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ORIGINAL ARTICLE
Year : 2022 | Volume
: 13
| Issue : 5 | Page : 62-67
Diabetes care during humanitarian crises due to floodings and earthquakes in IDF-MENA region: Pakistan experience
Samih A Odhaib1, Shabeen N Masood2, Jamal Belkhadir3, Mohamad Sandid4, Zaman Shaikh5, Farah N Farooq6, Fizza Naz7, Faryal T Masood8, Ayesha Ayub9, Ahmed Bilal10
1 Thi Qar Specialized Diabetes Endocrine and Metabolism Center, Thi Qar Health DirectorateThi Qar, Iraq
2 Department of Obstetrics and Gynecology, Isra University Hyderabad, Pakistan
3 Medicine and Endocrinology, Moroccan League for Diabetes, IDF-MENA Regional Chair, Morocco
4 Endocrinology Department, Lebanon Medical Centre, Saida, Lebanon
5 Department of Internal Medicine and Endocrinology, Sir Syed College of Medical Sciences, Karachi, Pakistan
6 National Institute of Diabetes and Endocrinology, Dow University of Health Sciences, Ojha Campus, Pakistan
7 Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan
8 Clinical Instructor, Dow Univesity of Health Sciences, Ojha Campus, Pakistan
9 Health Professional Education and Research Department, Faisalabad, Pakistan
10 Faisalabad Medical University, Allied Hospital, Faisalabad, Pakistan
Correspondence Address:
Prof. Shabeen N Masood
Department of Obstetrics and Gynecology, Isra University, Hyderabad
Pakistan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jod.jod_112_22
Background: Diabetes care in humanitarian crises after the devastating 2005 earthquake in Pakistani Jammu and Kashmir, and in 2022 huge floodings across Pakistan is challenging due to many topographic reasons related to the terrain and the infrastructureMaterials and Methods: In this article, 197 articles were reviewed from PubMed and Google Scholar using conveniently related search terms in the titles and abstracts published from (2000-2022). Additional information was retrieved from the official sites of active international aid organizations and news agencies. Results: It was found that the preparedness plans for proper diabetes care in disaster and non-disaster settings are unsatisfactory in malfunctioning healthcare infrastructures and the non-availability of life-saving medications like insulins. These plans are not fulfilling the needs of the people living with non-communicable diseases like diabetes and hypertension. The role of the international aid organizations after 2005 was directed toward immediate care of traumatic conditions and their complications, infectious diseases control, mental health, care for the elderly, and orphanage care but not covering the diabetes care. Conclusions and Recommendations: The healthcare authorities should adjust a disaster preparedness plan for the country, integrating noncommunicable disease control as a pivotal part and mitigating the current deficit in diabetes care for people in need in different humanitarian crises.
Keywords: Crisis, diabetes mellitus, flooding, humanitarian, insulin, Pakistan
Pakistan’s recent experience with natural disasters such as floods and earthquakes was dated back many decades. The latest floods started in June 2022 because of the abnormal monsoon rainfall season, close to three folds more intense than the past 30-year average. The rains have resulted in uncontrollable floods and landslides across Pakistan predominantly in provinces of Sindh, Baluchistan, and Khyber Pakhtunkhwa (KPK).[1] The floods have markedly damaged thousands of healthcare facilities, causing a marked shortage in access to health care. The disaster forced many healthcare professionals to abandon their cities, reducing already meager healthcare capacities. Vulnerable individuals such as pregnant and lactating women, people with disabilities, and those with chronic illnesses such as diabetes and hypertension are more vulnerable to the lack of healthcare access.[2]
The older experience was that of the 2005 devastating earthquake in the region of Pakistani Azad Jammu and Kashmir (AJ&K), where the marked geopolitical instability disrupted the healthcare provision at different levels, including diabetes care.[3] Diabetes care in AJ&K is challenging for many healthcare providers because of the predicted increase in the prevalence of the disease worldwide.[4] There has been a lack of well-defined epidemiological studies on diabetes mellitus (DM) in the area, especially in remote tribal areas. The overall reported prevalence of diabetes was 0.3%–8.35%, with some gender, age, geographic, and ethnic variations.[5],[6],[7],[8],[9] The gender difference was attributed to the social bias favoring males who get better medical care.[6]
This article aims to review the obstacles to diabetes care during the 2022 floodings and after the 2005 earthquake in Pakistan.
Materials and MethodsLarge-scale sequential references search was undertaken to have a detailed view of the effects of various crises on diabetes care during natural disasters. The search through published articles was done on PubMed and Google Scholar search engines.
