Destination Zero

Introduction

Diabetes and hypertension kill more people worldwide than HIV, malaria, and TB combined. Striking low- and middle-income countries particularly hard, often affecting working-age adults in the prime of their lives, these silent killers cause devastating and disabling conditions, leading to lost productivity and perpetuation of poverty. Yet, despite mounting acknowledgement of the scale of the problem, country health systems and international funding organizations largely neglect diabetes and hypertension. The Emory Global Diabetes Research Center has partnered with key Indian governmental and health research institutions, such as the All India Institute of Medical Sciences, over the past decade to address this issue. This global collaboration has developed and rigorously tested scalable, cost-effective digital technology tools combined with health work force training to improve programs that prevent and treat diabetes and hypertension. Destination Zero will expand the reach of this package of tools to strengthen community outreach and patient engagement programs in more than 100 districts covering more than 100 million people.

The Problem 

Diabetes and hypertension are two of the world’s costliest, fastest growing, and most deadly and disabling epidemics—and among the biggest threats to health and development in the 21st century. On a global scale, 425 million people suffer from diabetes and more than a billion have hypertension. Projections expect a nearly 50 percent increase in diabetes incidence worldwide by 2045 and a 29 percent increase in hypertension rates by 2025. Eighty percent of the burden of these two clinically linked diseases is experienced in low-and middle-income countries, where incidences continue to grow. India, a country of 1.3 billion people with rapidly changing demographics and economics, is at the epicenter of the global diabetes and hypertension epidemics. These diseases together affect over 275 million Indians, many young people, and their families, with disproportionately worse outcomes—such as higher rates of death, blindness, kidney failure, heart attacks, and stroke—seen among the poor and underserved.

The Solution

Decades of research has shown that behavioral changes related to diet, physical activity, and tobacco cessation are effective in preventing diabetes and hypertension. Advances in treatment can lessen complications in those who have already developed the diseases.These solutions, however, too often don’t reach those who need them most.

Destination Zero builds on the political will of the Indian government to eliminate the burden of diabetes and hypertension within the country and on our 10-year-plus partnership with India’s leading academic, public health, and health care institutions. We leverage the country’s existing primary health care systems and structures to effectively deliver proven high-quality affordable diabetes and hypertension prevention and treatment strategies. A community-based component takes advantage of an established cadre of community health workers, providing training and technologies so they can better educate and identify people at risk in underserved populations. The clinic-based component trains patient advocates and arms them with tested technologies to monitor patients’ health, update electronic medical records, provide personalized treatment plans, and ensure motivation to adhere with life-long treatment and care. Evidence from rigorous studies conducted internationally and in India (by our team) indicate that these interventions can reduce mortality and disability from these diseases by as much as 50%.

The Team

The success of implementing Destination Zero and tackling hypertension and diabetes head-on in India will be possible through the multidisciplinary strength of our global team. Composed of renowned researchers, business leaders, health professionals, and technology experts from the United States and India, our team builds upon its expertise in global health, health care delivery, workforce management, public health leadership training, computer science, data analytics, health services innovation and improvement, quantitative and qualitative analysis, and more. 

Key Team Members

K.M. Venkat Narayan, O.C. Hubert Professor of Global Health and Epidemiology, Emory Rollins School of Public Health, Director, Emory Global Diabetes Research Center 

Nikhil Tandon, Professor of Endocrinology and Metabolism, All India Institute of Medical Sciences

Shivani A. Patel, Rollins Assistant Professor of Global Health and Epidemiology, Emory Rollins School of Public Health

Kate Winskell, Associate Professor of Global Health, Emory Rollins School of Public Health 

Usha Ramakrishnan, Professor, Emory Rollins School of Public Health

Dorairaj Prabhakaran, Vice President and Professor, Public Health Foundation of India 

Joyce Ho, Assistant Professor of Computer Science, Emory College of Arts and Sciences 

Sandra B. Dunbar, Professor of Nursing, Emory School of Nursing

Q&A

A question and answer session with Destination Zero's principal investigator, K.M. Venkat Narayan, O.C. Hubert Professor of Global Health and Epidemiology, Emory Rollins School of Public Health, Director, Emory Global Diabetes Research Center

Diabetes and hypertension kill more people than HIV, TB, and malaria combined and cause even more disabilities that lead to devastating losses of income and productivity. These are not only deaths in old age—high blood sugar and high blood pressure are leading risk factors for premature death. Yet, they have been neglected in the global health agenda. Overall, chronic diseases such as diabetes and hypertension are responsible for 80% of the burden of poor health but receive only 2.5% of global funding.

