The views expressed are those of the author and do not necessarily reflect the position of FORESIGHT Global Health.
The level of engagement in public and private sectors and the resources levered to address COVID-19 have been impressive. Why have we not been able to have similar success in addressing type 2 diabetes, a disease affecting more than 460 million adults worldwide and consuming 10% of global health expenditures? Especially when the solutions are well known? I suggest that within the hardest hit populations— namely Indigenous peoples— there are some very “old ways” that can offer a better path to success in addressing this global crisis.
The situation around the globe does not tell a good story. We are failing society writ large, as more and more people are becoming diabetic with all the associated negative impacts on life trajectories and society. While my experience is limited to North America, research has shown that at a global scale Indigenous people suffer far higher rates of diabetes than the rest of society. In Canada, the prevalence of diabetes amongst the public has increased two-fold in the past decade. In Indigenous communities it is already at epidemic levels with a prevalence rate of 3-5 times higher than the non-Indigenous population. A young Indigenous person has an 80% chance of developing diabetes mellitus, and the Indigenous population is being diagnosed with the disease 17-20 years earlier than the mainstream population.
The long-term cost of this epidemic to society is extraordinary in two ways: first in its human impact, and second in its fiscal impact. In Indigenous communities, the diabetes epidemic has far reaching social and cultural implications. Because the incidence rate is occurring at increasingly younger ages, communities are prematurely losing their Elders and knowledge keepers. This in turn creates a compounding loss of culture and language and has an exponential negative impact on community development and growth.
Simply put, elders do not have the requisite time for knowledge transfer between generations and the deep teachings and practices that take years to embed. Further, even when they can manage to find time, elders are increasingly debilitated by diabetes (amputations, medical care, dialysis, diabetic retinopathy etc.) The fiscal impact is also significant. For Indigenous people living in remote communities, the average lifetime healthcare cost is approximately $285,300 per person. Preventative measures would cost considerably less. And yet, our systems are primarily focused on treatment of the disease rather than prevention. It is truly a crisis.
The origins of the crisis are well known and have deep roots in the social determinates of health and the effects of colonisation. Colonisation has a long, insidious tail that has resulted in the forced removal of Indigenous peoples from our lands, blatant attempts at cultural genocide and suppression of language and cultural practices that have for many thousands of years served Indigenous people well. Diabetes is a modern disease that is directly tied to poverty, social and economic exclusion, lack of access to healthy foods (or direct government support of unhealthy food systems of refined and processed foods,) reduced access to primary care, lack of information, and inadequate support programs. Yet the interventions that have been tried rarely “stick.” Why? Because they are not grounded in Indigenous culture and control has not been ceded to Indigenous peoples.
I believe that there is a more effective approach, based on a very old concept of sitting in circle and listening very closely to what is being said. This traditional approach is really a way of complex problem solving that looks at the causes (not the symptoms) of issues and takes a community-wide approach to addressing it. This would be seen in a modern context as mapping the system, mapping the community assets, and engaging the stakeholders in committing to problem solving. It also lets you learn who the key community champions are (often the aunties and matriarchs), engage them in solution building on what will or will not work in each specific context.
Our approach at the Raven Indigenous Impact Foundation has been based on this. Our Indigenous Solutions Lab, a project to co-create diabetes reduction interventions for Indigenous communities in Canada, has been conducted in ceremony and guided by Indigenous ways. This may not seem “innovative” but in fact doing this takes time and conscious effort. It has allowed us to build deep partnerships that will stand the test of time and build custom interventions that the community will own and see through.
This has led to a new type of holistic success indicator in the outcomes measurement space, mino-bimadzowiin. In traditional epistemology it is both a philosophical and practical concept meaning “living the good life”, which has at its roots clan teachings and in essence reflects the social determinants of health, including mental health. Who would not want to measure mino-bimadzowiin rather than A1Cs or BMI? It is a community-driven approach that speaks at multiple levels to cultural and Indigenous integrity and identifies what will work.
Equally important, the innovative financial vehicles used to support this are responsive to communities and not to the holders of the capital – whether that be public or private capital. Together with the World Diabetes Foundation, we are now developing a pilot Diabetes Reduction Bond/Community-Driven Outcomes Contract to finance the diabetes prevention interventions created by the Indigenous Solutions Lab. The goal is to raise private capital through the Bond and place government in a position to pay for successful diabetes outcomes in Indigenous communities.
I believe that Indigenous ways of knowing and being are key to driving transformational change in the fight against diabetes. However, for these types of changes to operate at scale requires broader changes in the ecosystem and its main actors, most critically on two fronts. First, we need to collectively recognize that those closest to the problem are those most adept to solve it, in any cultural context. Second, governments and health systems need to give up control and the desire to shape “programs” or “projects” in the image of the mainstream system.
In practical terms this requires putting communities in charge of delivering interventions and embracing new outcomes financing approaches. In the long run this will encourage innovation, save lives, decrease costs, and benefit society. What we have learned through the COVID-19 pandemic is that when societies are motivated to make great change happen to save lives, transformation can be achieved. •
TEXT — Jeff Cyr is Managing Partner at Raven Indigenous Capital Partners.