Memorandum

Novo Nordisk announces the Cities Changing Diabetes program – April 25, 2014

Executive Highlights

  • Novo Nordisk recently announced its new Cities Changing Diabetes program, which is aimed at combatting the problem of diabetes in urban areas; it will involve data collection, sharing best practices, and coordinating action among multiple stakeholders.
  • The program will operate in a set of global cities; Mexico City is the first (and currently only) city selected, and the company in the process of identifying cities in the US, Europe, and Asia.
  • Our report contains an interview with Novo Nordisk USA President Mr. Jesper Høiland, our speculation on some considerations regarding Novo Nordisk’s search for a US city partnership, and more.

“An emergency in slow motion” – those are the words used to describe the global urban diabetes epidemic in the introductory video for Novo Nordisk’s new Cities Changing Diabetes program. In so many of the presentations we attend at diabetes conferences, we see “environmental factors” referenced only briefly in an introductory slide on the causes of the diabetes epidemic, before the presenter goes on to discuss some aspect of diabetes pharmacotherapy or technology. While there are undoubtedly conferences about urban infrastructure that we’re not attending, and while of course drug and device solutions are vital in improving diabetes care for patients today, slowing the long-term rise in diabetes prevalence clearly will also require broader changes to our environment, as Novo Nordisk has highlighted many times before but particularly with this new global initiative. Big-picture historical trends, including increased reliance on the automobile, urban food deserts, increasingly sedentary lifestyles, and government policies that do not favor healthy behaviors, have all been key contributors to the rise in obesity and diabetes prevalence. Because these issues are particularly prominent in urbanized areas, it is not surprising that roughly two-thirds of diabetes patients reside in cities.

Given the scale and severity of the issues at hand, we were very excited to hear about Novo Nordisk’s Cities Changing Diabetes program, which seeks to map urban diabetes through data collection, best practices development and dissemination, and coordination and encouragement in multiple respects among multiple stakeholders. We were fortunate enough to chat last week with Mr. Jesper Høiland, the new President of Novo Nordisk USA, who spoke enthusiastically about the Cities Changing Diabetes program. “We are declaring war on diabetes,” he stated emphatically, stressing the importance of taking a population approach to improving diabetes outcomes. He argued passionately that all of society must be engaged in this effort – “[Diabetes] is everyone’s disease, so we all have to be concerned about it. [….] We all know people that have diabetes, whether that’s the person that’s driving the bus or it’s one of our colleagues or a close relative. Diabetes comes very, very, very close to heart for millions – and today, I would say, for every American.” We include selected quotations from our interview with Mr. Høiland in our report below.  

Notably, Mexico City was named as the Cities Changing Diabetes program’s first focus city, and we learned from Mr. Høiland that Novo Nordisk hopes to announce a partnership with a US city this summer (in addition to partnerships in other regions). In this report, we speculate on some of the considerations that Novo Nordisk and its collaborators might have in mind as they (together with the leadership of candidate cities) decide on a specific US partnership. Given the enormous amount of resources and support that the program could provide, we would see partnership as a major opportunity for many US cities. We also consider which US cities are possible candidates, based on our list of possible considerations. Novo Nordisk has put together an impressive range of informational materials on the Cities Changing Diabetes program, including a most compelling 75-second video, a sleek website and informational e-booklet, and an independent Twitter handle (@citiesdiabetes, appropriating the hashtag #urbandiabetes). We will be looking for equally impressive follow-through from Novo Nordisk and the program’s local collaborators and stakeholders.

Background

On March 28, Novo Nordisk announced a new partnership program, “Cities Changing Diabetes,” aimed at tackling urban diabetes around the world ( within a selected group of focus cities). The program was developed in partnership with University College London (UCL), an institution at the forefront of research on the built environment and health, and is supported by the non-profit Steno Diabetes Center, along with a wide spectrum of local partners (e.g. healthcare professionals, businesses, academia, and community leaders). Together, Novo Nordisk and its partners aim to: 1) map the challenges underlying urban diabetes (through extensive data collection), 2) share best practices and solutions, and 3) mobilize coordinated action among a range of stakeholders to battle diabetes in big cities across the globe. The program’s task, while daunting, could mimic the success of other global programs addressing widespread epidemics like HIV/AIDS and malaria. The campaign will be split into multiple phases: 2014 will be the initial discovery phase, which will focus on data collection and discussion. Next (presumably 2015 and onwards), Novo Nordisk and its partners will announce action plans for each of the focus cities.

