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ORIGINAL ARTICLE
Year : 2022 | Volume
: 13
| Issue : 5 | Page : 38-47
Impact of humanitarian crises on diabetes care in Iraq and Syria—IDF-MENA region
Samih Abed Odhaib1, Abbas Ali Mansour2, Suha Falah Khalifa3, Nadima Shegem4, Wael Thannon5, Michele Abi Saad6, Hazim Abdulrazaq7, Jamal Belkhadir8, Mohamad Sandid9, Shabeen Naz Masood10
1 ThiQar Specialized Diabetes Endocrine and Metabolism Center (TDEMC), ThiQar Health Directorate, ThiQar 64001, Iraq
2 Faiha Specialized Diabetes, Endocrine and Metabolism Center (FDEMC), College of Medicine, University of Basrah, Basrah, Iraq
3 Al Amal Hospital, Outpatient Clinics, Amman, Jordan
4 Jordanian society for the Care of Diabetes, Amman, Jordan
5 Lecturer in College of Medicine, University of Mosul, Mosul, Iraq
6 Chronic Care Center, Beirut, Lebanon
7 International Diabetes Federation, Regional Chair of Middle East North Africa
8 Head of endocrinology department LMC, President of the Lebanese Diabetes Association, LMC, Saida Lebanon, Lebanon
9 Red Crescent Hospital, Baghdad, Iraq
10 Department of Obstetrics and Gynecology, Isra University, Hyderabad, Pakistan
Correspondence Address:
Prof. Shabeen Naz Masood
Department of Obstetrics and Gynecology, Isra University, Karachi-Campus, Karachi, Sindh
Pakistan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jod.jod_105_22
This short review tried to discuss the factors that affect diabetes care during humanitarian crises after the political and military conflicts in post-2003 Iraq and post-2011 Syria. The pattern of the devastating effect of the conflicts on the suboptimal healthcare system and infrastructure is quite similar. Both countries’ long-term and continuous geopolitical instability and security concerns were barriers to applying any disaster preparedness plans. They had markedly exhausted diabetes care in these countries with similar mixed public and private healthcare systems. The influx of huge numbers of refugees with chronic diseases, especially diabetes, in the neighboring host countries created pressure on the healthcare systems. It urged some changes in the national policies with the needed help from the aid organizations to an extent. The internal displacement problem for huge nationals in their country exhausted the already exhausted healthcare facilities, with more burdens on the effective equal provision of diabetes-related medication and management tools. Still, diabetes care is not included as a vital part of the mitigation plans during crises in both countries, with the main concern the communicable rather than non-communicable diseases. Type 1 diabetes mellitus received less care during the crisis in both countries, with the insulin shortage being their major concern. The availability and affordability of diabetes medications in camp and non-camp settings were suboptimal and unsatisfactory. More active planning is needed to build a well-prepared healthcare system with diabetes care as an integral part.
Keywords: Diabetes mellitus, Iraq, refugees, Syria, war
Humanitarian crises continue to represent a major global health challenge. Political instability and conflict have displaced record numbers of people.[1],[2],[3]
There is limited epidemiological information about non-communicable diseases (NCDs) and diabetes control in Iraq and Syria during the humanitarian crises unfolding between 2003 and 2011. Diabetes care for affected populations within each country and refugees abroad is affected regionally by security and geographic barriers.[3],[4],[5],[6],[7]
The epidemiological shift of healthcare from communicable to NCDs is increasingly recognized as a new challenge for humanitarian agencies and host country governments, being a driver of excess morbidity and mortality in armed conflicts.[8],[9],[10] During periods of conflict, people with chronic diseases such as diabetes face numerous challenges, including inadequate access to medicines and testing supplies and food insecurity.[3]
Consistent with worldwide increasing trends for diabetes mellitus (DM) prevalence, diabetes has reached epidemic status in Iraq and Syria over the last decade, with a dramatic increase in its figures.[6],[11],[12],[13],[14]
There was a marked similarity regarding the vast destruction or collapse of healthcare infrastructure during the war in post-2003 Iraq and post-2011 Syria, leading to a severe public health crisis that has further impacted the population health of the population. As a direct and indirect result of the prolonged conflict, there was an increased burden for the patients with diabetes regarding the provision of essential diabetes care. The suboptimal nature of the health system in both countries could not cope with the emergent humanitarian crisis. There was no cushioning effect once the crisis began.[4],[5],[12],[15],[16],[17]
Health systems and humanitarian organizations continue to face challenges in providing integrated and cost-effective approaches to basic daily needs for individuals with diabetes.[10],[18] Aid organizations are progressively integrating diabetes care into acute medical response, but challenges emerged.[10],[19]
The national and international community faces immense challenges in addressing the needs of affected populations for refugees, internally displaced persons (IDPs), and host communities. Integrating the care of refugees who live in the non-camp setting in the host country’s healthcare system was challenging. Some host countries revised their healthcare access policy to match the current need of this population and decrease the burden on the care system for nationals.[20],[21],[22],[23],[24]
Hereby, we tried to evaluate the impact of the current humanitarian crises in Iraq and Syria on diabetes care in the national, IDPs, and refugees.
