MODULE #II.   CIC/WHAG: THE CIRCLE OF WHAT   

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 As we enter the circle of what, we find both questions and answers.  The conjecture questions start with “what if?” and then we offer some answers to questions in the form of “what is”.    Consider that we begin at sunset in the west.  There are no obstruction-induced shadows at night.  It is a time for unencumbered free thought, and aspirations. It is a time for “what if conjecture, even while dreaming with the stars.  With sunrise in the east, there is the “what is” light of objective reality.  Obstructions may now cast long shadows.  With progressively harsher sunlight, there is the generation of heat.  Thermal energy of heat may lead to a cooling afternoon sea breeze, but also may generate severe thunderstorms.   As we enter into our CIC/WHAG “circle of what”, we shall explore both dimensions of the aspirational and subjective “what if” and the definitional objective “what is”?  

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Keep going...

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?

II.A. THE WHAT IF QUESTIONS 

II.A.1 WHAT IF YOU HAD A BLANK PIECE OF PAPER?  

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What if you decided to take a novel catalytic innovation approach to develop a vision that is completely unbiased by preconceptions?   

What if you evaluated conventional wisdom and existing professional expert evidence-based opinions about what is right and proper for the developed world, absorbed the important knowledge-based information, but not narrowly defined directions?   

What if you then asked the question “If you had a blank piece of paper, how would you design a system to address the hypertension needs of low-income communities differently? 

We started with a blank piece of paper  

II.A.2.  WHAT IF YOU OPENED A SPECIFIC AND FOCUSED HYPERTENSION IN LOW-RESOURCE VENUES DIALOGUE?   

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What if you decided to take a novel catalytic innovation approach to develop a vision that is completely unbiased by preconceptions?   

What if you evaluated conventional wisdom and existing professional expert evidence-based opinions about what is right and proper for the developed world, absorbed the important knowledge-based information, but not narrowly defined directions?   

What if you then asked the question “If you had a blank piece of paper, how would you design a system to address the hypertension needs of low-income communities differently? 

We started with a blank piece of paper  

Preconception...

II.A.2.a. WHAT IF WE RE-DEFINED PRECONCEPTION AS A CREATIVE PROCESS?   

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Often, when we speak of preconception as a noun, we think of mind-set restrictions.  What if we considered preconception as the dynamic and creative phase that begins the birthing process for both individual persons and models?  

Collaboration that is only on a superficial level is limited and at significant risk of failure.  It only leads to an additive process of assembled existing parts that may end up as a random or re-sorted piecemeal collection of preconceived notions and ideas.  It will not evolve to maximally adapt to effectively function in a changed environment with paucity of resources. This level of defined preconception is a usually negative and a hinderance.

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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 creativnew model approach is more than a play on words.  It is an important choice for you to make.

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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?  

II.A.2.b. LANGUAGE AND COMMUNICATION VERSUS TRUE DIALOGUE  

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Presumably at some basic level we all understand the importance of communication, but what does that really mean? As we communicate, are we simply sharing focused and limited verbal or digital information?  Does our conversation represent a beginning or an end of the interaction?  William Isaacs at the MIT Dialogue Project and the author of Dialogue and the Art of Thinking Together has written about the difference between discussion with the goal to wrap up a process, and dialogue with the goal to open doors of possibility.  It is not only the process of talking and thinking together.  Potentially more importantly, it is also about shared listening which is often the genesis of unanticipated possibilities that we never would have thought about alone.  

Keep going..

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. 

II.A.3.  WHAT IF YOU DEVELOPED A BROADENED BASE OF WHAT IS CONSIDERED TO BE EXPERT OPINION?   

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What if you did not limit the dialogue to those with demonstrated hypertension expertise and leadership, and included those who may have no differential expertise in hypertension at all?  What if your search and recruitment was for those individuals who have demonstrated problem-solving acumen, with a vigorous leadership style and strength that is more horizontally than vertically oriented?   

What if..

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?  

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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. 

II.B. WHAT IS QUESTIONS AND POSSIBLE ANSWERS

We now shift from the aspirational questions to the more definitional answers, to discuss “what is?”.   

II.B.1.  WHAT IS THE HYPERTENSION IN LOW-RESOURCE VENUE EXPLORATORY TEAM 

DFZ. DENSE FACTUAL INFORMATION ABOUT COLLEAGUES IN CARE OR PARTNER ORGANIZATIONS.

