Hello! I'm Cyrus Shahpar, Deputy Team Lead for the Global Rapid Response Team at the US Centers for Disease Control and Prevention. Today, I will be talking to you about non-communicable diseases in complex humanitarian emergencies. I will begin by defining non-communicable diseases, I will then describe their impact globally, and their place in emergency settings. Throughout the presentation, I will highlight the underlying messages by calling them out as key points. WHO describes non-communicable diseases or NCDs for short, as generally diseases of long duration and generally slow progression, which require continuous care. In the Sphere Handbook, non-communicable diseases are described as including heart disease, stroke, hypertension, chronic renal failure, bronchial asthma, dialysis dependent chronic renal failure, insulin-dependent diabetes, and epilepsy. The handbook goes on to say that during emergencies individuals with chronic medical conditions are particularly vulnerable to exacerbations of their condition, or to complications such as secondary infections and are at risk when treatment is interrupted. Clinical stabilization and maintenance of therapy should be at the mainstay of the health sector response in humanitarian settings. Keep this in mind as we discuss NCDs in emergencies later in the presentation. Two concepts to help understand the difference between non-communicable and communicable diseases, are cause or transmission and affect or duration. Looking at the visual, we see that diseases can be classified into four sections based on cause and effect. There are acute communicable diseases like measles, and there are chronic communicable diseases like tuberculosis. There are also acute non-communicable diseases like injuries, and chronic non-communicable diseases like diabetes. People often confuse chronic and non-communicable diseases. It is important to remember that acute chronic classification is based on duration of illness, whereas communicable non-communicable classification is based on transmission. Our first key point therefore, is that non-communicable diseases are not always synonymous with chronic diseases. For the purposes of our discussion, we will consider four main categories of NCDs. First cardiovascular diseases, second chronic respiratory diseases, third diabetes, and fourth cancers. Now that we understand what we mean when we say non-communicable diseases, let's take a look at the burden of NCDs globally. Of the 57 million total deaths in 2008, 36 million were due to NCDs. That's 63 percent of all deaths worldwide. Eighty percent of these NCD deaths occur in low to middle-income countries. Age specific NCD deaths are nearly two times higher in these low income and middle income countries, than in high income countries. NCDs are not just a problem in high-income countries. These NCDs impact health systems in high, middle, and low income countries in various ways. Key components affected include financing, medical products and technologies, the health workforce, governance and health information sectors, and health service delivery. NCDs require multiple and different interventions over time, and can therefore become very expensive on a case-by-case basis. Despite their high cost to treat, NCDs receive very little global health funding, less than three percent. These findings bring us to the key points two and three, that NCDs are a big problem everywhere and that NCDs will become an even bigger problem in the countries least equipped to deal with them. The management of non-communicable diseases consists of both prevention and treatment. NCDs are largely preventable with proven interventions aimed at risk factors. Eliminating these risk factors; poor diet, smoking, lack of exercise, could prevent many NCDs. Treatment of NCDs includes both low-cost treatments such as those included on WHO's Essential Medicines List, and expensive secondary and tertiary treatments like dialysis. Key point number 4 summarizes the idea. NCDs are preventable and treatable, but medicine availability and affordability are limited in many low to middle-income countries. Now that we understand what NCDs are in their burden and management in non-emergency settings, we can examine their place in complex humanitarian emergencies. There is little information about NCDs in emergencies and conflict affected areas. NCDs are rarely on the agendas and mandates of humanitarian agencies, and have received minimal attention from the United Nations in the context of displacement. This lack of focus is problematic, as conflict areas are changing in nature. Forcibly displaced persons are increasingly coming from countries with higher incomes, longer life expectancies, and increased NCD burdens. This trend is visible in some of the major emergencies occurring right now, such as in Syria, Iraq, and the Ukraine. This lack of attention has led to a gap in official guidelines for the management of NCDs and CHEs. The Inter-Agency Standing Committee has minimum NCD specific guidance, and the Interagency Emergency Health Kit contains limited medications for NCDs. Common practical guidelines for NCDs and emergencies follow three basic tenants. First, the identification of existing cases, second, the resumption of treatment if interrupted, and third the avoidance of acute complications and exacerbations. Essentially, NCD management in emergencies does not aim to cure non-communicable diseases, instead due to limited conditions and scarce resources NCD management in these settings primarily seeks to manage pre-existing conditions. In addition to funding, considerations and challenges for managing NCDs in emergencies include, treatment interruption due to security or environmental conditions, difficulty with treatment follow-up due to displacement, dealing with older populations with limited mobility to access health services, losses of infrastructure and medicines, lack of guidelines for NCD treatment and untrained staff, and finally the disruption of acute care which can exacerbate non-communicable diseases. Yet despite the lack of guidelines and numerous challenges, three examples from around the world highlight the need to consider NCDs in emergencies. A study done by Green Now at all following Hurricane Katrina in the United States, discovered that evacuees were suffering primarily from chronic diseases. Hypertension, hyperlipidemia, and diabetes, were the most common diseases observed. Access to medications for these conditions were a major concern even two weeks after the disaster. In an emergency in Burkina Faso, 50 renal dialysis patients had to stop treatments when dialysis machines were damaged or destroyed by flooding. Following the Sichuan earthquake in May 2008 in China, 38 percent of all survivors needed clinical management of their NCDs before unnecessary surgical interventions could be performed. So, key point number 5 is that the focus of NCDs in emergencies is on treating pre-existing cases and avoiding acute complications or exacerbations. I hope by now you've realized that the management of non-communicable diseases in emergencies is an increasingly important consideration in emergency response. Evidence is limited and many important questions remain unanswered. These include; what is the scope of the problem in which diseases are most important? In which population should attention first be concentrated? Which risk factors are most relevant to CHEs? Given limited resources, which interventions are most applicable for CHEs? What are appropriate funding mechanisms? Ongoing priority areas include the development and enhancement of surveillance for NCDs. More accurate information is needed on disease burdens and mortality estimates in emergency settings. A second priority area is the advocacy for inclusion of forcibly displaced persons international and global discussion of NCDs. To finish, let's just review the key points highlighted throughout the presentation. One, non-communicable diseases are not always synonymous with chronic diseases, two NCDs are a big problem everywhere, and three, NCDs will become an even bigger problem in countries least equipped to deal with them. Four, NCDs are preventable and treatable, but medicine availability and affordability are limited in many low and middle-income countries, and five, so far management of NCDs in emergencies is focused on treating pre-existing cases and avoiding acute complications or exacerbations. Thank you.