Materials and MethodsArticles regarding diabetes care in post-2003 Iraq and post-2011 Syria during the conflict were retrieved from PubMed and Google Scholar with the search terms (country name) and (diabetes) in titles and abstracts.
There were 259 articles from PubMed and 201 articles from Google Scholar. Duplication in these articles was removed. Only 38 articles containing diabetes care during humanitarian crises were chosen.
Additional information and data were retrieved from reports of aid organizations that were in action during the crises of Iraq and Syria, whether on local or international levels.
The section on insulin preservation in Iraq is dependent on the cumulative experience of the authors in dealing with the different diabetes experiences of their patients.
The crises of IRAQ
The sectarian violence crisis (2006 – 2008)
All drug supplies, including diabetes medications, were supplied centrally from the Iraqi Ministry of Health (MoH) stores in the Capitol (Baghdad) to other parts of Iraq through the hospitals, primary healthcare (PHC) centers, and Public Health Clinics. Patients with NCDs receive their medications monthly according to a prescheduled regimen from the Public Health Clinics.[4]
The crises of 2003 exacerbated the damage of the already inadequate infrastructure. The sectarian violence crisis further exacerbated the sense of loss of security, which made drug storage and distribution unsafe within the country, with a marked shortage of patient supplies. A minority of patients bought diabetes medications from the private sector with expensive out-of-pocket costs.[4],[5]
In 2008, Mansour et al. showed that in Basrah City, 450 kilometers from Baghdad, at the time of the sectarian crisis and consecutive drug shortage, about a quarter of patients on insulin stopped all types of insulin, and a quarter of patients decreased the dose to make their insulin last longer; another quarter used expired insulin, while 15% of patients used insulin from neighboring countries without Iraqi quality control. The remaining 10% switched to oral antidiabetic drugs (OADs).[5]
The crisis of the Mosul (2014 – 2017)
Between June 2014 and July 2017, the City of Mosul – Northern Iraq, was entirely or partly ruled by the Islamic State. Patients faced multiple obstacles in procuring their medications because of costs, decreased availability, and, most importantly, insecurity. The primary concern of people was safety; healthcare was their second priority. Some PHCs providing care only prescribed insulin for ten days, after which the patient had to refill the prescription from the private sector, which was expensive.[8]
The Yezidis and other minority groups’ issues are of particular importance. They were displaced from Mosul-Ninevehin in the Summer of 2014. They were hosted by governorates of Kurdistan in 13 camps (Bajed Kandala, Bersive, Bardarash, Dawdiya, Chamisku, Essian, Karbato, Garmawa, Khanke, Maximilian, Shariya, Rwanda, and Sheikhan).[9]
Mobile clinics run by Médecins Sans Frontières (MSF) in Mosul-Iraq during 2015–2016 were examples of flexible, initial, and rapid but limited response. These clinics received patients with different NCDs, with diabetes constituting about 10% of overall consultations.[10]
The effect of internal displacement on the diabetes care in Iraq
The Iraq conflict has created about four million internally displaced persons (IDPs) (10.8% of its population and 10% of IDPs worldwide). Internal displacement within the country on a sectarian basis was pronounced during 2006–2010 to be maximized after the summer of 2014, when around 1.5 million persons were considered IDPs, mainly from Nineveh Plain, Mount Sinjar area, Anbar, and Saladin area. About 28% of Iraqi IDPs have been hosted in the three Kurdistan governorates, 72% in central and southern Iraq. Eight percent of IDPs in the central area of Iraq lived in governmental-controlled camp settings. An estimated 2.5 million IDPs were living in urban non-camp settings. Baghdad alone hosted more than 500,000 IDPs (42%) from Anbar, (32%) from Mosul, and (13%) from Saladin.[25],[26]
The most frequently stated NCDs were hypertension and DM, which are more challenging to treat at the PHC level than common infectious diseases. Access to essential PHC services and more specialized care for IDPs is complex.[8],[25]
Glycemic control post-conflict in Iraq
