Faces of Public Health: Daniel Zoughbie, Microclinic International
Building on epidemiologic evidence that suggests that healthy behaviors are transmittable across social networks, Microclinic International, a nonprofit international organization based in San Francisco, leverages human relationships to address both non-infectious and infectious diseases such as diabetes and HIV/AIDS. The theory behind the Microclinic International is that if negative behaviors such as smoking, unsafe sex and overeating can be contagious, so can positive, healthy behaviors.
The organization operates through “microclinics” that consist of small groups of people who share access to education, technology and social support as they work together to prevent and manage a deadly disease. Founder Daniel Zoughbie says the organization is “built on social relationships and social capital rather than bricks and mortar.” Microclinic works with local partners through community-based workshops with trained facilitators.
NewPublicHealth spoke with Zoughbie about Microclinic’s potential to reduce incidence of disease, both in the United States and abroad.
NewPublicHealth: What gave you the idea for Microclinic?
Daniel Zoughbie: When I was a college junior at UC Berkeley I wanted to do a junior-senior year project that would involve rigorous research, but also have an immediate impact on a community in need. My grandmother passed away from diabetes many years ago and I realized that a disease like diabetes is relatively simple to prevent and manage, and yet it is a leading cause of death and disability around the world.
So, I came up with the microclinic concept and piloted it in the West Bank with scholarship funds I was awarded at Berkeley. From the initial success of that pilot project I was able to expand to Jordan and recruit colleagues who worked with me to help build the organization. And then we expanded further. Today we’re running three microclinic projects in Kenya, supported by Google and other funders, in Jordan, supported by organizations including the health ministry and Her Majesty Queen Rania Royal Health Awareness Society, and in Appalachia, Kentucky supported by funders that include the U.S. Centers for Disease Control and Prevention and Humana.
NPH: What is the concept behind Microclinic?
Zoughbie: One of the most significant spaces for the prevention and management of major disease epidemics is actually not the formal health care infrastructure of hospitals and clinics alone—it is the spaces of homes and businesses and places where friends and family come together and can positively influence behaviors, such as eating healthy food, walking together, engaging in physical activity and helping each other monitor health conditions. Or, these kinds of spaces can be transformed into places where diseases spread. Families can sit sedentary in front of televisions. They can eat junk food together, and choose not to check on each other in terms of health monitoring and taking medications.
We are pursuing what we believe is the Holy Grail of public health—how do you change behaviors that leads to major disease epidemic and how can you change those behaviors in such a way that the healthier choices spread? It’s what we call “contagious health.”
NPH: Does the concept work in any culture?
Zoughbie: Initially, when we first started piloting the work in the Middle East and we talked about the success and measured our observations, many people told me that in the Middle East people are more communal and the concept would never work in another context such as the United States. But then we launched the concept in Appalachia, Kentucky, a rural area of the United States with its own share of challenges. We conducted a randomized controlled trial, which is the gold standard for measuring the efficacy of an intervention, and we saw a very big difference in the health outcomes between people who enrolled in our program and those who did not. That difference is not insignificant; it’s not just the difference of numbers. It means that somebody’s going to live longer and that they’re going to be out of the hospital more than their counterpart in the control group. It means that they’re going to have happier lives, they’re going to spend more time with their grandchildren and they’re going to be more productive members of society. And it really does have a contagious effect on society as a whole.
NPH: Does the concept work for any health issue that requires action by an individual?
Zoughbie: Yes, and that’s a good way to frame it. Take diabetes and obesity, for example, which are very much related to behaviors. Two major behaviors that can be changed are what you eat and how often you exercise or move. And then there are other behaviors, such as taking medication and monitoring weight, blood pressure and glucose. The global economy is losing more than $1 trillion every year simply because individuals and their groups are not able, for whatever reason, to engage in changing their behaviors concerning food and physical activity. Of course, there are other factors such as genetics, environment and socioeconomics. But our hypothesis is really that by leveraging the power of social networks we can help individuals change their behavior in a positive way, and then we can also harness that energy and motivation to change the behaviors of those around them.
