When we exit the circle of what, we will continue our dialogue and attempt to specifically and directly address the more universal shared self-interest question of many different potential network partners, and that is “what is in it for me/us?”   We will then conclude with the more practical “what is on the menu?” as an essential table of contents for moving forward, with “what are the tools in the CIC/WHAG Toolbox?   

As with all true dialogue, the final question is always “what have we learned together?”

In the obstetrical world, the preconception phrase and phase have a whole different meaning focused on creating new life.  The birthing process importantly requires a systematic approach to informational needs and preparation planning as part of the creative process.  The preconception creative new model approach is more than a play on words.  It is an important choice for you to make.

As we explore and try to develop a common language, we do need to build consensus around a unified vision of what is our model approach to hypertension in low-resource venues.  What does our hypertension animal actually look like?  What if it were not simply an animal photoshop mashup, but a miracle of genetic engineering and evolutionary adaptation to hostile hypertension environments?  

“Dialogos’ as a concept going back to the ancient Greeks, focuses on a center without sides.  Therefore, it is not a question of the differences between hypertension in high- versus low-resource venues.  It is not even a question of collaboration.  True dialogue goes to the ability to think, work, and most importantly create together.  It is about developing a relationship that channels the energy of any differences into something that has never been created before

We opened that dialogue, and most importantly we listened. 

“What if” you started with a core group of individuals from widely different professional backgrounds and perspectives, brought together by the common desire to serve, and to have an impact?  What if they are all dedicated volunteers uniting in common cause and in good faith to do something special, even as they struggle to define what that “something special” will look like with no initial blueprint to follow?  

“What if” this visionary group was united by the sense that there is unacceptable health inequity, with an inordinate burden of the adverse consequences of hypertension suffered by the poor and disadvantaged of our world described as the bottom billion?  

In the search for innovative solutions, we broadened the usual hypertension expert base to include many valuable diverse perspectives. 

“Dialogos’ as a concept going back to the ancient Greeks, focuses on a center without sides.  Therefore, it is not a question of the differences between hypertension in high- versus low-resource venues.  It is not even a question of collaboration.  True dialogue goes to the ability to think, work, and most importantly create together.  It is about developing a relationship that channels the energy of any differences into something that has never been created before

We opened that dialogue, and most importantly we listened. 

“Dialogos’ as a concept going back to the ancient Greeks, focuses on a center without sides.  Therefore, it is not a question of the differences between hypertension in high- versus low-resource venues.  It is not even a question of collaboration.  True dialogue goes to the ability to think, work, and most importantly create together.  It is about developing a relationship that channels the energy of any differences into something that has never been created before

We opened that dialogue, and most importantly we listened. 

When we visit and examine strength in low-resource venues, we find the amazing resilience of people living in those communities, with a strong desire and commitment to improve the health of their families.  We also find the incredible strength and dedication of many Faith- Based (FBO) and Non-Governmental (NGO) Organizations of all sizes and descriptions, who by virtue of their values tend towards service in areas of the destitute poor.  

Our opportunity is to educate and organize networks according to a defined knowledge base, and then efficiently bridge the gap between knowledge and action according to standards.  Only in this manner can you realistically move from holes to the strengthened whole, and it is a heretofore under-utilized opportunity that CIC/WHAG intends to build upon.

“Dialogos’ as a concept going back to the ancient Greeks, focuses on a center without sides.  Therefore, it is not a question of the differences between hypertension in high- versus low-resource venues.  It is not even a question of collaboration.  True dialogue goes to the ability to think, work, and most importantly create together.  It is about developing a relationship that channels the energy of any differences into something that has never been created before

We opened that dialogue, and most importantly we listened. 

The concept of primary care as a medical management focus is very important, and something that we will ultimately approach as a step–wise progression appropriate for many FBO and NGO medical mission inspired groups.  For now, we will make the simplistic observation that you put your toe into the waters of “primary care” the day that you give your first pill to a patient.  

