By Tamara Straus
Among the global health reports that keep Daniel Zoughbie up at night is a World Economic Forum and Harvard School of Public Health study, which predicts that over the next two decades the global economy will lose $47 trillion to noncommunicable diseases, such as diabetes and cardiovascular disease.
“Yet a very modest intervention that tries to make small changes in people’s behavior can have an enormous impact in terms of prolonging lives and saving under-resourced communities millions upon millions, even billions, of dollars,” says Zoughbie.
The modest intervention to which Zoughbie refers is a social network for “contagious health” behavior, basically a small group of family or friends who support each other to eat healthy and exercise regularly. Zoughbie has obsessively backed this social network idea since 2005, when he founded Microclinic International, using personal scholarships and startup funds from the BigIdeas@Berkeley competition. The UC Berkeley and Blum Center-seeded nonprofit has since gone on on to affect more 1 million people through the establishment of “microclinics,” community initiatives, and media campaigns across four continents.
The idea of positive peer behavior leading to positive health results may seem obvious, and that’s because it is. Microclinic International’s social network approach is based on old notions of community and self-help, says Zoughbie.
The idea also comes from a personal loss. As a junior in college, Zoughbie reflected on the premature death of his grandmother in the West Bank due to diabetes and had two intertwining epiphanies: 1) his grandmother did not have the public health information she needed to help her manage her disease; and 2) if she had been given basic preventative information and found a supportive network, she would have changed her diet and health regiment and lived much longer.
“She simply was not able to access a basic level of quality healthcare and education,” says Zoughbie, who was born and raised in the Bay Area.
Under the mentorship of UC Berkeley Professor Ananya Roy, an expert in urban studies and international development, Zoughbie began investigating how lower income communities organize themselves from the bottom up in the absence of effective or existent services. He travelled to Palestine and observed that community, not individual or institutional, ties are dominant—and that health behaviors are often social or cultural in nature.
In Palestine, for example, he observed one family with a diabetic father who passed around chocolate when entertaining a guest. Zoughbie remembers the daughter, who had learned about the dangers of diabetes from a Microclinic International program, admonishing her father for reaching for one of the chocolates.
“The daughter told her father that under no circumstances was he to eat that chocolate,” remembers Zoughbie. “In Middle East culture, this is a bit taboo: to tell your father what to eat or not to eat in front of guests. But the daughter cared more about saving her father’s life than causing some societal embarrassment.
“From these and other interactions, I realized that positive health behaviors could be just as contagious as negative health behaviors.”
Zoughbie was named a Strauss Scholar and a Haas Scholar in his junior year. He studied social anthropology at Oxford University on a Marshall Scholarship, and completed his doctorate in international relations there as a Weidenfeld Scholar. Yet he was not a traditional student. All the while, he used his university honors and credentials to travel, conduct research, and network on behalf of Microclinic International.
“While I was a Marshall Scholar, I went to South Africa and was on a bus, where I met somebody who introduced me to somebody else,” remembers Zoughbie. “One thing led to another, and I put in an application to the World Diabetes Foundation. We applied for almost $100,000 and, to my great surprise, Microclinic International got it.”
Stephen Shortell, UC Berkeley’s Blue Cross of California Distinguished Professor of Health Policy and Management, remembers Zoughbie as a young man easy to support. “He came up to me at a Blum Center function and asked whether we could meet and talk,” recalls Shortell. “He was attacking a very big problem—diabetes in developing countries—and I could see his concept was both promising and low-cost. I made some introductions.”
Zoughbie, now 30, has spent much of the past decade hustling to scale up his nonprofit. The key ingredient, he explains, has been persistence and endurance, “talking to lots and lots of people, and bluntly saying, ‘Hey, I have this idea, which has been piloted; it’s pretty simple and inexpensive to scale, and could save a lot of lives in under-resourced communities.’”
This kind of persistence led in December 2006 to the formulation of a Microclinic International pilot in Jordan, with support from Queen Rania’s Royal Health Awareness Society, the Jordanian Ministry of Health, and a former British Ambassador to Jordan. With support from A. W. Clausen, a former president of the World Bank and Bank of America, Zoughbie was able to establish Clausen Fellowships, hire really bright people, and take a more quantitative approach to understanding the effectiveness of the organization’s work and refine its model.
Microclinic’s diabetes social network model is based on four key strategies, or “4 Ms”—Meals, Movement, Medication, and Monitoring—and is intended not just to alter dangerous health behaviors but, more importantly, to sustain positive ones in groups of family and friends. As principal investigator for Microclinic International, Zoughbie has initiated several major trials, including a two-year, Jordan-based study published in Lancet Global Health, which found that for most patients, improvements in blood sugar control were sustained for two years after signing up.
Microclinic International also has achieved evidence of impact on the other side of the globe, in Bell County, Kentucky. There, it partnered with the health insurance company Humana to conduct a randomized control trial of 552 participants from five neighborhoods in rural Appalachia, where obesity and diabetes are widespread. Again, clusters of two-to-eight friends and family voluntarily came together to establish and spread healthy norms, such as regularly checking weight and blood sugar, exercising, watching calories, and eating fresh fruits and vegetables. A 16-month follow up of the cohort, published in a 2015 study in American Heart Association journal Circulation, found that a substantial majority of the TeamUp4Health patients experienced and maintained decreased in weight, waist size, and blood pressure.
“Leveraging the social network and peer influences and social networks for support may be important for fighting obesity,” said Harvard School of Public Health Scientist Eric Ding, who served with Zoughbie as co-lead author of the Circulation study and is director of epidemiology at Microclinic International. “We need to focus on more than the individual obese patient in isolation, and look to family and friend networks and the communities where people live.”
Zoughbie, whose PhD is in international relations—and who also serves as a political science scholar at UC Berkeley’s Center for Middle Eastern Studies (his recent book Indecision Points: George W. Bush and the Israeli-Palestinian Conflict was published recently by MIT Press)— views public health as fundamental to regional and international security.
“When a community is falling apart,” he says, “health problems often create a vicious cycle, in which people are poor because they’re unhealthy and they become more unhealthy because they’re poor. This cyclical nature of poor health creates the seeds for social unrest. It creates disaffected young people who don’t see any hope for the future.”
This connection between public health and societal stability is what drives Zoughbie to replicate the Microclinic International model in as many insecure places as possible. Backed by the Centers for Disease Control, Google, the International Diabetes Federation, Humana, Mulago Foundation, the Robert Wood Johnson Foundation, and the Horace W. Goldsmith Foundation, Zoughbie’s nonprofit is in expansion mode, working with over 260 people. Currently, the United Nations is partnering with Microclinic International to train 1,000 healthcare workers to reach hundreds of thousands of Middle East refugees through social networks by spreading health behaviors and thwarting preventable diseases and their complications.
“I see our model as helping repair the broken fabric of society,” says Zoughbie. “Groups of people helping each other to get healthier is a first step for broken communities to rebuild a future. There’s an old Arab proverb I like to quote: ‘When there’s health, there’s hope. And when there’s hope, there’s everything.’”