Now we're going to shift a bit to non-communicable diseases. In the past, this was not such a big lecture area, because the populations we dealt with that were displaced by disasters and by conflict, often didn't have much in the way of non-communicable diseases. That all changed with the conflicts in Iraq and the conflicts in Syria where now communicable diseases are a major problem. Here we have some pictures that illustrate some of the issues that we're dealing with. We have somebody having their blood pressure checked and we'll show some figures in a few minutes. A lot of hypertension exists in these populations. We see smokers. Smokers are contributing a lot to respiratory diseases and to cardiovascular disease. A lack of activity. Here we see a group of people in a photograph I took checking their iPhones. So rather than climbing up to the temple at the top of the mountain, they're sitting at the bottom as tourists, busy checking their iPhone. And they can check the pictures of the temple at the top of the mountain without actually having to go there, so it's not so much work. And then, the sweeping problem with the gaining weight, and all over the world we're dealing with lifestyle changes, and issues of overweight and actual obesity. Non-communicable diseases are also present in disasters. And this is a pie graph that comes from the Philippines, and the Philippines is a middle-income developed country. This is an area that was affected by one of the typhoons, and to the Philippines are in way of most of the typhoons passing through the east Asia region. And we can see in this pie graph that only 25% of diseases that were responsible for mortality in the Philippines were due to communicable diseases. So the balance was due to cardiovascular diseases to diabetes to respiratory infections and to malignancies. The three countries with large numbers of displaced populations, Syria, Columbia, and Iraq all have high non-communicable disease prevalence. This may be a problem in major disasters because the health providers may be more focused on communicable diseases and may not have the resources to deal with non-communicable diseases. We're dealing with populations that are now largely from urban areas and they are fleeing from urban areas to other urban areas. The non-communicable diseases are more prevalent in urban populations than rural populations. The majority of conflict-displaced populations now do not live in camps. They live in urban areas intermingled with other populations. Finding them and addressing their needs for treatment of non-communicable diseases is difficult. Those people displaced by conflict may have fewer assets, so if they have to buy their medicines for long term treatment and non-communicable diseases, they've got problems. They're farther away from their homes. They're farther away from support networks. They're displaced longer, and often, they have to pay out of pocket for their health care. And many depend upon private services. And they may flee with minimal amount of resources to address the needs of long term treatment for non-communicable diseases. This represents some data that was collected by colleagues here at Johns Hopkins, showing the proportion of refugees over age 40 who had four common non-communicable diseases. 29% of these had hypertension, 17% had arthritis, 17% had diabetes, and 11% had cardiovascular complaints. Now these were not people who just said, well, I have this. These were people who said, I have been previously diagnosed, and I have been under treatment at various times for these conditions. So you can see that these are substantial proportions of the population. And also, these are populations that may not be able to afford long term treatment for these types of conditions. So let's look at three aspects of non-communicable diseases in a disaster response. First off, let's look at the patients. And we have to say that non-communicable diseases are increasing whether we're having disasters or whether we're not having disasters. So, in a disastrous situation let's just expect that this is going to happen. Non-communicable disease happen more in older people. So, there's a higher dependency and there's a higher demand on the health services. Many of the older may have difficulty hearing. They may have difficulty communicating, and particularly they may have difficulty with mobility, so they may not be able to get to health facilities. So you might have excellent services for people with non-communicable diseases, but you've gotta go ten kilometers on the bus to get there and you have to walk two kilometers to get to the bus stop. So that's not going to help you if you have reduced mobility. There may be isolation, not just physical, but social isolation. There's certainly going to be depleted financial resources. We're also going to see issues of mental health. Not just issues of dementia among older people, but there may be pre-existing conditions, such as schizophrenia, bipolar conditions. And on top of that, we may be dealing with Post-Traumatic Stress Disorder in populations that have been exposed to conflicts. So we have major issues here. Another issue that we see in displaced populations, are the resources to provide mental health services are limited. We'll come back to that. And finally, the social networks that are necessary to sustain people with non-communicable diseases, especially older populations may be gone. So people don't have people that they can depend on, as they had in the past. Let's look at issues of health providers. Health workers may need to develop new skills to manage non-communicable diseases. They may not be familiar with these conditions, or the local treatment for them. And the pattern in an emergency might be different, and it might not be known. So there may be some initial epidemiological research that needs to be done to find out what that prevalence is, and why people are or why people are not utilizing the resources. There are issues of priorities, there's issues of triages, but how do you deal with this? In many circumstances, there may not be the resources to provide the long term treatment that is needed for a cardiovascular conditions or people who have serious respiratory problems. How do you triage these people and say, I'm sorry you're going to have to support this treatment for your condition with your own out-of-pocket resources because we as a health system don't have the resources for that. There may not be the laboratory capacity or facilities and it may require the