Studies evaluating glycemic control in young individuals with type 1 DM (T1DM) after 2003 showed shallow control figures even in relatively stable regions of Iraq. Kadhim et al. of Baghdad showed a rate of 23.8% in a cohort of 298 children with T1DM.[27] In contrast, Mansour et al. of Basrah found worse glycemic control figures in a higher number cohort (n = 741) with different enrollment criteria over a higher follow-up period.[28] Both studies attributed the low control rate to insulin availability and affordability concerning the dangerous regional circumstances affecting pharmaceutical storage issues of transporting insulin, i.e., availability. Also, social strife weakened health services delivery.[27],[28]
Iraqi diabetic patients in different care settings face many challenges during treatment to achieve target glycemia levels. There is a lack of health insurance coverage and certified methods for HbA1c measurements, except in some tertiary centers in the private sector, which resulted in only 13.8% of patients achieving glycemic control.[29]
“It was hard to preserve my insulin with unstable electricity.”
For many Iraqis with diabetes, it was very hard to keep their insulin injections in optimal conditions with power downtime. Listed are answers from real diabetes patients to the question, “How could you preserve your insulin during a time of crisis in your city?”:
Many respondents from Basrah, Thi Qar, Baghdad, and Mosul used the old way of keeping a piece of ice in half-filled small water can, with the insulin wrapped in a small plastic bag within the can and stored in a dark place.
“I am living in the desert where there is no electricity; my young boy and I had diabetes on insulin. We have no electricity at all. Instead, we keep our insulin within a small leathered wineskin filled with water to keep it cold to an extent” (56-year-old man, Samawa).“Back in 2003, I had a clay jar to keep my insulin with some water. I used to cover the outer part with a wet canvas rag” (64-year-old man, Shatra, 59-year-old woman, Basrah, 31-year-old man, Amara).“During electricity shutdown, I wrapped my insulin in a plastic bag, with a stone, and sock it in the clay water pottery (Hib). We use it for drinking water in ancient times” (Common practice in Shatra, Basrah, and Amara during 2003 crisis).“During the Mosul war, I used to bury my insulin in my garden to preserve it. We had no electricity at all. I was watering it daily, just like any plant. This was successful; I did not want to lose my insulin. Sometimes, I found it not suitable for injection. I use it. I had no choice” (59-year-old man, Mosul).“Expired or not, I used my insulin during the 2008 crisis in Basrah, it was working, or that what I wished. I have no glucometer at that time” (41-year-old woman, Basrah).“During the war of Mosul, I exhausted my insulin within the first month. Instead of my unavailable insulin, I used walking to burn as much (sugar) as I could. Still, I kept my pills to a lesser degree. Although we were far from the fire, we were also far from healthcare” (56-year-old man, Mosul).The syrian crisis
Syrians typically access medical care in the private sector or at facilities run by the MoH and university hospitals. From 2011 onward, the Syrian healthcare system has been tragically severed by the shortage of medication, resources, food, and human resources.[7] The combination of public and private healthcare services was dominant in urban rather than rural, with the latter being underserviced.[30]
The Syrian healthcare system is financed by public governmental fund, with a marked shortage in the insurance system, which cover less than 50% of working individuals in some ministries within the country.[31],[32]
Diabetes prevalence in Syria was around 12.6–14.8% from 2011 onward, with T1DM involving 5–7% of all diabetic patients.[13],[14]
The crisis within Syria
The Syrian conflict resulted in a unique significant humanitarian crisis in the world, with more than 6.6 million refugees worldwide, of whom 5.6 million are hosted in nearby countries, 6.7 million IDPs, and 13.4 million people in need of humanitarian and protective assistance within the country.[1],[2],[15]
There was a collaborative inter-organization effort between the United Nations High Commissioner for Refugees (UNHCR), the International Diabetes Federation (IDF), the World Health Organization (WHO), the International Committee of the Red Cross (ICRC), and MSF to establish NCD management programs with specific emphasis on diabetic care in Syria and neighboring countries. These organizations provided training to many healthcare workers to aid refugees in crisis.[3]
