Richard Smith: Hauling the private sector onboard to combat diabetes

Richard SmithThe golden phrase for countering non-communicable disease (NCD) is that we need a “whole of government and whole of society approach.” An important step on that path is obviously for all parties to talk together, and that’s why the International Diabetes Federation for the first time started its biannual conference with a “global diabetes forum,” with the title of “Harnessing the private sector expertise.” How did it go?

I can answer the question directly with data in that a vote at the end with an electronic gizmo showed that 37% were very satisfied and 40% satisfied. I wasn’t one of the 77%, but I wasn’t wholly disappointed. Over the years I’ve learnt that you often have to talk for quite a while before the real talking begins.

The organisers had spent a lot of time designing our meeting in Dubai. Increasingly a series of Powerpoint presentations is unacceptable as too boring and too one way, so you have to try and find a way to capture the “wisdom of the crowd.” There were perhaps 120 of us divided into something like 12 tables of 10 people, no doubt carefully selected. Each table had a facilitator, a notetaker, and four questions. Overall there were four sets of questions, four “thought leaders” to feedback the tables’ answers to the questions, and an uberfacilitator. In addition, with the gizmos we could not only vote (which we did only twice seriously) but also send texts, which appeared on a huge screen behind the uberfacilitator. Early next year a “Dubai Blueprint” based on the conversations will be published.

Little more could have been done to hear everybody’s views, but meetings, just like parties can be overorganised and lack that spontaneity that makes for a really good party. The route from 10 000 conversations to a blueprint will no doubt be convoluted, but each of us will come away with some thoughts—and these are mine.

The main thought I took away was that we don’t have a clear vision of success. What exactly do we want to achieve? We clearly aren’t going to rid the world of diabetes, and would success mean more or fewer people with diabetes? We might naturally think “fewer,” but when so many in the world with diabetes are undiagnosed, including in high income countries, success might mean more diabetics. Are we aiming for fewer premature deaths, fewer patients with complications, lower costs, or what? And whatever it is we want to achieve we need targets that are stretching but achievable. They will surely need to be country specific not global.

We need a clear vision of success in order to enthuse politicians and funders.  At the moment diabetes is becoming almost “normal”—just like obesity. As one woman in my group said, “You hear about AIDS and you think funerals,” but diabetes is just “one of those things.” But do we want people to be more scared? We may not, but there is lots of talk of the need for “outrage,” the kind of outrage that put AIDS at the top of the global health agenda.

George Alleyne, the former director of the Pan American Health Organisation, argued in the main conference that we need to frame our case in terms of head, heart, and wallet. We have lots of data to appeal to the head, although some of it based on sand. Our appeals to the wallets of politicians need more solid data, but it’s the call to the heart that is the weakest. Pictures of amputees and people blinded by diabetes don’t seem to work.

Everybody agreed that having many more patients active in “the movement” would be beneficial, and a politician from Britain reminded us that politicians listen more to patients than they do to professionals, who are always suspected of vested interest. Very few patient voices were heard at the recent United Nations meeting on NCDs.

There was lots of enthusiasm as well for “triple P” partnerships—public, private, people. Nobody seemed to know of one that existed, but they are to be devoutly sought. At the main conference we heard about the need for a new “social movement” to counter NCDs. I’ve been through that movie before and once devoted a lot of time to studying social movements—particularly the movement to abolish slavery, which has been described as the world’s first social movement. My cautious conclusion was that it’s not easy to create a social movement.

One of the problems for the International Diabetes Federation or any other organisation concerned with a particular disease is to know how much to devote resources to the one disease and how much to NCDs broadly. I’m an “NCD guy” not a “diabetes guy,” and I came away feeling that the diabetes people are conflicted—and nobody perhaps feels this more keenly than Ann Keeling, the chief executive of IDF but also the chair and driving force behind the NCD Alliance, which now has 2000 member organisations and is, I think, a magnificent achievement. It is perhaps the start of a social movement.

What is clear is that it will be a bad day if the disease groups start fighting each other—perhaps for resources—rather than working together. I saw some signs of this when some of the audience in the main conference moaned that diabetes was insufficiently “sexy and glamorous.” I couldn’t help thinking that they were perhaps fed up that they themselves were not more sexy and glamorous. Another recurrent message was that we should emphasise the link between diabetes and erectile dysfunction in order to motivate men to take diabetes more seriously. I’m unconvinced that the route to a man’s head or heart is through his penis, but maybe that just illustrates that I’m an out of touch romantic.

So after hours of somewhat confused conversation we arrived where we started at the conviction that we do indeed need a “whole of government  and a whole of society” approach and that the private sector, despite its conflicts of interest, does belong at the table. The meeting was a step to making it happen, but much more is needed.

Competing interest: RS works for the UnitedHealth Group, a for profit company. United paid his expenses for attending the meeting, and, contrary to what most people think, he travels economy class. Indeed, on this trip he sat in a particularly cramped space beside two corpulent men who had little sense of private space.