Ruth Hunter: Tackling NCDs in humanitarian settings is a growing challenge

Multisectoral networks have a vital role in meeting the needs of vulnerable people, says Ruth Hunter

Human suffering in humanitarian settings is not just a direct result of a conflict or humanitarian disaster but includes death and disability from non-communicable diseases (NCDs) such as diabetes, cardiovascular disease, cancer, and respiratory conditions. In parallel, global forced migration has reached a record high with 68.5 million people displaced from their home in 2018. [1] The average length of displacement is now more than 20 years.

Despite these statistics, the problem of NCDs has been largely neglected in humanitarian settings. We know little about the true scope of the problem, the influencing contextual factors, or which interventions are effective and feasible in these contexts. Recognition is growing that NCDs represent an emerging challenge in any humanitarian response, especially among urban refugee populations. In these settings, the international community and host country governments face numerous challenges in meeting the health needs of refugees. The management of NCDs is costly to donor agencies, depleting the limited resources available for healthcare of refugees.

In April 2019, Marthe Frieden wrote eloquently about dealing with the after effects of Cyclone Idai in Zimbabwe in her role as medical team leader in Médecins Sans Frontières’ (MSF) emergency response. [2] She highlighted the growing rates of diabetes, hypertension, and other NCDs, which are a key issue in both the acute and protracted phases of humanitarian action. The MSF teams work with local health ministries and other organisations in the short term to deal with such health conditions. However, little is known about the medium to long term actions that are needed to tackle this growing problem.

In terms of the diabetes crisis in the acute humanitarian setting, fundamental, basic needs are not being met. Managing diabetes presents an emergency situation. People are dying from type 1 diabetes because of lack of insulin, since diabetic ketoacidosis can be fatal within days without access to insulin. Insulin is rarely available in the humanitarian responders’ medical kit. People with type 2 diabetes faced with protracted displacement can have uncontrolled blood sugar levels for prolonged periods. This can lead to complications such as infection, blindness, and renal failure.

Availability and affordability of diabetic medication is poor in humanitarian contexts. David Beran and colleagues have written about the global variation in insulin pricing and distribution, highlighting the huge differences in insulin availability. [3] In high income countries such as the UK one in two people have access to insulin, whereas in Africa only one in seven people have access to insulin. [4] Kehlenbrink and colleagues and Boulle and colleagues detail other fundamental unknowns such as the thermostability of insulin and test strips, and lack of blood glucose monitoring equipment in humanitarian settings. [5,6]

The BMJ has published a collection of articles on solutions for prevention and control of non-communicable diseases (; nowhere is this work more needed than in the humanitarian setting. The management and control of NCDs faces many challenges in humanitarian settings because of violence, insecurity, and limited access to healthcare systems. There is little guidance to assist the international and local non-governmental organisations and others working in this field. [7] NCD guidance is largely based on evidence from high income countries. A systematic review by Ruby and colleagues found scant evidence on the effectiveness of interventions for NCDs in humanitarian settings, with only eight studies identified. [8]

My colleagues and I emphasise the need for multisectoral stakeholder approaches to tackle the global NCD crisis; in the humanitarian setting, we must come together to address these fundamental human rights issues. The Harvard Humanitarian Initiative is taking the lead, bringing together a range of multisectoral actors including academia, international NGOs, the private sector, funders, pharmaceutical agencies, policy makers, and practitioners, to discuss the diabetes crisis in humanitarian settings and agree a shared vision to tackle this crisis. The global challenge of NCDs and displaced populations is clearly a complex and urgent problem, requiring systems thinking and the application of complexity science methods. Given the protracted nature of many of these crises and the burden on the local health systems, the implications for both individuals with NCDs and local health systems are immense.

The challenge of NCDs in humanitarian settings is a rapidly emerging concern, and there is little evidence to help guide clinicians, public health practitioners, or policy makers. More action and evidence is urgently needed, and it will require the concerted effort of multiple actors working together towards a shared agenda.


Ruth Hunter is a researcher in the Centre for Public Health, Queen’s University Belfast, Northern Ireland. Her research interests include the impact of conflict on health.

Competing interests: None declared



This article is part of a series proposed by the WHO Global Coordination Mechanism on NCDs and commissioned by The BMJ, which peer reviewed, edited, and made the decisions to publish. Open access fees are funded by the Swiss Agency for Development and Cooperation, International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), UNOPS Defeat-NCD Partnership, Government of the Russian Federation, and WHO.


1 UNHCR. Forced displacement at record 68.5 million

2 Frieden M. The aftermath of Cyclone Idai—building bridges where we can. BMJ Opinion, 3 Apr 2019.

3 Beran D, Laing RO, Kaplan W, et al. A perspective on global access to insulin: a descriptive study of the market, trade flows and prices. Diabet Med 2019;00:18. PubMed

4 Basu S, Yudkin JS, Kehlenbrink S, et al. Estimation of global insulin use for type 2 diabetes, 2018-30: a microsimulation analysis. Lancet Diabetes Endocrinol 2019;7:2533. PubMed doi:10.1016/S2213-8587(18)30303-6

5 Kehlenbrink S, Smith J, Ansbro É, et al. The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries. Lancet Diabetes Endocrinol 2019:S2213-8587(19)30082-8. doi:10.1016/S2213-8587(19)30082-8. PubMed

6 Boulle P, Kehlenbrink S, Smith J, Beran D, Jobanputra K. Challenges associated with providing diabetes care in humanitarian settings. Lancet Diabetes Endocrinol 2019:S2213-8587(19)30083-X. doi:10.1016/S2213-8587(19)30083-X. PubMed

7 Jobanputra K, Boulle P, Roberts B, Perel P. Three steps to improve management of noncommunicable diseases in humanitarian crises. PLoS Med 2016;13:e1002180. doi:10.1371/journal.pmed.1002180. PubMed

8 Ruby A, Knight A, Perel P, Blanchet K, Roberts B. The effectiveness of interventions for non-communicable diseases in humanitarian crises: a systematic review. PLoS One 2015;10:e0138303. PubMed doi:10.1371/journal.pone.0138303