No Substitute for Hard Work: Dedication to the Diabetes Community

Ken Costa, author of Know Your Why: Finding and Fulfilling Your Calling in Life, said, “Your ‘why’ gives you a competing advantage, because if you are operating from ‘why,’ you are usually working with great passion and focus.” He went on to point out that, “Our ‘why’ has extraordinary ramifications for our work. It impacts our concentration, our drive, and our usefulness” (1).

I discovered my “why” several years ago. The questions that came to mind then were, “What is my ‘why?’” and “Why am I here in this place, at this moment?” My arrival at this place, at this time, for this reason, was shaped by my “village”—the many people who have played extraordinary roles in my social, personal, and professional life.

I am here because of my mother, Constance Kirksey, an educator in Florida’s Volusia County school system for almost 40 years. She created my thirst for learning and planted the seed of passion for teaching and student advocacy.

I am here because of my father, Sammie Kirksey, Sr., who did not finish high school, worked as a common laborer, and never met a stranger. He taught me to accept people where they are and that everyone matters.

I am here because of “Unk” Eddie Robinson, my mother’s oldest brother, who was a big man with a big personality. He taught me confidence and instilled in me that there was nothing I couldn’t do or achieve if I worked hard. His favorite line was “I am fat, but I’m pretty!” Little did he know how impactful that statement and attitude would be in the development of my self-confidence.

I am here because of Uncle Kenny—Kenneth Brown—my mom’s youngest brother, who as a 6-foot-plus, 300-lb, gay man, taught me the importance of family. He established high expectations for me and accepted no excuses for failure.

My family taught me the importance of equity and the recognition that diversity is both powerful and necessary.

I am here because of Florida A&M University (FAMU), a historically Black university founded in 1887. FAMU provided me with a strong academic and professional foundation on which I continue to build even now. During my tenure as a pharmacy student at FAMU, I became keenly aware of the gross health disparities and inequities that influence the poor health outcomes of marginalized communities. As a result, I left FAMU with a deep sense of obligation and a strong appreciation for community outreach and engagement.

Years after graduation, I was honored to return to FAMU to serve on the faculty of the College of Pharmacy and Pharmaceutical Sciences and the Institute of Public Health. For more than 25 years and two generations of students, I had the pleasure of paying it forward by teaching and training future pharmacists to become compassionate practitioners. It was also during this time that I developed an unwavering commitment to, and indeed a passion for, caring for people living with diabetes. It became personal. It became my mission.

I am also here because of the Neighborhood Medical Center (NMC), a federally qualified community health center that serves as the medical safety net for thousands of uninsured and underinsured people living in Tallahassee, FL, and surrounding communities. The center currently has five locations throughout Leon and Gadsden Counties. The NMC was the clinical training site for my students. For more than 20 years, I have been embedded in the practice as a clinical pharmacist, providing diabetes care and education and disease management. This professional path was only possible because the center’s administration and medical staff were forward thinking and had an early appreciation for the expanded role of pharmacists in this environment.

The special nature of our “neighborhood clinic” defines us as being relatable, accessible, and trusted as a community resource. We are an authentic part of our community.

We provide comprehensive primary care services that include chronic disease management, mental health services, and dental care. Our specialty services include obstetrics and gynecology, orthopedics, and psychiatry, and, finally, the glue that holds it all together is our case management services. Because of the coronavirus disease 2019 (COVID-19) pandemic, we implemented telehealth services for primary care, mental health, case management, and limited pediatric care. Today, we continue to offer many of these services via telehealth.

Our goal mirrors the Healthy People 2030 high-priority objective regarding social determinants of health (SDOH): to identify ways to create social and physical environments that promote good health for all. As shown in Figure 1, the Healthy People 2030 approach is based on five key areas of SDOH: economic stability, education, social and community context, health and health care, and neighborhood and built environment (2).

Many of our patients struggle daily to cover the cost of medications and testing supplies—even those with insurance (i.e., Medicare or Medicaid). High copays often impede access to appropriate care. A number of our patients face food insecurity. In addition to the high costs associated with eating healthfully, there is also a problem of limited access to healthful foods. The service areas of NMC include several neighborhoods that have been identified as food deserts (3). Trying to balance the high costs of food, medications, and other necessities of life is a constant challenge our patients must grapple with every day.

NMC’s patient population ranges from infants to seniors, and although it is diverse in many ways, >60% are African American (Table 1) (4). Ninety-eight percent of the patients we serve fall below 200% of the federal poverty level. Most are uninsured and live in public housing (4).

In 2020, the proportions of NMC’s patient population with diabetes and hypertension were 17.7 and 22.4%, respectively (4). Although our rate of diabetes was much higher than the U.S. rate of 11.3%, out rate of hypertension was significantly lower than the national rate of 47% (5).

Our diabetes care, education, and management program involves a multidisciplinary team consisting of a pharmacist who is a certified diabetes care and education specialist (CDCES), physician providers, nurse practitioners, medical assistants, mental health professionals, and case management counselors. Our team-based approach follows the recommendations enumerated in the ADA’s Standards of Medical Care in Diabetes (6), which is to align approaches to diabetes management with the Chronic Care Model. This model emphasizes person-centered team care, integrated long-term treatment approaches to diabetes and comorbidities, and ongoing collaborative communication and goal-setting among all team members (7).

