Microclinic International is a nonprofit organization that developed a model built on social and community networks and has applied it worldwide in areas where chronic disease is widespread. In 2011, Microclinic launched its first program in the U.S., deep in the heart of Appalachia, after being approached by Louisville-headquartered health care company Humana. The partnership operated a program in Bell County in eastern Kentucky and targeted two chronic health problems plaguing the county and overall region: obesity and Type 2 diabetes.
Microclinic and Humana reached out to the community and public health department in Bell County to seek out their input, and developed a randomized control trial for citizens. One group participated in the Microclinic model, which educates community members to adopt healthy lifestyles and, just as importantly, trains them to educate, motivate, and support other community members. Another control group received no intervention.
“The randomized trial that no one’s ever done in rural Kentucky before was, we did this for nine months and gave people this intervention,” says Eric Fiegl-Ding, chief health economist for Microclinic. The results were remarkable: according to Fiegl-Ding, participants in the Microclinic lost on average six pounds compared to community members in the control group, they improved their blood sugar, and they lowered their blood pressure. More importantly, participants kept the weight off, even up to a year after the program ended.
A Paradigm Shift from Treatment to Prevention
Microclinic founder and CEO Daniel Zoughbie says that he was inspired to create his health care nonprofit after watching his grandmother die prematurely from diabetic complications. He kept track of her struggles managing the disease and came to realize that all of the hardship she endured could have been avoided had she existed in a community where good health care practices were well-established and part of the social fabric.
“My grandmother’s death could have been prevented had she received important information that could have helped her change her lifestyle, but also if she had had people around her who could have helped her change what she ate and how much she exercised,” he says.
Fiegl-Ding also has a family history of diabetes. He has an academic background in epidemiology – the practice of studying how diseases spread and how to control them – and believes that the central tenets of epidemiology are crucial in reducing incidence rates of diabetes.
“We realize that 90 percent of all diabetes can be prevented by diet, lifestyle modification, and all these simple things we are not doing,” he explains.
The bedrock principle of Microclinic is that such modifications in diet and lifestyle are best achieved on a wide scale if they become adopted – and crucially, endorsed – by the patient population. Having a doctor advise a patient to change his/her diet and exercise habits is one thing. Having family members and friends apply positive peer pressure is much different.
To that end, Microclinic educates community members with an emphasis on collaboration and empowerment. Their program enlists area hospitals, clinics, physicians, public health departments, and even grocers in the cause, which is nothing less than effecting a paradigm shift in how health care is administered within a community.
“As a nonprofit organization, we stand in the intersection of many different players,” Zoughbie says. “And what our message is, everybody needs a seat at the table. The payers, the providers, we need to re-align the incentives so that when people don’t go into emergency rooms, when people don’t need to seek health care at overburdened public health clinics, everybody is benefiting.”
Changing the modern health care system from one focused on treatment to one on prevention is a complicated and arduous task, but well worth it in the end, Zoughbie and Fiegl-Ding argue, and the results of Microclinic’s efforts in places ranging from the Middle East to Bell County prove it.
“Our current structure is very reactionary,” Fiegl-Ding says. “When people get sick, then we get them insulin and other drugs and bariatric surgery, and put them on kidney dialysis if their kidneys are failing. It comes down to planning – we want to prevent a disease, but all of our financial incentives are currently aligned with treatment.
“In public health, we know that an ounce of prevention is worth a pound of cure,” he continues. “But how do we align our incentives so that if you prevent 1,000 diabetics in eastern Kentucky, that will actually be shared and invested in more prevention?”
“Good Health Is Contagious”
“I think that we’re accustomed to think about health in terms of the individual, and the individual biology of a person,” Zoughbie says. “We’re not accustomed to thinking about the sociology of diseases – how do social structures make individuals sick, how do the built environments around them make them sicker, and conversely, how can we actually use social relationships, social networks to prevent disease by changing simple behaviors.”
Zoughbie points out that much research has been conducted on how negative behaviors – from substance use to gang violence – are spread through social networks and peer pressure.
“You know what? Good health can be contagious, too, and it can spread through networks,” he says. “And public health systems, insurance companies, and communities can work together to propagate the spread of good behaviors.”
The decades-long effort by public health officials in the U.S. to reduce smoking is an example of an effective social network model. Such campaigns require an upfront investment in public education, followed by tireless effort and patience, but they help to achieve both improved health outcomes and lower health costs in the long term, Zoughbie explains.
“Health insurance companies save money when people are healthy,” he says. “Local public health clinics save scarce resources when people are not coming in with preventable illnesses. Families are happier when grandma can take care of the kids and spend time with them, and she’s not losing her eyesight because of diabetes complications. It’s just one of these win-win-win no-brainers.”
A few participants in Microclinic’s nine-month program were severely obese, and Fiegl-Ding notes that some of those persons lost over 50 pounds and kept the weight off. He contrasts Microclinic’s approach to weight loss with several fad diets he studied while working and studying at the T.H. Chan School of Public Health at Harvard University.
“This program does not require some expensive meal plan that you have to buy,” he says. “It’s not for-profit in any way – this is a low-cost, community-based program.”
“One of the amazing things about Bell County is that once this program got going, we sort of saw a cascade of other things happen that were led by the community,” Zoughbie says. As the Microclinic gained momentum, participants started a community garden, he notes. Corner stores also changed their supplies to stock more healthy foods, and walking trails were installed. “The community as a whole was much more excited about changing what they eat and exercising more,” he says.
Ultimately, the Microclinic program became sustained by community members in Bell County long after classes officially ended – which is the organization’s goal. This mirrored results from more than 1,500 Microclinics worldwide. It’s a model that both Zoughbie and Fiegl-Ding hope will continue to catch on in other areas in the U.S. plagued with chronic diseases such as Type 2 diabetes.
“We want to show that basically for every $100, you can actually save $1,000 on treatment,” Fiegl-Ding says. “And we know this – we know that prevention is much cheaper than all of the insulin, the bariatric surgeries, the kidney dialysis. We want to show that community health programs like this are actually relatively low-cost. And if you invest more in the community, that further reinforces community health welfare, that will actually pay for itself.”