Ukrainian Diabetes Care, Insulin Access 'Severely Disrupted'

Miriam E. Tucker

March 11, 2022

Diabetes care and access to insulin and other medications in Ukraine have been "severely disrupted" since Russia's invasion, with shortages resulting more from distribution problems than supply itself, according to multiple sources.

In 2021, there were about 2.3 million people with diabetes in Ukraine, roughly 7% of the total population. Of those, about 120,000 have type 1 diabetes and depend on insulin to live, while a similar number have insulin-treated type 2 diabetes.

Donations of insulin, other medications, and supplies have been pouring in since late February from sources including the Ukrainian diaspora, nongovernmental organizations, other European governments, universities, and product manufacturers. "The main problem now is logistic," Boris Mankovsky, MD, president of the Ukrainian Diabetology Association, told Medscape Medical News in an interview.

Insulin manufacturer Novo Nordisk's warehouse continues to operate, although deliveries have been curtailed due to shortages in delivery staff. The company is working to get medications to patients either through pharmacies or humanitarian organizations and has funded refugee support efforts, they said in a March 8 statement.

But even if the supplies reach the pharmacies, they may not reach patients for a variety of logistical reasons, noted Mankovsky, who is head of the Department of Diabetology at the P.L. Shupyk National Medical Academy for Postgraduate Education in Kyiv. "So, there are a lot of problems. I don't know exactly where the main bottleneck is, but there are shortages, definitely."  

Insulin supplies have also been distributed very unequally by region and type, with various shipments containing long-acting, short-acting, analog, or human insulins. "We're very grateful for all of it. But it's not centrally coordinated, which of course is understandable, but it means that a lot of donations go to one place and no supply goes to another," Mankovsky said.

Most of the donated supplies have been going to western Ukraine, where the capital Kyiv is located. "But the main problem now is the eastern part of Ukraine. It's difficult and dangerous to deliver any supplies there, especially [with] the terrible situation in Mariupol. Eastern Ukraine now suffers the most, at least at this minute," he said.  

Diabetes Specialists Continue to Work, at Least For Now  

Ivan Smirnov, MD, PhD, head of the Endocrinology Department at Kharkiv Regional Hospital, in the northeastern part of the country, told Medscape Medical News in an email, "I continue to stay in Kharkiv, in spite of the situation. A lot of people are killed, many people are wounded. My hospital is full of wounded civilians...a lot of buildings are destroyed partly and some completely."

Smirnov said that he and his colleagues "find the way to overcome the constant work. Part of the work is online consulting assistance for routine patients...But the main time now is dedicated to providing the diabetes patients with insulin. This is a heavy job to do indeed."

Mankovsky, who practices adult diabetology and endocrinology in Kyiv, continues to manage patients, but mostly remotely. "Practice is severely disrupted. I'm willing to see patients but it's extremely difficult and dangerous for them and probably not possible to travel to see me. So that's why all our communications now is distant, through phone or internet...We can communicate and I'm able to provide some recommendations for changes in treatment or some corrections in insulin therapy."

Despite the Russians closing in on Kyiv, Mankovsky said, "I've decided to stay as long as possible. Then, nobody knows of course but I think I have to...We hear explosions every day...I'm in the center of the city and the streets are empty. It's heartbreaking."

Supplies Are Reaching Refugees

Mankovsky said, "Now we have huge movement of refugees. Among them are a lot of people with diabetes who moved out of their place and nobody knows where they are. It's really a huge disruption."

According to the type 1 diabetes advocacy organization JDRF, many men with diabetes aged 18-60 are remaining in Ukraine to fight, despite the increased risk with the disease. But an estimated 15,000 children with type 1 diabetes and their families are attempting to escape the conflict by moving to the western regions of the country or over the borders.

"Those who make it to Hungary, Moldova, Poland, or Romania are being received with wonderful generosity. We have heard stories ranging from governments making it possible to pick up insulin free without a script to individuals emptying their cupboards of insulin for those whose need is urgent," JDRF said in a statement on March 2.  

For its part, Novo Nordisk has donated 55 million Danish kroner (about 7.3 million Euros, or $8.2 million US dollars) to support international relief organizations in assisting refugees.

