I recently had the opportunity to watch a Microclinic (MC) session in action. The setting was in Amman Jordan. On Monday, March 4 2012, at 8 am, I was picked up at my hotel by Ala’, a young nutritionist who works for Microclinic International (MCI). She explained to me that she was the featured speaker for that day, and planned to discuss fundamentals of nutrition with the MC participants. We headed to a community hospital in one of the Hills of old Amman, and found our way to a small meeting room barely large enough to hold the 25 or so attendees. At the front of the room was a table facing the audience, which was seated in plastic chairs. Two nurses stood behind the table, in the two corners of the room, one measuring weight and girth as well as blood pressure, and the other taking tiny blood samples to assay for glucose levels. A large ledger was on the table and contained extensive and well designed forms for data entry. The nurses were also handing out pieces of paper to each of the participants with their individual values, so that they could track their own progress. The participants seemed very interested in hearing their latest results.
I was invited to sit behind the table facing the audience, which meant that people walked by me as they approached the nurses to get their measurements. Some looked at me quizzically, others gave me a friendly smile, and others yet engaged me in some chitchat. People came in twos or threes, with spouses or friends, each group representing a microclinic.
As the participants settled into their seats, Amal, an energetic and self-assured young woman, and a pharmacist who is in charge of the Amman MCs, started the session. She introduced me as a member of the MCI board who had come to watch a session, and told them I was from Damascus but lived in America. Several of them piped up and told me how they had family in Syria, or were originally from Damascus themselves. Some told me they were praying for the safety of people in Syria. I found their warmth and concern very touching.
Amal then asked them about their level of activity during the previous week, especially that it had snowed, a rare event in Amman. Several women said they stayed at home because of the snow, but some men said they found ways to take walks in spite of it. Amal asked why the men did not encourage the women in being more active. She reminded them that the central idea is to encourage others to not only eat right, but to exercise, and that it was especially important to help the ladies be more active as they have more limited options. She then asked: “So what will you do if your wife resists the invitation to go for a brisk walk?” An older man replied: “Invite the lady next door!” Everyone laughed, and Amal said: “Sure, as long as the neighbor can invite your wife!” The funny man did not seem to think that was a great idea after all… This exchange would prove to be typical of the banter between the audience and the MCI staff or amongst the members of the audience. Occasionally, Amal would have to say: “While it’s great to joke and have fun, we really need to get serious now and get through the material.” Some audience members would nod in strong agreement and the jokers would settle down for a while. I was struck by her level of authority over the room, even though the audience was made up of older people. I found their compliance towards a younger woman remarkable.
After the initial exchange, the group was given their breakfast. It consisted of some fresh vegetables— half of a green pepper, a cucumber, a tomato, and then a “Fatteh”, a Middle Eastern dish consisting of cut up pita bread and garbanzo beans with a sauce made up of hummus, yoghurt and some olive oil, and topped with some toasted pine nuts. The meal also included a tiny container of unsweetened apple juice. Every one dug in, and I noted that they all reached for the vegetables first, before eating the main dish. Breakfast was the prelude for the discussion about nutrition. Ala’, the nutritionist, told them about several features of the meal that they were to keep in mind: The importance of starting with vegetables, the size of the portion of the main dish (it was actually moderately sized and quite filling), and the fact that it would have been preferable to eat a small fruit rather than drink the juice. But the fruit juice had been included as an example of an acceptable size that would not drive their blood glucose out of bounds. They were told that sweet juices, pop and other drinks of this sort were strongly discouraged.
Each of the participants then received a large version of the food pyramid, in Arabic, to put on their refrigerators, along with several other educational pamphlets. The rest of the session consisted of a thorough and easily understandable description of the various elements of the pyramid, with examples taken from Arabic meals. This was all connected not only to weight loss but to stability of glucose levels. There were numerous interruptions and questions. Some people took copious notes. But others shared their own opinions, perspectives, and jokes.
One of the points of discussion was about folk remedies that would miraculously control glucose level, thereby obviating the need for diet and exercise. One member of the audience told of drinking a tea made up from soaking berry leaves, and said that as long as he maintained this habit, he could eat all he wanted and maintain glucose level. And that the only reason he needed to stop is that the season changed and the leaves were no longer available. Somebody else chimed in to support this claim. Amal and Ala’ noted that there was no scientific evidence for the efficacy of such a treatment. Members of the audience argued that a lot of medicines came from such home remedies and they should not be ignored. Amal acknowledged that it was theoretically possible, but that no one knew the long term effects or potential toxic effects and until those are formally tested, such treatments could not be endorsed. Both she and Ala’ emphasized repeatedly that the information they were sharing was only material that had been clearly and scientifically established, and that this should be something that the group should keep in mind in spreading information.
Another interesting issue that arose was whether these nutrition ideas were for the patient himself/herself or would impact the entire family. Early in the session, a woman stated that she now cooks differently for herself than for other members of the family, and the session leaders suggested that she may wish to reconsider as she heard the rest of the presentation on nutrition, whereby she would learn of strategies that would make the meals nutritious and healthy without robbing them of taste. My own suggestion was to underscore that the vulnerability to this illness runs in families, and therefore the kids were at risk for developing it, and that a great gift that these women could give to their kids is to teach them a lifestyle that would help them prevent diabetes. Amal agreed and articulated these thoughts for the group.
Throughout the session, an ongoing refrain from Ala’ and Amal was the weighing of choices: “Do I want to eat this more, or do I want to preserve my sight more?”; “Do I avoid exercise, or do I lose a foot?”. It startled me at first, but I could see that it was impactful and necessary. That it brought people back to their reality and the critical importance of controlling their eating habits and enhancing their activity. But it also underscored a central tenet of MCI—that of having the power to control one’s destiny.
As the session was ending, several members asked for a follow-up session on nutrition. It was clear that they were very interested in this topic, felt there was a great deal of information to absorb and wanted a second chance to learn more. Amal promised them that there would be further opportunities. Several people walked up to me and asked me for advice on various health issues. When I explained that I was not a physician but a scientist who studies brain diseases, they asked me for advice on those. They warmly invited me to return and talk to them about the brain.
I left the session feeling exhilarated. It was simply terrific and was also great fun! I was struck by the positive and friendly atmosphere, by the session leaders’ ability to communicate a great deal of complex information with clarity, by the engagement of the Microclinic members with the leaders and with the rest of the group, by the balance between maintaining group spirit and ensuring the transfer of critical information. I kept thinking about the goodness of fit between the MC concept and the nature of the Arab culture—not only the close knit social structure, but also people’s gregarious nature, their interest in sharing information and their real delight in having special knowledge derived from an authoritative source! Even though every member was coping with a chronic and potentially devastating illness, it was clear that they were in good spirits, feeling in charge and hopeful, and that these feelings were, indeed, contagious.
Huda Akil, PhD is the Gardner Quarton Distinguished University Professor of Neuroscience & Psychiatry, Co-Director & Senior Research Professor at the Molecular and Behavioral Neuroscience Institute at the University of Michigan, Ann Arbor. She also serves as a member of the board of directors for Microclinic International.