Diabetes in war and disaster
In war or during a natural disaster, people with diabetes often go without the care they need because attention is focused upon dealing with medical emergencies. Speakers at the recent International Diabetes Foundation (IDF) meeting discussed what happens when diabetes care becomes a humanitarian issue, with Ukraine as a particular example. Dr Susan Aldridge reports.
Dr Iryna Vlasenko, Vice President of the IDF and a pharmacist working in Ukraine, gave an overview of the impact of the war there on people with diabetes and the action that is being taken to provide the care they need. A record number of Ukrainians have been displaced from their homes by the conflict, which poses a major health challenge, both in the country itself and elsewhere. Inevitably, dealing with trauma and infection takes priority over chronic conditions like diabetes – as has always been the case in a disaster situation.
Before February 2022, diabetes care in Ukraine was in good shape, Dr Vlasenko said, with insulin being reimbursed, other diabetes medications affordable and diagnostic testing widely available. Then, at the outbreak of war, half of the country’s pharmacies were unable to open, hospitals were destroyed and healthcare workers either moved away or could not get to work, while distribution of insulin and other medication was disrupted.
Within the first few days of hostilities, Dr Vlasenko began to mobilise and co-ordinate support in her role as Vice President of the IDF, working with the Ministry of Health to get government authorisation for their activities “Volunteers and patient organisations played a big role and I had so many calls from around the world offering help,” she said. Many people and organisations got involved, including the World Health Organisation (WHO), charities, NGOs, foreign governments and, of course, the IDF. “I would like to underline how much the IDF associations around the world helped us,” she added. “It shows that we are like family.”
Two to three weeks into the conflict, it became apparent that there was going to be limited access to diabetes healthcare, including pharmacy supplies (although glucometers and testing strips were still available). People needed more short-acting insulin, probably because of the stress they were under, while the mass migration underway called for an overall increase in supplies. Direct Relief, to whom Dr Vlasenko offered her “big thanks”, stepped in and has supplied 950 tons of medical aid, including insulin syringes, needles and medication, since 24 February 2022.
Meanwhile, the Ministry of Health organised a crisis hotline for people with diabetes from the start of the war and made insulin free rather than reimbursed (until July), as well as providing daily online updates of pharmacies that had insulin supplies.
Two to three weeks after that, outpatient clinic and pharmacy access improved in those areas where there were no active hostilities. However, drug prices had gone up 20% by then and hospitals were still providing mainly urgent care. “We also need to remember issues like dialysis, which may be hard if someone is on the road as a refugee,” Dr Vlasenko said. “And, of course, there is mental health as people are under stress all the time.”
As a pharmacist herself, she noted the important role the profession can play in a disaster situation. “They can provide immediate healthcare to affected communities as they [pharmacies] are more accessible than even supermarkets or banks.”
Meanwhile, refugees to neighbouring countries such as Poland are in need of support and thanks are due to IDF Europe who, in partnership with the United Nations High Commissioner for Refugees (UNHCR), have been working to improve services for them. At home, there has been a ‘medical collapse’ in the occupied territories, which is still a problem. However, mobile teams, consisting of a GP, a psychologist and a nurse, have been going out to look after people with diabetes. After two years of COVID and now war, there is concern about mounting diabetes complications, so the teams are looking at eyes, feet and cardiovascular health.
On reflection, how does Dr Vlasenko assess the response to the diabetes challenge posed by the war? There are certainly some positive points. “Healthcare providers and institutions have proven highly resilient in this situation,” she said. “We managed a co-ordinated humanitarian response.”
Inevitably, though, it has been hard to overcome some of the challenges. For instance, service delivery has had to be reactive rather than being driven by the proactive outreach that is a feature of good diabetes care. And, inevitably, healthcare worker capacity is still stretched. “The full burden of diabetes, particularly that of complications and psychosocial suffering, is not being addressed,” said Dr Vlasenko. Two key issues are the need for better management to avoid diabetes mortality and the logistics of providing a continuous supply of treatment, especially insulin.
Future priorities for diabetes care in Ukraine, whether or not peace comes, include health promotion, improving access to medication, HbA1c testing, adherence to treatment plans and more work on mental health. And, of course, the consequences of the war will be an increase in diabetes and its complications and economic burden. “Thank you for your support,” Dr Vlasenko concluded. “We really appreciate it. Please stay with Ukraine. We could not survive without you.”
Diabetes, disaster and the wider world
Dr Nizar Albeche, former Chair of IDF Middle East and North Africa region, who has also worked at Aleppo Hospital, Syria, brought a wider context to diabetes and disaster, both natural, such as hurricanes, tsunamis and floods, and man-made. Diabetes is always a low priority in these situations. People with diabetes have many needs and will inevitably suffer both immediate and long-term consequences when they are caught up in a disaster.
“What affects the outcome for people with diabetes is whether the disaster is occurring in a low-, middle- or high-income country,” he said. “Location is also very important.” He noted that Ukraine lies within a developed area of Europe and there has been lots of help coming in through various programmes, as Dr Vlasenko mentions above. “The courage of the Ukrainian people has been remarkable,” he said. “They were also quick to get worldwide support and set us an example of how to deal with a disaster through resilience and co-ordination.”
The opposite is true in Syria, a low-income country involved in a war that has lasted for 11 years. Millions have been displaced, hospitals destroyed and there have not been enough donations from outside. The health system there has all but collapsed – and it was not in good shape before the war began.
Many Syrian refugees went to neighbouring countries such as Lebanon and Iraq – which were not prepared for the accompanying healthcare burden – and found themselves without jobs or income. Refugees with diabetes, including children, had urgent needs for medication such as insulin.
However, things are changing. The WHO has set up a framework for addressing diabetes challenges and needs in humanitarian crises in low- and middle-income countries, and the IDF also has a Diabetes and Disaster Plan and is working with the WHO on this issue. Then there is the Boston Declaration, a new initiative for diabetes (see below). However, Dr Albeche concluded, lack of resources in a disaster situation remains an important challenge for low- and middle-income countries.
The Boston Declaration
The world is now dealing with the highest number of people ever displaced by disaster in history and 80% of them are from low- and middle-income countries. In the future, 1.2 billion could be displaced by climate change and natural disasters. In these situations, people with type 1 diabetes, in particular, are at acute risk of death and disability. “We need to deal with this on top of the projected increase in diabetes,” said Sylvia Kehlenbrink, director of the Non-Communicable Diseases in Conflict Program at the Harvard Humanitarian Initiative, USA. “Non-communicable diseases are always a small part of foreign health aid. A sustained and collaborative commitment is now needed from many players.”
This necessary commitment has been initiated by the Boston Declaration, signed by 40 international organisations after a meeting at Harvard University in 2019, when 100 people came together as a community wanting action on diabetes in disaster situations. The declaration has four declared targets: advocacy, universal access to insulin, improving diabetes data and seeking unified clinical and operational guidelines for diabetes in humanitarian crises.
To achieve these goals, the International Alliance for Diabetes Action (www.iadadiabetes.org) has been set up with a diverse group of stakeholders including NGOs, academia, charities and the private sector. It is hoped that the group can help provide quality care for all those with diabetes who find themselves caught up in a disaster situation.
Any opinions expressed in this article are the responsibility of the EASD e-Learning Programme Director, Dr Eleanor D Kennedy.