In Syria, before 2011, insulin was manufactured locally. Insulin is free of charge for all registered individuals with diabetes in the National Diabetes Program. During the conflict, many people with diabetes on insulin struggled to obtain insulin and testing devices. Organizations like WHO, IDF, The Syrian American Medical Society (SAMS), Life for a Child, DirectRelief, and T1International are many organizations working to provide insulin for Syrian refugees.[3],[31]
The survival of 400,000 Syrian diabetic patients relies on insulin access. Even if insulin is available, its regional distribution is challenging due to geopolitical barriers.[3],[31]
There were overall low dispensing rates for cardiovascular diseases (CVDs) and diabetes medications, and it was lower for female beneficiaries than males. The governorates under governmental control received a higher share than other governorates where non-governmental armed forces dominated due to insecurity.[31]
The limited insulin availability due to the current conflict may be another factor. Limited insulin supplies put 60% of Syrians who used insulin at significant risk.[3],[16] The problem of interrupted electric supply disrupted the insulin-sustainable cold chain during transportation and storage.[3] Patients with T1DM could have received their insulin through humanitarian organizations like WHO, the leading insulin supplier to Syria.[16]
In 2018, the ICRC started supplying insulin countrywide, according to a memorandum of cooperation with the Syrian MoH. It provides insulin for about 40% of registered patients with T1DM, covering 1/3 of the required insulin vials. ICRC supports 15,000 patients with T1DM monthly. In regions with difficult access even to oral antidiabetic medications (OADs), ICRC supports on an ad hoc basis with OADs. All cargo is delivered from Geneva regularly.[33]
The security and geographical situations affected insulin dispersal countrywide, especially those remote from the regime hubs or controlled by opposing forces to the Syrian government.[3],[31]
Challenges for individuals with T1DM in Syria
The situation for people withT1DM is highly dire and deserves special mention. Insulin may not be readily available during a crisis, leading to severe hyperglycemia or diabetic ketoacidosis (DKA). Patients on any type of insulin are at risk for life-threatening hypoglycemia when food supplies and meal timing are unpredictable. For individuals with T1DM, interrupted insulin therapy is a matter of life or death.[3],[7]
Based on T1DM prevalence, officials estimated that about 120,000 individuals with T1DM switched their locations, providers, and treatment regimens (especially between the unaffordable synthetic insulin to the 70/30 premixed insulin) at least once in the past few years, creating an insulin accessibility and availability challenges, increasing the risk of dysglycemia.[3],[7] Lack of appropriate preservation and cold chain compromised insulin integrity for many individuals.[3]
During the war, people with T1DM faced many survival challenges, like shortage and improper accessibility to insulin and food, inadequate testing supplies, restricted access to basic laboratory tools, and a shortage of healthcare providers. Healthcare providers face enormous challenges in modifying treatment, giving proper diabetes instructions, and handling life-threatening complications in suboptimal situations.[7]
Due to shortages in specialized medical personnel, pediatric and adult patients with T1DM were frequently followed by non-skilled healthcare providers who could not address primary nutritional and diabetes education. Many individuals with T1DM reported no education on diabetes self-management and glucose monitoring. Assessing the domestic conditions which affect the quality of care for individuals with diabetes was not achievable in most patients.[7]
The financial burden led to noncompliance with regular follow-ups, glucose monitoring, and regular evaluations. Furthermore, disadvantaged families maintained their children’s limited and precious insulin supplies by cutting insulin doses.[7]
Alali and Afandi’s study (July 2022) in Raqqa-Syria revised the causes of increased DKA incidence to be: lack of diabetes knowledge and education on the management of insulin on sick days, inadequate glycemic control, lack of DKA awareness and its consequences, incompliance to the treatment plans, scarce availability of insulin testing devices, lack of ketone-testing supplies access and affordability, and other reasons which were related to the remoteness of the area and geopolitical instability.[7]
The syrian crisis: refugees and host countries
