[MUSIC] Manmade and natural disasters can impact and pose special challenges for people with non-communic diseases. This was, for example, the case in a small poor village ravaged by floods in a post-conflict situation close to the Swat Valley in Northern Pakistan. While the local populations could receive treatment for trauma, for example, caused by a car accident or gun fire, there was no service for patients suffering from NCDs. >> What we saw was a bit of everything. It was a small hospital with medical and surgical care, emergency department, maternal health. And the patients would be the ones living there, it would be car accidents, shooting accidents, pregnant women. And then everyday, I mean, the medical patients we had would mostly be NCD patients or patients with NCDs. And then in the deterioration of that or in the complications of that, we would see these patients coming in with wound needing amputations. Because it was badly treated diabetes that could have been prevented. But now you needed to amputate a foot on a young person. We had a trauma center, and there the situation was a bit like in other places that the standard care for chronic diseases was not very high. So the patients didn't really have anywhere to go. And then they hear about this trauma center, where you can be treated if you have wounds. And they would come in claiming that the wounds would be from a trauma. And then it's difficult to say, no, not this wound, I will send you away when you know that that person has nowhere to go. But also knowing that, if it's a traumatic wound, you treat it in one way, if it's a diabetic wound, you treat it in a different way. So there's a little bit, do you believe the patient or do you stick to your rules? And many times you do, of course, want to do the best for the patient and try to treat it as a diabetic wound, and then hope that it [LAUGH] doesn't spread, that people come more for this. [MUSIC] When you're in a position where you're the coordinator, the overall responsible is supposed to be the one who guides the team and keeps the rules. And then you have the doctor, who is in front of the patient. And traditionally and naturally it is difficult for the doctor there to be the one, for instance, saying no, this wound we will not treat, because it's the wrong kind of wound. But it's not that much easier being in the next level, if you're still in the project and seeing that patient. Thinking, okay, that patient will take a bed from someone else, but it's still a patient of this community. And it's still the patient in need. And we can do something. One thing was if we couldn't, if it was something that we don't have the medicine for, it's maybe a bit easier, because there is no possibility. But here, we do have the possibility of treating the patient. We're just not really supposed to, because that's not what we're there for. But sometimes if you're the only one there, yeah, it's difficult to say no. >> Heidi Chistensen's concern, that many would want to seek the hospital trauma center to get lower limb amputation, was well founded >> In Pakistan, as many as 150,000 to 200,000 people lose their lower limbs due to complications of diabetes every year. 70% of them will die within five years of amputation. Overall, diabetes affects something like 17 to 19% of Pakistanis, or approximately 35 million diabetics in total. The National Institute of Child Health experts have further expressed the concern that diabetes in the juvenile population may be over 1.6 million. And one of them is Moneep. >> We had a small boy that also made a big impression on me, because we had him in our hospital for more than a month, I think. His name was Moneep, he was 5-6 years old and he had been diagnosed with diabetes several years before we saw him the first time. And he came in with fever, that was why they went to the hospital with him. He was looking malnourished. And then he had a very high blood sugar. We found out he had malaria, so we wanted to treat him for that. He had this big, big belly, that at first we were thinking is that part of his malnutrition, and then this high blood sugar that we couldn't get down. Knowing that he had diabetes for many years, of course that changed a bit to see what is it inside his belly? Is it part of the malaria? Is it his spleen that's enlarged? But in Pakistan you don't have the kind of malaria, not in this area, that normally gives you the enlarged spleen. So we actually had him ultrasound, thinking that it was the spleen. But eventually it didn't really add up, so we had to send him to a town next to where we were. He had a CT scan, and we saw that he had a very large liver. Trying to find out why a small boy has a large liver, there's so many reasons, so many rare reasons, that we had no chance of finding out what diagnose him with. So the conclusion was that he had been walking around with this untreated diabetes for several years and had these glucose deposits in his liver. So it was a very long term treatment of him, and of course he's a five year old kid, who doesn't want to be in the hospital. The parents were wanting to do the best they could for him, but had not really a big understanding of what the deceased was. They had obviously bought this blood glucose measure thing, but didn't know how to use it. And they were still bringing him white bread and rice. Trying to explain all the ways you can help with preventing diabetes was also a big part of it. >> Moneep's parents are far from the only ones not knowing enough about causes and management of diabetes in Pakistan in order to treat their kids properly. Lack of knowledge and awareness was observed among different poor and rural participants, which indicated the immediate need of diabetes awareness programs for these participants. And that is the conclusion of an article from 2016. But let's get back to Moneep. >> Eventually we managed to get the blood glucose a little bit down. We could treat his malaria. And then he was discharged after a month or a bit more. But it was mixed, because he is going to go home. To a family that might not have the resources to take special care of him, in a setting where outpatients follow-up of these kinds of diseases is not the best. So it was mixed. You do a lot but the future for him is probably not that bright. But he's a picture of a lot of the patients that we did see, that this is a young child. We also saw pretty young adults, in their 30s or 40s, coming in with complications to hypertensions and diabetes, that you would normally, after my experience, see with older patients in our Danish setting. >> Diabetes levels generally increase with age. However, there's increasing evidence that levels in persons under the age of 20 are also increasing. To assist those affected, the local communities can also be educated and powered to be more resilient in an emergency, insuring that people living with NCDs and disabilities have the knowledge and tools they need to manage their conditions. And also that local social networks understand their needs and can support them. But this is a long-term project. For example, educating the population to change lifestyles and dietary habits in Pakistan. >> The education of the population, that's not something you can do in a few months. It's difficult to do in a consultation where you have, maybe, ten minutes. Or we would do, sometimes, these educations in the waiting room. Then we would take the opportunity when people were waiting in line for something, to educate on health, which could be trying to encourage people to seek a doctor if they suffer from NCDs, among other things. >> Early planning can prevent later disaster related exacerbations of diabetes and other NCDs. And so can training of caregivers, emergency personnel or other health care professionals. It's not just a question about having enough medicine. >> One thing we did see in Pakistan, for instance, was that whatever people were suffering from, there always seem to be the standard treatment of some ringer lactate, some fluid, some metronidazole IV, which is antibiotics. And then some steroids, that was like triangle of treatment for anything. And while steroids might give people a little bit of a high sometimes and help them, it's not really the standard treatment of a lot of things. The consequences could be that, of giving this standard treatment, was that you could disguise some of the symptoms, making the patient feel maybe a little bit better for a while, but then having to come back being even worse than before. So it would be women with stroke or men needing amputations, and these are the adults that are supposed to carry the family forward, carry the country forward. So it has a big impact. That they get these complications at such a young age. And they get the substandard treatment of chronic diseases. [MUSIC]
