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World Diabetes Day – Diabetes in conflict areas

Non-communicable diseases (NCDs), including diabetes, increasingly contribute to morbidity and mortality in conflict settings, and the burden of those diseases has become prominent especially in middle-income settings. The outbreak of conflict pushes people with diabetes, who need life-long control and treatment, into a life with even more unexpectedness and instability.

One of many challenges that people with diabetes living in conflict-affected areas face is the limited availability of and access to insulin and other anti-diabetic drugs. There are many factors that play critical role in the process of insulin delivery to people with diabetes.  There should be enough supply and adequate storage, including cold chain facilities, for quality and safety; this requires a stable supply of electricity.  Another factor is the equitable distribution where well functioning transport infrastructure is available. In conflict settings, however, these are often impaired.  

Insulin crisis due to conflict has been documented in Iraq. Prevalence of diabetes in Iraq was estimated to be 10.2 per cent in 2010. This estimate exceeded total prevalence in the Middle East and North Africa region (9.3%) and is (nearly) equivalent to that of the USA (10.3%). The epidemiological transition has been experienced in this country, so there is an increased need for controlling and treating diabetes. However, Iraqi healthcare system was devastated due to continuous conflicts, political and economic isolation and public health funding cutbacks of 90% by Saddam Hussein in 2002 in comparison with spending in the previous decade. Twelve per cent of hospitals were destroyed in 2003, and Iraq experienced significant pharmaceutical shortages; more over, due to safety reasons, there have been issues in transporting insulin when it is available. Besides insulin shortages and lack of transport, low quality diagnostic tools, weakened service delivery after the sanctions, limited access to self-monitoring tests and prevention and treatment of complication were of concern in Iraq, according to a report by Iraq’s Ministry of Health.

People have different coping strategies to deal with insulin shortage. They may reduce insulin dosage, use insulin that passed the expiration date or use insulin that is imported without quality control. Some stop using insulin or change to other kinds of drugs to control blood glucose level. Those who rely on the market outside of the primary healthcare centers to get insulin are burdened with higher prices,which decreases access to the drug. Uncontrolled diabetes can lead to severe complications such as diseases related to cardiovascular system, liver, nerve and eyes, which can eventually lead to mortality.

One may ask a question: does conflict increase the incidence of diabetes? Stressful life events and environmental factors have been proposed as one of determinants of type 1 diabetes along with genetic predisposition to the disease, and this implies possible link between conflict-related stress and the onset of type 1 diabetes. To explain this, it has been proposed that impaired immune functions caused by psychological and environmental triggers may stimulate beta-cell related immune response, resulting in more diabetes-prone condition.  For example, there is a study in Israel reporting that there was increased incidence of type 1 diabetes in Israeli children and adolescents due to war-related psychological trauma, though cautious interpretation is needed because scientific consensus has yet to be made on the causality.

When it comes to type 2 diabetes, the hypothesis of ‘fetal programming’ may give a hint. According to this idea, nutritionally stressful situations that occurre during early stages of life – fetal and infant – design the structure and function of the body to cope with the situation. Thus, the long-term change in the body made in these critical periods determines disease pattern in adulthood. For example, a child who experienced maternal undernutrition may be more likely to develop chronic diseases such as type 2 diabetes and cardiovascular diseases if the metabolic system of the child failed to adapt to affluence in adulthood. This may have implications for conflict-affected populations with limited access to nutritious food as well as for those in rapidly developing countries. However there are a lot to learn more about the link, and long-term follow-up studies are needed.

As the importance of addressing diabetes and other chronic NCDs is increasingly recognized worldwide, not only in high-income settings but also in low- and middle-income settings, it will become more important to respond to the need for controlling chronic conditions in conflict settings. There is a lot of room for improvement to best support conflict-affected people with diabetes or pre-diabetic conditions, in terms of financing, health staff training, infrastructure, education and research. Diabetes and NCDs should be taken into consideration when assessing and intervening in conflict settings.