Cities Changing Diabetes Summit

November 16-17, 2015; Copenhagen, Denmark – Full Report – Draft

Executive Highlights

In this report, we provide our full coverage of Novo Nordisk’s Cities Changing Diabetes Summit, held last month in Copenhagen, Denmark. The inaugural summit brought together an unusual assortment of stakeholders for a diabetes conference; it was fantastic to see urban planners, public health officials, industry representatives, and a wide variety of nonprofit leaders come together for a big-picture discussion about how best to confront the urban diabetes epidemic. The two-day agenda was headlined by presentations of the initial research findings from the five participating cities (Houston, Copenhagen, Mexico City, Shanghai, and Tianjin) and discussion of how they can help inform a new model of diabetes vulnerability. It also featured exciting news about the future of the program, including the announcement of Vancouver and Johannesburg as the next two participants, a commitment by Novo Nordisk to fund $20 million in research over the next five years, and a new partnership with C40, a network of cities working to combat climate change. In between, we heard plenty of stimulating discussion on topics ranging from how urban design can help promote health to the proper role of government in these efforts.

See below for detailed coverage of these and other items from the summit, including an informative interview with Novo Nordisk Chief Medical Officer Dr. Alan Moses on the program’s goals and how its lessons could be applied to drug development. In case you missed them, be sure to check out our day #1 and day #2 highlights reports for our on-the-ground updates from the summit.

Table of Contents 

Detailed Discussion and Commentary

Welcome Session

Frank Jensen (Lord Mayor, Copenhagen, Denmark) and Lars Sørensen (President & CEO, Novo Nordisk, Bagsvaerd, Denmark)

The summit kicked off with inspiring words from Copenhagen Lord Mayor Mr. Frank Jensen and Novo Nordisk CEO Mr. Lars Sørensen – an excellent representation of the public-private nature of this program. In his remarks, Mr. Jensen aimed to answer the question, “why cities?” He explained that nearly two-thirds of people with diabetes live in cities, that good health is “fundamental” to a city’s well-being, and that rapid change is often more feasible in cities than at the national level. As an example, he cited Copenhagen’s successful efforts to become a bike-friendly city, noting that 63% of residents now bike to work or school and only one third of households own a car. Mr. Sørensen focused on framing the goals of the Cities Changing Diabetes program. He described the organizers’ role as articulating the problem, identifying social and cultural determinants of diabetes vulnerability, and finding new, relevant ways to defeat diabetes in cities. He also noted that Novo Nordisk is acting against its own interest in some respect by spearheading this program, as the company owes much of its success to the scale of the diabetes epidemic. While this is true on some levels, it is also the case that this program could have a positive impact on Novo Nordisk’s bottom line in the medium term if it leads to increased diagnosis and treatment of diabetes as well as prevention.

The Challenge of Diabetes in Cities

David Napier, PhD (University College London, UK), Stephen Linder, PhD (University of Texas, Houston, TX), Simón Barquera Cervera, MD (National Institute of Public Health, Mexico City, MX), Weiping Jia, MD, PhD (Shanghai Institute of Diabetes, Shanghai, China), Finn Diderichsen, MD, PhD (University of Copenhagen, Denmark), Ma Jun, MD (Tianjin Medical University, Tianjin, China)

Dr. David Napier synthesized the findings from the research supported by the Cities Changing Diabetes program over the past year, pointing to financial, resource, geographical, and time constraints as key determinants of risk in a wide variety of populations. He emphasized that financial constraints include not only absolute poverty that prevents people from accessing basic resources, but also perceived constraints that limit people’s capacity to be proactive and hopeful about their future. Resource constraints, while often linked to financial constraints, are more specifically defined as lack of access to local healthcare, medications, nutritious food, exercise, or educational resources. Geographical constraints encompass a range of problems magnified in urban environments, such as pollution, crime, infrastructure, and even isolation. The fact that time constraints made the top four came as a bit of a surprise to us initially, though the challenges Dr. Napier described certainly rang true. His main point was that patients have to prioritize, and healthcare is often nowhere near the top of the list for people of all social classes who are overwhelmed by work and family responsibilities. We wonder to what extent patients would be surprised (and may behave differently) knowing that by making choices surrounding time and diabetes, their outcomes may be less favorable.

  • Dr. Napier stressed that cultural as well as social factors must be considered when addressing diabetes vulnerability. This means asking questions like (i) Do patients feel like they have agency to make changes? Much of this is unconscious. (ii) Do dietary recommendations conflict with people’s food traditions? (iii) Is diabetes the person’s biggest problem? (iv) What does the person perceive as a normal or healthy body type? and (v) How do social and environmental transitions impact people’s health and perspectives? Many of these questions are complicated, even loaded. And for us to see the research community (at least Novo Nordisk) addressing these questions in a forthright manner makes us feel we’ve come a long way! It was interesting to hear about examples like a recent history of hunger and resource scarcity and findings that this can contribute to an obesogenic environment and the celebration of larger body sizes. While the findings may not seem surprising in isolation, as a composite, this makes us understand how complicated success in diabetes management can be.
  • Within these overlapping themes, specific factors were identified as particular contributors to diabetes vulnerability in each city. For the most part, all five cities followed the rule of halves: half of all people with diabetes are diagnosed, half of those who are diagnosed are treated, half of those who are treated achieve targets, and half of those who achieve targets avoid complications. There were some notable exceptions, such as the fact that 98% of people diagnosed with diabetes in Copenhagen receive some treatment (not 50%) and closer to 70% rather than 50% of diagnosed patients in Mexico are not at their glycemic targets. The overall prevalence of diabetes ranged from ~5% in Copenhagen to just under 18% in Shanghai. When looking at obesity figures, of course, one begins to feel the doom spiral for diabetes – i.e., if we think the current circumstances are disturbing, one might only wait 10-20 years for the truly staggering numbers to emerge. Indeed, our assessment of IDF figures understating what is likely in 2040 appears to be felt by many. Back on Cities Changing Diabetes, we were very interested to hear academic researchers from each city discuss a few key determinants of diabetes vulnerability in their populations.
    • Mexico City: Contributing factors included gender culture (women don’t want to be perceived as a burden to others – presumably this is a factor elsewhere but it really was a big one here), lack of access to healthcare and treatments, lack of trust in the health system, and limited knowledge about diabetes.
    • Houston: Researchers identified four categories of at-risk groups: (i) “isolated skeptics” – those with biological and economic risk factors who are the typical target group for population health interventions; (ii) “concerned seniors” – older people with economic security but biological risk factors; (iii) “financially pressured caregivers” – younger people with lower incomes and lots of family responsibilities; and (iv) “time-pressured young adults” – people who would typically not be considered high-risk but who don’t have time to implement lifestyle interventions. We weren’t sure what percentage of the total these groups represented and we look forward to more insights on learnings associated with the groups. Interestingly, Houston leaders did a study of “have-nots” – looking at different groups of people with similar risk factors to better understand what put some people at the tipping point of being diagnosed with diabetes while others weren’t.
    • Tianjin: Low diabetes literacy and education and mental health problems were identified as key contributors.
    • Shanghai: Lack of access to community health centers, increased caloric intake that accompanies economic growth, and low diabetes literacy were characterized as important factors.
    • Copenhagen: The situation is better here than in most places, but certain sub-populations like unemployed immigrants are not receiving the help they need, likely due to stress and lack of outreach by the health system. “We do not know who they are, where they are, or what they need,” said one obviously very committed and smart health official to us.

