Non-communicable diseases, NCDs, as a major public health issue in humanitarian situations is a fairly new concern, and the medical response to fully address that needs of patients is not always prioritized or in placed. This puts the patients and healthcare providers at the front line in a very difficult position. I had several cases where I really had to do difficult decisions like to prioritize the patient over another, and this was really painful to choose to refer this patient, not this one, because you think that maybe this one have a better chances to survive. I have to admit that for non-communicable diseases, especially when the patient was an elderly, I may have not made the right choice several times. Elderly people are particularly vulnerable. But among all the people who are living within cities, emergencies appear to increase the risk of NCD-related complications, which can lead to acute worsening or life-threatening deterioration. According to a literature review from 2015, heart attacks and strokes maybe up to two to three times more common than in normal pre-emergency circumstances, and the health clinics are not always prepared to respond to that need. When we started with the field hospital and the main goal was to treat patients with trauma. But very quickly, we started receiving a lot of requests from patients living with non-communicable diseases. So, we decided to open an outpatient department, providing consultation during the day basically, with general practitioner to treat those patients. Very quickly, we saw the number of patients raising. We were receiving patient from different village, like even villages that are 30 kilometer away from the consultation. So, we decided, based on the security situation, that we would be able also to run mobile clinics in some areas. So, we will going once a week to visit some remote villages to provide care for patients who are not able to come to our clinics. Most of them were patients living with NCD or with non-communicable diseases such as diabetes, cardiovascular diseases, hypertension, and asthma. The International Rescue Committee ran four mobile health clinics in Syria in 2017. Twenty-nine thousand and fifteen people were reached of whom around 14.5 percent received treatment for NCDs. While the mobile clinics can reach people who may not otherwise have access to healthcare, the care provided in mobile clinics cannot be as comprehensive as that provided in a stationary facility. We didn't have enough drugs and medical supplies to deal with these cases because we were more prepared for the trauma cases and for the emergency obstetrical cases. We couldn't treat with the correct medication, like those with cancers, or those with complicated diseases, with complication. We could only provide palliative treatment like drugs to basically reduce pain. We couldn't refer them to the neighboring countries because it was too complicated to ensure access for them and referral pathways were not established at the regional level at least for some conditions. Again, the priority was mainly given to patients with trauma conditions, who are inputted and/or had a very severe injuries, were prioritized over the patients who are living with non-communicable diseases. According to the World Health Organization's Emergency Response Framework, the initial response during the first 30-90 days of an emergency, management of NCDs should focus on treatment of life-threatening or those which have severe symptomatic conditions such as person with acute complications of their conditions or treating persons for whom interruption of treatment could be life-threatening. But sometimes the response is made extremely difficult, as in this case, by the crisis in Syria. Later on, the situation got even more complicated in northern Syria. So, we lost direct access and we were working through cross-border activity. So, we were based in Turkey and providing support to Syrian doctors remotely. We were sending the kits that were ready prepared. Very quickly, we realized that these kits were not adapted to their request. They were sending us a list of patients that needed drugs for non-communicable disease that we were not prepared to give them. Some areas were besieged and we couldn't send anymore of the drugs there. Some convoys took up to six months to reach the areas where we wanted to provide support. The option we had was to provide them with money, so that they can buy the drugs where they could. Issue was that we didn't have any information about the quality of the drugs that were delivered, that were bought. We really had very little control on the expiry date of drugs, on the condition of transport, condition of storage. So, we had very little control over the quality of care that were provided in the southern besieged area. Providing medical care in humanitarian settings is a complex affair. But what would quality of care of NCD-related conditions look like in a crisis like in Syria according to Mouna? I think that there is no right answers for the question regarding quality of care provided, in particular, in how to reach in besieged areas in Syria. The right answer would be that besiegement like attacks on health and misjudgment should not impede care for patients and in particular, for a patient who live with NCDs, with non-communicable diseases, because those patients, in particular, they need long-term treatment, they need to be referred when they have any complication, and we need to ensure continuity of care for them. Continuity of care is about providing quality care over time, and ensuring the continuum of care for people living with NCDs should be primary aim of the humanitarian response to prevent and reduce excess mortality for people living with NCDs. What else can be done to improve the situation in situations like the long-lasting conflict in Syria? To have a preparedness plan for patients who live with non-communicable diseases and to ensure that those patients are not cut from their treatment, we need to get all the lesson learned from this ongoing protected crisis and just start acting now. It cannot be delayed anymore. We cannot afford not to have a clear guidance, not to provide doctors and field stuff with a clear guidance on how to deal when they don't have the drugs they needed, when they don't have the referral pathway they needed for their patients living with non-communicable diseases. So, we need to provide the field stuff with the support because we cannot leave them like they are now without any guidance. We need to advocate at the different level on the importance of ensuring the continuity of care for patients living with non-communicable diseases.
