Stroll down the main hallway of the Joslin Diabetes Center in Boston, Massachusetts, and you’ll know right away why the adjective often connected to their name is “storied.”
A graphic timeline stretches down that hallway, sharing — over and over — breakthroughs in diabetes care that originated there. From the early pioneering efforts of Dr. Elliot Joslin to simply keep people with diabetes alive, to (almost exactly 100 years ago) the first insulin shots being administered to human patients, to breakthroughs in treatment and advances in how and why care is delivered, this legendary research and care center has long been at the lead.
This year, with CEO Dr. Roberta Herman at the helm and a new partnership with Cambridge, Massachusetts-based Beth Israel Leahy Health (BILH), Joslin hopes to not just honor that history, but to continue progress towards better treatment, less stressful access, and of course, an eventual cure.
Joslin is the world’s largest diabetes research center, diabetes clinic, and provider of diabetes education. It employs 600 people and has satellite clinics across Massachusetts, Maryland, Illinois, and New Jersey. BILH has more than 4,800 physicians and 36,000 employees.
“Together, we are a powerhouse of metabolic research,” Herman told DiabetesMine.
Herman, who lost her mother to a chronic disease at a young age as a child, has worked over the years in leadership roles in primary care, and later as chief operating officer of Harvard Pilgrim Health Care, one of the nation’s largest insurers. She took over leadership of the Joslin Diabetes Center in January 2020, in the midst of the COVID-19 pandemic.
DiabetesMine spoke with her recently about marking the legendary history of Joslin and the 100th anniversary of insulin, as well as the outlook on the current and future state of diabetes care.
Herman reminded us that Dr. Fredrick Banting — co-discoverer of insulin — and his team administered insulin to the first-ever patient, Canadian teenager Leonard Thompson, 100 years ago on Jan. 11, 1922.
After that, the team knew they had to get insulin into the hands of doctors who understood diabetes and could bring insulin use up to speed quickly.
Elliot Joslin was an obvious choice. The Yale and Harvard graduate was motivated to study and treat diabetes after his mother and aunt were diagnosed with the then usually-fatal condition.
While he did not discover insulin, he did — among many other things — create the world’s first diabetes registry, treat patients before insulin with diet to keep them alive (his aunt lived a then-astonishing 13 years with his plan), push for tighter control for better health (something that would not be validated until the landmark
Joslin was always about finding a way to live — and live long — with this disease.
He was a master at teaching how to live with the condition, as well as a promoter of education as a vital part of treatment.
Some of his most famous quotes still stand up today:
“The diabetic who knows the most, lives the longest.”
“It’s better to discuss how far you have walked, than how little you have eaten.“
“A well-trained nurse is of more value than the patient’s doctors.”
Today, education, healthy living, and good team support from not just from doctors, but from nurses and other healthcare providers is considered crucial to successful diabetes care.
By the time he passed away in 1962, Joslin had helped with the discovery and early use of home blood glucose meters, empowered Dr. Priscilla White to create programs to help women with diabetes successfully deliver and raise children, laid the groundwork for what is still a most influential program on longevity with type 1 diabetes (T1D) called The Medalist Study, and established his Joslin Clinic — sitting in the same place it sits now — as a world leader in care and breakthroughs.
Over the years, the Joslin Center has been responsible for a number of advancements that have improved the lives of people with diabetes.
The Beetham Eye Institute, located inside the Joslin Center, stands as a shining example of how quality care — made accessible — can better lives, Herman said.
That institute has been treating diabetes and eye disease for decades, offering the first laser surgery to stop sight loss back in 1967. Today, as Dr. George King told the crowd at a JDRF national conference 3 years ago, they’ve cut the incidence of sight loss in people with long-term diabetes from 40 percent to less than 1 percent.
Herman said the evidence is right there in the Beetham waiting room.
“Fifty years ago, there were as many seeing eye dogs as patients [here],” she said. “Now, there are almost none.”
Even laser surgery, which even recently was heralded as transformational, is becoming old school, she said. Today, they can treat and prevent diabetes eye disease with medication for the most part.
“That’s a huge clinical accomplishment,” she said. “But more needs to be done.”
Joslin’s pediatric care center is relatively new in comparison to the 100-year-old-plus Joslin program. It continues to focus on creating a program that supports the entire family, Herman said.
“It’s a family affair,” she said of having a child with T1D in the house. “We’re not just treating the child; we’re engaging the whole family. This is a 24/7 disease, and families need help with that across the board.”
They’re also focused on an oft-overlooked segment of the diabetes population: the teen transitioning to adult, and the family surrounding them.
“Technology should be the great equalizer,” Herman said of that phase of life, meaning that teens becoming young adults can both see their team remotely, and their families can assist them (as wanted) from the distance via continuous glucose monitors with remote options.