Collaborative, multidisciplinary teams are best suited to provide care for people with chronic conditions such as diabetes and to facilitate patients’ self-management (8,9). Utilization of this model has been essential in helping us improve our patients’ diabetes care. Our program incorporates disease management for type 1 and type 2 diabetes, hypertension, and hyperlipidemia. The services are evidenced-based, with primarily one-on-one encounters.

A retrospective review of 54 randomly selected charts of our patients with diabetes revealed a mean initial A1C of 9.61%. More than half of the patients entering the diabetes care and education program had an average A1C >9%. A 1.83% decrease in A1C was observed after 3–6 months of care. Although we face significant challenges daily, our patients report being extremely satisfied with the services we provide (Figure 2) (Neighborhood Medical Center, data on file).

We should all be excited about how far we have come in our efforts to improve care for people living with diabetes. However, we must also understand that there is an enormous amount of work still ahead of us. Unfortunately, our success and progress to date have not resulted in improved outcomes for a large percentage of people living with diabetes, many of whom represent marginalized communities. The perpetual health inequities and unconscious bias experienced by communities of color have fueled an inferno of health disparities that is characterized by higher rates of hospitalizations related to hypo- or hyperglycemia, higher rates of lower-extremity amputations, and higher mortality rates (10).

It is crucial for all of us to embrace the reality of these disparities and work to combat the factors that promote the health inequities that fuel their existence. We must engage with our communities and keep the lines of communication open to help them understand that we are here to help.

I am so proud that, in response to the grossly disproportionate impact of the COVID-19 pandemic on people living with diabetes, the ADA launched its Health Equity Now campaign and developed its Health Equity Bill of Rights for people with diabetes. This manifesto envisions a future without health disparities. It charts a course to ensure that the 133 million Americans living with diabetes or prediabetes, along with the millions more who are at high risk for diabetes—regardless of their race, income, zip code, age, education, or gender—get equal access to the most basic of human rights: optimal health (11).

In response to a rapid and ongoing increase in the cost of life-saving insulin, the ADA has exhaustively advocated for affordable insulin prices across the nation. As a result, 20 states and the District of Columbia now have enacted affordable insulin laws. Additionally, in November 2021, as part of President Biden’s Build Back Better Act, the U.S. House of Representatives passed the most sweeping measure to date to limit out-of-pocket copays for insulin nationwide (12). Hopefully, this groundbreaking legislation will help to end the consequential and potentially deadly practice of rationing insulin among our patients.

Earlier in 2021, the ADA launched the important Burdens of Diabetes campaign. In 2004, the federal government cleared the way for charitable organizations to help fill a gap in patient care through financial assistance. You may know of these patient assistance programs and use them to help support your patients in need. However, until this year, there was no such program focused on helping people with diabetes.

The Burdens of Diabetes campaign allowed ADA to change this by setting up its Patient Advocate Foundation, sometimes known as copays.org (13). The fund opened on January 26, 2022, and all available funds were dispersed within a 13-day time frame. Funds approved for use to cover copays, tests, supplies, and medications were dispersed on a first-come-first-served basis once patients’ applications were approved.

The ADA continues to fundraise and seek additional financial support to reopen the fund. Our experts estimate that 13 million people with diabetes would qualify for such financial assistance. For this reason, we need continued support for this effort. Please tell our colleagues about both the presence of this fund and the need for continued dollars to reactivate to aid people who qualify for assistance (13).

For these and so many other impactful initiatives, I am proud to be associated with and deeply involved in the activities of the ADA.

Health Equity Now, the insulin affordability initiative, and the Burdens of Diabetes campaign—taken together, this is an exceptional starting point. However, there is much more to be done. Allow me to share two action points.

There is justified extreme concern about the lack of access to diabetes education for many people living with diabetes. Diabetes self-management education and support is an essential component of diabetes care and has been proven to be an effective tool in improving diabetes outcomes (14,15). However, the number of DCESs is insufficient (16). In 2020, the Certification Board for Diabetes Care and Education reported that there were 19,783 certified DCESs and an additional 15,000 who were uncredentialed in the United States. This translates to one educator for every 16,000 patients (16). Even more alarming is the poor representation of communities of color within the current CDCES workforce. According to the career website Zipia.com, only 8.7% of DCESs are Black (17). Yet, African Americans are two times as likely to be diagnosed with diabetes and suffer a disproportionate share of the morbidity and mortality associated with the disease.

As a practicing pharmacist who provides diabetes care, education, and management, I am personally aware of the crucial role pharmacists can play. Multiple studies have demonstrated the effectiveness of pharmacists in improving diabetes outcomes (18). Despite their proven effectiveness, however, pharmacists are underutilized and are still limited in their scope of practice because they lack provider status and therefore face reimbursement challenges. I am advocating for this to change.

This is my short list of crucial action items for the diabetes community. Have you developed one of your own? Any effort to slow the diabetes epidemic will require all hands on deck. Collectively, I know that we can improve the lives of people with diabetes and reduce the disease’s associated morbidity and mortality.

I would like to thank all diabetes care professionals for all that you do in this effort and for your support of the ADA and its initiatives. I would also like to personally thank those many members of my village who have supported me through my professional journey. Finally, and most importantly, I would like to thank my wife, Karen, who is my biggest cheerleader and truly the wind beneath my wings.

I will leave you with a quote from Theodore Roosevelt that I often share with my students: “People don’t care about how much you know until they know how much you care.”