Conditions in asylum countries vary but overall are quite poor. Turkey, Jordan, and Iraq had formal and registered refugee camps; however, most Syrian refugees (85%) live in non-camp urban centers with the nationals, especially in Lebanon.[34]
Host-country healthcare policies have faced challenges by the sudden inclusion of Syrian refugees with different chronic diseases and NCDs, which could affect the quality of care for the citizens with NCDs.[20]
Management of serious NCDs, such as diabetes, during humanitarian crises, is an under-recognized problem, and there are no reliable number estimates for Syrian refugees with diabetes.[35]
A 2022 systematic review of pooled studies demonstrated high diabetes prevalence among Syrian refugees in neighboring countries, with a rate of 12%in the community setting and up to 48% in PHC settings.[36]
NCD management in humanitarian settings is poorly studied, and health responses have slowly moved away from the episodic clinical care paradigm. Syrian refugees may have developed NCDs after an extended displacement; therefore, it is likely that the people and policymakers do not well understand the disease burden and healthcare utilization.[18]
The role of host countries in addressing the health needs of syrian refugees
Syrian refugees in Jordan
Jordan hosts over 676000 UNHCR-registered Syrian refugees.[2] Most refugees live in urban non-camp settings in Irbid, Mafraq, and Greater Amman and obtain healthcare like nationals.[3] Such distribution has burdened Jordan’s capacity and infrastructure in health and several other sectors.[21],[37] UNHCR stated that about 40% of the refugees who resided in urban settings had reported difficulties in healthcare access for their NCDs.[38]
A survey of 1,550 Syrian refugees who resided in Jordan showed the overall diabetes prevalence was 5.3%, reaching a prevalence of 32% among patients older than 60. Most patients (63%) were treated with OADs alone, whereas 16% were on different insulin regimens, and others did not take any treatment at presentation. However, they showed very poor control in later investigations.[21]
Syrian refugees in Jordan could access PHC centers and public hospitals (with a referral from Public Health Centers). Moreover, providing uninterrupted care for NCDs and chronic diseases remains costly for UNHCR, aid agencies, and Jordan Government. Given the persistent funding problems, improving healthcare access for Syrian refugees is essential.[39]
Between 2014 - 2018, Syrian refugees were obliged to pay the exact cost at the PHC facilities as uninsured Jordanians, i.e., diverted refugee care from the public sector.[20],[22] Syrian refugees’ access to different NCD care facilities was diminished following Jordanian policy to significantly increase their official co-payments to “foreigners” levels. This policy imposed an extra burden on care from aid and NGO clinics. As a result, public services were only utilized for emergencies or needs that could not be met at NGO clinics.[20]
In January 2018, facing budget shortfalls, the MoH reduced refugee subsidies at public clinics (reinstated in March 2019). Household surveys mentioned some barriers to proper NCD care among refugees, like the high cost and the lack of knowledge about the availability of healthcare services. Interruptions likely affect disease control; in 2016, 25%of surveyed patients with NCDs in northern Jordan reported medication interruptions longer than two weeks during the past six months, primarily because of costs.[18],[21],[38]
In Irbid, MSF developed a primary-level program for diabetes care for Syrian refugees. Insulin prices were the most critical obstacle for care. Premixed insulin was the most expensive item, accounting for 14% of the total drug budget. Insulin-related products accounted for 34% of the drug budget. Still, global insulin pricing and availability disparities persist.[40]
Investing in access to NCD services will benefit refugees, reduce the long-term burden of care for NCD, and enhance the Jordanian healthcare system.[21],[37]
Ratnayake et al. studied more than 1000 Syrian refugees for their diabetes care. They found that long-term disease management is inadequate because Syrian refugees were generally aware of their diagnoses and had access to medication. Despite this, complications and factors associated with severe disease were highly prevalent.[18]
A survey of Syrian newcomers to Jordan done in 2020 found a biologically-based DM and hypertension prevalence to be 19.3% and 39.5%, respectively, for adults 30 years or older.[18]
Syrian refugees in Lebanon
Navigating health systems in host countries is challenging for Syrian refugees with high NCDs burden, particularly in a multi-provider system such as Lebanon.[41]