And then there is the type 2 diabetes (T2D) population, a group Herman feels Joslin can do better for and with. The BILH partnership, which will bring in about 100,000 diabetes patients and also offer resources throughout the BILH network, should help with that.
“That’s a question I’ve been asking from the start,” she said. “What is the proper role for Joslin to play in type 2?”
They’ve opened Latin and Asian clinics already, she said, “But there’s more to be done here too.”
The question she hopes to answer is: “How can we successfully shift some diabetes care to primary care?”
“The BILH health system aligns perfectly for this,” she said. They could, she believes, “amplify our impact fivefold,” but, steps toward this must be done with great attention to detail.
Primary care teams need help, she said, because management is more complicated now with both many more drugs to consider and varied lifestyle choices to incorporate.
“We will be testing the boundaries of what should be managed in primary care and what should get a referral [to a specialized diabetes clinic],” Herman said.
In other words, closer-to-home care is the goal, but so too is the understanding when a referral to another place is needed.
Joslin hopes to continue their quest to make diabetes care accessible and effective, to push forward with research projects both long-lasting and new, and to, overall, better the lives of all those living with all kinds of diabetes.
For Herman, heading up that push is both humbling and motivating.
She remembers the first time she walked into her office and the Joslin Library, which is stocked with not only literature but artifacts from the Joslin’s storied past, like Elliot Joslin’s dining room table. “I felt like a little girl walking into my dad’s office,” she said.
The first step toward further improving diabetes care is realizing that this condition impacts the world in a major way, she said.
“Diabetes was a pandemic before COVID made ‘pandemic’ a household word. And it still will be, probably, after [this pandemic passes].”
The coming era, she hopes, will make educational programs and team-approach guidance to living with diabetes more accessible to all.
The pandemic may have helped with that, but Joslin was on it prior, she notes. They introduced the concept of remote/online care back in 2015.
Before the 2020 national quarantine, less than 5 percent of patients were using telehealth for appointments. Once the pandemic hit, that jumped to 90 percent. Now, Herman said, Joslin will continue pushing accessibility for continued, and hopefully more frequent and impactful care.
A bonus benefit of that: Appointment cancellations have decreased exponentially, Herman said.
Research-wise, she said, The Medalist Program (funded for the most part by JDRF), will continue to look at those who live with T1D for decades and what we can learn from them.
Already, the Medalist Study has unlocked some key findings. Topping them, perhaps, is the finding that even people who have had T1D for more than 50 years still produce at least a small amount of insulin.
That finding leads into another key area of research Herman wants Joslin to continue focusing on: Beta cell reproduction.
“Beta cell research is a leading contender for curing diabetes,” she said.
Joslin has been key in advances to convert adult human stem cells into functioning insulin secreting beta cells that, they hope, can ultimately be safely transplanted into humans.
They’ve also been working on discovering ways to correct defects in beta cells, identifying new growth factors that stimulate beta cell regeneration, so those still functioning cells found in the Medalist Study can help. They’re also working on evolving technologies for detection, modulation, and protection against the immune response that causes the disease or threatens the potential viability of a transplant.
And what of the push to make insulin more affordable and accessible to all?
Herman said that advocacy and policy work is not in Joslin’s main charter, since they’re focused on treatment and research, but that they do help out any way they can.
First, if a patient is in need, they work to connect them to an insulin supply, be that via drugmakers’ discount programs or accessing insulin in other ways.
“With our patients, an important way our role is increasing is to help them make the best of their benefits,” she said, as well as guide them to resources like discount programs and clinical trials.
They also lend their voice whenever needed. “I do have an appetite for influencing policy,” Herman said, adding that when asked, she’s willing to show up and speak out.
The Joslin Center did take a vocal role, she said, in getting the Centers for Disease Control (CDC) to include both T1D and T2D as risk factors for COVID-19.
Herman said technology is being embraced and woven into diabetes care in many ways, and that will continue. Right now, about 50 percent of patients are choosing it, she said. They are still working on when and why patients should opt for telehealth versus in-person care visits.
Besides the telehealth shift that seems to be positive for patients, Joslin is studying how to better integrate technology into the lives of those who have diabetes and those who help them. That includes the T2D community.
Using technology like continuous glucose monitors early on in a T2D diagnosis could help people control the condition sooner, and possibly keep more people off insulin, she said.
“Insulin gets used too much,” she said of the T2D community. “And it takes way too much time to go from finding out to being ‘well-managed.’ We hope to change that.”
The BILH partnership will make those things more attainable, she said. With more of a “satellite presence” in more places, Joslin will be able to reach more patients, see trends and help guide better treatment on a wider scale.
Herman said she’s thrilled to be at the helm at this crucial time, while she is mindful of Joslin’s storied past.
“We will remain true to our founder’s purpose, which was to be on the leading edges of discovery, education, and treatment. I don’t think it’s any more complicated than that,” she said.