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As we began the brainstorming process, the exploratory team grew somewhat organically. It all began with an introduction by IBM veterans Robert St Thomas and Lisa Smith for Colleagues In Care to present their experience with CollaborHaitian as a program of collaborative medical learning in low-income countries, using the IBM Smart Cloud platform.  Robert is now retired from IBM, but continues work with IBM Smart Small city initiatives uniting his Information Communication Technology (ICT) and faith-based passions, has been involved with WHAG from conception and is now a CIC Board member

Lisa Smith has thirty-five years of IBM healthcare related experience focused on problem solving and solution development, and is a founding member of CIC.  The sentinel CIC presentation was for the INFOPOVERTY Group meeting at the UN, focused on ICT in low-income countries.  The Haiti Hypertension Best Possible Practice approach was used as an initial example.   

 

Quickly the dialogue shifted from ICT as a tool, to a dialogue on hypertension in low-income countries.  Subsequent UN presentations focused on hypertension and ICT for UN designated Small Islands and Developing States (SIDS) as well as Least Developed Countries (LDC), as Haiti has the distinction of being both.

Amjad Umar MS, PhD, who in addition to being the chief architect and director of the UN SIDS partnership, is Director and Professor of Information Systems Engineering and Management (ISEM) Program at Harrisburg University, and became very actively involved in expanding the hypertension in low-income venue dialogue.  Another critical “UN phase” advisory participant was Dr. Abraham Joseph PhD who has extensive experience in socio-political policy and development practice and very involved in Timor-Leste, as well as an advisor at the Public Service Institute at the University of Oklahoma.   

We listened to many Ambassadors and leaders and we heard a different hypertension perspective from many smaller low-income countries and islands from the Solomon Islands to Madagascar, Tonga, and the Caribbean including Jamaica and Haiti.  Through our colleagues, we also developed a better understanding about much larger low-resource venues such as Pakistan.  The lessons learned included a realization that if you are trying to change the world, and going to deal with governmental organizations, perhaps it is better to consider smaller well defined geographic spaces with limited number of leaders and political crosswinds to deal with.   

Beyond Dr Joseph, we learned much from Dr John Steffens PhD, the Executive Director of University of Oklahoma Outreach and the Public Service Institute (PSI), including   introduction to the importance of the faith community leaders as stakeholders.  CIC introduced the discussion of innovative hypertension programs to faith-based and other low-income country stakeholders at another University of Oklahoma sponsored UN conference.

The natural evolution morphed from stakeholders in general into the question of why not build on the CIC experience in medical missions, and specifically FBO and small NGO organizations in low-resource venues.  The dialogue on FBO and NGOs was wide ranging, from the Committee of Religious NGOs at the UN, to large Evangelical International Faith-Based Organizations, many Christian Denominations with global mission in some cases literally sending out multiple medical missions on a weekly basis.  The dialogue covered a wide spectrum even within single Faith-Based groups, for example from international Catholic Charities and Caritas to the more than 400 smallsized individual Catholic “twinning parishes” that are in local communities in Haiti alone.   

II.B.2.  “WHAT IS” SO SPECIAL ABOUT LOW-RESOURCE VENUES? 

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If we were to do classic SWOT planning analysis (Strength, Weakness, Opportunity, Threat), this is the obvious weakness and an imminent threat to low-resource communities.  We all know and accept that, and it could be an excuse to do nothing, but let us choose to look from a different vantage point.  It is also an opportunity. 

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“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. 

II.B.2.a. WHAT IS THE UNDERESTIMATED SPECIFIC STRENGTH AND OPPORTUNITY FOUND IN LOW-RESOURCE VENUES, AND IS IT PART OF A POSSIBLE ANSWER?

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Simply put, our CIC/WHAG goal is to get from the clearly identified present “holes to the potential future as a new “whole.  The less simply stated proposed solution is to find innovative ways to develop systems that go beyond present archetypes in order to develop alternativnon-traditional resources to supplement and complement existing traditional systems for critical hypertension diagnosis and control requisite activities.   

Keep going..

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. 

Almost there...

When we visit and examine strength in low-resource venueswe 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.  

That's it!

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.

II.B.3. WHAT IS PRE-PRIMARY CARE, AND CAN A HYPERTENSION PRE-PRIMARY CARE NICHE BE PART OF A POSSIBLE ANSWER? 

Start Here...