Before crossing that threshold, there are many valid hypertension-related activities that can be characterized as the “pre-primary care niche” within the continuum of primary care medical management.   These activities are the basic essential requirement for all who aspire to perform hypertension-related service in low-resource venues, and include community BP screening (Module V), teaching how to take an accurate BP measurement (Module VI) in Book Two.  The most important activity is the ability to teach, starting with public education and extending to counseling of individual high– risk persons.  This is the reason for such a comprehensive approach to what we need to learn and teach in Module VII, Book Three.   

By saying that these are activities that everybody needs to be able to perform, we are also saying that you do not need to be a trained medical professional with a degree.  With appropriate education according to defined standards, anybody can perform these defined task activities.   

In this regard, CIC/WHAG have adopted two interconnected mantras.  First is that “no potential resource be left behind” balanced by “if you are going to do it, do it right”.  

Using an expanded and previously neglected supplemental workforce of medical mission volunteers with demonstrated quality and well-defined limited tasks can have immediate direct consequences, when coupled with in-place FBO and NGOs.  In reality, the indirect consequence is that educational and other resources will be freed up for more focused “upstream” hypertension management activities.  The premise is that as supplemental and complementary resources are deployed in the community at the sharp point of community entry for BP screening and accurate BP measurement, there is an opportunity to transition from small scale decentralized “cottage industry” of medical missions to an organized network based on defined quality and communication.  As activities and resources mature, there may be progression up the step ladder of more organized approaches to primary care medical management.  

At the end of the day, throughout all modules, it is all about education and knowledge sharing.   

We need to teach what we need to know, and know how and what we need to teach, with appropriate adjustment for cultural understanding and literacy.   

 Within the primary focus of hypertension education and teaching, Book Three (Module #VII) is voluminous and all-encompassing.  Module VII is the largest and may be the most important module for all to master with the broad mandate of what we should know and teach.   The education module is about knowledge acquisition and becoming a teacher at many levels.  This reflects the CIC mission message that knowledge is power, but most powerful when shared.  You are the disseminators of accurate and approved information. Thus, the education module begins with how to be a teacher.  This includes the important aspects of health literacy, general literacy including coloring books for low-resource communities, and review of “teach back” and “show me” teaching techniques. 

The education module builds on the WHO/UN “4×4” approach of the identified four most important Non-Communicable Diseases (NCDs) including Cardiovascular Disease (CVD), cancer, chronic respiratory disease and diabetes, coupled with “best buy” risk factor modification targets of tobacco, alcohol, physical inactivity, and unhealthy diet.  There are extensive and very well referenced sections addressing cardiovascular risk factors that are modifiable by behavioral lifestyle change, and those that are metabolic and partially modifiable: 

If you were to focus your efforts on one major goal, it should be the mastery of the extensive information presented in the education module as it is truly what we need to know and teach.  By our comprehensive education approach encompassing many references and resources, we have presented a flexible learning approach that will allow you to go to whatever depth you feel comfortable. Simply put, it is all about learning the why and what (is important to know), before the practical how (to do it).  

As an orientation exercise, Module #IV goes through the process of situational analysis, in order to determine pragmatically your strengths and things that are not realistic to expect that you will be able to do.  It is related to the process of ongoing long-term management of identified patients with hypertension as the bottom line.  It injects an element of reality testing of where you stand in the pre-primary care to primary care parts of the nail.  

If you have an adequate hammer with medication financial support, but the length and gauge of the nail supporting structure is insufficient, then the nail will just bend at impact.  Hence, the need for standardized core curriculum module education and training with systems development around standardized algorithms as integral parts of the program.   

If the point of the nail is blunted, there will be difficulties entering into the community effectively without BP Screening.  “Know your numbers” is of obvious importance to individuals, but also of importance for organization and group decision making.  Hence, the importance of the situational analysis exercise. 

The simple and clear message of the hammer and nail is that it all has to work together. It requires a network including community health workers, nurses, physicians, mothers and families, leaders and program developers.  It also requires non-traditional FBO and small to medium sized NGO thinking together, with a willingness to communicate and collaborate with large governmental and non-governmental more traditional systems serving within defined geographic areas. As an integrated model, it traverses from community centers to mobile and fixed clinics, regional secondary, and tertiary hospitals. 

