F. Jacquerioz Bausch, D. Beran, H. Hering, P. Boulle, F. Chappuis, C. Dromer, P. Saaristo and S. Aebischer Perone
Non-communicable diseases (NCD) represent an increasing global challenge with the majority of mortality occurring in low- and middle-income countries (LMICs). Concurrently, many humanitarian crises occur in these countries and the number of displaced persons, either refugees or internally displaced, has reached the highest level in history. Until recently NCDs in humanitarian contexts were a neglected issue, but this is changing. Humanitarian actors are now increasingly integrating NCD care in their activities and recognizing the need to harmonize and enhance NCD management in humanitarian crises. However, there is a lack of a standardized response during operations as well as a lack of evidence-based NCD management guidelines in humanitarian settings. An informal working group on NCDs in humanitarian settings, formed by members of the World Health Organization, Médecins Sans Frontières, the International Committee of the Red Cross, the International Federation of the Red Cross and others, and led by the United Nations High Commissioner for Refugees, teamed up with the University of Geneva and Geneva University Hospitals to develop operational considerations for NCDs in humanitarian settings. This paper presents these considerations, aiming at ensuring appropriate planning, management and care for NCD-affected persons during the different stages of humanitarian emergencies. Key components include access to treatment, continuity of care including referral pathways, therapeutic patient education/patient self-management, community engagement and health promotion. In order to implement these components, a standardized approach will support a consistent response, and should be based on an ethical foundation to ensure that the “do no harm” principle is upheld. Advocacy supported by evidence is important to generate visibility and resource allocation for NCDs. Only a collaborative approach of all actors involved in NCD management will allow the spectrum of needs and continuum of care for persons affected by NCDs to be properly addressed in humanitarian programmes.
The increasing burden of non-communicable diseases (NCD) is a global challenge causing, according to the World Health Organization (WHO), 71% of global deaths (41 million) in 2018, with 85% of the deaths in people between the ages of 30 and 69 years occurring in low- and middle-income countries (LMICs) . NCDs and humanitarian crises often co-occur in LMICs, providing additional challenges for the management of NCDs in these settings where weak health systems collide with the challenges of a humanitarian response. The number of displaced persons (either refugees or internally displaced) has reached the highest level in history, estimated at more than 70 million people . Until recently NCDs in humanitarian contexts were a neglected issue [3, 4]. Humanitarian contexts are changing. Protracted crises are now also impacting higher income regions, such as the Middle East, and more displaced persons are settling in urban areas rather than traditional camp settings [5, 6]. This results in impacted populations being more likely to have pre-existing NCDs. All these factors influence the burden of NCDs seen in humanitarian crises as well as the approaches needed to address NCD-related health needs.
The WHO’s Global Action Plan (GAP) for the Prevention and Control of NCDs for 2013–2020 includes recommendations regarding NCDs in the humanitarian response . This document states “it must be ensured that the use of the services does not expose the users to financial hardship, including in cases of ensuring the continuity of care in the aftermath of emergencies and disasters.” The recommendations also highlight the need to “improve the availability of life-saving technologies and essential medicines for managing NCDs in the initial phase of an emergency response.” Continuity of care in this context refers to: “access to comprehensive services and interventions that address the health needs and the well-being of a person, from the identification of a health condition until the recovery of a functional state consistent with the context” .
Given the relatively recent focus on NCDs during emergencies, humanitarian actors recognized the need to harmonize and enhance NCD management in humanitarian crises. Indeed, the humanitarian community has increasingly addressed the needs for NCD care in their activities  and developed organization-specific programmatic and clinical guidance. However, there is a lack of a standardized response during operations [3, 10, 11], which is essential to guarantee continuity of services to people in crisis settings, as well as a lack of evidence-based NCD management guidelines in humanitarian settings [12, 13]. WHO’s Package of Essential Noncommunicable Disease Interventions (PEN), provides a basis for NCD care in LMICs, but needs to be adapted to humanitarian settings to address the additional challenges of NCD care during crisis, which include disruption of health care services due to damaged and destroyed health facilities, lack of health care workers, difficulties in access to health facilities due to security constraints or damaged infrastructure. Therefore, a common approach of all actors in the field is needed to answer to the needs of patients with NCDs in crisis settings. The aim of this paper is to present operational considerations, aiming at ensuring appropriate planning, management and care for NCD-affected persons during humanitarian emergencies.
The informal working group on NCDs in humanitarian settings, formed by members of the WHO, Médecins Sans Frontières (MSF), the International Committee of the Red Cross (ICRC), the International Federation of the Red Cross (IFRC), the International Rescue Committee (IRC) and others, and led by the United Nations High Commissioner for Refugees (UNHCR), teamed up with the University of Geneva and Geneva University Hospitals in order to develop the operational considerations needed to address NCDs in humanitarian settings. This was done by applying a modified nominal group approach through a series of face to face meetings and email exchanges, informed by expert knowledge and relevant literature .
Humanitarian response interventions are usually prioritized according to needs and resources. NCDs encompass a spectrum of diseases and care requirements, and a prioritization of NCD services/interventions are required based on the available resources (human, financial, etc.) and on the context . The list of conditions considered as a priority is based on feasibility during an acute humanitarian crisis, burden of disease and demand, avoidable premature deaths as defined in the priority NCDs of the WHO , those which have severe consequences if left untreated , and pre-crisis availability and capacity of the health system .
Priority NCDs and prioritization of care delivery in humanitarian settings
The priority NCDs to be included in humanitarian responses, as defined by the informal working group, are cardiovascular diseases (including heart failure of any etiology and coronary heart disease), high blood pressure, asthma, chronic obstructive pulmonary diseases (COPD), epilepsy and diabetes. In addition, long-term complications of NCDs, such as disability, stroke or amputation from diabetes should be considered (See Table 1). In accordance with the public health approach in humanitarian crises, some services/interventions need to be temporarily deprioritized in the initial phase of the response and integrated later on. Other interventions might not be relevant or feasible at the health facility where care is provided. For example, provision of cancer chemotherapy or dialysis for end-stage renal disease is rarely possible  and cannot be sustained by agencies with short-term mandates. These patients should be referred to second and third level hospitals wherever possible, as they require resource-intensive diagnostic and treatment means. Moreover, by enrolling patients into long-term programs and life-long therapies such as cancer care and renal dialysis comes financial and ethical responsibility . However, supportive/palliative components of care should be provided at every stage of the response .