Presumably at some basic level we all understand the importance of communication, but what does that really mean? As we communicate, are we simply sharing focused and limited verbal or digital information?  Does our conversation represent a beginning or an end of the interaction?  William Isaacs at the MIT Dialogue Project and the author of Dialogue and the Art of Thinking Together has written about the difference between discussion with the goal to wrap up a process, and dialogue with the goal to open doors of possibility.  It is not only the process of talking and thinking together.  Potentially more importantly, it is also about shared listening which is often the genesis of unanticipated possibilities that we never would have thought about alone.  

Keep going..

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. 

Keep Reading...

The concept of primary care as a medical management focus is very important, and something that we will ultimately approach as a stepwise 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.  

Almost there...

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.   

Just about...

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”.  

II.B.4. WHAT IS THE CIC/WHAG APPROACH, AND IS IT A POSSIBLE ANSWER   

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Instead of World Hypertension Action Group, WHAG could easily also stand for World Hypertension Audacious Goals.  WHAG is audacious in the belief that we need to start small with simple disruptive innovation good enough solutions, called catalytic innovations when done for social change. These are solutions that are flexible according to circumstance, with the common thread of helping multi-level practitioners to do their job better.  Incorporating low-cost volunteers and community health workers, armed with a defined knowledge base in support of integrated comprehensive management algorithms, may have the highest dividends.  

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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.  

II.B.4.a.    WHAT IS THE CIC/WHAG HAMMER AND NAIL MODEL?

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The CIC/WHAG Hammer and Nail conceptual model graphic was first developed by Colleagues In Care, as an attempt to illustrate how to incorporate a hybrid traditional and non-traditional hypertension work force into the spectrum of care from pre-primary care to primary care levels. The transition to management is the general dividing point between pre-primary and primary care activities, either in fixed or mobile clinic scenarios.  Requisite servicerelated tasks and performance standards for all participants are outlined clearly by a defined comprehensive knowledge base represented by the core curriculum series of essential (Book Two) and education (Book three) modules. When we move into primary care and management, Book Four in essence is the nexus of what we need to know, and how we need to do it.  

II.B.4.b. WHAT IS THE RELATIONSHIP BETWEEN EDUCATION MODULES AND THE CIC/WHAG HAMMER AND NAIL MODEL? 

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At the tip of the nail, the sharp point of community entry for community-based hypertension is that of BP Screening, according to standardized approaches and a priori decisions on the scope of the activity and data collection efforts. (Module #V).   

Accurate BP measurement is an absolute necessity not only for BP screening, but for hypertension diagnosis and management.  This requires standardized training and specific documentation of skills.  (Module #VI and VI Supplement handbook).  Accurate BP measurement contributes to the strength of the nail, from BP screening, to diagnosis, prognosis, treatment and control.  This is Book Two, The Essentials.  

The core curriculum modules are integral to the CIC/WHAG integrated system.  

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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 teachingBook 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...

The education module builds on the WHO/UN “4×4” approach of the identified four most important Non-Communicable Diseases (NCDsincluding 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: 

Knowledge Points

Risk Factors

#1

MODIFIABLE: 

  • Harmful Use of Tobacco
  • Harmful Use of Alcohol
  • Physical Inactivity, Sitting, and Screen Time
  • Harmful Dietary Choices, Including Trans-Fats and Refined Sugars
  • Obesity, Visceral Adiposity (Fat Belly)

#2

METABOLIC AND PARTIALLY MODIFIABLE

  • Insulin Resistance and Type 2 Diabetes
  • Dyslipidemia, Including High LDL Cholesterol and Triglycerides, Low HDL
  • Metabolic Syndrome
Just about finished...

Beyond a simple BP number, prognostication requires an understanding of total cardiovascular risk.  Multiple risk models are discussed, with bottom line prioritization recommendations for updated WHO and ACC Risk Calculators, as part of a total risk evaluation strategy.  

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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 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.  

II.B.4.c.  WHAT IS THE IMPORTANCE OF THE CIC/WHAG HAMMER AND NAIL MODEL AS AN INTEGRATED SYSTEM?  

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It is important to realize that the hammer and nail system is indeed an integrated system. If you do not have the hammer of appropriate medications, you will not be able to effectively drive the nail at the management flange point of impact for clinics, and you certainly will not be able to grow to higher levels of clinical care. Hence, the importance of realistic budgeting, and attention to supply chain management. 

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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.   

Keep it up..

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 togetherwith 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. 

You did it!