  • Mexico City is the first city to join the program, and hosted the launch of Cities Changing Diabetes on March 28. While we don’t know the criteria Novo Nordisk is using to choose focus cities, we note that Mexico City has a number of factors that make it an appealing launch city.
    • With a population of 20 million, Mexico City is one of the largest metropolitan areas in the Western Hemisphere, and Mexico has the sixth highest rate of diabetes worldwide with over 10 million Mexicans suffering from the disease (according to the IDF 2013 Atlas, Mexico’s diabetes prevalence rate was around 12%, higher than the US). Mexico’s obesity prevalence rate has also surpassed that of the US.
    • Both the public and private elements of the Mexican healthcare system must bear the sharply rising cost of diabetes treatment; as a result there is huge public interest in bringing this issue to the forefront.
    • Mexico Minister of Health Dr. José Armando Ahued Ortega is quoted prominently on the Cities Changing Diabetes website, stating that “diabetes is the number one health challenge in Mexico City.”
    • With a slew of large-scale initiatives to fight obesity and diabetes in Mexico City (like the country-wide tax on soda), there is tangible interest in reversing the obesity and diabetes epidemics. Notably, former New York City Mayor Michael Bloomberg has taken a major interest in helping turn around Mexico’s obesity problem.
  • We eagerly await Novo Nordisk’s announcements on its US partner city and partner cities elsewhere in the globe.

 

Interview with Mr. Jesper HøILAND, President of Novo Nordisk North America

We were fortunate enough to chat with Mr. Jesper Høiland, head of Novo Nordisk North America, who spoke enthusiastically about the Cities Changing Diabetes program, and shared additional detail on the selection process for new program cities. Notably, we learned from him that Novo Nordisk and its partners are hoping to pick cities in the US (in addition to other regions) in May or June. He shared that Novo Nordisk is planning to engage wide range of stakeholders, including private and public players, in the program, and sees the program as the “glue” that brings these different groups together. Also included below were some of Mr. Høiland’s thoughts on a broader set of issues, including regional trends in healthcare infrastructure and reimbursement, Novo Nordisk’s investment in R&D, and on challenges in the regulatory environment.