The Burden of Diabetes: An Urban Perspective

Roman Rosales Aviles, MD (Vice Minister of Health, Mexico City, Mexico)

Dr. Roman Rosales Aviles drilled down into the factors contributing to the diabetes epidemic in Mexico City and some of the government’s efforts to combat it. He explained that like most cities, Mexico City has substituted chronic diseases for infectious diseases as it has developed. At this point, diabetes prevalence in the city has reached 13.9%, up from 8.9% in 2006, and the country as a whole has the second highest obesity rate in the world. Dr. Rosales Aviles noted that the costs of these epidemics will likely only increase going forward, as many people with diabetes are undiagnosed and the costs will rise as the patient population ages and develops more comorbidities. He highlighted several programs the city government has implemented to address this problem; most attempt to target it at its source by preventing overweight and obesity:

  • Muevete: Promotes physical activity and provides an orientation to nutrition; implemented in workplaces and schools and for older citizens.
  • La Ola Blanca: Students measure glucose and blood pressure and learn about healthy habits.
  • Menos Sal y Mas Salud: Informs people about the health risks of salt consumption.
  • Traffic light campaigns for food: Arguably one of the more well-publicized initiatives; provides an easy means to distinguish between healthy and unhealthy foods
  • El Medico en tu Casa: Aimed at vulnerable groups such as the elderly; provides medical services in people’s homes and promotes family support
  • Early detection clinics in metro stations. We love this idea, which is in the same vein as offering basic health services at a place like CVS or Walmart – meeting patients where they are can go a long way toward improving screening and prevention. 
  • Specialized diabetes outpatient center: Involves physicians, dietitians, and other professionals who provide training to patients’ families and others.

Health of our Global Cities

Richard Florida, PhD (Rotman School of Management, University of Toronto, Ontario, Canada)

Dr. Richard Florida, a well-known urban studies theorist and author of The Creative Class, argued that the same factors associated with economic success in contemporary cities are also associated with better health outcomes. He explained that for most of human history, economic development resulted from exploitation of natural resources. Even though the Industrial Revolution brought enormous changes to economic structures, the combination of raw materials and human physical labor was still the cornerstone of growth. Dr. Florida argued that this has all changed, and that the “creative class” is the real driver of today’s economy. The rise of the creative class and an economy based on innovation rather than labor has gone hand in hand with urbanization because “cities are where ideas come to mate and reproduce.” He noted that the main factors associated with economically successful cities in this context are diversity and a high concentration of knowledge workers. These factors are also associated with happiness, and with better health outcomes. However, despite all of the progress that has resulted from urbanization, Dr. Florida stressed that the increasing rates of urban poverty and inequality, and the negative health outcomes that go along with them, are a major concern. As he bluntly put it, most people from the working-class community where he grew up “are either obese or dead.” Like many other speakers at this summit, he advocated embedding physical activity and social connection into the fabric of cities. He also stressed that this effort will require input from all sectors, including governments, corporations, and international entities like the UN. He closed with the intriguing suggestion of creating the equivalent of a teaching hospital for cities, where people could learn and share best practices for creating healthy urban environments. 

Nutritious Urban Food Systems

Marc Van Ameringen (Executive Director, Global Alliance for Improved Nutrition)

We were very impressed by Mr. Marc Van Ameringen’s perspective on the common links between tackling malnutrition and obesity/diabetes. He focused in particular on the “double burden” of under-nutrition and overweight/obesity that affects many communities, especially in the developing world. He emphasized that urban food systems have not been designed with health in mind, and that inequality is often built into the system: wealthy people have access to high-quality food almost everywhere in the world, but poorer people often simply lack purchasing power. Mr. Van Ameringen made the case for a fairly strong government role to address these problems, suggesting that useful initiatives could include subsidies for healthy food, taxes on unhealthy products, education, food labeling, and incentives for new businesses to develop healthy products. He acknowledged the grumbling about the “nanny state” that often accompanies government interventions, particularly in Western countries, but suggested that these interventions can work even when there is opposition from the private sector. Not to be too antagonistic, Mr. Van Ameringen also stressed the need for multi-sector partnerships in areas like nutritious food waste where industry and government have common interests. He also suggested that purely government-based interventions may be more effective in developing countries where the government plays a larger role in the economy, whereas company-led interventions may be more effective in skeptical Western countries.

Questions and Answers

Q: Rural areas have the highest increased risk of mortality in Mexico. In urban areas it’s less prevalent.

A: The prevalence is different in different parts of the world. In Africa you see more than double the burden in urban areas because of rapid migration, and in Asia too. Latin America is farther ahead in some ways. You have to select where partnerships can happen. In areas where we’re polarized like soda, there’s not a place for partnership. We have to be more strategic and not as polarized as we have been. It’s important to ensure government is part of partnerships.

Q: Can you give an example of a partnership your organization has with the private sector?

A: We’re in 40 countries redesigning the food system. We’ve added fortified micronutrients to food, working with governments and Unilever in a commitment to improve the nutrition of farm workers. There are other examples where it has been a total disaster. In some areas more hard-nosed advocacy and lawmaking is a better path.

Q: In government-industry partnerships, is there ever a conflict between food safety and nutrition?

A: Companies often want to partner because it will improve their brand. You have to pick where you partner. Be very selective, make clear what the outcome is, and make sure there’s enough consensus that it’s good for everyone. Food safety is one of the big problems we’ll face. Local regulation doesn’t necessarily stop that. There’s a need to invest in quality control infrastructure. We don’t have it now. We’ve invested in national systems for 15 years and don’t think we have a lot to show for it. Mars decided to create a large food safety facility in China as a global public good.