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  

II.B.5. WHAT IS” THE IMPORTANCE OF DATA COLLECTION IN THE CIC/WHAG MODEL? LOCAL DATA BASE FOCUS AND LINE OF INFERENCE    

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While CIC/WHAG has ICT differential expertise and computer capacity for data base collection, we are taking a different approach.  WHAG data base capability is not specifically for research or publication purposes. Data is not to be sold. Participation in international data bases such as ISH/WHL is optional, though highly encouraged.  Elective data collection is for the specific use by partnering groups to make datadriven decisions in order to support endeavors to do their job better.  Locally generated community BP screening data will be a first step in the WHAG algorithm for BP Management in Low Resource Venues that goes beyond standard medical recommendations that are not fine-tuned for local realities.   

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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.  

II.C.  WHAT IS” EXACTLY THE MEANING OF PRIMARY CARE? 

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The hammer and nail model emphasizes medical management as the transition point between pre-primary care and primary care activities.  In reality, that is only the beginning of the journey as the destination is not adequately defined.  What is then required is a closer focus on defining what comes under the rubric of “primary care”.   

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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.)

II.C.1. WHAT IS THE STRATIFICATION WITHIN CARDIOVASCULAR AND COMPREHENSIVE PRIMARY CARE LEVELS 

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Theoretically, there should be no stratification of levels, as ultimately the goal is an integrated system where pre-primary care interfaces seamlessly with primary care clinics, even if geographically separate.  It is all about teamwork and effective hand-offs. 

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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 

II.C.2. WHAT IS THE PRE-PRIMARY CARE TO CARDIOVASCULAR PRIMARY CARE GRADIENT, AND IS IT A POSSIBLE ANSWER? 

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Let us then step back and look at the gradient, not as distinct points but as an integrated process.  It has been stated that with respect to the WHO HEARTS Technical Package for Cardiovascular Disease Management in Primary Health Care the “people who will find the modules most useful”  are:  Ministry of Health NCD policy makers at the national level; health/NCD program managers at the sub-national level; facility managers and primary health care trainers  at the primary care levels.   

Keep going..

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!  

II.C.3.  WHAT IS THE CIC/WHAG INTEGRATED HYPERTENSION PROGRAM LADDER, HOW DO YOU CLIMB THE STEPS, AND IS IT A POSSIBLE ANSWER? 

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Theoretically, there should be no stratification of levels, as ultimately the goal is an integrated system where pre-primary care interfaces seamlessly with primary care clinics, even if geographically separate.  It is all about teamwork and effective hand-offs. 

Image break...

Keep going..

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 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 partnershipshaving learned the important CIC/WHAG lessons of connecting, coordinating, communicating, collaborating, and most importantly experience and knowledge sharing.    

II.D. WHAT IS IN IT FOR ME/US? MOVING TOWARDS THE SHARED INTEREST BOTTOM LINE  

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To speak to the concept of self-interest for some would appear that you are casting aspersions upon individuals or organizations.  In reality, though we might all consider ourselves altruistic or unselfish, the world does revolve around a healthy degree of self-interest.  What is important is to make sure that the self-interest does not evolve into selfish-interest.   

The "Meta Leader"..

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.    

Continue...

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:  

II.D.1.  INDIVIDUAL VOLUNTEERS 

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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.   

We look to build....

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..

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.   

II.D.2.  MEDICAL MISSIONS 

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If you are a part of a medical mission, whether large or small, it is important that you take the time to evaluate where you are both geographically and developmentally, using theCIC/WHAG situational awareness tool in Module IV.  This will give a reality-based assessment of what it will take for your mission to be successful and sustainable, and will allow a clear view of mission goals.  Whether pre- primary or primary care defined intent, all participants should be comfortable with the core module Book Two Essentials materials, starting with BP screening and measurement, as well as Book Three Education.  If treating patients, then you need to also master the information in the Book four on management, medication, adherence, and use the algorithm needs assessment and evaluation tools including branch pointsBooks Five and Six advanced medical modules may not be appropriate for all levels, but always available as a resource.  

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 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. 

II.D.3.  FAITH-BASED ORGANIZATIONS

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If you are part of a Faith-Based Organization (FBO), from the local parish to the international level, thank you for living your faith through service. All faiths have a foundation in concepts of social justice and service, and many gravitate towards areas of low resource and severe poverty for medical missionary outreach.  Presumably, this includes an understanding that extreme poverty increases both morbidity and mortality risk on multiple fronts, and the importance of social determinants of health and disease. The needs are many, and we are all humbled by the enormity.   As CIC/WHAG, we are now challenging FBOs with the recognition that hypertension causes more deaths than other NCD or all infections combined, and that it should at least be considered as one more arrow in the coordinated FBO outreach quiver.    

