Over two decades ago, I had just launched the Journal of Diabetes Nursing and was beginning to appreciate the multi-faceted nature of diabetes. However, it remained beyond my comprehension that the prefix ‘diabetic’, so often flippantly and irreverently ascribed to ‘patient’, ‘condition’ and even ‘nurse’, could also be attached to the foot, which I was later to understand may or may not still be attached to the body.
It was something of a surprise, therefore, when a couple of years later I launched The Diabetic Foot Journal. This was followed shortly by an invitation from Have I Got News For You to submit it as their publication of the week. I dutifully sent Angus Deayton a couple of particularly colourful issues and suspect it was at this point that one of his hapless researchers realised that this funny-sounding concept of a foot with diabetes may in fact not represent the best platform for comedy. We were promptly replaced by Budgerigar Bulletin — no associated tweets in those days.
While the process of realisation undergone by that particular researcher as to the potential seriousness, indeed horror, of diabetic foot complications may have been somewhat sudden, recognition among the general health care community has perhaps been a little slower over the years. Stories have abounded of inadequate foot reviews (socks and shoes in situ) or about delayed referrals of ulcers leading to unnecessary amputations. So have things really improved since that first issue of The Diabetic Foot Journal in 1998?
Often described in those days as the Cinderella speciality, did the diabetic foot ever get to the ball? While the past 20 years have seen significant improvements in awareness, understanding and management, particularly in the community, the soft music and happy ending still seem a way off. Even so, my hope is that the journal has played a meaningful role in raising awareness of the diabetic foot, its management and, importantly for me, its connection to a real person on the end of it.
The original decision to launch the publication stemmed from circumstance rather than planning. A short sound bite in The Times in 1997 mentioned Smith & Nephew’s imminent UK launch of Dermagraft®, a new therapy for chronic diabetic ulcers. Created from babies’ foreskins, the product itself might have been considered a snip even if the price was generally not. A rapidly organised meeting with the company’s marketing director allowed me to present my even more rapidly prepared proposal for a new quarterly journal for which I hoped he might wish to provide sponsorship. His affirmative response meant that The Diabetic Foot Journal became a serious possibility although to produce it in the proposed 6 months presented a challenge.
My problem was that apart from a dummy front cover I’d produced for the pitch, I had little else to support the promises I had made! A little cart-before-the-horse perhaps, but I now had to find out just what the diabetic foot was all about and seek out some people who might help me create a publication around it. Hence my journey among the foot soldiers began.
It is ironic that the two people who convinced me that at least some of my promises might be achievable were podiatrists. Ironic because at that time, so few podiatrists were raising their head above the diabetic foot parapet; very different from the situation today. The sheer enthusiasm and charisma of Alistair McInnes and Ali Foster (they were like the favourite teachers you remember from school) started to turn what had begun simply as a business challenge into more of a personal pursuit around a topic that seemed to matter so very much to such a small and committed band of like-minded clinicians. This was a group that was perhaps not afforded the same renown or pharmaceutical funding streams enjoyed by colleagues working within the better known or more commercially attractive areas of diabetes. Controversial perhaps, but true I feel.
With Alistair accepting the role of journal editor, an inaugural editorial board was assembled which, without exception, comprised individuals for whom the diabetic foot was both a passion and a vocation. The likes of Matthew Young — who began as associate editor and was to become such a superb future editor and conference director — Gerry Rayman, Anne Scott, Mike Edmonds, William Jeffcoate, Andrew Boulton, Ann Knowles and Neil Baker were powerful and passionate contributors who made the journal both educationally valuable and valued. Meanwhile, my wonderful colleague Sophie Perks provided in-house organisation and sanity. Up until that time, no publication had focused solely on the diabetic foot. Most articles on the topic tended to appear in more generic diabetes titles, often top-end research journals that were simply not being read by the swathes of healthcare professionals coming into contact on a regular basis with people with diabetes, particularly within the community environment. The Diabetic Foot Journal, therefore, became a purveyor of practical advice to ‘the masses’, a voice piece for essential principles rather than high science.
While there were some calls among board members for more rigour and increased research content, the journal remained true to its core values, providing not just a vehicle for readers of all types and levels, but also in extending its search for new writers beyond those core members of the diabetic foot ‘elite’. While we have always welcomed articles from the latter group, indeed often depended upon them, we have also been keen to promote communication among all individuals wishing to share relevant information on the subject. We are proud that the current spread of authors, in terms of demographics, speciality and experience, has increased hugely from the first few issues and this is surely positive given the wide variety of clinicians now managing people with diabetic foot problems.
While diabetes in general represents a therapy area into which pharmaceutical companies invest huge sums of money to support product research and marketing, the diabetic foot has traditionally remained on the periphery of this funding model. Few pharmaceutical products are even associated with the foot outside of those used (if not specifically developed) for neuropathic pain.
Thank goodness then for the device companies, those in wound care in particular; while they often lack the huge budgets of the pharma world, they do perceive the diabetic foot as an area worthy of investment. Hence it was in the late 1990s, that the launch of Dermagraft was followed by that of several advanced wound care solutions, such as Regranex® (Smith & Nephew) and Promogran® (Acelity), which were accompanied by large kick-off conferences and promotional campaigns. The world of the diabetic foot was suddenly benefiting from a new focus (and some extra funding) and the journal was enabled to continue its journey as well as extend its communication beyond the written to the spoken word.
In 2000, the journal’s first conference took place in Edinburgh and was repeated a few weeks later in London. The former event ruffled the feathers of no less than two delegates who despite turning up at the venue were unable to pass through the foyer. The cause of their reticence was the proliferation of stuffed birds displayed around the walls of the venue, The Royal Museum of Scotland; these individuals both suffered from ornithobia, a fear of birds! Something had to give and sadly it was our delegates who took flight. One wonders in retrospect whether Have I Got News For You’s aforementioned decision to replace The Diabetic Foot Journal with Budgerigar Bulletin was perceived as part of an ongoing conspiracy by this unfortunate pairing.
In terms of funding for these events, it was once again industry sponsorship that provided the opportunity, this time from Convatec who were promoting Hyalofill® at the time. Without such support, the extension from journal to events would have represented an almost insurmountable challenge. However, the popularity of the conferences, in no small way attributable to the commitment of Matthew Young as programme designer and chair, ensured their continual existence even to the present day.
It has been a privilege to participate in the diabetic foot world over the past 20 years even to such a peripheral extent. Our core contributors, many of whom have made it their life’s work to do whatever is necessary to raise awareness and improve management in this area, have provided us with their time and expertise for very little or no financial gain. The size of their honoraria and that of their hearts sit at opposite ends of the spectrum. I hope that they have enjoyed the journey, which is of course still ongoing for most, and that their passion remains undented even within a healthcare world that becomes evermore challenging on so many levels. I thank you all.
So Cinderella may not yet have married her prince, but the good news is that her large team of supporters are still working hard to transform her future and her ongoing story has been heard by a wide and largely receptive audience. And, on occasion, the slipper has even fitted (with or without an orthotic). Whether the individual keeps it on is another matter.