Initially, the search terms used were: [(flooding) and (diabetes) and (Pakistan)], [(diabetes) and (Kashmir)], [(diabetes) and (AJ&K Azad Jammu and Kashmir)] in the titles and abstracts published from 2000 to 2022. One hundred ninety-seven published articles were included using these search terms. Additional references were extracted from the official sites of the international aid organizations, which supported the victims in different countries with different crises. Some information was extracted from the official sites of press media in the region of interest. There were 24 relevant published articles from six websites in this review.
Results and DiscussionAbsence/lack of effective disaster preparedness plan
Care for noncommunicable diseases (NCD) in general and diabetes is vital in any humanitarian setting, especially in low- and middle-income countries. In both of these unfortunate events in Pakistan, most governmental and nongovernmental agencies lack clear context-adapted care models for individuals with diabetes or any NCDs.[10] Accomplishing the global target of reducing NCDs’ mortality by one-third is not achievable without highly effective healthcare policies to be effective in communities with the humanitarian crisis, like the case in AJK in the last two decades.[11],[12] Achieving such a goal for sufferers at risk after the 2022 floods is not applicable currently, given the acuteness of the disasters, with unknown or unpredicted deterioration in the health care of people with NCDs such as diabetes or cardiovascular disease, with an associated increase in mortality.[13]
The cost-effective policies must include evaluating the present diabetes status of the individuals at risk, guaranteeing adequate hydration, frequently checking the blood glucose, and avoiding dysglycemic effects by ensuring optimal compliance with the already prescribed regular medications or the newly prescribed ones. Furthermore, the prevention of the long-term complications of these NCDs, such as DM and hypertension, is a vital part of these policies, which must be affordable to those individuals at risk[10],[12] because, in the absence of functional health structures, they could suffer from a loss of care sustainability.[14]
The problem is not limited to diabetes only
The healthcare infrastructure in disaster affected areas of Pakistan may be inadequate, malfunction, or suffer damage. There has been a shortage of the availability of healthcare centers, equipment, and human resources,[5] which further added to the miseries of the people with health problems.[15]
The difficult geomorphological nature of some areas and difficult climate adjustment in many Pakistan regions created many problems regarding healthcare provision in some areas.[15] They changed the doctor–patient ratio to one doctor for every 3866 people, whereas the World Health organisation (WHO) recommended a figure of 1:2000.[3],[16]
This disruption of the healthcare services in these affected areas could have an instant and/or remote health impact on morbidity and mortality for many individuals with diabetes.[13],[17]
Flooding can cause widespread damage to crops and livestock, affecting the quantity and quality of food. Undernutrition or malnutrition remains a major threat to health.[13]
Transhumance pastoralist
The healthcare disparities, accessibility, and affordability impediment are pronounced for the transhumance pastoralist tribals in AJ&K due to topographic mobility issues and the difficult agro-climatic conditions.[18] These people adopt local ethnomedicinal practices, known as Dhoks locally, to treat many illnesses, including diabetes. Local studies defined three species of medicinal plants to treat diabetes.[19],[20]
How did glycemic control change in any humanitarian crisis?
The causes of dysglycemia in individuals with diabetes in any humanitarian setting are multifactorial: overeating due to hunger or insufficient food, fear, noncompliance or interruption of therapy, disturbed exercise patterns, daily activities, and restricted costumery cooking diversities.[21] The rationed foods following natural or manmade disasters are usually carbohydrate-loaded, especially given by different aid organizations, with no considerations for diabetes in the acute care of crisis.[21],[22],[23]
The interrupted or nonavailability of insulin and other drugs during the crisis and a lack of knowledge about the usual or altered treatment regimen may add to the anxiety of people with diabetes and their inability to seek the proper medical care.[24]
Role of nongovernmental organizations (NGOs) and aid organizations in diabetes care
The size of both disasters is vastly huge, and the local and central governmental efforts were not enough to cope with the causalities. The local and international non governmental organisations (NGOs) had a limited role in providing diabetes care in the old disaster of AJK and the recent flooding. Their participation is limited to controlling infectious diseases (human immunodeficiency virus, tuberculosis, and hepatitis C, malaria, dengue) and providing very little mental and psychological counseling. For example, the mobile clinics of Médecins Sans Frontières (MSF) in the remote areas of Chhattisgarh provided some help to vulnerable people with limited or no access to health care.[25],[26] From 2000 onward, MSF administered a mental health program in Srinagar, the most urban area in AJK.[27] Diabetes care is not a part of the scheduled care in these clinics.