Q: Should the role of government be different in different regions?

A: In a lot of the developing world, the government has a much bigger role in the political economy than in Western countries. You can do quite a lot in emerging countries when the government takes on an agenda and wants to move forward. Bangladesh, Mexico, Brazil, and China are all examples where the governments have stepped up. There’s more skepticism in the US and Europe about the nanny state and fights over soda taxes. In these environments, companies may be more effective.

Q: Kids who are 15 now will be running things. I’m keen to listen to their perception of how their demographic will be impacted by current policies. Listen to the young.

A: I couldn’t agree more. Half the cities will be filled with 18-year-olds. Despite social media, it’s hard to find out what young people want. We did a survey of 100,000 adolescent girls in India about nutrition. We learned what they wanted was to delay marriage, not have their first baby until age 25, and learn IT skills. It’s not everything you expect.

Care and Treatment

Alan Moses, MD (Chief Medical Officer, Novo Nordisk, Bagsvaerd, Denmark)

Novo Nordisk Chief Medical Officer Dr. Alan Moses turned away from his typical focus on the latest drugs and treatment algorithms and approached the care and treatment of diabetes from a broader public health perspective. He argued that all elements of good diabetes care come back to prevention: prevention of developing the disease, of developing early complications, or of progressing to a devastating outcome. At the earlier end of the spectrum, he stressed that diagnosing more people and identifying those who need more intensive intervention earlier in the disease progression is critical, in terms of both patient outcomes and cost. In our view, one could push the starting point back even earlier to the prevention and early treatment of obesity and prediabetes. Dr. Moses then advocated for “case stratification,” in which people diagnosed with diabetes would be entered into registries and stratified by severity of disease so that the most expensive, sophisticated resources could be targeted to those who most need them. The next element is care delivery, which Dr. Moses stressed must involve a wide array of providers ranging from community health workers to diabetes specialists. It can also involve caregivers completely outside the healthcare system, such as family members or members of a church. We thought the role of non-physician or even non-HCP caregivers was one of the most important themes that emerged from this and other sessions during the summit. As one participant aptly put it during discussion following Dr. Moses’ talk, “community health workers look like the people they’re trying to get into the system” and are therefore often much more effective at gaining patients’ trust.

Questions and Answers

Q: Thank you so much for meeting with us, Dr. Moses. We’ve been struck here by the extent to which people are aware of diabetes but often don’t realize the consequences. So many people said “I didn’t realize how devastating this was until I saw the complications.”

A: One challenge is how much do you scare the patient at diagnosis? It’s not easy, it depends on their cultural and social milieu and their response to the first interaction. You don’t want to hit them over the head. It’s an ongoing discourse.

Q: In Mexico people not in the healthcare sector are being inserted and becoming diabetes educators. Maybe we’ll see progress in areas not well handled by physicians.

A: At the medical school level, diabetes education represents a tiny fraction of physicians’ education. 25% or more of all patients in the Western world in the hospital have diabetes. Physicians who don’t have experience are caring for them. At the national level, we need the medical school curriculum to educate physicians about diabetes.

Q: We did a huge screening study and the most important factor was to have people who saw themselves as at risk go to a primary care provider. That was a great barrier.

A: That’s very insightful information. That’s why I’m so intrigued by the concept of community health workers going out and dragging people in or dealing with the issue so they can benefit from some intervention.

Q: Treating diabetes is not difficult but much of the solution is in the organization of care. At Steno we’ve been running courses for diabetes doctors for 10-15 years, and we hear that many doctors see 100 patients per day but they see them often. Undertreatment goes hand in hand with overtreatment. Maybe we should see patients less often but offer decent care. For example, we could do a foot exam regularly and monitor whether minimal care is applied.

A: I agree. That can often be done at the community level in their home, such as through a self foot exam. There’s nothing as devastating as limb amputation. It disrupts quality of life and takes them and others in their family out of the workforce.

Q: Community health workers look like the people they’re trying to get into the system. The provider community doesn’t recognize that people without advanced degrees can play a significant role that providers can’t because they have people’s trust. How do we bridge that gap?

A: Maybe we can hope this program will put more focus on doing that.

Q: One big challenge in Mexico is that the level of care is very weak. You can take ideas from developed countries but bringing them to Mexico is hard. We have so many people with diabetes and we need lots of workers and educators, but there’s not money from the government to hire them and train them. We need to think about a new model of care for poor countries. There’s been some discussion in Mexico about pay for performance. Do you know if there’s experience with pay for performance systems in the developing world?

A: I have no personal experience. There’s room for lots of experimentation. In the last session someone from South Africa said they’re exploring a model where they have 17-18 year olds in junior city councils, and they have a junior mayor. They’re talking about activating them to go out and help.

Comment: Working with diabetes in rural Uganda, patients themselves work as a resource. They go to the clinic and get educated about diabetes, and they spread their knowledge. We see them as a resource.

Panel Dialogue: The Leadership we Need to Defeat Urban Diabetes

Ninna Thomsen (Mayor of Health and Care, Copenhagen, Denmark), Eduardo Jaramillo Navarrete, PhD (Ministry of Health, Mexico City, Mexico), Zhang Fuxia, MSc (Tianjin Health and Family Planning, Tianjin, China), Jia Weiping, MD, PhD (Shanghai Institute of Diabetes, Shanghai, China), John Nolan, MD (Steno Diabetes Center, Gentofte, Denmark), Lars Sørensen (Novo Nordisk, Bagsvaerd, Denmark)

One clear theme that emerged from this panel, made up primarily of public health officials, was that leadership from sectors beyond public health will be required to effectively address the urban diabetes epidemic. As Dr. Eduardo Jaramillo Navarrete noted, the Mexican government was much more interested in addressing the diabetes and obesity epidemics when the issue was presented as a matter of national productivity rather than “just” a health problem. This sort of multi-sector approach is of course a cornerstone of the Cities Changing Diabetes philosophy. Steno Diabetes Center head Dr. John Nolan celebrated the fact that this is the first conference he has attended in his 25 years in diabetes that featured conversations with architects, urban planners, and others completely outside the traditional diabetes field. Novo Nordisk CEO Mr. Lars Sørensen also noted that it is in companies’ best long-term interest to contribute to healthier cities, even if this specific effort could hurt Novo Nordisk’s performance in the short term (though as mentioned above, the program could also benefit Novo Nordisk if it leads to greater diagnosis and treatment of diabetes). We also loved the focus on pleasure and enjoyment of urban life during the discussion by both Dr. Nolan and Ms. Ninna Thomsen, who noted that Copenhagen’s public health policy is called “Enjoy Life Copenhagen.” Toward the end of the discussion, the conversation turned to the proper role of government regulation. The consensus seemed to be that some regulation is required, even if it is unpopular. As Mr. Sørensen put it, most of Novo Nordisk’s accomplishments have resulted from a balance between “stimulating released creativity and a bit of control and regulation.” As mentioned at other points during the summit, the right balance between government- and industry- or nonprofit-based solutions may be different in different regions depending on cultural expectations.