II.D.3.a.   METANOIA  

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Some in Christian traditions believe that there should be a preferential option for the poor.  That would suggest a belief that people in the bottom billion should not die from the consequences of uncontrolled and untreated hypertension, just because they are poor and without appropriate resources.   This requires metanoia, or a change of mind, in the secular sense of transformation from being separate from to interconnected with the world.  The Catholic Christian tradition, as reflected by the writings of Thomas Merton and Anthony de Mello, speaks of metanoia in the framework of “repentance” as a total change of heart and mind turning away from selfishness to God.  The exhortation, building on the secular golden rule, is to love your neighbor as yourself (Luke 10:27) or even on a higher level the command to love one another as I have loved you (Luke 15:12).   

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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.      

Keep up the good work...

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

II.D.4.  NON-GOVERNMENTAL ORGANIZATIONS

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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.  

Keep going..

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.  

Done!

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!  

 

II.D.4.a. VALUES AND VALUE 

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Beyond shared values, we would also like to address the value proposition that is the basis of the modular CIC/ WHAG education approach.  As the first step along the values and value pathway, we suggest a broad-based adoption and philosophical commitment to theCIC/WHAG R-7** Strategy of doing the right things right.  Specifically, that means that after appropriate BP screening and hypertension diagnosis, assurance that you have the right provider, doing the right thing, the right way, to the right patient, at the right time, in the right place, at the right cost.  This is all superimposed upon the assumption that * access to knowledge is a professional right, and that * access to basic hypertension services is a human right.    

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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. 

II.D.4.b.  SMALL TO MODERATE SIZE NON-GOVERNMENTAL ORGANIZATIONS 

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Small to moderate sized NGOs could start with hypertension screening and education as an adjunct to present community activities at a small cost. The overt benefit of enlarging their service footprint reputation in a high risk and return patient subset may translate into a higher value for donors supporting the NGO mission.  Most donors may have a personal, family, or friend experience with the adverse consequences of hypertension that they can identify with.  For example, NGOs with outreach to the community for nutritional and school support could easily incorporate BP screening and education.   

II.D.4.c.  LARGER SIZE NON-GOVERNMENTAL ORGANIZATIONS  

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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   

Keep going..

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   

II.D.5. GLOBAL (INTERNATIONAL) HEALTH ORGANIZATIONS  

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Let us next initiate a family dialogue with international health organizations by saying that we are indeed humbled by the enormity.  We are humbled by the enormity of the task, even when interventions are aimed at a more limited Non-Communicable Disease NCD target of hypertension and cardiovascular disease.  

We are also humbled by the enormity of the long record of success demonstrated by excellent large organizations such as WHO, AHA, the UN, ISH and WHL. WHAG strongly endorses the vanguard approach taken by WHL in 2016 spearheading an urgent and important call to arms for high blood pressure prevention and control.  

II.D.5.a. UNITED NATIONS SUSTAINABLE DEVELOPMENT GOALS (SDG)   

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Health is fundamental to human development, and healthy people are critical to sustaining societies.  Starting with hypertension as the most impactful Non-Communicable Disease (NCD), if we are to ever realize the aggressive large scale 2030 UN Sustainable Development Goals (SDG), specifically related to goal 3- Good Health and Well-Being, we need to do better in global hypertension control.  UN SDG 3.4 is more specific and pertinent– a one-third reduction, relative to 2015, in the risk of death at ages between 30 and 70 years old from cancers, cardiovascular diseases, chronic respiratory diseases and diabetes by 2030.  As of the recent third UN High-Level Meeting on Non-Communicable Diseases (NCD) on September 27, 2018goals have been met for only 35 countries (16%) for women and 30(16%) for men.  This disappointing timely data reporting buttresses the WHAG argument that we will urgently need a “no potential resource left behind” integrated novel approach that extends well beyond the status quo.   

The comprehensive discussion..

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).   

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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. 

II.D.6.  PRIMARY CARE CLINICS AND FINANCIAL CHALLENGES  

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The challenge, as observed after many years of effort in living laboratory lowresource countries such as Haiti, is that programs that are focused on the primary care entry level are difficult to fund adequately long term in the absence of strong local, regional, and national financial supportThere is then a binary go/no go decision made.  