MSF actively participated in the aid during the 2022 floods in different affected areas. MSF provided mobile primary healthcare clinics to deliver care for the emerging infectious disease in different affected areas with floods, drinkable water provision, and provisions of limited sanitation services such as in Sindh, Baluchistan, Rajanpur, and Punjab. Limited mental and NCD care and outpatient consultations were provided to some individuals in KPK and Punjab, in addition to basic health services through three mobile clinics.[26]
Merlin and HelpAge International began working together in Pakistan-administered Kashmir in 2006 after recognizing the lack of specialist health services for older people in the 2005 Kashmir earthquake response. Their main concern was to deliver age-appropriate health services to older people in areas of conflict and disasters.[28]
The aftermath of the 2005 earthquake and 2022 floods
On October 8, 2005, an earthquake measuring 7.6 on the Richter scale struck AJ&K, killing about 73,000 people from Pakistan. The exhausted diabetes care supplies could not be replenished effectively.[22],[29],[30] The short-term health urgent needs were not adequately addressed, especially for elderly victims from rural areas, including individuals with diabetes.[31]
A large-scale, long-term humanitarian crisis could have multilevel community effects, economic and financial effects due to affordability, accessibility, and availability of health care during the crisis, social effects due to loss of exercise, and psycho-mental effects such as posttraumatic stress disorder.[22],[29],[32] The morbidity and mortality of the victims of such crises may be attributed to the interaction between neurohormonal, hemodynamic, physical, and emotional factors.[33]
The remote mobile health service clinics by NGOs and international aid organizations during both disasters were examples of the limited care provision and inability to cope with the current demand after the disaster. These clinics were the main source of care 3 months after the disaster for the people who had NCDs such as diabetes by basic available medications. However, no treatment guidelines were followed.[26],[34]
Dialysis services during the 2005 earthquake
The nephrology team from MSF started preparing for dialysis services 3 h after the earthquake. Overall, 88 victims had acute kidney injury (AKI), 55 of whom received different hemodialysis sessions, out of whom 11 died (i.e., a mortality rate of 21%).[30]
Literature search shows a lack of data about the prevalence of diabetes in earthquake victims who had AKI, nor those who received hemodialysis and/or died, in any published article or from any publication from the aid organization that was working in the rescue and help services during the Kashmir earthquake. No information is available on the scope of acute kidney injury (AKI) during the current 2022 floodings.
Public health services to reduce preventable diabetes-related amputations[
35]
In 2017, the Muzaffarabad Physical Rehabilitation Center and the Department of Health in Azad Kashmir, supported by the International Committee of the Red Cross (ICRC), started a public health joint project to address the preventable cases of diabetes-related amputations, which constituted 10% of the overall amputation in individuals from AJK. The main intervention of this low-cost initiative was to create diabetes awareness for early detection. The second intervention was to train female healthcare workers to overcome gender inequity in the health care. These women were trained for early detection and referral.
The second low-cost initiative was to improve the referral system for different diabetic foot cases from the local basic health units (BHU) to the Combined Military Hospital to get appropriate management. Accordingly, the healthcare workers in the local BHU managed some nonemergent cases after receiving enough medical supplies and training in managing diabetic foot injuries. All the training sessions, including those dedicated to female healthcare workers, were carried out by the local diabetes center.
During the coronavirus pandemic, the ICRC and Tele Distant Consultation (TDC) started the third initiative of teleconsultation and doorstep medical services to around 1800 patients across Azad J&K and other cities.
Recommendations by IDF for people living with diabetes during disasters
Unexpected natural disasters, such as hurricanes, floods, earthquakes, power outages, terrorism, wars, and tornadoes, can seriously devastate human lives, especially those with chronic illnesses such as diabetes. These disasters lead to no electric supply, refrigeration for insulins, loss of medications supply, shortages of healthy food choices, shelter and clothing. Such calamities also bring other problems with them like absence or lack of clean water and sanitation, non-availability of personal hygiene items and sleeping space. Therefore, it becomes tedious for people with diabetes and other chronic conditions to get the ongoing care and treatment they need. A good planning and infrastructure may enhance the resiliency of people with diabetes before, during, and after disasters.