From Leadership to Action

Mark Watts (C40 Cities Climate Leadership Group)

C40 Cities Climate Leadership Group Executive Director Mr. Mark Watts delivered an inspired presentation on how his organization can be a useful model for the Cities Changing Diabetes program. The group was founded ten years ago in response to the lack of attention to climate change at the G20 summit of world leaders. Since then, it has grown to include 82 “mega-cities” that account for 25% of the world’s GDP and have collectively taken 8,068 concrete actions to reduce emissions as of 2014. Mr. Watts explained that city leaders “have developed a model of collaboration that works,” contrasting the progress in cities on climate change over the past decade with the inertia on the issue at the national level. He noted that the member cities have reported that 30% of their actions resulted directly from sharing knowledge and best practices with other cities in the network, showing that meetings like this summit can be far more than just talk. He also stressed that climate change and the diabetes and obesity epidemics share many root causes in urban settings, and addressing one can have a significant impact on the other. Mr. Watts ended on a tantalizing note, hinting that the group is “looking forward to working more with Novo Nordisk” – we can’t wait to watch the learnings happen here. In addition to the direct collaboration announced toward the end of the summit, we think the Cities Changing Diabetes program could learn a lot from C40’s emphasis on actionable, measurable goals and partnerships with large foundations like the Clinton Climate Initiative (presumably many meetings like this are taking place already).

The Vision for Cities Changing Diabetes

Jakob Riis (Executive Vice President, Novo Nordisk, Bagsvaerd, Denmark)

Novo Nordisk Executive Vice President (and powerhouse) Mr. Jakob Riis opened day #2 of the summit by noting that all five participating cities have committed to action (though he did not provide further details on what that action will look like, which we thought was wise – he made it clear there would be much thought about all the learning that had happened over the past two days). Notably, he confirmed that Novo Nordisk would be forging an alliance with the C40 Climate Leadership Group – we are very happy to hear this.  He explained that the action ahead could be community-level initiatives, or might relate to action on a number of other fronts including equal access, partnership-based, policy integration, replicable, research-driven, social and cultural understanding, and technology-enabled solutions. We also learned that there will be another summit, likely in 2017, by which time Novo Nordisk plans to have more robust, detailed data and the initial implementation of solutions chosen.

It’s All About Community: From Grassroots to Grasstops

Faith Foreman, MD (Houston Health Department, Houston, TX)

We were impressed by Dr. Faith Foreman’s clear, passionate, and compassionate presentation on the efforts she and other officials have spearheaded in Houston. She stressed that health equity should be a key goal for city leaders and advocated for a “grassroots and grasstops” approach that involves both leaders and community members. She cited several examples of prevention initiatives led by the Houston government: (i) AIM, in which health department workers go door to door to assess people’s immediate needs and identify issues of most concern to the community; (ii) Go Healthy Houston, a cross-sector effort to get healthy foods into grocery stores in poor neighborhoods; and (iii) Cigna Sunday Streets, an effort to open streets to pedestrians and cyclists every Sunday that is sponsored by Cigna (we’d love to know how those negotiations went). In a similar vein to Mr. John Kania’s talk in the same session, Dr. Foreman closed by urging city governments to engage as many private and nonprofit-sector partners as possible.

Health Insurance Policy

Yu Ruijun, PhD (Tianjin Municipal Bureau of Human Resource and Social Security, Tianjin, China)

Dr. Yu Ruijun discussed the burden of rising costs of diabetes treatment in Tianjin, which she noted has a population almost three times higher than that of the entire country of Denmark. We were interested to hear that diabetes is considered one of 13 “special diseases” in China for outpatient reimbursement purposes, meaning the level of reimbursement is higher than that for other diseases. While this is good news for patients, it means the dramatic rise in diabetes prevalence has a strong, immediate impact on the healthcare system. Dr. Yu discussed several efforts by the Tianjin government to promote prevention and better treatment of diabetes. One of our favorite examples was an online pharmaceutical distribution system that allows patients to order medications online and have them delivered within 24 hours. We imagine patients getting therapy within 24 hours helps engagement enormously, and the ability to then handle reimbursement online is also a huge plus. Dr. Yu shared that over 20,000 people are currently using the program, and the goal is to reach 50,000 in 2016.

Community-Based Diabetes Prevention and Control

Cai Chun (Shanghai Health and Family Planning Commission, Shanghai, China)

Ms. Cai Chun discussed the role of community health centers in confronting the rising diabetes prevalence in Shanghai through increased screening. She explained that these centers are fully funded by the government and provide basic clinical and public health services; each is responsible for ~100,000 patients. In a diabetes context, the centers see patients with diabetes four times a year and those with impaired glucose tolerance twice a year to monitor blood glucose, provide information about risk factors and medication adherence, and offer health education. Ms. Cai noted that the number of patients at these centers has rapidly increased in recent years along with the prevalence of obesity and diabetes. The good news is that awareness of diabetes has also increased since these initiatives began. In 2002, only 50% of patients seen at the centers were aware they had diabetes, compared to over 68% in 2013. The bad news is that this increased awareness, combined with population growth, aging, and increased incidence and prevalence of diabetes, has created a significant burden for the healthcare system. Ms. Cai argued that it may now be time for the system to focus on equity, quality, and effectiveness of care, rather than just on coverage. To this end, she noted that Shanghai began a project three years ago to redesign electronic health record systems so that providers can offer more precise services and target interventions to newly diagnosed and high-risk patients.

