Dr Sylvia Garry, Rachel Thompson
From starving children in Yemen to bombed-out hospitals in Syria, today’s media offers many images depicting the impacts of conflict on health. Where conflicts occur, international and local aid workers rush to treat the wounded and assist with essential food supplies and vaccinations.
However, many people in humanitarian crises also suffer and die from chronic diseases, which now account for 7 in 10 of all deaths worldwide. Conflicts contaminate the air and water, reduce access to nutritious food and create stressful living conditions. This makes people sicker and more susceptible to chronic illness. At the same time, health workers flee, hospitals are targeted and there are medication shortages.
An increasing challenge…
Humanitarian systems were not designed to provide the long-term care required for chronic diseases. As more middle-income countries – with large pre-existing chronic disease burdens – are affected by conflicts, this is a growing challenge. In addition, the length of conflicts has increased, creating protracted complex situations with no clear demarcation of where humanitarian needs stop and development needs start.
Despite the amount of trauma in Syria, half of all deaths are due to a chronic disease. Surveys have identified that at least 1 in 5 Syrian refugees have a chronic disease, although this figure is much higher in elderly populations. Many have unmet chronic health needs and cite a lack of access to healthcare as the main barrier to getting those needs met. This is not a problem limited to conflicts in the Middle East, as NGOs working with the displaced Rohingya populations in Bangladesh have found.
The risk factors that are associated with the global epidemics of smoking-related disease and obesity (including poor diets, lack of physical activity and stress) escalate in conflicts. Prevention efforts to slow illness progression by promoting healthy lifestyles may not be possible in environments when food, water and space for exercise are limited and not prioritized. Meanwhile, treatment usually involves long-term therapies, careful monitoring by trained healthcare workers and, often, daily access to medications that may not be available.
…With no simple solution
Interruptions in medication – an asthmatic without inhalers, a diabetic without insulin, a cardiac patient with no access to heart medications – are life-threatening, and management of complications requires access to health centres capable of performing specialist investigations and surgery. In unstable settings, providing continuity of care is especially difficult when access routes become dangerous or are blocked: supplies cannot arrive and people may be forced to flee.
Médecins Sans Frontières has created health passports for patients in Lebanon to monitor treatments over time at their clinics. The next steps may include sharing data between organizations and creating electronic records that cannot be lost or destroyed.
In pre-conflict Syria, pharmacists played an important role in managing hypertension. In humanitarian situations, this is a role usually undertaken by doctors. However, by understanding local contexts and the local workforce, these activities could be shifted to pharmacists in Syria, a model that may be applicable in other contexts.
Ensuring access to drugs such as insulin that require refrigeration is a challenge in disrupted settings. Innovations such as heat-stable insulin may offer a solution to provide consistent access to this life-saving medication, both in conflict and other resource-limited settings.
Close cooperation between humanitarian agencies, development organizations and governments will be required to manage chronic illness sustainably in protracted crises. The World Health Organization is promoting joint planning and programming between sectors to improve access.
However, the cost of managing chronic needs for long periods is significant, and who pays for long-term care (the cost of which exceeds humanitarian budgets) in conflict settings is not clear. Momentum around chronic diseases in the wider global health world has not yet reached those living in conflict, who are still being ‘left behind’ from progress towards universal health coverage and other UN Sustainable Development Goals.
Within the biggest ongoing conflicts, chronic diseases receive the least attention but represent one of the most important health issues for populations. To save lives and prevent further suffering, they must become more of a priority.
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