New Efforts to Aid Those With Diabetes in Humanitarian Crises

LISBON — New efforts are underway to better coordinate global assistance for people with diabetes endangered by natural and man-made humanitarian crises.

"Humanitarian crises represent a major global health challenge. Healthcare during emergency response has understandably focused on trauma, infectious disease, and other acute conditions. Chronic diseases have historically been given low priority," Iryna Vlasenko, PhD, said at a symposium during the International Diabetes Federation (IDF) 2022 meeting.

Yet, both natural disasters such as earthquakes and floods and non-natural events like wars and other conflicts that disrupt care settings and supply chains pose dire threats to people living with diabetes, noted another symposium speaker, Sylvia Kehlenbrink, MD, director, global endocrinology, Brigham & Women's Hospital, Boston, Massachusetts.

"Adults and children with type 1 diabetes who cannot access insulin and continuity of care in a crisis are at acute risk of death and disability, with avoidable suffering and loss of individual agency and dignity. This is a very pressing imperative," added Kehlenbrink, who is also director of the Noncommunicable Diseases in Conflict program within the Harvard Humanitarian Initiative.

According to Kehlenbrink, there are currently more than 100 million people displaced from their homes due to conflict and violence worldwide, the greatest ever in human history. About 78% of those refugee situations are protracted, sometimes lasting years or even decades. And, more than 80% of these populations reside in lower- and middle-income countries, "the same areas most affected by diabetes and where the projected rise in diabetes is anticipated to be the most dramatic."

Moreover, as many as 1.2 billion people could be displaced by 2050 due to climate change and natural disasters, she added. "This is an issue that we're going to have to deal with in the coming decades on top of the growing diabetes epidemic globally."

New Efforts Underway, Declaration Soon to Be Updated

Kehlenbrink has led assistance efforts beginning with the 2019 Boston Declaration, which outlined the urgent needs for people with type 1 and type 2 diabetes in crisis situations.

And from that, theInternational Alliance for Diabetes Action (IADA), a nonprofit organization, was created as a "partnership of international organizations from various sectors working together to connect, share, and collaborate both bilaterally and through a wide variety of events to collectively improve diabetes care in humanitarian crises," she said during the IDF symposium.

In February 2022, Kehlenbrink and colleagues published findings from a survey of 83 humanitarian crises areas in 27 countries in 2018 conducted by a consortium including the International Committee of the Red Cross, the International Rescue Committee, Doctors Without Borders, and the UN High Commissioner for Refugees.

Among many findings, the survey revealed that there was no standardized data collection system across, or even within, organizations, and that one third of sites didn't provide insulin. Instead, people with diabetes were often sent to hospitals to receive insulin injections, necessitating daily travel.

Following a third Diabetes in Humanitarian Crises symposium, held at Harvard University in October, another report will be coming out soon with updates to the Boston Declaration, including priorities for 2023-2025, she said.

Ukraine: Diabetes Situation Has Improved, With a Lot of Assistance

During the IDF symposium, Vlasenko, who is associate professor of pharmacy at Shupyk National Medical Academy of Postgraduate Education, Kyiv, summarized the situation for people with diabetes in Ukraine, which became a major crisis soon after the Russian invasion when insulin and other supplies weren't being delivered to pharmacies. Most children with diabetes and their mothers left Ukraine for neighboring countries such as Romania and Estonia, where they have been able to access supplies for the most part.

More recently, the situation has improved so that people with diabetes in most of Ukraine — except for Russian-occupied territories — are able to obtain needed medications, although often with increased co-pays, while supplies such as glucose test strips, syringes, and pen needles are still sometimes in short supply.

"Action in Ukraine has been based on communication, partnership, and management," Vlasenko said, crediting several groups for their assistance including "the IDF, the Ukrainian Ministry of Health, the World Health Organization, pharmaceutical companies, Direct Relief, governments of other countries, IDF member associations, nongovernmental associations, patient organizations...and many individuals," she noted.

Diabetes Crisis in Syria: Ongoing but Receiving Less Attention

Ongoing humanitarian disasters in other parts of the world, such as the ongoing Syrian refugee crisis, haven't received the same attention as, for example, Ukraine.

During another symposium, Nizar Albache, MD, highlighted differences between the two crisis situations, as well as the stark contrast between humanitarian disasters that occur in higher- versus low-middle income countries. Albache practiced endocrinology at Aleppo University Hospital in Syria in 1986-2012 before becoming a consultant in the endocrine & diabetes department at Hôpital du Creusot in France.