Urban Planning and Policies

William Lau (A. Alliance Design International, Singapore)

Mr. William Lau shared several examples of using urban design to create health in Singapore, where the government is making green spaces and places to bike and walk a central part of new development efforts. These efforts include creative solutions like a walking/running track on the roofs of buildings and park connectors so people can walk or bike between parks. Policies like very high prices for cars (“my cousin in America can buy four or five cars for the cost of the one that I own”) and a fee for driving in the center of the city have also helped make commuting by car less appealing – this is definitely true in San Francisco! As Mr. Lau acknowledged during Q&A, such approaches may work best in developing countries with an influential government that takes these concerns seriously. He said it may be less applicable to well-established cities and those where the government has less direct control over the built environment, though we believe a great deal can be done even in more established cities where residents understand the goals.

Questions and Answers

Q: You talked about access to green parks and initiatives to make people move. How many people move and what is the obesity and diabetes prevalence?

A: The honest answer is I don’t know. I’m an urban planner. I believe we’re not so organized; we don’t measure diabetes per se.

Q: How do you implement policies in well-established cities?

A: We have done it and it didn’t come easy. It requires lots of government determination. Hopefully countries will not be forever developing, like that kid that never quite becomes an adult. We have two jobs: working with the government to design new cities and fixing problems in existing cities. The government must have strong will. You see the transformation of China. They’ve marched ahead in the last 20 years. India was comparable to China 20 years ago, but the government is always arguing and people are not united. You can do a test pilot. Because of political change every four years you can’t think long-term. Look at 20 acres to transform in four years. Once you have one successful prototype, it doesn’t solve the whole problem but people will see you have delivered and maybe you can multiply it.

Q: How do people afford real estate in Singapore?

A: Jobs. There’s a Central Provident Fund that takes away 20% of your salary, and the employer gives another 20% to the government. If you don’t pay the next month, you go to jail. China imitated this policy.

Q: Is this focus on city planning your personal initiative or the government’s? Is it supported by government regulation?

A: The planning is very central. The government owns 80% of the land, so it has lots of freedom to design an ideal city.

The Need for a Citizen-Centric Approach

Helle Søholt (Gehl Architects, Copenhagen, Denmark)

Ms. Helle Søholt emphasized the extent to which healthy cities put people at the center, much like the goals of patient-centered medicine. This starts with changing the “key performance indicators” for urban design to include people’s activities, happiness, and use of public spaces in addition to traditional factors like traffic, economic growth, and demographics. There is so much to this! Ms. Søholt focused particular attention on making public spaces more inviting, which can lead to both increased physical activity and less social isolation, which we believe has major potential to change how engaged some patients feel. One element of this that we had not thought much about before is that cities should be built on a human scale – “we need to relate to the size of places we design.” Ms. Søholt also argued that the concept of “alternative transportation” is a misnomer and that it should be possible to make walking and biking the default modes of transportation. For example, the majority of Copenhagen residents bike to work, and surveys show that most cite convenience, not health, as the main reason for doing so. Ms. Søholt suggested that starting with pilot projects is an effective way to begin implementing urban design initiatives.  As one example, she cited a 2007 pilot project in New York City in which creating more space for pedestrians in Times Square led to reduced travel time, fewer pedestrian injuries, and increased public satisfaction – 74% of people surveyed said the area had improved dramatically after the project.

Solutions Require Cross-Sector Collaboration

John Kania (FSG, Boston, MA)

“If you want to change the system, you have to get the system in the room.” Mr. John Kania spoke to the group on the theory of collective impact. We thought this was very useful for the group. He focused on the importance of cross-sector collaboration to address complex problems like diabetes prevention, explaining that complexity goes beyond “simple” and “complicated”. He argued that we need to move toward a more coordinated, cross-sector model that can produce collective rather than simply isolated impact (which we think there is a lot of in diabetes). Facilitating such collective impact is FSG’s mission, and he offered several examples of successful initiatives it has supported, including the StriveTogether education initiative in Cincinnati, OH, the Shape Up Somerville campaign to address childhood obesity in Somerville, MA, and the Unidos Contra Diabetes program focused on diabetes prevention in a vulnerable area of Texas. We were surprised to hear to what extent collective impact had been used elsewhere in diabetes, and we were very impressed with the numbers. He also shared several tips for success for any collaborative initiative: (i) it is crucial to have a “backbone organization” whose sole purpose is coordinating all other participants (this rarely occurs in diabetes that we’re aware of); (ii) organizations should look for “silver buckshot” (lots of small solutions) rather than a single “silver bullet” (the weapon metaphor was unfortunate); (iii) sharing credit is more productive than taking credit (basic, but he said it’s important to acknowledge); and (iv) the goal should be a perpetual state of both planning and doing. We agree that this sort of cross-sector model that Cities Changing Diabetes exemplifies likely offers the most promise for tackling a problem as complex as urban diabetes. We believe that Novo Nordisk has effectively taken on the role of “backbone organization” and we hope it will continue to ensure that the participating cities’ efforts remain coordinated and streamlined going forward. As a sidenote, we’d be interested to know at what point Novo Nordisk realized it was playing this role. We believe of course that many other backbone organizations would exist as efforts expand, but for #urbandiabetes, Novo Nordisk would continue with this role. It has brought a team to this effort that has been utterly professional, passionate, and clearly extraordinarily hardworking.

Humanizing Diabetes Care and Prevention

Edwin Fisher (Peers for Progress, Chapel Hill, NC)

Dr. Edwin Fisher discussed how peer support can help address the social determinants of diabetes risk. He emphasized that most patients spend approximately six hours a year in a doctor’s office (at most!) and 8,760 hours a year managing diabetes on their own – “people need help living those 8,760 hours.” Peer supporters can be particularly well equipped to provide this help, as they often engender more trust and have much more time than the typical healthcare provider. The support they provide can include assistance in daily management of diabetes, links to clinical care and community resources, and social and emotional support. The emotional support component appears to be particularly important; Dr. Fisher cited studies showing that social isolation is as lethal as cigarette smoking, Dr. Fisher’s organization, Peers for Progress, has funded 14 peer support projects in nine countries and published evidence demonstrating that they are feasible, that they have an impact on A1c and quality of life, and that organizations are willing to adopt and sustain them. He believes this approach is a practical, effective, and cost-effective way to address the components of diabetes vulnerability discussed in such detail yesterday. We agree and believe that the role of peer supporters, community health workers, and other non-HCPs in diabetes prevention and management needs to be an important part of this discussion.

