In August, 11-year-old Syrian refugee Raghad Hasoun died after human traffickers threw her insulin into the sea. Her parents, fleeing the conflict, packed their daughter’s medication into two separate bag. If they lost one, they would have some spare. The, after wading through 300ft of head-height water, they made it to the boat, desperate to find a better life elsewhere. But their traffickers, armed with assault rifles, ordered them to throw both bags overboard. Raghad died on the fifth day.
Mohammad, a refugee in Lebanon for two years, lost everything during the war. He now lives day to day, scrambling to take care of his diabetes and provide a regular diet for his family.
Amina, also in Lebano, hasn’t had insulin after her house was bombed and she had to flee Syria. Her life revolves around getting insulin. She goes wherever she has to in order to stay alive.[1]
Forgotten victims
These stories, and stories like them, draw attention to some of the forgotten victims of any humanitarian crisis: those with diabetes. Despite receiving help from non-government organisations such as Santé Diabète, people with diabetes generally remain untreated during times of crisis. A study published in the Avicenna Journal of Medicine said of the conflict in Syria:
“Specific concerns remain for the chronically sick. It is estimated that more than half of those chronically ill have been forced to interrupt their treatment.”[2]
How diabetes is treated during a humanitarian crisis
Moreover, there are serious flaws in the way diabetes is treated by relief efforts. A paper published in Conflict and Health outlined the common failure to address the problems associated with diabetes during a humanitarian crisis.[3] Drawing on the example of Mali, the authors wrote:
“One lesson from the experience is that although people with diabetes should be included as a vulnerable part of the population they are not considered as such.”
A paper by Alessandro Demaio et al. echoed the argument, drawing attention to the frequency with which diabetes is ignored during times of crisis.[4] The authors identified that the World Health Organisation (WHO)-coordinated Inter Agency Emergency Health Kit “contains limited medications for [non-communicable diseases (NCDs)] (e.g. no insulin in the current version).
None of which is to say that diabetes is ignored entirely, and there are several positive examples. After the Nepalese earthquake in April, Indian Minister of State and Professor of Diabetes and Endocrinology Dr. Jitendra Singh organised the delivery of 75,000 free vials of insulin.
A complex problem
But insulin runs out, and we’re left with the deeper problems that lead us back to the same bleak situations, time and time again. As the Conflict and Health study goes on to identify: “within a complex emergency different ‘diabetes populations’ may exist with different needs requiring tailored responses, such as internally displaced people versus those still in conflict areas.”
Perhaps the biggest obstacle is the fact that humanitarian crises are more likely to affect countries with fragile infrastructures in the first place. Demaio et al. write:
“Developing countries are often disproportionately burdened by both NCDs and disasters in comparison to higher income countries. Developing countries face the greatest burden from global and regional conflict as well as increased vulnerability to the effects of climate change and natural disasters. Many of these situations are exacerbated by the increasing levels of urbanisation and slum-populations.”
So not only are they more likely to be affected by diabetes, they’re more likely to be affected by disasters, both natural and man-made. The unstable economies of developing nations make it more difficult for healthcare systems to deal with the aftermath of a crisis. In Syria:
“The WHO also noted that production and import of medicines has been almost completely eliminated due to issues including destruction and close of pharmaceutical facilities, economic sanctions, currency fluctuations and budget cuts. This scarcity of life-saving products (including insulin) has caused many deaths. An updated Essential Medicines List for the country has been created, which aims to support international medical aid efforts. An estimated $900m is needed to cover these essential medicines and supplies over the next 12 months.”[5]
The World Health Organisation estimates that 57 per cent of Syrian hospitals have been damaged by the conflict. 36 per cent of them are out of action.
The consequences
Managing diabetes is particularly important during a time of crisis because not doing so leads to further costs down the line, in addition of the human costs. For any healthcare system, the most expensive part of managing diabetes is complications, and complications are caused by uncontrolled blood glucose levels. The MSF website states:
“The situation for ordinary people, whether wounded in the war, needing assistance in childbirth, or care for chronic conditions such as heart disease and diabetes is desperate. Without insulin, patients are coming in with … and we have had some with a gangrenous foot that requires amputation.”[6]
As Demaio et al. put it:
“The morbidity and disability associated with NCDs is normally life-long. Therefore, suboptimal management during and after a disaster not only has immediate health effects, but can also have lasting social and health ramifications. A lack of appropriate care for even a short period can result in greater levels of chronic morbidity and suffering, as well as poverty entrenchment.”
It’s clear that diabetes management during a humanitarian crisis is not a simple problem. It cannot be solved overnight. The problems for developing nations stack up on top of each other – the higher rates of diabetes, the lack of a suitable infrastructure, the increased likelihood of an international crisis – and it isn’t clear which one needs to be solved first. In this case, diabetes draws attention to much deeper problems of political and economic inequality.
References:
[1] https://www.msf.org/article/lebanon-syrian-refugees-struggle-live-diabetes
[2] https://www.avicennajmed.com/temp/AvicennaJMed2351-4199729_113957.pdf
[3] https://www.conflictandhealth.com/content/9/1/15
[4] https://currents.plos.org/disasters/article/non-communicable-diseases-in-emergencies-a-call-to-action/
[5] https://www.avicennajmed.com/temp/AvicennaJMed2351-4199729_113957.pdf
[6] https://www.doctorswithoutborders.org/