Ivan Tkac, MD, PhD, professor of medicine at Safárik University, Faculty of Medicine Kosice, Slovakia, is assisting refugees, including those with diabetes. Slovakia is predominantly a transit country for refugees from Ukraine, he told Medscape Medical News

"However, in solidarity with Ukraine, we are providing emergency medical care for both Ukrainians and refugees from third countries leaving Ukraine," he said, noting that those individuals are primarily foreign students who had been studying there.    

"Asylum seekers receive full medical insurance paid by the Government of the Slovak Republic. As part of this care, the refugees are provided with the necessary amount of insulin and other antidiabetic drugs, as well as medical devices needed for the treatment of diabetes. The European Commission has pledged to supply Slovakia with the necessary quantities of medicines for the treatment of diabetes in the coming weeks as part of its assistance to the countries bordering Ukraine. In addition, some humanitarian organizations are organizing supplies of insulin and other medicines for soldiers fighting in the Ukrainian army," Tkac said.

How You Can Help

A number of organizations are providing assistance specifically to people with diabetes, as well as broader medical assistance to people remaining in Ukraine and to refugees.

A collaboration between the Ministry of Health of Ukraine, the humanitarian agency Direct Relief, and the International Diabetes Federation (IDF) is working to determine where supplies are short, to secure donations within Europe, and to open up "green corridors" within Ukraine to deliver them quickly to where they're needed. They have asked those who wish to help to donate to Direct Relief and direct donations to the "Ukraine crisis."

Another effort organized by IDF Europe is Connect Solidarity, a program that "aims to facilitate support from IDF Europe member associations across Europe wishing to help other national diabetes associations in Ukraine's neighboring countries, provide advice, medicines, and supplies to Ukrainian refugees."

IDF President Andrew Boulton, MD, told Medscape Medical News that he has been in almost daily contact with senior colleagues working in diabetes in Ukraine, and that he is working with the organization's affiliated charity Life for a Child in addition to the other charitable agencies. "We will continue to do our utmost best to help those with diabetes living in Ukraine. However, this is, of course, very challenging, and we hope that we are doing the best we can in such a difficult situation. We all hope and pray that this situation is soon resolved."

The European Association for the Study of Diabetes is taking a somewhat different approach, by encouraging its members to "support people with ill health, including diabetes, with donations through established [nongovernmental organizations] that have the capacity to help on site, such as United Nations High Commissioner for Refugees or International Committee of the Red Cross."

Mankovsky told Medscape Medical News that he is very grateful for all the support from around the world: "Just thanks. I've got so much support, so many phone calls, so many letters...not just me, all of us. People-wise and friendship-wise we feel support. It's really important, emotionally and with insulin supply and other medications. Without that, it would be much more difficult."

Pandemic-Prompted Changes Enable Wartime Diabetes Care

Dramatic changes in diabetes care delivery in Ukraine necessitated by the COVID-19 pandemic have proved indispensable during the Russian invasion.

In a piece published in 2020 in the Journal of Diabetes Science and Technology, Mankovsky describes how the pandemic hit just as Ukraine's health system was pivoting from government-controlled to insurance-based.

Prior to the pandemic, patients with both type 1 and type 2 diabetes were regularly admitted to hospital for routine checkups, insulin dose management, and other treatments, a "remnant of the Soviet-era medical practice, which emphasized heavily on hospital admissions," Mankovsky told Medscape Medical News.

This was the case, he wrote in the article, "despite the common understanding that such a system was a waste of resources...this policy was changing much slower than we wanted."

But the COVID-19 pandemic changed that practice "abruptly and dramatically," so that all hospitalizations for patients with diabetes were stopped unless there was a real metabolic emergency.

Subsequently, Mankovsky wrote, "Almost every health professional recognizes the particular importance of the new ways of communications with patients and with other colleagues."

Indeed, in his email to Medscape Medical News, Smirnov mentioned that the routine diabetes management work he is still able to do remotely despite the extreme disruption in his region "is easy because of long-term COVID-period experience."

Also due to the pandemic, insulin prescriptions were switched from traditional paper to electronic transfer, so that patients could easily pick them up at the pharmacy. "This new...system proved to be not just very convenient for all parties involved, but in the current situation, it allowed us to prevent so many medically unnecessary visits to the clinics, which otherwise would have presented the real threat to the patients' health and risk to get them infected," Mankovsky wrote in 2020.

Now with the new danger, he said, "the inability to see patients is probably the least of our problems."

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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