The Road Ahead

Charlotte Ersbøll (Corporate Vice President, Novo Nordisk, Bagsvaerd, Denmark), David Napier, PhD (University College London, UK), John Nolan, MD (Steno Diabetes Center, Gentofte, Denmark), Lars Sørensen (CEO, Novo Nordisk, Bagsvaerd, Denmark)

The organizers of the summit closed out the agenda with a broad look at the future of the Cities Changing Diabetes program. We were very moved to hear Ms. Charlotte Ersbøll, Novo Nordisk Corporate Vice President and a major planner and “doer” related to this initiative, share that this summit could have benefited from greater inclusion of patients’ perspectives. We would love to see community health workers and others on the “ground floor” involved in the initiatives moving forward, and particularly attending the 2017 summit so other leaders can learn from them. Dr. David Napier echoed this point and stated that he would love to see field workers presenting their work at future summits. Dr. John Nolan reiterated his earlier comment that this event was unlike any diabetes meeting he has attended and said it had raised the possibility of “collaboration outside the usual suspects.” He also noted that the new focus on vulnerability is the biggest insight he will take back to his clinical practice. Finally, Novo Nordisk CEO Mr. Lars Sørensen closed by welcoming Vancouver and Johannesburg into the program, celebrating the partnership with C40, and discussing the need to scale the program so any interested cities can become involved or find inspiration without being official participants. Attendees also had the opportunity to vote for which guiding principles they most favored for the program in the future. We’re guessing that all will receive serious consideration – we also believe that most will have community-level action and partnership and social and cultural understanding elements. Most will likely have a technology component. We look forward to learning more about what is chosen for prioritization going forward.

Interview

Alan Moses, MD (Chief Medical Officer, Novo Nordisk, Bagsvaerd, Denmark)

Our team had the opportunity to speak more in depth with Novo Nordisk Chief Medical Officer Dr. Alan Moses about the structure and goals of the Cities Changing Diabetes program, the insights gleaned from the initial research, and the value of evidence from non-RCT sources. Dr. Moses described the pace of progress so far as “remarkable,” noting that there may already be some actionable items coming out of the initial year of research. He suggested that the common structure provided by the program was a significant factor behind this efficient pace. We agree that this is likely one of the most valuable roles Novo Nordisk can play in this program – a common framework for the research should help facilitate more generalized interpretation and development of solutions. Dr. Moses suggested that qualitative research of the sort conducted by this program can provide “texture” for more quantitative data. A similar concept can be applied to the world of drug development: Dr. Moses suggested that “real-world” evidence can provide a more complete picture of a drug’s effectiveness than data from randomized controlled trials alone. He also reiterated comments from his talk during the summit about the promise of community health workers who can visit patients in their homes and gain a much more holistic picture of their lives than is possible in a typical office visit. See below for a full transcript of this informative conversation.

Kelly Close: We vividly remember going to Houston a year ago for the announcement that the program had been launched. That actually was not very long ago. So to see all that research out of Houston…

Dr. Alan Moses: One of the most remarkable things to me is that if you give academic centers an opportunity to just research things, it might take five or ten years to get this kind of stuff. To have five cities do this in a year to a year and a half and actually have results that we can begin to think about analyzing in a different way is impressive. It may actually not only result in more research. Research always results in more research, and that’s fine. That’s what research is meant to be. But there may be some actionable items coming out of this, and that is remarkable.

Kelly: Why do you think that is?

Dr. Moses: That is actually one of the things that I believe Novo Nordisk and the project brought to the cities. It brought a construct in terms of how to approach this. It’s having an overview of what you’re trying to accomplish and having a vehicle to do it. The vulnerability assessment is part of this. That really is a new algorithm to introduce the concept of qualitative interviewing to some areas that have never done it before. Yet we’ve trained up the healthcare workers who completed the qualitative interviews to the point where the data are not only interesting, but are actually becoming interpretable. It’s a major step forward and I think that was all facilitated by the structure and experience at UCL. If we had given individual grants to the cities to do something like this, I am absolutely certain we would not have these kinds of results at this point in time. Not that they weren’t motivated to do it. They were incredibly motivated to do this, so it’s not a negative. It’s a positive that you can put a structure around it.

Emily Regier: How do you translate results from qualitative interviews into something that is large-scale, rigorous, and applicable on a population basis?

Dr. Moses: I think qualitative interviews provide insights that are sometimes very difficult to get otherwise. It provides the texture for quantitative data. And sometimes texture is really important to understand how to approach an issue, particularly when you’re talking about something as complex as the sociocultural economic issues that reside within the urban environment on top of whatever genetic risk factors that are further developed with diabetes. We understand a lot about risk for diabetes as it relates to the medical issues. We haven’t done well identifying specific genes, but we know there’s a huge genetic component to it. And what we struggled with is what leads individuals to move from this at-risk situation to developing overt disease because of the other elements around them. And these are just insights into that situation. It’s informative, it’s not definitive. There’s another element too, and that is this is not just being conducted by academic research centers. There is buy-in from the city governments or even the national governments, probably some more than others. And that’s tremendous impetus to get this done.

Kelly: It sounded like that had something to do with choosing the cities in the first place.

Dr. Moses: Commitment is important. Initiating a research project when you have partners who aren’t really interested in doing it doesn’t make a whole lot of sense. It was a screening process of identifying cities that had the infrastructure and the desire to make a change and then matching them with the academic expertise necessary to carry out the research.

Kelly: The whole vulnerability concept is interesting, because we as patients in the US are reminded of it all the time. People in fact say to us all the time, “Well, it’s very different for you guys. You have access to technology and you have access to insulin and you’re not working three jobs” and struggling with many social problems. And we obviously are very lucky in that we have a lot. But the vulnerability still applies.

Dr. Moses: If you think about vulnerability of type 1 diabetes, you’re not talking about the social conditions and sociocultural elements causing the disease or bringing out the disease on a genetic background. But if you think about how patients with type 1 diabetes do with their disease and translate that into the vulnerability assessment, many of these same things apply. Just think of the elements that were put up this morning and track that back to type 1 diabetes, in terms of outcomes, not diagnosis. I think the key here is that the same siloed cultural elements that predict an increased likelihood of developing type 2 diabetes also predict poor outcomes after diagnosis. And I think that also applies to type 1 diabetes, though that hasn’t been part of the discussion. But it hasn’t been studied. That’s a hypothesis.

Emily: Did any of the elements surprise you?

Dr. Moses: Each of the elements makes sense. Putting them together in this way is what I think was less predictable. Sometimes the composite is far more positive and far more powerful than the individual elements. That was my biggest surprise. As somebody who had essentially no experience in qualitative research prior to this, I’m struck by the common themes that have come out of the interviews. I think that’s very informative as well. I think it may help us design better health delivery models both for case identification and patient education and ultimately patient care.