Unfortunately, the lack of sustainable and reliable funding does not allow support of demonstrated quality programs with adequate outreach breadth and depth through this solo public health avenue alone.  This challenging problem is manifest by a demonstrated increasing hypertension control gap between high-income and mid-income countries as compared to low- income countries.  Appropriately, whenever possible, the approach should be to support in-country public health and health ministry efforts by virtue of collaboration and cooperation.

II.D.6.a. POTENTIAL NOVEL SOLUTIONS  

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For our FBO and NGO partners, the observation that has been made is that there is an almost reciprocal relationship between the weakness of national public health infrastructure in low- income countries, and the involvement of FBOs and NGOs. Living in that gap successfully is our challenge.  Fortunately, every problem is also an opportunity.  The opportunity thatCIC/WHAG has identified is the ability to organize and leverage FBOs and small to moderate size NGOs to transform from a cottage industry to an effective hypertension work force.  Services provided by FBO and NGO collaborating “volunteers” with independent support is essentially a form of subsidy that is available by virtue of collaboration and inter-connectivity.   

This changes the landscape..

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.   

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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 governmentmediated 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.  

II.D.7.  GOVERNMENTS  

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This is an appropriately timed segue into the government organizational dialogue. CIC/WHAG has focused on the UN Small Island and Developing States (SIDS) hypertension efforts, via a broad-based ICT initiative partner.  Similarly, WHAG has evaluated small scale hypertension model evaluation in other UN Least Developed Countries (LDC) with the common bond of low resource.  The attraction is the ability to start with small and simple model programs with well identified partners capable of effecting change.  Once you have models of proven efficacy that are built up and tempered by local circumstance and buy-in, rather than trickled down as an absolute mandate, the simple models can be scalable for larger area penetration to test and build up from the ground up.  

II.D.7.a.  NATIONAL GUIDELINES, FORMULARIES, AND A DEVELOPED CENTRAL LIST OF PLAYERS 

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Though there is often antagonism towards good enough solutions with a tendency to want an unattainable ideal, governments may enable the simple WHAG approach as a first step.  As a major step forward, governments are strongly encouraged to get behind and endorse realistic national hypertension guidelines, as well as a national formulary of approved hypertension drugs at lowest possible cost.   

The major contribution...

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. 

II.D.8.  MEDICAL INDUSTRY AND BUSINESS 

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Industry endorsement of the WHAG program approach is also important. Obviously, the greater the outreach, the greater the potential for medical industry and business support and input, specifically related to medications, devices, and technology.  One might presume that there are opportunities even in low-income countries for goods and services to support a well-organized vigorous hypertension control effort.  Communication with industry is important as a minimum.  One important example might include engaging in dialogue about the high sugar and sodium in processed food and drink and its contribution to hypertension and CV Disease sequelae.  This is a process that has been initiated in high-income countries and the Caribbean with impact 

There are also very valuable lessons to be learned from business and business consultants as medical systems are developed, and WHAG is paying attention.  

II.D.9.  FOUNDATIONS  

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Finally, let us initiate an all-important dialogue with foundations.   By virtue of the ability to make funding decisions, large foundations are in an influential position to be able to set priority agendas and define narratives by framing questions.  If WHAG aspires to be the glue, also need the all-important mortar to bind together chosen larger building blocks.  Perhaps that is why they are called foundational!   

II.D.9.a.   INCENTIVES FOR INTERCONNECTIVITY IN SUPPORT OF A COMMON VISION  

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Foundations could enable the WHAG approach as an integrated, simple, flexible, and presumably inexpensive overhead model for first step implementation.  Perhaps more importantly, foundations could encourage inter-connectivity by incentivizing larger organizations to function as hubs to support smaller group spokes.  As a complement to governmental run regional clinics, trained and vetted physicians in supported FBO/ NGO local primary care clinics would act as referral support for outreach teams.  This would function as transition from pre-primary care to medical management and treatment initiation in the stepladder primary care progression described.  In selected circumstances, this might mean oversight based on the WHAG hypertension protocols, and the use of telemedicine, which would allow monitoring of medical therapy virtually off site.    

Keep going..

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”.   

II.E.  A PERSONAL INVITATION TO THE EDUCATION AND TRAINING FEAST 

II.E.  A PERSONAL INVITATION TO THE EDUCATION AND TRAINING FEAST  

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Our low-resource venue approach is quite different, and with different expectations. Think of it as a high-volume self-service buffet, and not a fixed menu meal served by others.While we happily serve individuals, we are also oriented towards serving shared interest groups 

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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 

II.E.1.a.  WHAT IS IT ABOUT FISH? 

