COMMENTARY

'None of Them Survived': Diabetes in the Time of Humanitarian Crises

Sylvia Kehlenbrink, MD; Mark Harmel, MPH

Disclosures

October 08, 2019

This transcript has been edited for clarity.

I first became passionate about diabetes and humanitarian crises when I spent a month practicing general internal medicine at a small district hospital near the Congo-Rwanda border. We had many refugees come through from the Congo at that time, including a number of young men who were clearly in diabetic ketoacidosis.

Because we did not have insulin or glucose strips with which to monitor them, they all died within hours of presenting to the hospital. None of them survived. Those with type 2 diabetes kept being readmitted to the hospital because we were unable to manage their hyperglycemia, although we were able to manage their infections or trauma.

This experience led me to dedicate my career to this issue. Today, about half a billion people worldwide are affected by diabetes, 80% of whom are living in low- and middle-income countries. This is projected to increase over the next 20 years as a result of urbanization, climate change, global warming, etc., so the crisis will get even worse.

At the same time, low- and middle-income countries are predominantly and disproportionately affected by humanitarian crises. Most people who are displaced due to conflict spend decades as refugees or internally displaced people. The average duration of this conflict-induced displacement is 27 years, and these people have diabetes. As a result, humanitarian actors are now having to take on broader roles.

Yet, at present, data on this issue are not being collected. There are no evidence-based guidelines on how to manage diabetes best in these circumstances, and there is no education. Medicines, including insulin, are not routinely supplied in these contexts, which is a death sentence for anyone with type 1 diabetes.

Taking Action

For this reason, we organized a symposium in early April at Harvard University, where we convened more than 100 leaders in global and humanitarian health, including various academic institutions, the Centers for Disease Control and Prevention, the World Health Organization, and pharmaceutical and diagnostics companies. The objectives were to discuss this issue, build partnerships, figure out how to collaborate, prioritize the most immediate needs as a community, and design projects going forward.

Out of that meeting, we published the Boston Declaration in TheLancet Diabetes & Endocrinology, which outlines this incredible and urgent need for insulin, especially for those with type 1 diabetes, and the need for chronic care for people with type 2 diabetes.[1] This care includes cardiovascular risk management and all comorbidities, which would hopefully pave the way for improved care for other chronic diseases.

The group, comprising 64 signatories from about 43 different organizations, outlined four major targets to work toward. The first is improved advocacy and global awareness, which is a major need. The second is improved access to insulin, essential medicines, and diagnostics for diabetes and hypertension. The third major target is to develop improved clinical and operational guidelines that are coherent among organizations, and the last target is improved data collection, surveillance, and monitoring across organizations. These are the four main targets that we're setting out to tackle over the next 3 years.

Many new projects are beginning, and we would love everyone's involvement. If you would like to get involved, you can contact me via the Global Endocrinology website, or contact any humanitarian organization, including Doctors Without Borders, the International Committee of the Red Cross, and Save the Children. They're all doing phenomenal work, they definitely need this money, and they will put it to good use.

Thank you.

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