  • As background, prior to assuming his role as President of Novo Nordisk USA, Mr. Høiland led Novo Nordisk’s global International Operations, made up of 150 countries with the “emerging markets” segments and 40 Novo Nordisk affiliates, from 2004 through 2012. During his tenure in this position, he more than doubled the number of employees in the International Operations cohort, increasing to 3,910 from 1,900 (a 105% increase!). Having been with Novo Nordisk since 1987, we would certainly say that he knows the company well! Mr. Høiland has led marketing functions for Canada, Belgium, and France, and has served as General Manager of Novo Nordisk Australia. Most recently, Mr. Høiland held the role of Senior Vice President of International Operations in Switzerland. Given his experience in such a diverse range of countries and cities, we think Mr. Høiland is particularly well suited to help bring the Cities Changing Diabetes program into the United States. More broadly, with so much experience under his belt and a clear drive to help improve the health in America, we hope that Mr. Høiland will drive the company to stay actively involved in a range of public health initiatives (for example, Novo Nordisk has sponsored Partnership for a Healthier America’s Building a Healthier Future Summit two years in a row).
  • Mr. Høiland’s comments on the Cities Changing Diabetes program:
    • “We are declaring war on diabetes,” Mr. Høiland underscored when discussing the Cities Changing Diabetes program. Novo Nordisk’s aim with the initiative is to ensure that in the future people with diabetes live a healthier life than has been the case in the past. Mr. Høiland emphasized the importance of taking a population approach to improving diabetes outcomes, and that all of society should be engaged in this effort – “[Diabetes] is everyone’s disease, so we all have to be concerned about it. [….] We all know people that have diabetes, whether that’s the person that’s driving the bus or it’s one of our colleagues or a close relative. Diabetes comes very, very, very close to heart for millions.”
    • Mr. Høiland shared that Novo Nordisk is hoping to work with cities in the US and other regions around the world throughout 2014. This way, Mr. Høiland noted, Novo Nordisk will be able to answer questions like what opportunities are available for meaningful growth in, for example, the US, and how do those compare to the opportunities present elsewhere. Given the variations that exist in different cultures’ dominant lifestyle characteristics, Novo Nordisk sees a need to focus on improving diabetes care not just “in terms of injecting insulin,” for example, but also in terms of the lifestyle that should be supported by public health efforts. To understand the needs of any given city, Novo Nordisk needs experience on the ground in that region.
    • More specifically, Mr. Høiland stressed that he wants to help underserved populations, who likely don’t have access to optimal diabetes care and live in environments that aren’t  conducive to health – for example, living in a food desert makes it especially challenging to eat a healthy diet. Even when fresh food items are available, Mr. Høiland is concerned about the competition these foods face from readily available and inexpensive  unhealthy fast food – “It’s easier to go out and buy a complete [fast food] meal for $3.50 to $4.00, than it is to go to the nearest grocery shop, buy all the healthy food, go home, prepare a meal, and thereby get a healthy outcome.”
    • Novo Nordisk would invite a consortium of private and public players to be involved in each Cities Changing Diabetes program. Novo Nordisk wants the program to be driven by community involvement, rather than by Novo Nordisk itself. Instead, Mr. Høiland sees Novo Nordisk being the “glue” that brings the stakeholders together and is willing to offer the resources needed to address most developed cities’ diabetogenic environments. In particular, Mr. Høiland emphasized that the city initiative must have “political endorsement at the very highest level.”
  • Mr. Høiland’s comments on other issues:
    • On the challenges within the European and US healthcare markets: I do believe that what we’re seeing in Europe is the governments are […] setting a very high bar for companies bringing major innovative drugs to the market. It has meant, to a large extent, that development and research in the European pharmaceutical industry has diminished, as far as I can see it. Whereas, we can say that the North American market has been open to paying for innovation and towards new ways of doing things.
    • On where he sees the European healthcare system going:
      If I look 10 years out, I do believe that the Europeans are not going to be happy with their healthcare system. So I think everyone is going to have an insurance component that will provide basic, basic care for those who really need it. And then, if you want to have care over and above that, you could be paying for it either yourself or in the form of insurance. The healthcare system that I think [the EU] is driving towards is the Swiss model.
    • On where he sees the American healthcare system going: Ten years from now, I think that the current healthcare model (in terms of paying and providing) is becoming much more focused on outcomes driven healthcare than we haven seen in the past. I think there will be many Americans who will not be happy with that model – what you could call a single tier system or ACO or HMO – where you have one provider looking after you.
    • On the cost and quality of care provided in Europe and the US: It’s a relatively expensive model run in North America. Having said that, I also think that the care is much better in North America than what we are currently seeing evolve in the European continent.
    • On the high level of cost-sharing in many US health plans and Novo Nordisk’s role working with payers: The self-insurance component is relatively high – I think it’s by far too high for patients with a chronic disease like diabetes. I think that’s where Novo Nordisk has expertise. We will have to take our position to try to help make sure patients with diabetes are looked after in an appropriate and affordable way, because we know a lot about the cost of diabetes in our society.
    • On the challenging regulatory environment: Our hope is, of course, that by bringing new, better and more innovative products onto the marketplace, that we will make life for those with diabetes as simple as possible.
    • Mr. Høiland on Novo Nordisk’s investments in diabetes-related R&D: Novo Nordisk continues to invest 15%-plus of its total turnover on research and development. We’re the second largest investor into diabetes research after the federal government We’re spending to the tune of over $2 billion on research in the area of diabetes every year and we will continue to follow this avenue. We’re looking ultimately to find the cure for diabetes and we are making some progress in that direction but it’s far from fast enough. We are expanding our research facilities in Seattle [at the Type 1 Diabetes R&D Center]. As we’re speaking, we’re doubling our manpower up there.
    • On the importance of lifestyle modification: If as a society, we are not able to change our lifestyle — by eating better, engaging in regular physical activity, and maintaining a healthy weight – then we will not be able to fully address the burden of diabetes. So, we know that 26 million people today have diabetes. Ninety percent of them have type 2 diabetes. We know that if we can identify them and intervene early in the course of the disease with evidence-based programs provided in the community – like the National Diabetes Prevention Program – we can help people prevent or delay the onset of type 2 diabetes and therefore help them lead a much healthier life. And that’s basically the job as I see it: to make sure that people’s health is looked after.
    • On poverty as a contributor to disease: Some people are living in a situation where it’s easier to go out and buy a burger for $3.50 or $4, than it is to go to the nearest grocery shop, buy all the healthy food, go home, and prepare it. […] The frightening thing is today we don’t even really know how patients are being treated in some parts of some cities.
    • On diabetes’ impact on society: This is everyone’s disease and everyone’s problem, so we all have to be concerned about it. As it is, we cannot talk enough about diabetes because the diabetes prevalence rate is at one out of 10 in the US. That means we all know people who have diabetes whether that’s the person that’s driving the bus or it’s one of our colleagues or a close relative.
    • On racial/ethnic disparities in diabetes: Diabetes doesn’t play fair:  its impact is different if you are Chinese or Hispanic or African American or White Caucasian. There’s a different prevalence and incidence by ethnicity, and that has to be taken into account when we are looking at the problem of diabetes..

