Even as the New York City Department of Health announced this month that city diabetes deaths had reached an all-time high, millions in diabetes prevention money for New York was sitting in Washington, snarled by a year-long federal-state dispute over Medicaid funding. If that $25 million had been used in very specific ways that work very well to teach people with high blood sugar to out-rightly avoid diabetes, it would have already saved some $207 million in Medicaid costs for new diabetes cases that unquestionably could have been prevented.
But the prevention didn't happen -- and not just in New York. Unfortunately the public haranguing of the fat and the unexercised has created a nationally defeating public imagery of a problem population for which there is no realistic solution. Yet, quite to the contrary, massive research shows that, with about $400 of direct education, most people in the most direct danger of diabetes -- people with what is commonly known as "pre-diabetes, or very high blood sugar -- will take proper measures to avoid becoming diabetic.
The failure of American medicine and the American public health establishment to insist that people on the edge of diabetes receive this direct education, now so well proven to help the majority of them avoid their danger and renew their health, is a key factor in the United States' appalling, bankrupting and unnecessary diabetes epidemic. I'm sitting in the South Bronx which has the worst diabetes epidemic in New York State and I don't know of anyplace that better validates that prevention is available to people with "pre-diabetes." The same would be tragically true in low-income, high risk neighborhoods across the nation. Yet, in declaring obesity a "disease" this week, the American Medical Association didn't bother to point out here is a mammoth "diseased" population from whom American medical practice withholds extraordinarily well proven education strategies that actually can help most of them.
Massive research, on which the National Institutes of Health has easily spent $100 million over the past decade, has shown again and again and again that educating and coaching people with high blood sugar to start moderate exercise and lose moderate amounts of weight is TWICE as EFFECTIVE as standard medication in preventing them from developing out right diabetes: this education is also cheap. The education course costs some $400 to provide 22 sessions of knowledge and coaching that slashes the prospect of diabetes by almost 60 percent; by contrast, in New York State, the annual "extra" cost for Medicaid patients who develop diabetes is $7,000 -- year after year after year.
The first study of this prevention course, funded by the National Institutes of Health, was published in the New England Journal of Medicine in 2002; based on results from 3,000 people, it clearly documented the almost 60 percent reduction in diabetes cases among pre-diabetics who took the course -- results that were the same for men, women, blacks, whites and Hispanics.
It is very rare in health -- and especially in health education -- to see this kind of undisputed win. Multiple follow-up studies in the years since the first N.I.H. research have confirmed these outcomes over and over; moreover, further study has confirmed that "nonprofessional", or peer counselors, can be rapidly trained to provide this diabetes prevention education and that they achieve the same impressive results in avoided diabetes cases as health educators with master's degrees. The Centers for Disease Control has judged the education course as absolutely the lead strategy for diabetes prevention and it made it the centerpiece of what it now calls the National Diabetes Prevention Program.
All told what we have here is a win-win-situation. There is the reduction in sickness and the reduction in health costs; there is, very importantly, the fact that you can train the residents of poor neighborhoods, themselves, to teach diabetes prevention, developing both local enthusiasm for fighting diabetes and local jobs.
But, what we don't have -- despite the optimistic Centers for Disease Control name -- is a National Diabetes Prevention Program because, except for scattered grants, there is no steady funding to actually provide preventive education. In a nation with an estimated 79 million pre-diabetics, we have refused to provide effective diabetes prevention for the decade that we have perfectly well known how.
One can only conclude that educating people to take control of their own health -- especially people long subject to public health messaging that brands them as unreachable and unteachable -- is something the United States refuses to do.
The particular funding which New York has been unable to use currently is part of its Medicaid waiver funds -- money that states claim back from the federal government for "innovative" uses based on the Medicaid savings they achieve through health reform. The federal government has held back these funds as part of an overall, year-long dispute about New York State Medicaid -- perhaps understandable given the state's various Medicaid scandals. What isn't understandable is that there's always an excuse, somehow, not to allocate prevention funds which absolutely nobody disputes would save millions of dollars in the costs of ongoing illness.
The truth is that, in the long years of growing sickness since the N.I.H. released the astounding results from the first study, many levels of government could have implemented the National Diabetes Prevention Program. State Health Departments could have funded their own education programs. Many parts of the federal government -- particularly the Center for Medicare and Medicaid Services -- could have funded the national implementation of the Diabetes Prevention Program; after all, the federal government would only have been saving itself billions in Medicaid and Medicare costs for diabetes. The Obama Administration could have made the Diabetes Prevention Program a centerpiece for its $15 billion in federal health stimulus funds -- which would have had the double impact of radically improving the health of poor communities while providing them with jobs that local residents could quickly learn to undertake. But that didn't happen either. Almost nothing from the stimulus went to proven prevention in communities overwhelmed by diabetes and other chronic disease.
No. A solution to the nation's most epidemic disease that comes by widely educating and empowering the poor, the minority and the fat to seriously take control of their own health has little interest for either the nation's health or political elites. In the middle of all its public haranguing (some of it with merit) and demands to control what people eat and drink, one never hears the Bloomberg Administration or its health minions mention the Diabetes Prevention Program or demand that it be as available as sugary drinks be unavailable. Actually, the Diabetes Prevention Program is so little mentioned in public "discussions" of health policy and possibilities that the general public is hardly aware that something so well proven and possible exists. But, why would elites mention it -- when their preferred approach is to harangue, control and medicalize.
Why tell the public that teaching the nation's largest group of poor and ill to take care of themselves is twice as effective as tethering them for life to standard medication?
That would change everything.
Note: Anyone who wishes to push for a Diabetes Prevention Program for New York can
help by signing our petition at Change.org, requesting that CMS Director, Cynthia Mann and State Health Commissioner Nirav Shah finally resolve their impasse and put this key prevention money to work.