Just call me Czar

So I got some guff for trashing the IDF’s Global diabetes guidelines the other day. Among other things, I got an email saying, “Well, if you’re so fucking smart, what would you do instead?”

You know what? I don’t know what I’d do to stop the epidemic, but I know how I’d do it. And it doesn’t involve sitting around an air-conditioned boardroom with a bunch of people with alphabet soup behind their names talking about best-case care, and then throwing my hands up in the air when it comes to places with no money, no roads, or no electricity. Pontificating about what’s best in theory is meaningless and pointless. You need to get out into the field to understand the problems at the grass-roots level, and then fix them regionally. Hey, diabetes is not one size fits all. Nor can the fix be one size fits all. There is no big fix when it comes to diabetes. We need to stitch together a quilt of solutions.

That said, I think the effort should be centrally organized, so we can swap resources and ideas. So to that end, I nominate myself as Global Diabetes Czar. But I’m going to need a few things.

Like a small team… and a jet. Well, the loan of a jet, anyway. Something big enough to get me and my crew to sundry parts of the world, but small enough to land at flea-bitten dirt air strips off the beaten path in the Third World. And I need the jet stocked with a generous supply of chilled Malbec wines, insulin, Evan Williams cinnamon whiskey, and a never-ending supply of CAO Eileen’s Dream and Caramelo Joe cigars. In the 4.7 inch long, 30-ring size, please. I think better when I’m smoking or drinking, and do my best thinking when I do both together. And this job is gonna require my best thinking.

What kind of a team do I need? I need a whip-smart epidemiologist who can help me understand local variations of cause and effect. Why does one group of dFolks in a given country do OK, and others do not? I need a cultural anthropologist to help me understand how the locals view health, disease, and medicine. I need an economist who really understands global finance and can work up national and societal cost/benefit ratios of various therapeutic options on the ground, and sort through the complexity of global supply chains. And I need a political scientist, some brainy sort who knows how every government is supposed to work and how each one really works. The King doesn’t have any power? Really? Who knew? The Minister of Agriculture actually runs the show here? Well, let’s go talk to him. And I need a pharmacist, probably a European one. I need someone who can help me understand the multitude of non-FDA drugs I’ve never been exposed to. I think that’s it. To be honest, I don’t need a doctor or an Endo. I understand the disease. It’s the total environment of the patient groups that I need to understand.

All of these people have to have diabetes. Sorry, no sugar-normals allowed. Except for the flight crew for the jet, of course.

That’s it. That’s all I need. Four people, a jet, the booze and cigars. Oh, right. And food and insulin and test strips and stuff for me and my crew. Got any gazillionaires in your rolodex? Hell, someone with a few billion could easily write a check for this project; it really isn’t that expensive. Fund me for five years and I’ll change the face of the epidemic. I bet if we had one quarter’s revenue from Januvia we’d have money left over in the end. Of course, Merck wouldn’t want to fund this. Slowing down the epidemic—
much less halting it or reversing it—would be bad for business.

And I’ll need a few part-timers, too, in addition to my core team. Folks that speak the local languages to interpret when we arrive.

So what would I do with this team and the jet?

I’d go all over the world. To every country. All 196 of them. Even Korea and Iran if they’ll let me land without shooting me down. And I wouldn’t talk to the political leaders, or health ministers, or big shots. I’d talk to the folks in the trenches. The docs in the field. The nurses at the clinics. The community health workers who visit the small villages. Hell, I’ll even talk to the witch doctors if that’s what they’ve got. And I want to talk to pharmacists and patients and families. Teachers, priests, soldiers, bankers, street vendors, prostitutes, and the guy that runs the corner grocery store. Because I want to understand the total environment in each place. The problem isn’t that we don’t understand diabetes. The problem is that we don’t understand diabetics.

How would I talk to these people? I’d be myself, frankly. I’m not going to be the white guy wearing a tribal gown in a sea of black faces. I don’t have time for that kind of nonsense. Political correctness be damned. And that’s what I’d tell everyone I meet. Sorry, I’ll probably make a social buffoon of myself, but I’m the Diabetes Czar, you people have a diabetes problem, and I don’t have time for a tea ceremony. Let’s go somewhere where I can smoke a cigar so I can think, and let’s talk about what’s working and not working around here. Oh, do you happen to have a bottle opener on you?

I’ve found in my travels that most people prefer it when you’re genuine, when you’re yourself—so long as you’re open minded—rather than when you try too hard to dot every cultural “i” and cross every cultural “t.” Well, except maybe in Japan. But hey, this is a disease that’s in many ways an American one (compare global diabetes rates before and after the arrival of McDonalds restaurants), so I think cowboy diplomacy is justifiable.

We need to learn some basic things before we write a prescription. Does education work for a given group of people? Hell, if not, let’s medicate them and move on! Will certain cultural groups not take white pills? Let’s color the pills blue and get on with it! These guys over here don’t trust the white-coats? OK, how do we get the witch doctors on board with metformin? It’s just French Lilac, after all.

Not enough medical folks? Who can we train? Diabetes doesn’t need a doctor. It just needs treatment. Treatment that’s tailored to the patient and takes into account the patient’s total environment. No electricity for insulin? How can we get enough Frio packs to the right places? I don’t think there’s any problem that can’t be solved if we think outside of the box, especially if we take our brains to the site of the problem and look with our eyes, touch with our hands, and listen with our hearts. And to do that, you’ve got to get out in the field. You can’t do this by committee from Brussels.

I think it would take five years. Four years to globetrot the epidemic and see what is being done and not done. To visit places where things are working. Then visit places where things aren’t working. One more year to figure out what will work where, and make it happen. To cut and paste ideas. To create a global solution, but one that’s tailored for each and every place. Each and every patient.