a successful lifestyle intervention in diabetes. It can’t be a theoretical model – a program has to change people.

The power of a peer community and network was central to her key points. Brazilians are “ready to accept peer-to-peer education.” Group educational sessions offer multiple benefits: effective use of people resources and the ability to allow patients to learn from each other’s experiences. This is very progressive from a diabetes programming standpoint, but over time we may have outcomes that support her hypotheses.

She also mentioned the importance of cheap and accessible early detection (e.g. urine strips). Using the PSF primary care network in Brazil would be a good place to start to help push people into the system.

Dr. Li,jianxin, Director of Cardiovascular Diseases Prevention Department, Shanghai Center for Disease Control and Prevention

China has done a lot to increase its spending in public health efforts and I was very curious to understand their priorities as they relate to diabetes and other chronic diseases. We met with the head of the China CDC for Shanghai (many policies are done by city or province), which is considered a leader among provinces for initiating policies that will be adopted nationally.

China’s CDC is largely focused on awareness and prevention among the larger population (somewhat similar to the WHO priorities). In 2000, they initiated a long-term strategic plan for chronic disease. In addition to public awareness, however, most of their investments have been centered on new technologies and resources for physicians in the hospital and community center setting. They have not yet developed sophisticated chronic disease management models (CDM) to address the current population and are concerned that as more people enter the system, they will be less equipped to handle them.

Dr. Hj. Titi Renawati, Director Diabetes Programs, Ministry of Health of Indonesia

Dr. Titi Renawati started Indonesia’s public health efforts on diabetes just two years ago. Developing a program with Indonesia’s leading experts in the field of endocrinology, HIV/AIDs, primary care, nutrition, and diabetes education they have developed efforts focused on (1) general awareness and (2) physician education materials in the primary care setting. This program is still a pilot being conducted in three districts in Indonesia.

As a country with 17,000 islands 33 provinces, Indonesia is prone to logistical challenges with any national programs. How do you promote a program nationally when the culture and geography is so fragmented? With the government focused on prevention (similar to HIV/AIDs efforts), Dr. Renawati asked if Project HOPE could help with capacity building both at the primary care and community levels.

I could relate to Dr. Renawati’s internal struggle in the nascent years of developing her office on diabetes. At the end of the day, both prevention / promotion and healthcare capacity building have to occur. So how does the government decide what role it takes? For Project HOPE, understanding the local priorities and investments can clarify where they as an organization can have the largest impact. Operationally, best practices across countries can help us determine (when we know our priorities) how to most effectively spend and track our investments over time.