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In education Module VII.F.2.e.i. we discuss the dietary benefits of high Omega-3 Poly Unsaturated Fatty Acid (PUFA) cold water fish such as tuna, salmon, mackerel, etc. It goes deeper than that.   

Recall the adage that if you give a man a fish you feed him for a day; teach a man to fish and your feed him for a lifetime.  By bringing together all the necessary resources in one easily accessible place, our goal is more than to feed one person. The ambitious goal is no less than to turn active participants into fishing leaders and teachers, able to use the flexible tools and what has been learned to feed and satisfy the knowledge appetite of many others. To do so would be a truly shared blessing. 

It goes even deeper still.  Once you clean the fish, there is also benefit of the fishbone skeleton!  We will be using the fishbone organizational model as a way to navigate the compendium of modules and pertinent sections. 

II.E.1.b.  WHAT IS IT ABOUT DESSERT?  THE MULTI-LAYERED CAKE 

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We are committed to the use of the most sophisticated social learning ICT and e-education tools on the CIC/WHAG website.  Despite the high technology options, the fact is thatyou cannot get there by an average 34 or even up to a maximum 140-240 charactertweet!   It is more complex than that, but there are options available.  

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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 wedgesyou could start with the superficial frosting.  This is found in the CIC web site quick introductory WHAG information and a mindmap 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.   

DFZ. All CATEGORIES

ACTION POINT

This is section is a DFZ and Action Point

Navigate to enter content 

We are using cutting edge technology to facilitate the introduction to key concepts, and there is an easily accessible intermediate layer of video take-home messages and apps.   

However, if you believe in the primacy of knowledge, at some point you will need to make the decision whether or not to delve deeper.  The foundational source documents are comprehensive and dense, and it may be that it is initially appropriate to skip over certain sections or to place a bookmark to come back to.  

 

When you do so, there are certain navigation tools (outlined in I.B.1.a.) with areas identified as optional color-coded Dense Fact Zones or DFZsorted generally as:  dense factual information about pathophysiology, pharmacology, biochemistry, or engineering; dense factual information from literature reviewdense factual information about global guidelines or international organization statementsor even dense factual information about Colleagues In Care or partner organizations.  

Navigation through the substantial amount of important knowledge information presented, especially in Education Book Three, will take experience and the development of comfort in the optimal use of the Knowledge toolbox.  Like any new large project, this will take patience to work out a strategy and tactics that work best for you and your learning style.  

II.F. WHAT IS SPECIFICALLY ON THE CIC/WHAG MENU?

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Theoretically, there should be no stratification of levels, as ultimately the goal is an integrated system where pre-primary care interfaces seamlessly with primary care clinics, even if geographically separate.  It is all about teamwork and effective hand-offs. 

Image break...

II.F.1. THE CIC/WHAG MENU AS THE KNOWLEDGE BASE TABLE OF CONTENTS

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As we present the CIC/ WHAG menu, you might consider it a multi-course meal which is an unusual but effective analogy for low resource and potentially nutritionally challenged and food insecure venues. The first course is Book One with four modules as introduction of why, what and who as well as situational analysis, which might be considered the appetizer. Another early course is Book Two, The Essentials of BP Screening and BP Measurement, which is a relatively light soup. The main courses could consist of Series Book Three on education as a very large salad, and Book Four as the seven modules on basic hypertension management is the main course. The final dessert courses of Book Five and Six include advanced modules on hypertension interaction in other complex medical conditions, choices that may not be of interest for all after a large meal. 

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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.

CIC/ WHAG MENU (Table of Contents)

TABLE OF CONTENTS: 

BOOK ONE: INTRODUCTION   

MODULES 

#I.  CIC/WHAG: THE WHY QUESTIONS 

#II.  CIC/WHAG: THE CIRCLE OF WHAT 

#III.  CIC/WHAG: WHO IS WHO.  THE IMPORTANCE OF INTERCONNECTIVITY 

#IV.  SITUATIONAL AWARENESS 

 

BOOK TWO: THE ESSENTIALS 

MODULES 

#V.  COMMUNITY BP SCREENING 

# VI.  ACCURATE BP MEASUREMENT 

#VI. SUPPLEMENT.   2020 CIC BP MEASUREMENT HANDBOOK 

 