The high influx of 1.1 million Syrian refugees to Lebanon made it the country with the highest refugee per capita worldwide. Still, they are termed as (displaced, not refugees), and they cannot legally seek asylum in Lebanon because Lebanon did not approve the 1951 UN Refugee Convention. There is no camp setting for Syrians who fled Lebanon and no parallel healthcare system; instead, refugees are dispersed across the country in villages, towns, and cities. Their care is integrated into Lebanon’s existing health system. This crisis created a healthcare shortage and pressure on the country’s highly pluralistic fragmented, poorly regulated, privatized health system.[42],[43],[44]
Motivated by the lower cost, the Syrian refugee’s health-seeking behavior is PHC-based. The private sector is spared from covering life-saving emergencies, labor, and child care.[45]
Syrian refugees bring learned behaviors and expectations based on their previous health experiences. In Syria, before the current crisis, specialist care could be sought directly without requiring a general practitioner referral, which is similar to what is there in Lebanon. Still, many Lebanese health facilities require a referral from GP before consulting the specialists, which is costly and time-consuming for most refugees.[43]
In Lebanon, about 40% of Syrian refugees are not receiving needed care because of high out-of-pocket costs. About 77% of individuals with NCDs stopped or changed their medications, including insulin or OADs, without appropriate medical advice due to medication costs.[43]
MSF continues to provide care freely for refugees in the Shatila Camp-Southern Beirut using a multidisciplinary and comprehensive care model through patient-centered, contextualized, and adapted treatment protocols. The educational support system, despite the challenging circumstances, was helpful.[46]
In 2014, as the Syrian conflict continued and the situation for refugees became more catastrophic, Dr. Nizar Albache, together with IDF-MENA and many other humanitarian organizations, began work to provide insulin for refugees in Syria and beyond (including Lebanon and Turkey) to organize workshops for healthcare workers in the region and to collect donations and raise funds, forming the (MENA Help Syrian Diabetic Refugees Initiative). From 2016 on, they established five free diabetes clinics for refugees in Lebanon.[35]
In 2015, Elliott and colleagues conducted a clinic-based survey among Syrian individuals with diabetes in Bekaa-Lebanon. They found that 30% of patients received a diagnosis of diabetes during displacement, along with comprehensive diabetes education.[47]
Haderer and her team performed a quantitative study of 29 Syrian diabetes patients visiting MSF clinics in Wadi Khalid and Shatila in Lebanon to explore the barriers to their diabetes care. They go through considerable challenges in navigating the healthcare system, which limits their access and interrupts disease management. Continuity of care for such vulnerable people and people with other chronic diseases needs special attention.[41]
Syrian Refugees in Turkey
By August 2022, Turkey has hosted more than 3.6 million refugees from Syria; half of them are children, making Turkey the country with the highest refugee burden worldwide.[2] Most Syrian refugees (98.4%) reside in host communities, while less than two percent continue living in the remaining seven temporary accommodation centers in Southeast Turkey.[1] The WHO health survey in Turkey reported a diabetes prevalence of 2.5% among Syrian refugees and 0.4% among children below 14 years of age.[48] The Temporary Protection Regulation (TPR) limits the healthcare access of UNHCR-registered Syrian refugees to their host city only.[23]
The Turkish MoH planned to establish Migrant Health Centers, where Syrian doctors and nurses provide services to Syrian under temporary protection, with support from Turkish doctors and nurses. These centers encouraged the integration of displaced healthcare professionals. Syrian refugees had better-quality care in these centers by bypassing the language and cultural mismatch.[19] NCDs have received less attention, perhaps because of the challenges of providing continuous care to a large population and the less urgent nature of these conditions.[49]
Syrian Refugees in Iraq
Syrian refugees in Iraq receive free medical and educational services, but the country’s infrastructure is overwhelmed by the needs of its people.[50]