Impact of disasters on glycemic control
Review of published studies after the gulf war shows that there was disruption of glycemic control manifested by an increase in HBA1c in both Type 1 and Type 2 diabetes. There was also measured increase in weight on average by 1.4 kg in people with type 2 diabetes and by 1.5 kg in people with type 1 diabetes. Similar increase in mean hemoglobin A1c values were seen after the earthquake, in Japan from age matched controls in non-affected areas (7.74% to 8.34%)[36] as well as Hurricane Charley occurring in 2004 in United States. After these disasters qualitative study identified the pressing issues involved in providing proper care for people with diabetes which included non-availability of medications for patients, lack of patients’ preparedness and self-awareness of medical information, lack of ability to access medical information and poor coordination of aid efforts due to lack of communication and collaboration among private and public aid institutions. Thus, guidelines were made in regional languages to help people with diabetes and to prepare them for disasters. Learning from their experience it is asserted that all governmental and non-governmental agencies and NGOs should follow those guidelines and publish guiding literature in local languages to help educate people with diabetes. Early evacuation should be priority number one. Awareness should be created in people with diabetes for taking certain items with them like a Diabetes ID card, waterproof and insulated disaster kit — containing glucose strips, lancets, glucometer with extra batteries, medications with long expiration dates including insulin, syringes, glucose tabs, antibiotics ointments/creams, prepackaged snacks such as unopened crackers of long expiry, dry unsweetened cereals. Special advice is required to be given on foot care like clear instruction for not to walk bare foot, wear sturdy shoes, check daily for any blister, sore or ulcer.[37] All efforts should be made to ensure good hydration and avoidance of activity in heat. People may be informed of advantages of wearing light colored cotton clothing, avoiding periods of hunger and over eating. Awareness should also be created to keep all prescriptions for ready reference regarding oral medications and insulin with formulation and dosing. The health care providers should write the prescription in the regional language of the people with diabetes writing should be water proof or covered with plastic coating. Due to disaster, storage of insulin can be challenging; insulins in vials or cartridges and short acting insulin pens (opened or unopened) can be left unrefrigerated for 28 days in temperature between 59–86-degree Fahrenheit;[38] however, NPH pens alone or in premixed pens are good for 14 and 10 days, respectively; Detemir pens and glargine pens for 42 days and 28 days, respectively. However, Insulin pens and vials not in use and refrigerated can be used till their expiration date. People may be encouraged to maintain daily activities and prevent being bedridden and to regulate proper glycemic control. Likewise public preparedness strategies need to address short and long term needs of people with diabetes and the healthcare professionals and organizations should be aware and educated about these guidelines.
Conclusions and RecommendationsFor individuals with diabetes, the risk is more pronounced during any humanitarian crisis. Diabetes care plans and policies are suboptimal and unsatisfactory in meeting the urgent needs of individuals with diabetes during the unpredicted humanitarian crises because of the large-scale terrain geomorphological difficulties, suboptimally organized health infrastructures, and topographic difficulties.
After the crisis of 2005, different aid organizations tried to help ease the morbidity and mortality burden on individuals with NCDs and those with diabetes in this area. These aid organizations support governmental healthcare facilities to an extent. Still, a disaster preparedness plan should be set appropriately to meet the need of the people at risk.
Such disaster preparedness should start with the identification of the risks, which render certain people more vulnerable than others. These factors include limited physical capacity and mobility, individuals who need chronic medical care, weak social networks, and poor logistics and resources to flood awareness. In order to prevent future morbidity and mortality occurring from natural disasters, we need to educate and produce awareness in people with diabetes about the continuous use of medicines or insulin in times of need as well as educate their family members to take care in situations of emergencies. Emphasis should be given on diabetes education and on self-management skills during the time of such stressors. The vulnerability level of the population with such factors may change during the crisis, according to the level of preparedness and the quality of care. Although hard to anticipate, individual preparedness for such disasters should be assessed for vulnerable people. Previous aid organizations’ experience in similar disaster across the world recommended to keep a waterproof and insulated Disaster Kit—containing glucose strips, lancets, glucometer, medications including insulin, syringes, glucose tabs, antibiotics ointments/creams, prepackaged snacks, and healthcare provider’s medical prescription, plastic coated and water proof inside the kit box. Individuals at risk could keep all water proof prescriptions for ready reference regarding oral medications and insulin with formulation and dosing.
Acknowledgment
The authors would like to thank Syed Imran Shah for professionally editing this article to its final form.
Authors’ contributions
SAO contributed to the study conception and design. Material preparation, data collection, and analysis were performed by all authors. The first draft of the article was collected and written by SAO and reviewed individually by each author. Critical revision for important intellectual contents was done by SAO and SNM. All authors read and approved the final article.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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