The conceptual framework is logical and simple.  Implementation is the challenge, and CIC/WHAG believes that it can be facilitated by Information and Communication Technology (ICT), up to and including virtual or tele-medicine.  UN SIDS are not the only islands. There are many land-locked islands as well, as it is isolation that is the issue.  Yet, no matter how much ICT is available, success depends primarily on your willingness and desire to communicate and be inter-connected in a collaborative network relationship.   

In essence, the WHAG program as developed is based on the “Four C’s”: Connectivity, Communication, Co-ordination, and Collaboration.   

CIC/WHAG is adopting what has been described as a line of inference approach.  That is to say that we know that medications work to lower measured BP levels for the majority of patients in the community population, with a relatively low percentage of resistant severe hypertension.  We also know that lower BP means less stroke as the most palpable family and community adverse outcome.  We are taking the stand that we do not need to dedicate very limited financial resources for expensive data collection efforts and analysis in order to document further proof of what has already been proven. In many ways, the line of inference approach may evaluate systems rather than individual outcomes.  That is to say, what systemic models improve the number of patients being treated with the appropriate level of medical therapy with high levels of medication adherence.  

Under the most general definition, primary care is essentially health care delivered at the basic, not highly specialized, level. The implication is that care is delivered at the community entry site, and not a distant referral site. The World Health Organization in 2010 developed a Package of Essential Noncommunicable disease interventions for primary care (WHO-PEN).  The 2016 WHO and Global Hearts Initiative (GHI) published the HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care with multiple hypertension and diabetes protocols. (See more detailed summary in Module VII.P/Q.)

You can think of the stated WHO and similar models as top-to- bottom trickle down approaches where the HEARTS Technical Package targets start from the national, proceed to the sub-national levels, and then to the specific primary care level of the primary care clinic.  Unfortunately, this model tends to not reliably penetrate further than the urban academic and formalized national program levels.  The CIC/WHAG approach is more building from bottom-to-top or bubble up, starting with practitioners in destitute poor mostly rural communities.   

Nevertheless, similar to a dialogue having a center and no sides, there is an obvious middle meeting ground to be found.  It is equally obvious that solution models are not mutually exclusive, but synergistic.  

As noted in multiple intermediate and advanced clinical modules, there are three built from the ground bubble up CIC/WHAG levels, depending upon building a substantial knowledge base and aspirations to higher level of service.  These CIC/WHAG levels are: I. volunteer and community health workers; II. nurses and physician providers; and III. teachers, leaders, and program developers.  Armed with knowledge, the motivated CIC/WHAG on the ground providers have aspirations to grow to level III as teachers and leaders.  It is specifically at that level that those providers meet the WHO trickle down managers and trainers at the cardiovascular primary care level.  This could be the operational definition of integrated and complementary approaches that we all should be aspiring towards!  

As we envision the CIC/WHAG defined steps in the progression, the first three steps are essentially those described as the pre-primary care niche activities.  

STEP ONE:  COMMUNITY BP Screening.  Book Two. Module V.  

STEP TWO:  Training to Measure BP Accurately .  Book Two.  Module VI.  

STEP THREE: Education and Teaching Program.  Book Three. Module VII.  

STEP FOUR: Basic Hypertension Clinic  

You are officially in the primary care realm when you start with a basic hypertension clinic with intervention via individual high-risk counseling and potential medication as the next or fourth step (Book Four, Modules ## VIII, IX, X, XI, XII and XIII, XIV). 

STEP FIVE: Community Anti-Stroke Center  

The fifth step in the progression is the unique community anti-stroke center, related to high-risk stroke prior-vention and post-vention (Module # XVII), HIV (Module # XV), and pregnancy (Module XVI), Book Five, as well as possible treatment of rheumatic fever, anticoagulation and rate prevention for atrial fibrillation (Module # XVIII), Book Six.  