Syrian refugees, mainly of Kurdish origin from Hassaka and Damascus, began arriving at the Duhok governorate in 2012, leading to the opening of the camp (Domiz 1) the same year. The region of Kurdistan/Northern Iraq currently hosts a large number of refugees as well as IDPs. Different aid organizations are working with the local authorities to provide shelter, nutrition, education, and healthcare, among other things. However, the refugee burden on the area and the inability of healthcare professionals to handle this influx are increasing with the rising number of IDPs coming into Kurdistan.[50],[51]
The Shamsi et al. study suggested that the diabetes prevalence within the camp (Domiz 1) was lower than expected (0.55%). The study described obesity as a significant observation and related these findings to decreased physical activity, dietary factors, continuous stress, and poor psychological health. The latter factors may promote or aggravate insulin resistance, creating a negative loop leading to increased obesity and insulin resistance. The study showed that 82% of diabetic individuals had poor glycemic control. The mean glycated hemoglobin (HbA1c) was 9.35% and 8.80% in T1DM and T2DM patients, respectively. The shortage of medications in the only PHCC forced many patients to change their regimens.[50]
Syrian Refugees in Egypt
The refugee community in Egypt has significant health needs with a multitude of chronic conditions, including hypertension, DM, disability, and cardiac diseases, as well as serious mental health concerns.[24]
According to UNHCR, more than 140,000 Syrians reside in Egypt in non-camp settings, with aid from WHO.[2] In general, refugees have access to Egyptian public health and education but face discrimination in accessing these services.[34]
The population of Syrian refugees within Egypt is largely urbanized, with varying degrees of basic healthcare, excreted an extra burden on the existing healthcare systems.[24]
The UN-Syrian Refugee Response in Egypt involved a collaboration between WHO-Egypt, UNHCR, the Ministry of Health and Population (MoHP), and the aid agencies. The WHO helps build the PHC capacity by servicing the Syrians who fled their country to Egypt, creating a response network for infectious diseases, early management of NCDs, and improving mental health services. A joint action of the WHO and the Egyptian MoHP improved Syrian refugees’ access to secondary and tertiary care through four highly specialized medical centers dedicated to the healthcare of refugees.[24]
Syrian refugees in Saudi Arabia
The Saudi authorities used the term “Arab Brothers and Sisters in Distress” to describe the Syrian nationals who fled Syria after the war in 2011. Around 700,000 Syrians live in non-camp urban settings in KSA, i.e., 5.5% of its population. The UNHCR received aid from the King Salman Humanitarian Aid and Relief Center (KSrelief) and Saudi Fund for Development (SFD) to coordinate the basic humanitarian efforts.[52] Till the preparation of this article, there was no data about diabetes care in this subpopulation in Saudi Arabia.
Non-health challenges faced by Syrians in Non-Arab countries
For Syrian refugees residing in non-Arab host countries, financial hardship is associated with poor health. Language barriers created frustration for newcomers as they were often left feeling that their provider was not interested in their care. This created a scenario where some only accessed a provider if their medical concern was serious. Language barriers created challenges with healthcare access and chronic disease management. Some refugees used mobile translation applications to manage appointments when translators were unavailable. Failure to use such services may be considered the largest barrier to healthcare access in some host countries.[3],[53],[54],[55]
Conclusions and RecommendationsThe disaster preparedness plans set by health authorities in Syria and Iraq were exhausted by the long-term and continuous geopolitical instability and security concerns in both countries.
Care for diabetes is suboptimal and unsatisfactory in this region due to conflicts and the poorly organized infrastructures in the countries. Different aid organizations helped ease the burden on individuals with NCD and those with diabetes.
Individuals with diabetes were significantly affected by the drug shortage, especially in active war zones. People with diabetes, whether within the country or in the host countries, face many challenges related to the availability and affordability of diabetes care. Many individuals with diabetes are at risk in some camp settings where the care provided by NGOs and Aid organizations is suboptimal.