Kelly: We’ve noted the flaws of randomized controlled trials for a long time. This is convincing evidence that observational data is very important in addition to randomized controlled trials. Doesn’t this come at a time when observational data is going to be easier to get?

Dr. Moses: It will be easier to get and good observational data can be very informative. They just inform in different ways. It’s a matter of synthesizing the two elements together to come up with a better understanding and then turn that into an appropriate solution.

Kelly: On some level, the average randomized controlled trial is taking away all the complexity and just looking at what the medicine is doing.

Dr. Moses: If you’re talking about randomized controlled trials to look at drug efficacy and safety, you’re absolutely correct. How you can introduce elements that are more “real world” in that setting without disrupting the trial is really challenging. That’s why it’s so important to have these additional types of data. Do I think this is less valuable than a randomized controlled trial? No, not at all. I think it’s just different.

Kelly: Doesn’t it imply that most randomized controlled trials, unless they’re truly in community settings where not that much is happening with the control group…

Dr. Moses: It’s very hard to do a randomized controlled trial in a community setting.

Kelly: Right. And we get the impression from the FDA that they want input on what different outcome measures they should be using on the drug side.

Dr. Moses: I think the biggest impediment to doing these less traditional trials has been the regulatory implications of doing them. If they’re not accepted, why would you do them upfront? After you get your drug approved, then you think about how to do them so you can understand how to best use your drug in the real-world environment. I’m delighted to hear they’re interested in pursuing that. I have a particular interest in some endpoints that need to be pursued. JDRF is starting an initiative to better define hypoglycemia from both a clinical and regulatory perspective. We know how to define it in terms of what is hypoglycemia, but do we really know what matters in hypoglycemia? That’s the kind of thing we need.

Emily: If you were designing a development program for a drug or a new intervention without regard to the regulatory considerations, what would it be?

Dr. Moses: We can’t say anything is without the regulatory aspect because we have to demonstrate efficacy and safety. But what you also want to do ultimately is demonstrate effectiveness, and that’s very different from efficacy. The ability to demonstrate effectiveness generally requires a longer duration. Will patients adhere to the medication in a real-world setting? In other words, if somebody is not standing on their shoulders every two weeks or every month in a clinical trial setting, will they continue to take the medication and will they benefit from it? I think those are the kinds of issues where we have to do a better job. One of the challenges is that today’s payers want that information at the time the drug is approved for reimbursement purposes. And sponsors are not anxious to do those trials until they know the drug is going to be approved. Why put another $50 million or $100 million into a very large-scale effectiveness trial of a drug that isn’t approved?

Kelly: Adherence might actually have to do more with some of the factors discussed today than anything else.

Dr. Moses: Sure. And then you decide who is your population, who are we going to treat or “randomize” into this trial, because you have to compare it to something. You compare it to a historical control, to whatever they were on in the run-in period. There are strengths and weaknesses of any particular design, but the important thing is how you gather data that will convince physicians that this thing really works and is easy enough to use that it will result in a good outcome for the majority of your patients.

That’s what we’re trying to do now as a company is identify the treatments that could make a real-world difference for the largest number of people. What’s very destructive in clinical practice is to start the patient on something, have them fail, go to the next thing, add it on to the last thing…we’ve talked so many times about this escalation to failure. Wouldn’t it be nice to have a treatment that you could start near the beginning or early in their disease that would sustain them for years? And whether that produces some legacy glycemic effect, who knows, but those are the kinds of things that can be tested. But if you think about having to do a five- or ten-year trial to demonstrate durability and effectiveness in a proprietary compound that has a limited patent life expectancy, you get to the point where the systems don’t seem to be in sync.

Kelly: I would have thought payers would be psyched about what you’re doing because this is actually what’s going on in the real world.

Dr. Moses: I don’t think payers have any concept of the Cities program. It also depends what you mean by payers. Remember in some cases, the partners in this are the payers. If we’re talking Copenhagen, there is a single payer.

Kelly: Kaiser or Medicare is sort of like a single payer, right?

Dr. Moses: No, I mean with Medicare there are differences in plans all over the place. The US system is incredibly complex from a payer perspective. There are different incentives and then we put the PBMs in the middle of all this. It gets really complicated. If you look at China, the cities can be capable of funding the healthcare. In Mexico City, the city government also has a big role in the delivery of healthcare through the community health centers to the public system. Then the partners are the payers and they recognize that something has to be done. That is incredibly forward-looking. Conceptually, I would be happy to do something with Kaiser or a single large payer in the US where you could test some of these concepts. That’s not speaking for Novo Nordisk.

Kelly: Should we infer that there might be more upside here for cities that have single payer systems?

Dr. Moses: I don’t want to go that far. What I’m saying is that if the government and the payer are the same and they generate data that suggests a new way forward, it’s more likely that action is going to be taken than if all those elements are separate. Diabetes is a huge problem in China. They have a larger percentage of diagnosed patients and they have a very high prevalence. They are becoming more obese and suffering from all the cultural and societal elements you heard about this morning. So if the Chinese government, whether it’s the city government or federal government, decides this is something they’re going to apply resources to…when China decides to supply resources, they apply the resources and things happen. That’s not going to be tomorrow, but I think if the research continues it could happen. There’s so much more research to be done, particularly in Shanghai and Tianjin. Shanghai’s a little bit ahead of Tianjin, so they can see how it might translate.

The real reason for doing this is to catalyze a rethinking about how we can approach diabetes and make a difference, how we can bend the curve. Whether it’s a 50% reduction in the increasing rate of obesity and the savings that come from that or whether it’s something else, I don’t yet know. Full case identification and the application of very simple public health policies at the individual patient level already could begin to blunt, not the curve of diagnosis in diabetes, but the risk of developing complications from diabetes. The worst thing in the world is to have a patient diagnosed when they come in with a retinal hemorrhage or a foot ulcer because they’ve had diabetes for 15 years out of control. The next thing they know they lose their limb.

That can be avoided, and you know full well that’s where the economic cost of diabetes is, in addition to the impact on the individual, which is horrendous. One of the great advantages of this meeting is that it may energize the whole community to rethink how to approach type 2 diabetes. Not that every finding here can be translated into an action plan, but I think out of this will come a composite of approaches, some of which are more applicable to one geographic area or one city vs. another.