The Syrian crisis has lasted more than 11 years and resulted in over 6 million internally displaced people and 5.5 million refugees. In 2017, there were 705,700 reported cases of adult diabetes in the country with more than half dependent on insulin. Albache coauthored a 2019 paper about the situation.

Unlike Ukraine, which has maintained its healthcare system despite the Russian attacks, the system in Syria completely collapsed. Also unlike Ukraine, Syria did not receive much outside assistance. Of Syria's neighbors, only Turkey provided medical care to refugees, whereas others including Lebanon, Iraq, and Jordan do not have the infrastructure to provide refugee care, Albache explained.

"The local health system wasn't able to provide medical care. A lot of hospitals and medical centers were destroyed. There were not enough resources or donations," he said.

A program initiated by IDF and other organizations in September 2016 to assist Syrian refugees at nine diabetes clinics in Lebanon provided free care to 3639 patients and produced significant improvements in A1c levels. But it was discontinued in November 2019, primarily for reasons related to costs.

"It's a long crisis and the sponsors were unable to continue their support," Albache said, adding, "the challenges are much bigger in low- and middle-income countries. Because diabetes is a chronic disease, it needs more infrastructure, prepared medical teams, and centers...We are constantly looking for sponsoring to continue our programs."

Tigray, Ethiopia "Much Worse" Than Ukraine

After Ablache's talk, Solomon Tesfaye, MD, research director of diabetes and endocrinology, professor of diabetes medicine, Sheffield Teaching Hospitals, UK, commented from the audience about another extremely dire humanitarian situation for people with diabetes that has received little media attention: health delivery problems in Tigray, Ethiopia, due to the ongoing conflict between the federal and Tigray regional governments.

"It's a worse disaster than Ukraine, but not publicized. About 2 million have been internally displaced, and no insulin at all is coming in...The health system there has completely collapsed. This has led to patients with type 1 diabetes dying from [diabetic ketoacidosis]."

However, Tesfaye noted, "There has been a peace treaty signed recently, so one hopes that there will be a flow of aid...Hopefully with the truce insulin will flow in."

Indeed, Kehlenbrink told Medscape Medical News: "There are many ongoing conflicts and crises that are not getting anywhere near the attention Ukraine is getting," including Yemen, Afghanistan, South Sudan, and Venezuela/Columbia. But, she added, "diabetes is everywhere, and with climate change and concerns around escalating climate migration, this will be an issue globally."

IADA: Producing Results

Launched in November 2021, the IADA's mission is to "ensure vulnerable people in humanitarian crises have access to quality diabetes care, and to stop the unnecessary disability and death of people living with diabetes in these settings," Kehlenbrink said.

Two IADA projects that have borne fruit thus far are an insulin-switching guide for Ukraine, given the varying availability of different insulin types, and a groundbreaking 2021 study conducted in Kenya demonstrating insulin may be more heat-stable during 28 days of use than current labeling suggests. "This is reassuring for that particular site, so providers could give patients insulin to take home," she noted.

Other ongoing projects include the Open Access Diabetes: Diabetes Education for All (DEFA) program, which provides diabetes education and clinical guidance for healthcare providers, including online materials for individuals living with diabetes in humanitarian settings, and a trial to determine whether long-acting insulin analogs should be included on the WHO Essential Medicines List.

Kehlenbrink told Medscape Medical News: "IADA is still young and small, but the idea and hope is that it grows and serves as a coordinating body and helps with advocacy, convening, accountability, setting the agenda, etc, kind of like [Gavi, the Vaccine Alliance], [the United Nations Programme on HIV and AIDS], or the Stop TB Partnership have done in the infectious diseases space."

As of now, she explained: "The humanitarian community has really been rallying and working together to improve care. The momentum has been great and the World Health Organization is taking a big lead on a number of high-level initiatives that we're supporting. The collaboration and goodwill have been very encouraging and we're just getting started."

Kehlenbrink is chair of the IADA and serves on the Scientific Advisory Panel of the Medicines Patent Pool. Vlasenko and Albache have reported no relevant financial relationships. Tesfaye has received honoraria and consulting fees from manufacturers of diabetic neuropathy treatments.

IDF 2022. Symposium presented December 7, 2022.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape, with other work appearing in The Washington Post, NPR's Shots blog, and Diabetes Forecast magazine. She is on Twitter: @MiriamETucker.

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