COPENHAGEN –  While conflict and natural disasters are usually played out in the media against dramatic scenes of mass casualty response and rescue teams, there’s an iceberg of chronic health conditions that can be even more life threatening and these need far greater attention in emergency response. 

That is the theme of a global high level meeting here this week – which aims to raise the profile of non-communicable diseases (NCDs) in humanitarian settings.

The health officials from most of WHO’s 194 member states, as well as UN non-governmental organizations and relief agencies, convenes as the world faces more humanitarian crises as a result of conflict, climate change and natural disasters, than almost anytime in the last half century. 

The past 10 years has seen a three-fold increase in displaced people – some 117 million people in total as compared to about 40 million only ten years ago, said Sajjad Malik, of the UN High Commission on Refugees (UNHCR) which co-organized the meeting along with WHO. 

More emergencies and displaced people than ever before

In 2023, WHO responded to 63 health emergencies worldwide, up from an average of 40 a year a decade earlier. This includes both acute as well as protracted crises in settings ranging from the massive earthquake that hit Türkiye and Syria in early 2023, to grinding wars in Ukraine, Sudan, and most recently, Gaza.  

At the same time, some 70% of premature deaths [before age 70] are attributable to chronic diseases including diabetes, cardiovascular and lung diseases and cancer, and most of these deaths occur in low- and middle-income countries. 

 “We are facing a tsunami of NCDs,”  declared Dr Faras Hawari, Minister of Health of Jordan, which is co-hosting the meeting together with Denmark. 

People living with NCDs are among the first victims of all disasters

“We are living in a perma-crisis of emergencies and tensions. They also blur  the artificial distinctions that we tend to make between communicable diseases and non communicable disease, between one country and another,” said WHO’s European Regional Director, Hans Kluge, also speaking Tuesday. 

What few may realize, however, is that people living with NCDs are typically “among the first victims of all disasters,” Kluge added later at a press briefing. “They are at increased risk during emergencies. For example, the incidence of stroke and heart attack are up to three times the normal levels.” 

Traditionally, health sector response to humanitarian emergencies was designed to deliver  “surgical teams and mass casualty management, epidemic prevention, response and immunization campaigns,” remarked WHO’s Executive Director of Health Emergencies, Mike Ryan.

“But what we don’t see is the iceberg of mortality that occurs because people lose access to those long term services that keep people alive and well,” Ryan said. 

Recalling scenes from the early days of Russia’s invasion of Ukraine, Kluge described meeting with “elderly women with heart problems, diabetes, typically which can be managed. But all of a sudden these management conditions become life threatening.”

Calls for Gaza cease/fire continued UNRWA funding 

The conference takes place as conflicts in Sudan, Gaza and elsewhere continue to create acute disruptions to health services and systems, upon which chronic care, as well as acute disease and injury management, depend. 

“There are about 13,000 cancer patients in Gaza and only about 2000 have been able to get therapy or treatment.  At this point it’s very complex, and difficult to manage these patients,” said Hanan Balkhi, director of WHO’s Eastern Mediterranean region, which covers an arc of  North African and Middle Eastern countries from Libya to Afghanistan, including Israeli-occupied Palestinian territories. 

“We continue to witness in real time one of the most devastating humanitarian crises of the century,” said Hawari, of the Gaza crisis. 

He and Ryan repeated previous calls for an urgent ceasefire, as well as for continued funding for the UN Refugee Works Agency (UNRWA), which they described as a critical backbone of Gaza’s health system.  

“We need to support an immediate end of this bloodshed and allow the entry of humanitarian and medical teams,” Hawari said of the Gaza situation.  

“Over half of all public health care in Gaza is delivered directly by UNRWA,” asserted Ryan. “Over 1.3 primary health consultations have been delivered by UNRWA since October 7. And they are intimately involved in the delivery of non-communicable disease care, all across Gaza and beyond.”  

UNRWA has faced a crisis of confidence amongst key donors in the wake of Israeli allegations that some employees joined the Hamas forces that led the 7 October invasion of some two dozen Israeli civilian communities, killing over 1200 people. Days afterward, Israel invaded the tiny enclave in a bitter war with Hamas that has now led to the deaths of nearly 30,000 Palestinians. 

Ryan added: “Since the beginning of the conflict and October 7th, and despite the horror of what has befallen the Israeli people in the barbaric attacks on civilians, the reality is that the catastrophe that has unfolded in Gaza must stop,” he concluded, to a round of applause. 

Eastern Mediterranean region is hotbed of crises 

“The conflict in Gaza stands as one of the most challenging crises in modern history,” added Balkhy, who took up her post as EMRO regional director a few weeks ago.   

