NCDs in humanitarian crisis
During my most recent trip to Africa, I worked at Kisoro District Hospital in southwest Uganda, not far from the Congolese-Ruwandan border, treating local Ugandan villagers as well as an influx of refugees from the nearby Democratic Republic of Congo. I almost breathed a sigh of relief when an individual would walk into the hospital with a cough or fever. Malaria and tuberculosis were well treatable in Kisoro. After just a few days of anti-malarial, anti-tuberculous or antibiotic therapy most patients recovered quickly, within days, sometimes hours. Even anti-retrovirals were available and an effective HIV program in place in this small district hospital. The success of the global efforts made in the arena of infectious diseases was evident.
It was an entirely different story when someone presented with high blood sugar levels or diabetes. With the limited resources that were available, it felt near to impossible to treat these individuals. Insulin was available only sporadically and oral anti-diabetic medications were frequently unavailable or, when present, prohibitively expensive. Even if glucose-lowering agents were available, being able to monitor blood sugar levels was often not possible. The situation was equally grave at the largest hospital in the country. The designated 'diabetes ward' had no glucose strips. No EKG machines. No dialysis facility.
I vividly remember a young woman in her early 30s, mother of 3 young children, with kidney failure secondary to diabetes. Her body face and body were swollen and she laid on her bed pounding her chest trying to alleviate the pain from pericarditis. Without dialysis capabilities and very limited insulin supplies we were unable to help her and she died a few weeks later. None of the type 1 diabetics I encountered in Africa survived. During my month is Kisoro two young men presented to the hospital with deep, gasping breathing and a fruity odor to their breath, suggestive of diabetic ketoacidosis. Without the ability to administer insulin or monitor their potassium levels, they both died within hours. Other diabetic patients were continually readmitted to the hospital with dehydration, recurrent infections or wounds that would not heal.
The heavy burden of chronic, non-communicable diseases (NCDs) globally is striking. According to the WHO, an estimated 36 million deaths were thought to be due to NCDs in 2008, accounting for 63% on the deaths that occurred globally. This number is projected to increase to 55 million by 2030 with the most rapid rise expected to occur in developing countries. The diseases that make the largest contribution to the morbidity and mortality of NCDs are cardiovascular disease, cancer, chronic respiratory diseases and diabetes.
Diabetes has been described has one of the largest global health emergencies of the 21st century with an estimated 415 million people currently affected worldwide. This number is expected to rise to 642 million by 2040. Reports suggest that 77% of individuals with diabetes live in low- and middle-income countries (LMICs) and 90% of new cases of diabetes will occur in developing countries. Africa has the highest percentage of undiagnosed people (~67%) and 1 in 10 people in the Middle East and North Africa have diabetes (9.1% prevalence). Moreover, in developing countries those affected are most frequently between the ages of 35 and 64, their most economically productive years and more than half a million children under the age of 14 are living with type 1 diabetes. Sobering reports suggest that children in Sub-Saharan Africa with newly diagnosed type 1 diabetes often have a life expectancy of less than one year.
Not only are LMICs disproportionately affected by NCDs, but also suffer the largest burden of humanitarian crises. The UNHCR Global Trends Report estimates that a staggering 65.3 million people were displaced from their homes as refugees or internally displaced persons (IDPs) in 2015- the highest level ever recorded. Individuals with NCDs are more vulnerable in crisis situations, emergencies exacerbate NCDs and there is invariably a healthcare gap for those with chronic disease during and following emergencies. Moreover, emergencies are increasingly becoming protracted with the average length of conflict-induced displacement being 17 years, which results in significant health ramifications.
Despite these massive global changes, the problem of NCDs in humanitarian emergencies and conflict settings has largely been neglected. The international community is increasingly challenged with how to manage NCDs in such settings. There is a lack of evidence-based guidelines for the management of NCDs in fragile states and it is unclear what interventions are effective and feasible. Increased advocacy, education and awareness around NCDs is needed to rally the global community to action. The burden of disease in emergencies needs to be further evaluated. Given largely fragmented NCD care in fragile states, improving coordination and collaboration between humanitarian agencies, academia and governments is crucial to build capacity, monitor and evaluate the delivery of NCD care. Moreover, access to essential medications, such as insulin, must be improved and the impact of NCD preventive activities and preparedness for crisis further addressed.
Although this seems an insurmountable task, the impressive progress that has been made in the management of communicable diseases demonstrates that large-scale change is achievable with global collaboration, research and advocacy. Therefore, let us face this new frontier in global health with courage to establish feasible and effective interventions in order to improve humanitarian action and join international efforts to prevent, control and ultimately reduce the burden of NCDs, in particular in the world's most vulnerable populations.
Provided by Public Library of Science
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