So people come to our program and say, hey, I’d love to sign up. And we say, great, but you have to bring friends or family to join with you. And let’s say they bring two or three other people—their sister, their best friend and their mom—and they come to our class together and there are other social clusters just like those. You can think about it as a layer: individual learns how to change their behavior, they learn some basic information, but they also have this group that supports them and actively encourages them to change their behavior.
NPH: Do you think that microclinics will become a standard approach for getting people to be able to change their behaviors to improve their health?
Zoughbie: We have two goals. One is an intellectual contribution to global health. We want nothing less than to push for a paradigm shift in the way in which public health practitioners around the world categorize, prevent and manage major chronic disease epidemics that are related to human behaviors. So, a disease can be biologically infectious, such as HIV/AIDS, or it can be non-biologically infectious, such as Type 2 diabetes, but the behaviors leading to the major disease epidemics are often times rooted in socially contagious behaviors. If that’s true, and there seems to be quite a bit of emerging evidence for this, then the response from the global health community really needs to be one that thinks about intervening in these disease epidemics at the level of the social network. The intervention needs to be one that doesn’t simply try to slow or stop the spread of an epidemic, but it actually needs to be one that tries to turn the whole thing around. Because if a behavior such as smoking or overeating or sedentary lifestyle can be socially contagious and spread from person to person, from peer to peer, then why can’t good health be made contagious and spread through social networks in the same way? So that paradigm shift is the theoretical or intellectual contribution you want to make, and that’s why we have a very rigorous research program which the Robert Wood Johnson Foundation is funding through its Pioneer portfolio.
The second aspect is very practical, which is that we actually have a program that has been demonstrated to make people healthier. We feel like the microclinic program should be prescribed to patients in public health departments around the world and perhaps other health care facilities in the same way that a blood pressure medication is prescribed or a diabetes medication, and that it can in many ways become part of the process of caring for patients.
NPH: What is the payment model?
Zoughbie: We are currently funded by a range of grants, private donations, private foundations, governments and private corporations. In terms of the future, we can show organizations such as public health systems how to implement the concept and there can be a fee attached to our work.
NPH: What’s next for your company?
Zoughbie: We’ve been moving through different stages as an organization. What has been so rewarding for us has been that we’ve gone through the early pilot stage and then we’ve gone through the process of producing a clinical trial and doing some very high level research and collaboration with researchers from top universities around the world. So what we’re going to be doing now is, for example, in Appalachia and Jordan we’re working on the continued expansion of the programs. Our goal is to complete a national expansion in the coming year in the Kingdom of Jordan, to expand throughout the state of Kentucky, and we are also going to be expanding around Mfangano Island in Kenya. We’ll also be initiating a program in Qatar and we hope that having two major projects in the Middle East will continue to encourage the expansion of the microclinics throughout that entire region.
We also recently launched a partnership with the United Nations offices that are based in Jordan, so our hope is also that that opportunity will serve as a way of opening doors for future expansion, both regionally and internationally.
NPH: What about expansion in the United States?
Zoughbie: We would very much like to expand to the surrounding states, but also elsewhere in the United States. For example, we’re based in California and there are pockets of significant need here in California, and we see ourselves potentially being able to expand the model here in our own backyard.
I think what distinguishes the microclinics and the microclinic model is that we don’t simply want to create support groups; we don’t want to create joint groups where doctors counsel patients together. We don’t want to create anther Alcoholics Anonymous where groups of strangers come together to share their problems. All of those are worthy endeavors and many of them have lots of really impressive data behind them.
What we’re saying is that there exists in society these social networks and we can actually harness the social network itself and bring it into a centralized place and connect these mini-networks with other networks of people who are going through similar things. And we can use these networks to harness the level of pressure from intimate friends, close family members, the larger class dynamic of those who are in the program together, and ultimately the influence of the local public health system and the authority and responsibility that they carry. We can leverage that to change the behavior of a single individual, but then we can also flip it and we can say that individual, as part of their own trajectory of health progress, also need to feel responsible for the health of those around them and to actively look to alter the behaviors of those in their network and beyond their network in the community at large. That’s the social contagion that is really fundamental to our program.