“The conflict has depleted an already under resourced health systems. Thousands were killed or injured and over 1.6 million displaced, including 350,000 people living with chronic conditions.”

But Gaza is not alone. Throughout the eastern Mediterranean region, conflict-related crises abound, and so do NCDs.

“The Eastern Mediterranean region is home to 745 million people. Of those, 140 million require humanitarian assistance. That is almost one in every five people. The region is the source of 58% of the world’s refugees, and 33.7 million people have been forcibly displaced among its 22 countries and territories – 13 are directly or indirectly affected by conflict; nine are classified by the World Bank as fragile state state situations,” Balkhy said.  

“Regionally, two-thirds of annual deaths are attributable to NCDs. The likelihood of premature deaths due to NCDs range from 17.8% in non-fragile or complex affected settings to 25% in fragile and conflict-affected contexts.  Cases of heart attack or stroke, asthma might double or even triple in frequency immediately after a disaster.

Identifying technical bottlenecks to ensure access is important, but only one dimension of a multi-pronged challenge. For instance, the region’s political and economic fragility makes it much more difficult to develop and maintain a robust health workforce, she observed, saying: “Health worker retention is extremely complex. It’s like a sieve with big holes.”

Sudan – from reform to collapse

“Before the war, Sudan was undergoing robust health system reform,” Balkhy added, citing the other great regional hotspot. “However, after 10 months of conflict, the health system is reaching collapse. Over 7 million people remain displaced, while  1.7 million people are seeking refuge in neighboring countries. 

“The conflict has led to over 13,000 deaths and 26,000 injuries. Around 9,000 haemodialysis patients including 240 children, face severe risks due to service disruptions and 4,500 kidney transplant patients require uninterrupted treatment.  Since April 15 WHO has verified 60 attacks on health care leading to 34 deaths and 38 injuries among the health workforce. 

“Attacks on health care include attacks on health facilities, transport personnel, patients, supplies, and warehouses. Refugees and migrants face barriers to accessing health care especially for the management of NCDs during protracted crises.”

 NCD kits and local solutions  

Despite growing awareness of the need for addressing NCDs in the health emergencies context, ”there remains a considerable journey head to fully integrate NCDs into the [WHO] Health Emergency and Response agenda,” Balkhy said.  

One successful approach has involved the development of NCD kits containing a pre-packaged set of basic healthcare supplies for treating diabetes, cardiovascular issues and strokes. So far these have been distributed in humanitarian settings in 28 countries around the world, Ryan noted. 

But standardized solutions also fall short, stressed Kluge, “We need local solutions for local challenges. In Ukraine, we started dispensers for medicines where health facilities were destroyed. In Turkiye, it was mobile health teams. 

“Each context is unique,” added Ryan. “If you go to a village in the Ukraine, it will be a very different age and disease profile than a refugee camp in Uganda.”

Additionally,  finding  “sustainable resources” to add NCD solutions to packages of humanitarian health care remains the other big  challenge, particularly in light of the burgeoning number of such crises.  While some donor countries, such as Denmark,  continue to make very significant contributions to crisis response, available funds falls far short of the swelling needs, Ryan said. 

Health worker retention and attack  

And kits of equipment and medicine are not enough on their own, Ryan stressed, 

Taking diabetes as one example, Ryan explained that preserving the cold chain so as to get  insulin to a crisis zone is only the first step in a much more complex process.  

“It’s not just the insulin,” he said. “It’s the care package that goes around the insulin. It’s the knowledge of the health worker for dosing, it’s the self-testing of the sugar levels. 

“We are doing that right now in Gaza, the advantage that we have despite the huge degradation of the system, we still have health workers who go to work every day. 

However, health workers in some parts of the world, including Gaza, Ukraine and Sudan also face daily threats, just as a result of showing up to work.    

“We don’t have the protection for the health workforce in the field,” said Ryan. “Health is under attack in a way that it has never been before. Our health system has become a target and we have to  stop it.” 

In terms of NCDs, as such, this week’s meeting aims to muster a “coalition of the willing”, in the words of Ryan, as part of the lead up to the fourth high-level UN General Assembly meeting on NCDs, set for 2025. 

“We affirm our commitment to reducing the burden of NCDs in humanitarian settings and strengthening our emergency response at all levels, do joint efforts and leveraging our collective expertise,” Balkhy concluded.

“But at  times the solutions have less to do with medicine.. It has to do with diplomacy,” she added. “Once again, we do need peace.” 

Image Credits: Abdulsalam Jarroud/TNH, E. Fletcher/Health Policy Watch , Democracynow.org, UNHCR, WHO EMRO.