BOOK THREE: EDUCATION CORE CURRICULUM  

MODULES 

#VII.  EDUCATION: WHAT WE SHOULD LEARN AND TEACH 

 

BOOK FOUR: HYPERTENSION MANAGEMENT 

MODULES 

#VIII.  MEDICAL MANAGEMENT 

#IX.  MEDICATIONS/THERAPY  

#X.  MEDICAL ADHERENCE 

#XI.  COMPREHENSIVE NEEDS ASSESSMENT:  EVALUATION AND TREATMENT REVIEW 

#XII.  WHAG HYPERTENSION IN LOW-RESOURCE VENUES: PROTOCOL ALGORITHM FLOW CHART DESCRIPTION  

#XIII. A.  TESTING AND PROGNOSIS: PROTEINURIA (URINE DIPSTICK) PIVOT POINT  

#XIII. B. TESTING AND PROGNOSIS: LEFT VENTRICULAR HYPERTROPHY (LVH) PIVOT POINT 

#XIV.  HYPERTENSION AND ETHNICITY: AFRICAN ANCESTRY PIVOT POINT 

 

BOOK FIVE: HYPERTENSION AND ADVANCED CLINICAL CONDITIONS 

MODULES 

#XV.  HYPERTENSION AND HIV 

#XVI.  MANAGEMENT OF HYPERTENSION THROUGHOUT A WOMEN’S LIFETIME: CHILD-BEARING YEARS, AND HYPERTENSION IN PREGNANCY 

#XVII.  HYPERTENSION AND STROKE 

 

BOOK SIX: HYPERTENSIONTHE HEART AND THE KIDNEY  

#XVIII.  HYPERTENSION AND HEART DISEASE: ATRIAL FIBRILLATION/ RHEUMATIC HEART DISEASE 

#XIX.  HYPERTENSION AND HEART DISEASE: CORONARY ARTERY DISEASE 

#XX.  HYPERTENSION AND HEART DISEASE:  HEART FAILURE 

#XXI.  HYPERTENSION AND THE KIDNEY, THE CYCLE OF CHRONIC KIDNEY DISEASE 

 

BOOK SEVEN: ADVANCED LEADERSHIP 

#XXII.  SOCIAL DETERMINANTS OF HEALTH (AND DISEASE)  

? SUPPLY CHAIN MANAGEMENT AND LOGISTICS 

? ICT  

? STAKEHOLDERS 

II.F.2  WHAT IF PEOPLE LEARN DIFFERENTLY?  THE FINAL “WHAT IF” QUESTION 

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We can attempt to facilitate your journey, once a decision has been made to cross the motivation and dedication threshold, and take that first step.   

People have different ways of learning.  If preferred, rather than one slice at a time, the total hypertension in low-resource venue compendium will be able to be accessed as booklets and series of books, beyond individual modules.   Though knowledge is freely shared, printingof shared materials by members of the CIC Glocal Hypertension Network for other commercial purposes is strictly prohibited.   

Comprehensive pertinent references and resources can also be accessed and reviewed,organized by module.  Note that though comprehensive, a conscious decision has been made to not put in an academic manuscript specific numbered footnote format, and journal titles are not abbreviated to be more helpful for the un-initiated.  Resources all have active electroniclinks associated and are clearly delineated.   

By definition...

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...

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.   

Keep going..

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. 

II.G. WHAT LESSONS HAVE WE LEARNED TO CARRY FORWARD?  

Start Here...

Life always teaches us lessons.  As we have shared this brief life experience, let us ask the final question and that is what are ten important things we have learned together? 

Always start with a blank piece of paper...
  • 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!  
Keep going..

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. 

REFERENCES AND RESOURCES

REFERENCES

REFERENCES  

Isaacs, W.  Dialogue and the art of thinking together: a pioneering approach to communicating in business and life. 1999. Doubleday, a division of Random House.  New York.  

Marcus LJ, Dorn BC, Henderson JM, Ashkenazi I.  Linking multi-dimensional problems to complex multi-parity solutions.  The walk in the woods: A guide for meta-leaders.  2008. Program for health care negotiation and conflict resolution.  Harvard School of Public Health.  

Collins JC, Porras JI.  Built to Last: Successful Habits of Visionary Companies.  New York.  Harper Business.  1997.  

Christensen CM, Baumann H, Ruggles RSadtler T. Disruptive Innovation for Social Change.Harvard Business Review. 2006.  84(12).  

REQUEST ORIGINAL SOURCE DOCUMENTS

Module II

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