Diabetes in humanitarian settings - different challenges for different emergencies
The consequences of a disaster, and the resulting response required to support people with pre-existing diabetes and to prevent the development of type 2 diabetes among the rest of the population, are a function of several factors such as:
Type, size and nature of the affected area.
Duration of the disaster.
People’s experience with such disasters.
Local infrastructure and socioeconomic situation.
Size of humanitarian support provided locally, regionally and globally.
Sudden onset disasters
Sudden onset disasters, whether natural disasters such as earthquakes, tsunamis, floods or manmade disasters such as the onset of a conflict, wreak havoc on people’s normal environment.
In the aftermath of such disasters, the medical care structure, medicine supplies and living environments are disrupted. This poses unique challenges to people with chronic diseases such as diabetes, who need a stable environment to manage their condition optimally. In disaster situations, people with diabetes may not be able to access the required medicines and supplies, or not in sufficient quantity, as a result of:
Drug shortages or difficulties in reaching distribution points
Loss of prescriptions and medical records
Damage to medical facilities
Lack of diabetes training among emergency healthcare personnel
This situation is compounded by disruption to food, water and utilities. Often people in emergency zones have to subsist on inadequate foodstuff such as preserved foods, canned products, instant noodles, and boil-in-the-bag foods, and their ability to cook is more limited. As has been seen in many emergencies across the world, these situations often lead to poorer glycaemic control as well as increases in systolic and diastolic blood pressure, which can potentially lead to life-threatening complications and premature death.
Diet and exercise regimens may still be affected several months after a disaster, and many people affected may additionally suffer from post-disaster emotional stress.
After the Hanshin-Awaji earthquake in 1995, where more than 50% of houses and buildings in Ashiya City were destroyed, the HbA1C levels of 144 people with diabetes were shown to have increased from 7.22% prior to the earthquake to 7.47% 10 weeks later.1 A study of 177 people with diabetes also showed an increase from a mean HbA1c value of 7.74% in December 1994 to 8.34% in March 1995.2
Similarly after the 1999 Earthquake in Marmara, Turkey, where about 20,000 people died and 40,000 were injured, a study of 88 people with type 1 diabetes showed that more than 50% had experienced problems with glycaemic control during the first days following the earthquake, with 13.6% reporting problems with insulin supply and 59.1% reporting issues with their food supply. Hba1C and insulin requirements both increased three months after the earthquake, and HbA1C levels were back to similar levels one year after the earthquake as they had been prior to the earthquake.3
Displaced people on the move
Displaced people with diabetes fleeing an emergency often lose all ability to manage their condition and access required medicines and supplies, often resulting in long-term life-threatening complications. Their arrival into unprepared locations puts severe pressure on healthcare resources and poses a significant challenge. Health systems struggle to respond to the emergency and provide healthcare for the new arrivals and their existing population. The problem is often compounded when the host country is a low or middle-income country.
At the beginning of the refugee crisis in Macedonia, in the summer of 2015, the migrants who arrived were generally fatigued, with blisters and/or heat exhaustion. Assistance was provided either by the Red Cross teams in the field, or for more complicated issues, by the local hospitals. Due to Macedonia’s small size, most migrants did not stay for long, except when in urgent need of medical assistance, such as during child birth, or for example in case of appendicitis or pneumonia. Camps had therefore little by way of trained medical personnel or medical supplies. The only diabetes medicines available to the Red Cross were Metformin and Diabeton (Gliclazide). These were given once evidence had been obtained that the migrants were on such therapy and after their blood glucose had been measured. People with diabetes in need of insulin had to be taken to local hospitals.
Healthcare costs were covered by the Macedonian government for all migrants, and migrants were therefore able to seek medical care, even when lacking documentation or identification. This rapidly led to the Macedonian health system being overwhelmed, when the number of migrants arriving daily reached 11,000 in November 2015 at the peak of the crisis. Given this large influx, many diabetes cases probably went undetected, with care probably received in Serbia.
While the Macedonian government did its best to provide for the migrants, diabetes care and treatment relied mainly on the assessment of emergency personnel who first came across the migrants and was further complicated by the uncertainty surrounding both their immediate and long-term needs.