Aid organizations provided unsatisfactory help to individuals with diabetes who were victims of the humanitarian crises in Syria and Iraq. These NGOs need more coordination and improvisation of existing facilities for the public and policymakers to decrease the morbidity and mortality of diabetes complications with the improvisation of the already present help channels.
Rapid and effective response plans need to be in place to help people with diabetes in the camp setting overcome challenges like medication continuity and food restrictions; efforts should be directed toward better integrating this population into the new healthcare system.
This short review summarizes the proposed actions during these humanitarian crises or any similar crisis locally or globally to be set in short- and long-term settings.
Short-term setting (Days to Weeks)
Systematically categorize individuals with T1DM and prioritize insulin for therapy.[3]
Set priorities for diabetes care in high-risk individuals, like elderly patients, pregnant women, and individuals with diabetes complications.[3]Guarantee continuous accessibility to life-saving medications. Active healthcare facilities during a crisis should be equipped with diabetes management appliances like glucometers, test strips, insulin syringes, intravenous dextrose 50%, and ketone test strips. Laboratory tests for HbA1c, lipid profile, renal function test, and urine microalbumin are pivotal to the long-term management of diabetic patients. Without laboratory testing, point-of-care HbA1c technology can provide test results within minutes.[3]The WHO developed an accessory (Interagency Emergency Health Kit) to deliver a quick share of essential medicines during humanitarian crises for about 10,000 persons for approximately 90 days. The package contains a seven-day supply of OADs, insulin, insulin delivery supplies (individual-specific), glucometer and its batteries, flashlight, lancets, glucagon kit and rapid-onset glucose source, and personal identification tools.[3],[56]Include the training of humanitarian HCWs on diabetes emergencies in the original disaster preparedness training. The education should include individuals with diabetes in areas of high disaster burden, focusing on sick-day rules, dysglycemic events, and focused information about the medication.[3]For people with diabetes who stay in shelters or temporary camp settings for an extended period, insulin storage could be a hurdle for proper management in these humanitarian settings. The humanitarian coordinators should be aware of providing well-stored essential diabetes medications, including insulin.[57]Establish a referral system, mobile clinics, and community-based services, especially for patients in remote and hard-to-reach areas.[10],[26],[46]Funding (Global and national) needs to align with the current realities in the field to foster better collaboration between all healthcare providers.[20]Long-term setting (Weeks to Months)
Continuous and diverse accessibility to essential medications, especially insulin and insulin delivery systems, should be guaranteed, by national or international manufacturers, with the best quality control measures.[10]
Recognizing that the inherited weaknesses in the PHC network contribute to deficiencies in delivering the essential package of health services and increase the burden on hospitals in areas with nonfunctional or poorly functioning PHC services, the priority is strengthening service delivery. Ensure that PHC has essential diagnostic and therapeutic measures for NCD and diabetes care in the high humanitarian crisis burden.[3],[20]Establish national diabetes self-management guidelines, including pre-disaster education, preparedness, and insulin access. The proposed policy will improve interagency aid collaboration and provide better quality, delivery, and effectiveness of healthcare for people with diabetes.[3],[56],[57]A better comprehensive diabetes care plan should be implemented in crisis-prone areas, wherein diabetes educators will begin to have a more significant role in maintaining a doctor-patient relationship, creating diabetes awareness, and educating the people who are compliant with their therapeutic regimens and lifestyle changes or those who have uncontrolled diabetes yet.[3],[57]Build and improve the local capacity by training HCWs on diabetes care. Increase trust in the national health system, and boost the numbers of national specialists (anesthesia, trauma surgery, obstetrics, internists, etc.) and nursing staff.[57]Establishing effective community health insurance coverage would decrease the community’s healthcare gap.[25]Telemedicine centers could help some patients with communication problems and fill some gaps in healthcare in some areas.[26],[46]Acknowledgment
The authors would like to thank Syed Imran Shah for professionally editing this article to its final form.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Author contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by SAO. The first draft of the manuscript was written by SAO and all authors commented on previous versions of the manuscript. Critical revision for important intellectual contents done by SAO and SNM. All authors read and approved the final manuscript.
References
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