India is at the epicenter of the global diabetes and hypertension epidemics, due in large measure to the changes of its lifestyle—embracing loss of physical activity and shifting to poor quality diets. These diseases together affect over 275 million Indians and their families, with disproportionately devastating health impacts and death among the poor and underserved due to inadequate management. Moreover, families often are forced to spend large proportions of their income and liquidate assets to finance care, perpetuating a vicious cycle of poverty.

Half of all people with diabetes and hypertension don’t know they have it. Many more people are at heightened risk for developing the diseases. Our research has shown that lifestyle prevention programs can prevent at least a third of those people from developing the disease, but they have to be identified and brought into the system.

Our community-based component leverages the work already being done by community health workers who have been mobilized by the government of India to tend to the health needs of their communities. We are giving them training and apps we have developed, using the strongest evidence, with our Indian partners that will allow them to educate their patients about the signs, symptoms, and prevention strategies around these diseases via smartphone viewable videos or other technology mediums (e.g., WhatsApp, cellphones text messages). They will also be able to identify patients suffering from the diseases or at high risk of developing them and refer them to the clinic. 

We are also using well-designed media campaigns to raise awareness of the diseases and how lifestyle changes can prevent them.

Physicians are in short supply in India and their time is extremely limited. We are training a nurse, or other non-physician health workers as available, within the clinic to act as a patient advocate whose function is to help the patient navigate the system, interface with the doctor, answer questions, and provide support. Through years of working with our Indian partners, we have developed and tested support technologies that track the patient’s health, update electronic medical records, and provide personalized treatment suggestions to prompt both the patient and the physician.  

For more than 10 years, we have partnered with the Indian government and the country’s leading health sciences and public health institutions. During this time, we have measured the health and economic burden of these diseases in India. We have conducted numerous studies and interventions around diabetes and hypertension prevention and improvement to care at every level of health clinic within the Indian health care system hierarchy, and we have shown that we can improve glucose and blood pressure control and hit control targets among patients.  We have also demonstrated that we are able to both substantially reduce the risk of developing disease in the community population, especially by focusing on high risk individuals. We are at the stage of scaling up this work by integrating our package of prevention and management tools within routine operations of the public health care system to enhance the quality of government initiatives. Our demonstration study of Destination Zero in Punjab has revealed a huge proportion of undiagnosed diabetes and hypertension in the community. It also highlighted a need for tools to help with community outreach and to track patients within the system. We are delivering the right technologies at the right time in high need areas.

Our project builds on the goals of the Indian government, which has identified the elimination of suffering from diabetes and hypertension as a high priority. We are working with the governmental and health care structures and systems that are already in place, adding our expertise to improve them through support, training, and technologies. So far, there has been tremendous excitement and enthusiasm at the national and state levels for this work.

Destination Zero will reach 100 districts covering over 100 million Indians of diverse class, caste, ethnicity and gender to ultimately reduce disability and death, lower healthcare costs, and avert income lost and poverty due to diabetes and hypertension. But it can go even further. This approach is applicable in low- and middle-income settings across the globe, and even to underserved populations in high-income countries, and is viable for all manner of chronic diseases. Our goal is to make our tools and expertise widely available wherever there is a need.

Select Publications


Effectiveness of a multi-component quality improvement strategy to improve diabetes care goals: The CARRS Randomized Controlled Trial
Ali MK, Singh K, Kondal D, Devarajan R, Patel SA, Shivashankar R
Annals of Internal Medicine

The stepwise approach to diabetes prevention: Results from the D-CLIP randomized controlled trial
Weber MB, Ranjani H, Staimez LR, Anjana RM, Ali MK, Narayan KMV, et al.
Diabetes Care

Noncommunicable diseases — Where worlds meet
Narayan KMV, Ali MK, Koplan JP
The New England Journal of Medicine

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