 

Possible Considerations in the Search for a US Partner City

In our view, the possibility of being the inaugural US city in the Cities Changing Diabetes program would be an immense opportunity for any city. The partner city would stand to receive a great deal of research attention to better characterize local health trends, as well as enormous support in coordinating and implementing a set of solutions to the problems identified during the data collection phase. Of course, it is important to view this stage of the project as a mutual search for a partner rather than a unidirectional selection process – in addition to Novo Nordisk selecting the city, the city must select to be a part of the program as well. We imagine that political considerations, resource limitations, and any number of other issues could be important factors to consider from the perspective of city leadership. Novo Nordisk and its collaborators have not disclosed much regarding the ongoing partnership process – below, we list a set of 11 possible considerations that Novo Nordisk, its collaborators, and the leaders of possible partner cities might be considering during the partnership process. Subsequently, we suggest 11 US cities that meet a number of those considerations. We must emphasize that the lists below are highly speculative, though we hope they will still be illuminating and thought provoking. Of course, narrowing down hundreds of potential cities to a dozen was a challenging task – so many US cities have a great need for help to improve diabetes care and general public health.

Our 11 speculative considerations:

  • Broad recognition of the severity of the diabetes epidemic, and willingness to focus on the issue: To be successful, there needs to be a reasonably high level of buy-in on the part of multiple stakeholders, from the public up through the government. It may be difficult for Novo Nordisk to select a city that has more pressing immediate concerns, which might not be willing to dedicate the necessary effort to this program.
  • High diabetes incidence: The selection of Mexico City as the first city in the Cities Changing Diabetes program demonstrates that Novo Nordisk and its collaborators are interested in regions where diabetes is particularly prevalent (Mexico has one of the highest diabetes prevalence rates out of OECD countries). Similarly, in the US, we imagine that Novo Nordisk will be looking for a city with a high diabetes prevalence, where there is great room for improvement. While this criterion is important, it may not be the most useful in narrowing down a list of cities: across the board, diabetes prevalence in American cities is relatively high. 
  • Size: Again, based on the selection of Mexico City, it appears that Novo Nordisk is interested in effecting change in very large urban areas (Mexico City is one of the largest metropolitan areas in North America). In addition to providing the opportunity to impact a large number of people, larger cities are more likely to possess the urban infrastructure (both physical and social) to promote program initiatives.
  • Community interest: Cities Changing Diabetes will benefit greatly if the local public community is interested in the idea, and if there is already a widespread awareness about the issue of diabetes.
  • Political support for change: The public sector is one of the key stakeholder groups outlined in the structure of the Cities Changing Diabetes game plan. Novo Nordisk will be most successful in an area where the politicians are willing and able to support the initiative. In some cities, politicians are already engaged in high-profile public health campaigns (think, New York’s former mayor Mr. Michael Bloomberg or Philadelphia’s current mayor Michael Nutter). However, we also believe that cities without established high-profile campaigns could also be selected, as long as local politicians recognize the severity of the issue and are willing to get in the game.
  • Industry support for change: Similarly, in the vein of broad stakeholder participation, we believe businesses must be willing to support change in the community – for example, attempting to reduce the amount of sugar consumed would be much more challenging if local stores were not willing to reduce the amount of sugar-sweetened products they sold.
  • Urban structure and infrastructure: Novo Nordisk might have a preference for more centralized cities over spatially and politically fragmented cities – centralization will help simplify the process of coordinating political action when it comes time to actually implement solution. However, in more fragmented cities, perhaps the program could focus on the individual neighborhoods where diabetes prevalence is particularly high.
  • City resources: Although Novo Nordisk and its partners will go a long way in providing resources to support the Cities Changing Diabetes program, the selected city must also have sufficient resources to implement solutions on a broad scale. Even modest programs, such as urban vegetable gardens, farmer’s markets, or grassroots physical fitness programs, will require significant investment, well beyond the scope of what Novo Nordisk could be expected to contribute.
  • Potential for private-public partnerships: These sorts of partnerships will be key in implementing solutions on a broad scale. Key areas to look for partnerships will be in K-12 education, higher education, the food industry, and within the healthcare system itself. We hope that Novo Nordisk’s work with the Partnership for a Healthier America (which focuses on private-sector involvement) will help the company coordinate these sorts of partnerships.
  • Presence and strength of academic medical centers: We believe that the presence of academic medical centers could help achieve program goals, through additional research as well as partnership with these local institutions’ ongoing programs and efforts.
  • Proximity to Novo Nordisk’s corporate presence in New Jersey: Novo Nordisk Inc.’s location in Princeton, New Jersey might be a key factor in determining which cities the company considers for the initiative – working with a city that is more proximal to company leadership may help the company stay more aggressively involved with the local program.