STEP SIX: Cardiovascular Primary Care 

The next and sixth step is a big one, and that is to enter into the realm of what is essentially integrated cardiovascular primary care.  This by definition requires a foray into diabetes education and management starting with first-line metformin (Section VII.I), as well as high blood cholesterol education and potential management, with evaluation of total cardiovascular risk including potential selected medication with WHO EML approved statin drugs.  (Section VIIL.3.). This would also be the appropriate place to begin to address the interaction between hypertension and Chronic Kidney Disease (CKD).   

This top step, in certain circumstances, might be an opportunity to partner with organization such as The Global Heart Initiative and RESOLVE to Save Lives and participation in the HEARTS approach, and to consider adoption of the WHO-PEN NCD protocol for diabetes detection and type 2 diabetes treatment (meaning metformin). 

FINAL STEP: Comprehensive primary care    

The final step is stepping off the ladder to a landing with a name on the door called comprehensive primary care.   When you open the door to grow beyond the limitations of CIC/WHAG mission and capabilities, you hopefully meet new large partners to expand the care mission further to incorporate integrated primary care.  This presents an opportunity for growth of your scope of service via extended network partnerships, having learned the important CIC/WHAG lessons of connecting, coordinating, communicating, collaborating, and most importantly experience and knowledge sharing.    

There is a cited “Meta Leader” negotiation technique called “a walk in the woods”,based on the concept of interest-based negotiation experience between the U.S. and Soviet Union over nuclear weapons.  The lessons learned are that self-interest can be a positive if it is used to build on enlarged and enlightened interests that ultimately become shared interests.  With this concept of acceptable and appropriate self-interest, let us review the “what is in it for me” process as the first step in dialogue with many different groups with an eye towards defining shared interests to build on.    

In order to go beyond generic groupings of potential partners, definable self-interest does require some thought regarding specific situational analyses as well as the closing reflective question in Module III of the Introduction series, “Who am I?”.  For now, let us start with generic group categories:  

We look to build consensus by addressing different constituencies. Let us begin by speaking to individual volunteers.  There is extreme value in your contributions, large or small.  As Martin Luther King enlightened us in his The Drum Major Instinct sermon, “everybody can be great, because everybody (anybody) can serve”.  Thank you for your desire to serve the destitute poor.   

If you have a dream, and if you want to serve, there will be opportunities to make it happen, especially related to modifying core source documents and programs for local use.  If you have brought your hypertension control dream to fruition, we will give you the platform to share your experience as a successful community model for others who may be facing similar challenges.   

 By definition, medical missions are in underserved areas.  It is therefore important that your group interconnect with governmental and other larger organizations performing service in the regions of focus.  It is the ultimate goal of CIC/WHAG to build ICT communication systems to facilitate that process. 

This is hopefully something we in the CIC/WHAG partnership of all faiths can universally agree upon.  Wherever one looks within their own faith tradition, the similar message of service to the poor and disadvantaged is there.  It is in the Judeo-Christian tradition.  It is in the tradition of Islam with strong foundational beliefs in service to the poor and a holistic view of health. The decision to step up to participate in the battle to save millions of anonymous lives across the globe threatened by uncontrolled and untreated hypertension would presumably fit into this broad- based faith inspired framework, and quite worthy of the effort.  It simply requires a change of mind, and an understanding of the importance of this work impacting not just individuals but families and communities.      

To our faith-based brothers and sisters, we say thank you.  You do tremendous work. In the hypertension battle you represent an incredible untapped resource.  We hope to be able to organize your passion and energy in order to leverage change, especially for the destitute poor who deserve our respect and attention

Let us address directly colleagues from Non-Governmental Organizations (NGOS), and let us state unequivocally that WHAG has no intention or desire to become yet anothercompeting NGO looking for advantage in a crowded world stage.  That is not our goal.  Our belief is that every hour that we spend in a reinventing the wheel exercise of marketing and infrastructure development is an hour that is taken away from things that we actually do well.  Rather than competing with existing NGO and other organizations, we look to be the glue that brings together organizations with common cause in an innovative new paradigm.  This collaborative approach takes advantage of other’s strengths and existing organizational prowess, while allowing partnering organizations to more efficiently operate in the hypertension arena via knowledge sharing.  In this way, we can all focus energies on potentially disruptive innovative ways that we can do our jobs better.  

