All right. Now, what is being done to address NCDs in humanitarian situations? Let's begin again by looking at the global attention to NCDs. It's actually only relatively recently that NCDs have received attention at the global level. Whereas high-income countries have dealt for the issue for decades, the Millennium Development Goals made no mention. Three out of eight goals dealt directly with health, and one dealt directly with hunger, but they focused on communicable, nutritional, maternal, and childhood health. This is changing. The Sustainable Development Goals, the SDGs, have only one health goal out of 17, but that goal does include a much broader vision of health, including NCDs as target number 3.4. A High-Level Meeting of the UN in 2011, with another planned for 2018, specifically note that NCDs are a threat, not only to health, but beyond as a wider societal and economic concern. We've also seen some improvements resulting from this increased attention. Both prevention and treatment of heart disease have shown clear improvements at the global level, and there are some examples of improvement in lung cancer rates, as smoking rates have decreased and lung cancer seems to decrease 30 years later. But what does this situation look like with regard to the attention to NCDs in emergencies? It took even longer to recognize the importance of NCDs and emergencies. The traditional focus on communicable diseases was strong, and with good reason. Epidemics, such as Ebola, have caused disproportionate havoc. Even though the number of deaths from Ebola was relatively small, 11,000 people, the economic impact on the three West African countries that were concerned was dramatic. The World Bank estimates a loss of about 2.8 billion US dollars. Up until 2012, it was difficult to get attention to NCDs in emergencies. I know this from personal experience, as I introduced an NCD module in our course on health and emergencies here at University of Copenhagen in 2009. As far as I knew at the time, that was the only one in existence. We also authored with colleagues a call to action in 2013. It took us quite some time to find a journal which thought it was important to talk about this issue. WHO had draft guidelines, but nothing which could be used officially. Many organizations had no means to address NCDs, and therefore, they did not even diagnose, and it's a reasonable clinical principle that you do not diagnose an illness if you don't have the means to treat it. Of course, estimates right now are that only about half of all cases of NCDs have been diagnosed. However, awareness has grown. The displaced populations of Syria or Iraq have high levels of NCDs and need treatment, and that has helped raise awareness. One of the most widely used standards for humanitarian response is the Sphere Manual. In 2011, for the first time, it included a brief introduction mostly focusing on ensuring that existing treatment was not interrupted. But the 2018 edition of Sphere is expected to have much more detail. However, such a standard is difficult to live up to if you do not have access to the medicines needed for treatment. One of the approaches of the humanitarian response to acute emergencies is to have preparedness in the form of, for example, prepackaged materials. That is also true for medicines. A group of organizations under the leadership of WHO recommend a list of medicines to be included in the so-called Interagency Emergency Health Kits, which can be shipped out at moments noticed they're prepackaged. Until recently, there were no NCD drugs included in that case. But in 2016, a revised version included medicines to treat at least acute conditions related to NCDs, and a modified content has now been proposed for the Eastern Mediterranean. WHO has developed basic standards for clinical care in low-resource settings, which are also being used. In 2016, WHO and an Interagency Task Force produced guidelines for action on NCDs at different phases of emergencies. It's important to distinguish between the different NCDs. Something like diabetes has clear methods for risk reduction, for example, reducing obesity, relatively simple diagnosis, clear increase in mortality and morbidity within a few hours or days if medication is interrupted, and relatively inexpensive and simple treatment with insulin. Others are much more complex. For example, cancer. So, what are some of the results of this raised attention? Given that a concerted response is very recent, and that effects take a long time, it's perhaps not so surprising that there are very few studies which examined and demonstrate impact. Again, this is not unusual for humanitarian action. It's exceptionally difficult to collect data in emergency situations, especially long-term data. One review found only eight studies from the period 1980-2014, which assessed results of interventions in low- and middle-income countries, whereas there were 130 studies describing results from interventions on communicable disease. So, it still to come. However, there are some very promising, small-scale interventions, many of them qualitative at community level. Some of them deal with community interventions, which show that they can lead to improved risk behavior, such as less smoking, and better compliance in taking medicine. Many studies proposed actions to be taken, including making a list of people with NCDs before the disaster, or people who have disabilities. For example, that is done by countries as diverse as Vietnam and France. Another proposal is to stock medicines and to have treatment protocols in place where you can prioritize. To my mind, we should approach NCDs differently than other health conditions. One thing is that we have to get better at helping people with NCDs in the aftermath of a sudden onset disaster, where they may have increased levels, but another is that in long-term humanitarian situations, where people have been refugees for decades, it's important that we recognize that NCDs are just part of the normal burden of disease. Of course, as always, more research and pilot projects are certainly needed in all humanitarian work and particularly, this one which is fairly recent.