providers to use more in the way of physical diagnosis and they may not have those type of skills. We may have to change our treatment schedule to be something that's simplified or improvised. There are maybe inadequate record keeping so it's not easy to determine from one visit to the next what this patient has been taking, especially if the patient has had longer periods of time when because of economic reasons they've not continued their treatment. But also, we have to think about the health providers. In emergency situations, there's often not good continuity. People may work for three or four weeks or a month or three months, and then they move off to something else and the next time that the person with hypertension or type two diabetes seeks care there's going to be new provider who cannot read the handwriting of the previous provider. The health services have problems because health services have to set priorities, and here we see a photograph of people trying to set priorities or what kind of medicines are we going to provide for this community that has many people with non-communicable diseases. There's a rapid return of people sometimes who have been affected by disasters. So they start on treatment and the next time a visit to the clinic is due for these people they may be gone and we don't know where they are. We have to be sure that patients have access to specialized services. So it may require visits from the cardiologist or the endocrinologist, and maybe they're there, maybe they're not, maybe they can be afforded, maybe they can't be. And then the issue of patient records. One of my personal goals is to see how we can develop portability of patient records that can be kept on a cell phone. So if a patient has to move from place to place some element of their medical care is preserved on that SIM card of their telephone. And then finally, what is the financial support available for non-communicable diseases? Treating people with hypertension month after month after month is a lot more expensive than treating somebody with scabies or a single attack of malaria. And there may not be the financial resources to support these people. Now how do we deal with the medicines for non-communicable diseases? Medicines mostly come through emergency drug kits, or emergency health kits in emergency situations. And these can be delivered just about any place in the world, in about 24 to 48 hours. In this illustration you see the cover of The Interagency Emergency Health Kit, the 2011 edition. This lists the medicines that should be made available in emergencies. Many medicines have not made this list and it produces problems. Now morphine has finally made this list. Realizing that many people might be in terminal conditions, many people may have serious injuries that they need major analgesia for, so at least we have some access to morphine now. There are only five cardiovascular drugs on this list, and many patients may have been on more sophisticated medicines before they were displaced, and this might be a problem. There are no diabetes medicines on this list and there are no treatments for asthma, which is a major problem. So we have, in the emergency drug kit, some very basic things that try to meet the health needs of many populations. But for non-communicable diseases, we haven't done very well at all. There's a limited availability of psychotropic medicines. The Ukraine crisis has pushed us to do a bit better. And so now there's a supplemental kit which has been put together which can be ordered to deal with populations that have high levels of non-communicable diseases. And these contain not only some medicines, but they also contain some supplies such as a glucometer and also inhalers to deal with people with specific issues in non-communicable diseases. Often displaced populations have to purchase their own medicines and they may not have the resources to do that. Compliance is a problem partly because of the lack of medicines, but it might be also a problem because the health providers don't understand the conditions and how they should be treated appropriately. And finally we're just thinking about palliative medicines. For people that have terminal conditions that no longer have any hope of treatment or for various financial reasons cannot receive treatment, we're starting to think about, what's the appropriate palliative approach? But up until just recently nobody thought about these kind of issues. Now in this slide I want to talk about some of the key messages for communicable diseases, particularly those that remain a challenge in humanitarian emergencies. These communicable diseases are going to change as the population changes and as climate changes. There's going to be a rapid change in drug sensitivities. In many situations particularly those that are dealing with outbreaks of diarrhea such as shagalla. Children account for a large proportion of people seeking care for communicable diseases. Diseases that are brought in by refugees or by the displaced population, these can be passed over to the host community. The host community can be infected as well. Many diseases which affect the displaced populations are present in the community already. So if the displaced population has not been subject to issues of cholera in the past, but they are displaced into areas where there is cholera, then this is a high risk. Populations may move from a high altitude where there was no malaria, into a low altitude, where malaria becomes a major problem. Let's think about the key messages for non-communicable diseases, because we're seeing these increasingly commonly in displaced population. Often they are more difficult to manage than communicable diseases because primary staff lack the skills. The specialists are not easily accessible. The essential medicines needed for these non-communicable diseases are lacking. There's a problem with continuity, with record keeping, with compliance. And there's often a lack of consistent protocols available for treatment. The control of non-communicable diseases often needs a major change in lifestyles. And how to communicate this, where is the health education, the health promotion for this? We're not set up to handle this in emergency situations. So now we've looked at both communicable diseases and non-communicable diseases. And we've seen some of the issues that arise for dealing with displaced populations, and some of the many challenges you're going to have to face if this is a population that you're going to be providing services for.
