Event: ‘Non communicable diseases: prevention and management in contemporary crisis and conflict zones’
Dr. Lucy Maconick, MSc Public Health student
Date: 22nd January 2018
Venue: Royal Society of Medicine
Dr. Ghasaan Soleiman Abu Sitta, Assitant Professor in Surgery, American University of Beirut and Co-Director Conflict Medicine Program, Queen Mary University London
Dr. Lilian Kiapa, Senior Technical Advisor, International Rescue Committee
Dr. Éimhín Ansbro, Research Fellow in Non-communicable diseases in Humanitarian Settings, London School of Hygiene and Tropical Medicine
Chair: Professor Richard Sullivan, Co-director of Conflict and Health Research Group and Professor in Cancer Policy, Kings College London
This event, arranged by the Kings Centre for Conflict and Health and Global Health Royal Society of Medicine, looked at the issues around the turning point for humanitarian health provision in conflict zones.
Professor Sullivan kicked off the discussion by describing the current challenges for humanitarian actors and national health services in tackling NCDs in conflict zones.
He described how humanitarian actors are now working within ‘transitioned’ countries in the Middle East and North Africa with a high prevalence of non-communicable disease, compared with the ‘un-transitioned’ countries traditionally worked in by humanitarian agencies. Humanitarian agencies and host governments are being forced to operate within complex and dynamic environments, considering security, counter-terrorism, development and peacebuilding alongside traditional humanitarian roles.
When considering the provision of NCD care in these settings, there is additional complexity. Non-communicable diseases are not made up of one component, and their management ranges from simple primary care interventions to more complex models of care for diseases like cancer.
Countries receiving an influx of refugees from conflict need to be simultaneously caring for the demands of refugees whilst also delivering on their Sustainable Development Goal commitments for their home population.
Professor Ghassan Abu Sitta described the ‘Ecology of war’: how conflict can not only cause immediate danger to civilians but also causes long lasting changes in the ‘biosphere’ in which people live. These includes changes to the social, physical and biological environment that persist after the conflict has ended.
He argues for a more inclusive view of conflict medicine in the modern world. The distinction between combatants and civilians is increasingly blurred; there are multiple simultaneous wars and daily shifts in the front lines of conflict. As a result, we need to combine the traditional health needs of war, such as shrapnel injuries, with non-communicable diseases, and consider the political and social contexts in determining health. He drew on his experience working in Palestine to illustrate how conflict results in 80% of patients presenting with breast cancer to a large hospital in East Jerusalem seeking help only in the palliative phases. Factors contributing to this include the migration of doctors outside of Palestine, that chemotherapy drugs are not allowed into Gaza and the fact that 45% of patients cannot leave the Gaza strip.
Dr. Lilian Kiapi illustrated how International Rescue Committee (IRC) is providing primary care provision for refugee populations. Their acute emergency package now includes non-communicable disease provision, focusing on continuity of care for those already diagnosed and the prevention of complications. They use a comprehensive model aimed to support individuals in health promoting behaviours. This includes consideration of economic opportunities and an enabling environment as well as treatment. However, examples of preventative medicine such as cervical screening in refugee camps are no longer funded. Dr. Kiapi, however, feels we can do more in humanitarian settings around prevention, and when pushed to name her number one intervention, said she would like to see more safe spaces to exercise in refugee camps, which would be both feasible and valuable.
Dr. Éimhín Ansbro presented an evaluation of a MSF diabetes outpatient program in DRC, outcomes of which were evaluated over a period of relative stability and then instability.
The service was established according to need identified in the area. MSF field workers reported high levels of presentation of diabetes to their clinics and were forced to respond by providing an ad-hoc NCD service. This was then supported and developed by a delegation from MSF.
A major challenge was how evidence-based guidelines for diabetes used in high income countries often require frequent follow up and provision of home glucometers (to measure blood sugars). These protocols would clearly need to be simplified and adapted, but evidence around how to adapt them and how to develop good quality NCD care in low resource and conflict settings is lacking.
Additional challenges include how traditional advice about dietary adaptations for NCDs can seem inappropriate and unrealistic when patients are relying on food rations. Follow up and continuity is a key component of NCD care, but during the MSF project in DRC, conflict disrupted service provision and medication supply. Despite this, they were able to demonstrate reasonable outcomes for diabetes care even during times of instability. Chronic care programs can employ emergency preparedness to minimize interruption, such as emergency medication packs and increasing level of medication stock.
Dr. Éimhín Ansbro referred to a systematic review of NCD interventions in humanitarian settings conducted by researchers at LSHTM, which show some evidence for benefits of protocol driven care, but recognises an overall knowledge gap:
In the Q&A discussion there was a recognition that humanitarian organisations can be concerned about the open-ended nature of NCD care and the risk of becoming ‘trapped’ without a clear exit strategy.
However as demonstrated with the example of the MSF conflict in DRC, where the burden of disease exists, humanitarian staff are already responding by treating what comes through the door. Current formal NCD programs are aiming to improve and systematize this existing response.
There were audience calls for the consideration of pharmacy supply chains, palliative care and occupational health as integral in NCD provision in unstable settings, showing the diversity of the potential areas into which this field could move.