Protracted or complex emergencies
In a protracted emergency where the humanitarian needs may extend over a long period of time, or in conflict/complex emergencies where there is a significant or total breakdown of authority, the challenge is two-fold:
The first relates to people with pre-existing diabetes who require access to ongoing medical care and medicines, prevention and education programmes and, more generally, the ability to lead a healthy life in the setting in which now find themselves – conflict zones, refugees camps, refugees or asylum seekers in non-camp situations. In protracted emergencies with large numbers of displaced people, the health systems of host countries are placed under severe pressure, having to respond to the immediate needs of the newly-arrived population and plan the provision of longer-term medical care – ideally to the same level as their indigenous population.
The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) estimates that of the 3.5 million Palestine Refugees receiving care at its own health centres, diabetes prevalence was 5.9% on average, with just under 50% of them having their diabetes under control. Prevalence in refugees over 40 years of age was 12.1%, ranging from 8.6% in Lebanon to 15.9% in the West Bank.
A study of 430 patients attending an endocrinology clinic in Sana’a on the effects of the war in Yemen, which started in March 1995, showed an increase in the HbA1C level from 7.7% before the war to 8.6% during the war. More than one fifth of these people were displaced, and just over 8% had discontinued some or all of their diabetes medications during the war. The lack of insulin caused some patients to stop or want to stop using insulin, which they could not keep cold, as they believed that insulin that had not been kept refrigerated could not be used.4
The second relates to successfully preventing the development of type 2 diabetes through appropriate access to screening, prevention and education campaigns, and enabling the displaced population to access healthy foods and lead a physically active life.
A stratified nutrition survey of 2,005 households in October-November 2010 in the four Western Sahara refugee camps in Algeria showed that 9.1% of children suffered from global acute malnutrition, 18.6% were underweight and 2.4% were overweight. Of the women, 53.7% were overweight or obese, and 71.4% had central obesity, showing the potential risk for these populations to develop diabetes and other NCDs.5
Of the 5.8 million Palestine Refugees registered with UNRWA in 2016, only 29% lived in official UNRWA camps. Fighting overweight and obesity is a real problem for those refugees. In a 2015 clinical audit conducted by UNRWA over 1,600 people with diabetes in 32 of its largest health centres, close to 66% of these people were obese and a further 25% overweight.6
1. Takakura R, Himeno S, Kanayama Y, Sonoda T, Kiriyama K, Furubayashi T, Yabu M, Yoshida S, Nagasawa Y, Inoue S, Iwao N (1997) Follow-up after the Hanshin-Awaji earthquake: diverse influences on pneumonia, bronchial asthma, peptic ulcer and diabetes mellitus. Intern Med 36: 87–91. 2. Kirizuka K, Nishizaki H, Kohriyama K, Nukata O, Arioka Y, Motobuchi M, Yoshiki K,Tatezumi K, Kondo T,Tsuboi S: Influences of The Great HanshinAwaji Earthquake on glycemic control in diabetic patients. Diabetes Res Clin Pract 1997;36(3):193–196 3. Sengul A, Ozer E, Salman S, Salman F, Saglam Z, Sargin M, Hatun S, Satman I, Yilmaz T: Lessons learnt from influences of the Marmara earth- 55. quake on glycemic control and quality of life in people with type 1 diabetes. £n<foa-/2004;51(4):407-414. 56. 4. The Effect of War on the Control of Diabetes in Patients with Type 2 Diabetes Mellitus in Yemen: A Cross-Sectional Study Butheinah A Al-Sharafi and Belqes A Al-Tahami. Endocrinol Metab Syndr 2017, 6:4 5. Grijalva-Eternod CS,Wells JC, Cortina-Borja M, Salse-Ubach N, Tondeur MC, Dolan C, et al. The double burden of obesity and malnutrition in a protracted emergency setting: a cross-sectional study of Western Sahara refugees. PLoS Med. 2012;9:e1001320. 6. 2015 clinical audit of diabetes care among Palestine Refugees, UNRWA