Based on these considerations, below are 11 cities that could potentially serve as partner cities in the Cities Changing Diabetes program (listed in alphabetical order). Clearly for the program to work optimally, the individual cities’ level of interest in participating in an initiative such as Cities Changing Diabetes; we would hope (and expect) in most cases that interest would be high.

  • Atlanta, GA: Novo Nordisk may partner with Atlanta because it is home to the CDC and Emory University, both of which are excellent healthcare research hubs. A number of corporations have significant presences in Atlanta, providing excellent prospects for public-private partnership. While the Atlanta metropolitan region is fairly decentralized, the Fulton County government has shown immense initiative in combatting obesity and diabetes through initiatives such as Georgia SHAPE.
  • Baltimore, MD: Baltimore has a rather high diabetes prevalence rate, at 10.5% (the US average is 8%). The city also houses Johns Hopkins University, which has a strong tradition of healthcare research. Additionally, Baltimore is a relatively centralized city, allowing changes to be more easily enacted throughout the area.
  • Birmingham, AL: With one of the highest diabetes prevalence rates in the US (at 10.7%), Birmingham seems like a city where Novo Nordisk could really help move the needle on the rate of diabetes. However, we are unclear about how receptive the citizens, politicians, and industry would be to “Cities Changing Diabetes” since few other health initiatives have caught on in southern states.
  • Chicago, IL: The city’s primary advantage, in our view, is its strong existing healthcare infrastructure – it is also one of the largest cities in the US, and is fairly centralized. Additionally, the city may be able to work with the University of Chicago to provide research support.
  • Cleveland, OH: With the Cleveland Clinic, Cleveland, OH, has become a hub for medical research and innovation, which could work very well with the Cities Changing Diabetes program. Additionally, Cleveland’s city government has embarked on a large campaign to improve city infrastructure, and many younger people are moving to the city.
  • Detroit, MI: There is a strong grassroots effort in the city to help improve the health of Detroit residents, through initiatives such as urban vegetable farms, making this city a possible partner for Novo Nordisk. The city has experienced sharp economic decline in past decades, and arguably is a city in great need of assistance and coordinated action. However, the city’s economic and political troubles may also present challenges in terms of resources the government is able to provide.
  • Houston, TX: As the fourth largest city in the US (according to 2012 population data), Houston would make a good location within this region for Novo Nordisk to focus on. Houston’s relatively low healthcare coverage rate (according to ACSM American Fitness Index) presents challenges, but also opportunities for significant improvement. 
  • New York City, NY/Newark, NJ: By choosing to focus its efforts on New York City and Newark, Novo Nordisk would be able to help a vast and very diverse metropolis. Led by former mayor Michael Bloomberg, New York City has played a role in helping to start many health initiatives – we imagine Mr. Bloomberg could be a strong local leader and program ally even though he is no longer in office. New York City also boasts a relatively centralized political structure, robust infrastructure, and proximity to Novo Nordisk’s US headquarters.
  • Philadelphia, PA/Camden, NJ: Philadelphia and Camden both have had many health initiatives recently; The Campbell Soup Foundation helps build healthy lives in Camden (one of the most underprivileged cities in the US),  and Mayor Michael Nutter has consistently worked to get a soda tax enacted in Philadelphia. Additionally, the Philadelphia/Camden area would be close to the New Jersey base for Novo Nordisk Inc.
  • Pittsburgh, PA: Pittsburgh is host to Carnegie Mellon and the University of Pittsburgh, two research powerhouses that Novo Nordisk may be able to harness. It remains to be seen how much this city would be able (or willing) to invest significant resources in diabetes programs.
  • San Francisco/Oakland, CA: We, of course, would be very happy with this choice – it is hard to beat the Bay Area community in terms of enthusiasm for broad change. San Francisco and Oakland have been leaders in healthy food initiatives (there is huge interest in local sustainable agriculture, and San Francisco is considering a soda tax), and we would anticipate massive local buy-in should the cities be selected. Additionally, the region’s proximity to fresh fruits and vegetables would help the initiatives take root.

--by Hannah Deming, Hannah Martin, Katharine Sanders, Jenny Tan, Manu Venkat, and Kelly Close