Let's begin by asking, why is it important to address non-communicable diseases in humanitarian situations? One of the best ways to know the health situation of a population, which has been hit by a disaster, is to look at the health situation before the disaster hit, the so-called baseline situation. So, let's begin by taking a look at some global levels and trends. Historically, epidemics and starvation were the big killers, killing millions if not tens of millions. In recent decades that has changed. In 2015, for example, the estimate was that 71 percent of all global deaths were due to non-communicable diseases or NCDs, especially what we referred to as the big four: heart disease, cancer, diabetes, and chronic lung disease. Those are chronic conditions which take a long time to develop. They are generally there both before and after the disaster occurs. So, that's the first important pattern. A second important pattern is to note that although this increase in NCDs began in high-income countries, by now, it has reached middle-income countries and is also affecting low-income countries. Around three quarters of deaths to NCDs now occur in middle and low-income countries, and most countries have high levels of prevalence 20-30 percent of the population are living with an NCD. I think it's also notable how much the levels vary among different countries. For example, if we look at this map of the prevalence of diabetes, which is based on World Bank data, you can see that the levels are not that high in the European region. The average is about six percent, whereas they are higher in the Arab world estimated at around an average of 12 percent. What's particularly striking is that the sub-region with the highest rates is region of the small states of the Pacific region, where it is about 15 percent. Now, let's look at the risk factors. What are the causes of NCDs and why are NCDs levels increasing? I mentioned the four big NCD: heart disease, cancer, diabetes, and chronic lung disease. There are also four big behavioral factors which increase the risk for those NCDs: tobacco use, harmful use of alcohol, unhealthy diet and inadequate exercise. There are many reasons those risk factors have increased. Number one, we have gotten much better in controlling communicable diseases, such as smallpox or plague, and avoiding catastrophic starvation. Populations are aging as a result of increasing life expectancy and lower birth rates and older people on average we're likely to die from NCDs. Thirdly, urbanization in 1950, less than 30 percent of world population were living in urban areas. Today it's more than 55 percent. People living in urban areas are much more exposed to some of the main risk factors for NCDs. Also average incomes have increased greatly, $450 in 1962, more than $10,000 in 2016, and that interacts with all the previous factors. Finally, globalization may also have an effect, for example, as lifestyles and products spread across the globe. So, what might cause excess mortality and morbidity in humanitarian situations? The important thing to remember is that NCDs are generally chronic or long-term. So, clearly if 20-30 percent of the population are living with an NCD before the disaster strikes, that condition does not disappear but the disaster. No is it likely that new conditions will suddenly appear. It's more likely that existing conditions will get worse. What are the reasons that might happen? Well, first of all, the populations affected by humanitarian situations are changing. In the 1990s, the affected population were in low-income countries like Rwanda, Afghanistan, Democratic Republic of Congo. Today, increasingly the affected people, especially those who have been displaced, are from middle-income countries with older more urbanized populations like Iraq or Syria. Those countries had good health systems before the crisis where people with NCDs were receiving treatment and therefore they survived. Secondly, there are many reasons one might expect rates to increase in a disaster. People may flee the disaster in a great hurry, causing stress for people with heart disease. People with diabetes may hurt themselves and develop wounds which will not heal and that will lead to amputation. People with asthma may be exposed to dust, smoke or mold which increases the risk of an attack. Third, health systems may have broken down, making it more difficult for people to access the medicines and the care that they need for their chronic conditions, especially if they are fleeing the disaster with countries like Syria being a prime example. Fourth, lifestyles may be compromised. There may be less access to healthy food, there may be stressful situations leading to more smoking or to alcohol use etc. Fifth, many people rely on families and networks and these relationships may be broken down if people are displaced. There are also some examples of new cases which do arise from the disaster, for example, people with crush wounds from collapsing buildings may develop renal failure if they do not have access to dialysis. Now, let's now focus on the evidence of increased mortality and morbidity. So, what's the evidence that all of this is happening actually? There's quite a good deal of evidence from high-income countries. Of course, the situation varies according to the disease. There are examples of cardiovascular disease and asthma increasing up to 2-3 times immediately after disaster. There is little evidence that cancer prevalence or mortality increase but an interruption of palliative care that is more pain relief for example is destructive. Beyond the immediate effect, there more longer-term effects if society does not recuperate and revert to normal functioning. For example, estimates are that in the 2017 hurricane in Puerto Rico that caused over 5,000 excess deaths, two-thirds of them due to lack of access to health services over a three-month period after the hurricane. But evidence from the low and middle-income countries is more limited. There's very scarce evidence to show increases in rates of mortality and morbidity, but to a great extent this is due to the fact that data are not available for baseline populations as maybe only about half of the cases have actually been diagnosed and comparisons therefore are not possible. There is also a good deal of evidence that more and more of the people seeking health care do so because they have an NCD that's why they go to the clinic. This is true for example for the earthquake in Pakistan in 2005 or for the Syrian refugees in the Zaatari refugee camp. More than half of the households of Syrian refugees in Lebanon reported having a member with an NCD, but only a minority received care due to the high cost. There are some studies that indicate that risk factors increase. For example, smoking amongst refugees in occupied Palestinian territories is double that of a resident population one study, however this is also not terribly well-documented. There also some qualitative studies indicating the several barriers which people face, including that they have very little knowledge of the symptoms or causes of NCDs. So, our conclusion is the contemporary populations affected by disaster have high rates of NCDs to start out and therefore will also need treatment after disaster. In addition, there are many reasons to expect levels to increase and this is confirmed by what is happening in high-income countries,