For example, if in Mexico other leaders look at data from Mexico City and say, there’s something to be learned here, let’s see if we can attack this differently in Guadalajara, then that’s a good thing. The same thing in Johannesburg. If they have findings, what about Cape Town? What about small cities? Does this have to be a big city phenomenon? Maybe small cities are better equipped in some respects because it’s a matter of scale. They can reach a larger percentage of their population with fewer numbers of healthcare workers. Maybe this is a model for them as well. If you can attack it at the small city level, you could have a run-on effect. So I think there are all sorts of interesting opportunities. We don’t know how this is going to play out over the next few years other than the fact that we’re committed to making sure it continues. You’ve heard this $20 million commitment of financial and intellectual resources to the problem.

Emily: Do you know what the research is going to look like in those next five years? Was this a one-year project that has now ended or are those studies still ongoing?

Dr. Moses: In some cases they’re still ongoing. In other cases, it’s a matter of coalescing all the data that’s been gathered. You’ve heard some of it presented today, but there’s a lot more data buried in there. Their biggest challenge is the amount of data they have. The goal is to have a better understanding and to look for the similarities and differences between these cities. Some are going to be uniquely cultural. China is different from Mexico, it’s different from Houston, and it’s clearly different from Copenhagen. But I think we can find common elements across diverse areas. That’s an indication of the strength of the signal.

There’s a fine line between acting prematurely and acting on the basis of clear direction from the data. There has to be a little bit of caution in this. I think to expect that we’re going to change the nature of diabetes in these cities in two years or three years is completely unrealistic. However, if over that period of time an approach can be designed and piloted in certain areas with demonstrable results – that is, better outcomes like a higher percentage of individuals identified, more getting into treatment, better A1c levels – then this will have been wildly successful.

Kelly: A lot of the discussion spoke to engaging patients. I think it’s also engaging doctors and promoting community health. Can you talk about that and how you might measure engagement?

Dr. Moses: It’s not a matter of engaging diabetes specialists. They’re engaged but they’re…

Kelly: I think a lot of them seem very stressed, and also looking at the medical school classes…

Dr. Moses: That’s what I was going to get into. I think the specialists are engaged. But I think we have to stop and think because we’ve been thinking very medically up to this point. Let’s think from a public health perspective. Is the need more physicians specializing in diabetes or is the need more individuals who have sufficient knowledge about diabetes to make a difference at the patient level in the community? I think that’s a fundamental question we have to ask. At the same time, and this is what you were getting at, we have to do a much better job educating young physicians about diabetes. To think that at Harvard Medical School, a medical student has two hours of experience in diabetes, though I don’t know exactly where it is today. 25% of the patients in the hospital have diabetes and 8% to 12% of the outpatient population (depending on age and geography) have diabetes, and they don’t really know what to do with it.

Kelly: It’s hard to be successful.

Dr. Moses: It’s almost impossible to be successful because you’re also treating the hypertension, the hyperlipidemia, the gout, the congestive heart failure, the COPD. You’re trying to get them to the smoking cessation program. They’re also depressed so they’ve been on an SSRI, or they may be HIV-positive. All of these things are so overwhelming that diabetes just falls to the bottom.

Kelly: Is there anywhere globally where there isn’t this much stress on how much time you can spend with a patient? Who’s the best at community health?

Dr. Moses: It depends how you define community health. You could define it as a community health center where a patient goes in and sees a healthcare worker, or you could define it as a healthcare worker going out into the community and seeing the patient at home. And it’s a huge difference. They still have to maintain a schedule, but the ability to understand the needs of the patient in the home setting is ever so different from understanding the needs of the patient in an office. There, the patient is asked, “How are you doing?” “I’m okay.” “Well, I saw that your A1c was 8.3%. Have you been taking your medicine?” “I couldn’t really afford my medicine.” “Well, maybe we should think about something else.” It’s a totally different conversation. You go into the home, you see the patient. The community health worker can go into the kitchen or pantry and see what kind of food is there and get insights into how to approach the care plan or the recommendations for that individual.

I’m not talking about a sophisticated diabetes care provider. I’m talking about somebody who’s had X number of hours – I don’t know what it is – of education around diabetes and the general treatment approach. These people will not be prescribing, but they’re going to say “You really need to have something prescribed. Let’s get you into the clinic. I understand what’s going on here in the house and I’m going to communicate that.” Personally, I think the question is how do you get the data so you understand and get a composite view of the patient, then of the community, then of the city, then of the state, then of the country so you could begin to do population management based on individual data. And I’m not talking about individual blood glucose values. I think for a disease like diabetes that is absolutely critical. I think it’s critical for weight management as well and for multiple other non-communicable diseases like rheumatoid arthritis, obstructive pulmonary disease, asthma. I don’t care what it is; we just are not doing a good job collecting the right information and sharing that information with a panoply of healthcare providers who may not be involved but could be involved in that patient’s care.

Emily: What do you think is the most important message for us to communicate to our readers?

Dr. Moses: That there are findings that provide new insights into some of the determinants of the development of diabetes and that what we need to do is not rethink how to approach the disease. The clinicians aren’t necessarily going to buy into that at all. But from a public health perspective, we must. Clinicians, particularly clinician scientists, tend to focus on the latest developments, devices, drugs, discoveries of new genes that may be related, etc., but diabetes has become a public health problem and we’re not using the right tools to address that. That’s what this is about. It’s a wakeup call to me to say that we’ve got to think about the big picture. It doesn’t mean that Novo Nordisk is going away from developing new drugs. But what’s so exciting to me is that we as a company recognize that we can’t do this alone. We can’t even begin to touch the surface of this. But we can catalyze others to do it. For me, that’s the most important part of it. That says that we are committed to diabetes and to changing diabetes. It makes me feel good about being here.

Kelly: In China, why are the problems so different in Shanghai vs. Tianjin?

Dr. Moses: First of all, remember it’s like talking about the difference between Alabama and Maine. China is a composite of different ethnic groups, and whether that plays any role or not, I don’t know. But don’t think of China as a unified entity. Plus the cities are in different stages of development. Shanghai is much more sophisticated. It’s more modern. It’s been modernizing for the last 30 years. I was there two days ago and I hadn’t been there for about 14, 15 years. And 15 years ago, I had never seen as many cranes in my life. In fact, I remember learning 15 years ago that one half of the world’s active cranes were in Shanghai at that time. Think about that for a moment. It’s totally mind-boggling, and it’s the same way now. The place is just exploding and it’s a modern city. There’s a vibrancy there and the economy is going bananas. I think it’s in the top 15 cities in terms of cost of living in the world. So it’s not cheap, but people can afford to live there. Tianjin is probably 10-15 years behind.

-- by Emily Regier and Kelly Close