We recognize that metrics and outcome analytics showing fiduciary responsibility for donations, and competition for funding, is a pragmatic reality in the NGO world.  It is quite understandable that there is a tendency to build up walls to survive and thrive in a manufactured parallel competitive universe.   To break down these walls, at some point itrequires trust and a mutual respect that needs to be developed over time.  This is why WHAG shares information, with the intent to empower others to join the team effort with a very favorable cost-benefit ratio.  WHAG has decided to take the first step and is reaching out to offer support to those who share our values.   

Simply put, we are here for you, to support the potential of what you can do!  

To the extent that we accept the validity of the value proposition discussion, and ultimately focus on cost and quality determinants of value in the WHAG Low-Resource Algorithm, there are valid WHAG arguments to be made for both small geographically based and large international focused NGO participation. 

Larger NGOs, especially those who are involved internationally with maternal and HIV programs, are already deeply involved in communities with known patients.  Therefore, they have an inside track on adding high value hypertension intervention including management to existing programs.  Again, the added cost to integrate WHAG approaches to existing programs is minimal compared to a de- novo approach starting from ground zero for other NGOs.  It is a natural alignment, and one to be strongly encouraged.  As a marker of importance, there are specific pregnancy (Module # XVI) and HIV (Module # XV) advanced hypertension modules available for your review in Book Five.    

The comprehensive discussions of alcohol and tobacco abuse are covered in detail in Education Book Three, Module VII.  Specifically discussed are UN SDG #3A to strengthen and implement the WHO Framework Convention on Tobacco Control (FCTC) in VII.C.1.c., and UN SDG #3.5 for the prevention and treatment of substance abuse, including narcotic abuse and harmful use of alcohol in VII.D.1.a(b).   

The 2000 UN Millennium Goal (MDG) # 5 to improve maternal health is also a very high CIC/WHAG priority, as is the 2015 UN Sustainable Goal (SDG) to decrease the global Maternal Mortality Rate by 2030.   (see Book Five, Module XVI.C., and Figures 12 and 13).  

In both general and specific terms, the comprehensive CIC/WHAG program is supportive of and within the framework of both the UN Millennium (MDG) and Sustainable Development (SDG) Goals. 

This changes the landscape.  From a scenario where it would not be a realistic expectation for FBO and NGO groups to give up their identity in order to simply donate funds to the governmental organizations, they can augment their roles and reputations by assuming functions that they can do well in a comprehensive network while complementing and supporting governmental institutional efforts.  This would then free up resources that may be better spent on the primary care management and treatment ends of the integrated spectrum.   

Larger NGOs may be able to extend efforts into primary care clinics, and do it well, potentially in underserved regions where there is inadequate resource for government–mediated support.  The beauty of this approach comes back to value, driven not by competition but by collaboration and the ability to deliver a desired outcome at a low cost. With demonstrated equal to improved quality at a lower (essentially subsidized) cost, by definition value is increased and high.  Obviously, with collective outcomes far exceeding what individual components could achieve on their own, this is something that all participating partners can identify with, and take pride in.   It is the whole that both fills the holes, and is larger than the sum of the parts.  

The major contribution that national governments could make, whether at the UN Ambassador or Ministry of Health and National Administrative levels, is to have an accurate list of the NGOs and FBOs working in their impacted at-risk regions.  This has to be more than a simple laundry list, but should be accompanied by an assessment of which organizations are known to cooperate and collaborate well with others including the Ministry of Health.  In this way, with more selective recruitment of strong FBO and NGO organizations with shared goals and values, the functional integrated hypertension network can be developed more effectively and efficiently. The greater the number of collaborators, the greater the reach. 

