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A new normal in humanitarian aid: treating middle-class diseases

“Non-communicable diseases have been neglected so far, but the situation is becoming dire”

Close up of syringe for insulin injection. The number of diabetes cases is expected to double by the year 2030 in sub-Saharan Africa, fueled by urbanization, diet, poor access to health care, late diagnoses and lack of understanding about a disease that i Phuong Tran/IRIN

Treating undernourished children, boosting nutrition for pregnant women, and even providing a statistical basis for the term “famine” have all become routine parts of humanitarian health programmes. But the routine is changing.

As conflicts and crises overtake middle-income countries like Syria and now Venezuela, aid organisations must deal with obesity and non-communicable diseases (NCDs) such as diabetes, heart disease, and high blood pressure.

In 2017, the World Health Organisation for the first time added medication for diabetes to its standard Interagency Emergency Health Kit – a package of supplies and pharmaceuticals that can meet the needs of 10,000 people over three months. In October that year, in Syria and Iraq, it also started testing a supplementary kit containing medication for non-communicable diseases.

“It was the first time that such a need was recognised,” said Amulya Reddy, a medical advisor at Médecins Sans Frontières, speaking of the Syrian refugee crisis. Before the Syria crisis, she said, “treating NCDs wasn’t part of the routine emergency actions. It was considered more of a medical speciality – most organisations had no experience.”

In more than half of Syrian refugee households in Lebanon, for example, at least one person was diagnosed with at least one of five NCDs in 2016 – three of which (hypertension, cardiovascular diseases, and diabetes) are diet-related.

Yet steps toward treating chronic diseases among these newer groups of refugees have not kept up with the growing need. Added to that, development and humanitarian organisations face data and funding stumbling blocks as they rethink ways to work together to combat non-communicable diseases.

“NCDs have been neglected so far, but the situation is becoming dire. We will need to adapt to the new challenges – and fast,” warned Slim Slama, a medical officer for NCDs for the Eastern Mediterranean region at the WHO. “Most of the humanitarian system has been geared towards the acute conditions.”

New international guidelines offer a roadmap to humanitarian organisations dealing with such conditions. The Sphere Handbook, a compilation of standards in relief work released last month, includes more detail on NCDs than its previous 2011 edition.

It states, for example, that a patient should not miss medication for non-communicable diseases more than four days a month. The Ebola epidemic and “Syria changed everything in terms of how we frame humanitarian response,” Christine Knudsen, Sphere director, told IRIN.

In addition, the 2018 Global Nutrition Report, released last month, says the issue of diet-related chronic conditions has “barely been on the radar of those responsible for responding to crises until recently.” The study is commissioned by a group of international NGOs, drawing inputs from members of governments, civil society, academia, multilateral organisations, and private businesses.

Different incomes, different problems

In low-income countries, more than half the adults are most likely to die from communicable diseases, conditions arising during pregnancy and childbirth, and nutritional deficiencies. In middle-income countries, the pattern changes, with higher numbers of deaths due to obesity and NCDs linked to a more affluent but unhealthy diet and lifestyle.

The upper and middle classes of poor countries, too, are more likely to suffer from chronic conditions. In terms of absolute numbers, the WHO estimates that 78 percent of global deaths from NCDs took place in low- and middle-income countries. In addition, rising obesity in poorer countries is a sign of risk for non-communicable diseases. A recent life expectancy forecast published by a British medical journal, The Lancet, stated that NCDs as cause of premature mortality will double by 2040.

Screening for and treating diseases such as diabetes, heart disease, and high blood pressure has become central to MSF’s operations in Jordan, Reddy said. “It became obvious very quickly that the majority of the refugees had NCDs, and those would need to be addressed.”

The Lebanese example

Hala Ghattas, an associate research professor at the Center for Research on Population and Health at the American University in Beirut, who contributed to the Global Nutrition Report, said there is a need to move beyond traditional response, especially as “humanitarian crises are increasingly occurring in middle-income and low-income countries that are going through demographic and epidemiological transitions”.

In the report, Ghattas and her colleagues analysed how humanitarian agencies addressed various NCDs among Palestinian and Syrian refugees in Lebanon.

They found, for instance, that the Lebanese Ministry of Public Health and the UN’s refugee agency, UNHCR, worked together to respond to the high incidence of NCDs among Syrian refugees by providing subsidised care in the primary healthcare system as well as a referral system for secondary and tertiary care. This meant that 75 percent of the refugees’ treatment costs were covered.

Their research showed that 34 percent of the Syrian refugee population aged 18 to 69 years are overweight, 29 percent are obese, and 49 percent have elevated total cholesterol levels. In related research, the International Committee of the Red Cross has reported that diabetes is the cause of more than 25 percent of amputations in one third of their centres in the Balkans, Iraq, Lebanon, Liberia, Pakistan, South Sudan, Syria, and Yemen.

And yet, progress has been slow.

The United Nations General Assembly passed a political declaration on NCDs in September, but it fell short of extending guidelines for crisis situations. “For the first time, there was a reference to disasters, which is a good step, but there was no reference to NCDs in conflict situations,” said Slama.

The way forward

As they try to adapt, health workers are increasingly borrowing lessons learned by the medical and emergency communities during the HIV epidemic in conflict-affected countries like Rwanda and the Central African Republic.

“We’ll have to work towards simplifications in the process, decentralise programmes, and make them more community-based,” Reddy said, adding that data collection on the rates of NCDs among populations in crisis situations is “consistently difficult”.

A lot of the initial work by humanitarian responders in crisis situations is geared towards meeting basic needs and focusing on the most vulnerable in any group. In Lebanon, for example, Ghattas said it took time for the data to catch up with the services. The first survey on NCDs was conducted in 2014, after emergency responders had started caring for those with urgent needs.

“Systems are still ill-equipped to handle NCDs, and as a result there is little evidence on what works and what doesn’t,” Slama of WHO said. As more evaluation results are gathered and new research emerges, medical practitioners will be able to tweak their approaches and tailor them to specific contexts.

For Slama, one of the biggest challenges will be to train medical staff. “We should measure the impact not just in terms of distribution but also provision of care. It is important to look at service utilisation, and to see if people are getting the services they need,” he said.

According to Ghattas, increasing talk of the “humanitarian-development nexus” – a new catchphrase in aid circles that underlines the need to join up emergency and longer-term responses – might be a good sign for the recognition of NCDs in crises.

Some experts are hopeful this trend will result in higher funding for cross-cutting programmes. Currently, the most optimistic estimates put the share of NCDs in global Overseas Development Assistance at two percent, making it a blind spot in the larger global health community. “So, not surprisingly, when conflicts occur and systems collapse, NCDs amongst affected people are ignored,” said Slama.

In a time of increasingly dwindling resources and competing needs, raising funds for NCDs is a tough battle. Or, as Reddy put it: “Unfortunately, NCDs don’t bring in money from donors in conflict situations; starving children do.”

(TOP PHOTO: A syringe for insulin injection. In 2017, WHO added medication for diabetes to its standard Interagency Emergency Health Kit. CREDIT: Phuong Tran/IRIN)


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