TWENTY-EIGHT-YEAR-OLD Jack Perkins has lifestyle choices middle-class people take for granted. From his home in Valencia, it's walking distance to both a Whole Foods and a Vons supermarket.
He exercises daily -- lifting weights in his condo's workout room or jogging through safe, quiet, meandering streets. "It's almost like it's designed for runners and walkers," he says.
Maria Sahagun's Huntington Park home has bars on the windows and doors, and the 61-year-old doesn't venture far on foot.
Her neighborhood has a hefty supply of mom-and-pop food markets where the variety of chips and sodas vastly exceeds that of fruits and vegetables.
Robberies in her neighborhood are 75% higher than the county average, so she walks on busy Pacific Boulevard only in daylight, and never alone.
Perkins, who has health insurance, and Sahagun, who does not, both have diabetes. He has Type 1, and since childhood his pancreas has not been able to make insulin; she has Type 2, and can no longer make enough insulin nor properly respond to it. For each, the disease means using insulin, medications, diet and exercise to do the work the pancreas cannot do.
Diabetes is afflicting more people, at younger and younger ages, sending doctors, insurers and public health officials into a tizzy as the epidemic threatens to overwhelm the healthcare delivery system. The annual cost of healthcare for an adult with diabetes is more than $13,000, and rates of Type 2 have risen sharply in the wake of the upsurge in obesity in this country.
A bold experiment is unfolding in Los Angeles County that may serve as a lesson for the nation as it battles the epidemic.
Experts know that the cost of care could be much lower if patients could take simple measures to control their disease and avoid complications: nerve damage, amputations, heart disease, blindness, even death. But surveys show that many, even those with adequate health insurance, do not get that care, which is costly and labor intensive, demanding daily attention from patients and timely responsiveness from doctors.
Poverty creates additional obstacles, such as finding fresh vegetables or a safe place to exercise. Study after study shows that low-income people have less access to healthcare and a greater risk of getting sick and dying prematurely.
But in an odd twist to the usual healthcare disparity story, more than 1,000 L.A. residents in low-income areas, most of them uninsured or on MediCal, are getting the gold standard of aggressive diabetes management -- better, even, than many with insurance who live in ritzy ZIP codes.
The care is taking place at clinics in East L.A. and South L.A., two communities with the highest rates of diabetes in the county, as well as three other outlying clinics. A team of L.A. doctors is participating in the experiment, training nurse practitioners, pharmacists, social workers and community educators to intervene in a way that doctors cannot do.
They're offering frequent patient checkups to monitor the disease, and teaching patients to track blood sugar, get out and take a walk, cut out the doughnuts, all the things they need to do to keep complications at bay.
They are reaching people with uncontrolled disease in some of the county's poorest pockets.
"The county patients [in the program] receive care that is as good, and probably better, as anywhere in the country," says Dr. Mayer B. Davidson, endocrinology professor at Charles Drew Medical Center and UCLA.
Davidson and others hope that if such a program is multiplied across L.A., and if similar programs are adopted across the country, the approach could slash the soaring cost of treating diabetes and save thousands of hearts, eyes, feet and lives -- of the insured and comfortably well-off as well as the poor.
There are signs that it's working. Studies so far show that patients in the program have improved blood sugar and have had fewer emergency room visits and hospitalizations.
The intensive program is a response from local academic and public health experts to the crisis ahead. One of those experts, Dr. Anne Peters, professor at USC's Keck School of Medicine and an endocrinologist who specializes in diabetes, works both sides of the disease's socioeconomic divide.
Peters has a Beverly Hills practice where she sees insured patients, including Perkins, and offers an intensive program not usually available to even those with good health coverage. She has cared for many of her private patients for years. "I know them so well," she says. "It's the old model of having a doctor who takes care of you your whole life."
But she also has a second job: supervising teams of workers on the same intensive model at five clinics including the Edward Roybal Health Center in East L.A., and the Hubert Humphrey Health Center in South L.A.
Sahagun, a patient at Roybal, is part of the experiment.
She has had diabetes since she was in her 20s, and for decades thought of it benignly as a "touch of sugar."