Foundations could support by implementing a system of financial incentives that go beyond the status quo of verbiage and paper relationships that check the box while giving only lip service to effective true collaboration.   Reward for vibrant mutually beneficial partnerships that enhance novel approaches to the refractory challenge of low-income country hypertension control could leverage outcomes that would represent substantial foundation Return On Investment (ROI).   

For all, we hope that you come away with a sense about CIC/WHAG that “they get it”and that “they are talking to me”.   

Therefore, we supply this very detailed information as the defined knowledge base nutritionally sound menu.  Your choice is based on where you are, and what you need to do in order get to the place where you are able to do the right things right and have an impact.  It is your individual and collective decision, driven by your appetite for knowledge and the number and volume of meals you are interested in partaking in.  We are simply extending our hand to assist and support your journey in any way possible, and to prepare the meal.  

You can think of the education and training modules as a multi-layer cake of up to twenty- five variable size wedge slices (also potentially cut into large book slices).   Within the e-education module wedges, you could start with the superficial frosting.  This is found in the CIC web site quick introductory WHAG information and a mind–map flow of interconnected concepts and links.  From there, you could go deeper to relatively quick introductory bulletpoint hypertension information via a text box summary. These text boxes are identified by logoas either CIC Knowledge Point or WHAG Action Point, depending upon whether it is something you should know, or something you should do.   

Book Seven may offer advanced leadership topics such as ICT, stakeholder relations, logistics and supply chain management, and social determinants of health and disease, and may be considered an beverage to relax with after a dense clinical meal. In more practical terms, let us consider the CIC/WHAG Menu as somewhat of a table of contents, as outlined below. As an organizational structure, all modules, sections, and subsections are identified by a hierarchy of alphabetical and numerical descriptors. You can then use this organizational structure to drill down deeper into specific modules in order to explore specific topics by page number. By use of fishbone and other organizational tools, it is hoped that extensive cross-referencing will by very beneficial as explore the total compendium of knowledge. The expanded table of contents organization allows cross-pollination across multiple modules, and there are also multiple internally described links between sections and subsections within modules. There will also be resources as a glossary and definition of terms.

By definition, these references and resources are frozen in time, relative to the initialmodule publication.  The ultimate goal is to put the composite extensive summary of references and resources on the website, and using the community support making this a dynamic source of updated vetted references and resources important to the world of hypertension in low-resource venues,  as more of a living (rather than fixed in time historic)document.  

In addition, there may be practical handbooks for practitioners.   The most comprehensive is the Module # VI. Supplement Handbook on BP measurement, focusing onauscultatory/ manual technique and device calibration issues important in low-resource venues   There are also multiple educational videos and apps for BP screening and BP measurement.   

This variable approach has been taken with the understanding that all learn differently.  There is also an intimidation factor, and we clearly recognize that a very small minority of patrons would be motivated to just sit down and read the whole compendium.  In reality,because of the comprehensive nature of what is being presented, you actually could not digest the whole meal at once.   For this reason, there are different strategy options and many tools in the CIC/WHAG toolbox. 

• Always start with a blank piece of paper 
• Listen, listen attentively, and then listen creatively 
• Turn preconception into a creative process 
• True dialogue is not a debate, and you need to avoid the sides 
• From the center, especially important when outside your comfort zone, listen to and learn from all expert opinion 
• Disruptive and catalytic innovation is all about helping individuals (and through them communities) to do their defined jobs better 
• Embrace your inherent unselfish self-interest to share with others as a growing combined interest 
• Remember that programs for low-income/low-resource communities cannot be simply “High Income LITE” versions  
• Never accept that there is only one solution for all.  Think of viable alternative solutions, and then ask “why not here?” and “why not now?” 
• Connect, Communicate, Coordinate, and Collaborate.  Remember the 4 C’s!  

We have completed the “circle of what” and we are back where we started. 

Our goal and mission are simple:   BRINGING TOGETHER THOSE UNITED IN THE PASSION TO ALLEVIATE INDIVIDUAL, FAMILY, AND COMMUNITY SUFFERING DUE TO THE RAVAGES OF UNCONTROLLED HYPERTENSION IN LOW RESOURCE VENUES 

We must do a better job working together.