In Lebanon, kilometers from the Syrian border, working with Médecins Sans Frontières (MSF) to address the needs of Syrian refugees with chronic, non-communicable disease (NCDs), spectacular complexity requires acknowledgement.
The treatment of chronic disease in humanitarian emergencies is reasonably new for MSF. It is reasonably new for the humanitarian and disaster health community as a whole.
“As the leading cause of death globally, NCDs were responsible for 38 million (68%) of the world’s 56 million deaths in 2012. More than 40% of them (16 million) were premature deaths under age 70 years. Almost three quarters of all NCD deaths (28 millions), and the majority of premature deaths (82%), occur in low- and middle-income countries.” (World Health Organization 2014).
Syria is a lower-middle income country (The World Bank).
In June this year, the UN Refugee Agency (UNHCR) released their 2014 report on forced displacement documenting an all-time high (since record keeping commenced) of 59.5 million people forcibly displaced, 13.9 million more than the previous year. Syria was reported as the world’s largest source country of refugees. With 1.15 million registered refugees in 2014, Lebanon was the third top host, while at 232 refugees per 1,000 inhabitants, it is the leading host proportional to national population (UNHCR 2015).
Combine the leading cause of death in the world with the largest population of displaced people. The magnitude of what we are trying to do is honestly felt on the ground, every day, in every moment of challenge, every success, and every failure.
We treat predominantly patients with diabetes, coronary artery disease, hypertension, asthma, chronic obstructive pulmonary disease, thyroid disease, and epilepsy. The most challenging of all is diabetes. For the two months I’ve been in Lebanon thus far, the focus has been on working with our multi-disciplinary team, with local and expatriate staff, and with the support of the team in Europe to improve the access to chronic disease care for displaced Syrian people, and to then optimize the care they receive. Diabetes is our current focus. Diabetes, and its many sequelae.
One month ago our team commenced case study meetings as a quality improvement exercise. We meet to discuss in detail patient files as a team, pooling our resources to analyse how we can better provide individual care. The third patient in our case study series has died age 45 of heart disease, leaving behind a wife and children displaced by war and now affected by the consequences of diabetes and heart disease. The ordinary lives behind the statistics of premature cardiovascular mortality in humanitarian emergencies.
Successfully managing diabetes is not easy with every drug at hand; money to spend; a supportive, structured, sophisticated health system with primary, secondary, and tertiary care; and a well-educated, stable population. The aetiology is often multifactorial. Many medications and investigations might be needed. Long-term treatment and adjustments are likely necessary. For ideal outcomes, people need to control challenging lifestyle factors such as diet and exercise. And when people get unwell with concurrent illnesses, careful tertiary care is required.
For various politically founded reasons particular to Lebanon, Syrian refugees here don’t live in camps. We are treating a transient population, often lacking a home base or reliable transport, embedded in a complex security context. Educational backgrounds vary, and we are working hard to address the gaps.
Access to secondary services has challenges. It’s a small sentence to write, but the ramifications can be immense. People are grieving, and will be quick to reasonably tell you that their diabetes is no priority in view of their grief for lost children, lost siblings, lost spouses. Some dead. Some missing.
Our team’s preoccupation in our daily job is how we can do this better, and on concomitantly documenting barriers to care and lessons learned to inform how we move forward in this and other emergencies. Our project is an ethical win and yet a grey space that deserves constant attention. We are here. We are doing it when many others are not. I cannot give MSF kudos enough for undertaking this challenge. However, once we create access, once we open the door, ours becomes the ethical responsibility to identify and overcome barriers to care in order to obtain excellent outcomes. From where I sit, surrounded by ideas, feedback, referrals, reports, and endless notes—on my phone, my arm, various post-its, in note functions on my computer, and in my faithful Moleskine notebooks—this is an exciting challenge.
Consult by consult; we are working to effect change. I am learning about the context and about different ways of obtaining outcomes from the five local general practitioners with whom I’m working. One of our local doctors entertains me so much with her zest and enthusiasm. I love her energy and feel her frustrations. I sat in a consult watching her gesticulate wildly and speak carefully and emphatically, one recent afternoon. The consult was progressing in Arabic, well beyond my greeting-only language level, but oh the wonders of non-verbal communication!
The patient was subtly glancing sideways at me as if to suggest her doctor was happily mad. I asked the doctor what she was talking about. In her unique manner she turned to me and said, emphatically, “So”. Pause for dramatic effect. “So! I said to her”. Pause. “I said to her that her diabetes is like a husband. You may not want to know everything about him, but you have to. You have to know about his family, about what he likes, what he doesn’t like. Your diabetes is like this. Like it or not, interested or not, you have to know it”. I loved it. The patient loved it. Perfect analogy for a Syrian lady sweating in a black polyester abaya on the last day of Ramadan in northern Lebanon.
Long before I became a doctor I studied a little more broadly. Theology, literature, philosophy, and mathematics dominated a number of my post-secondary years. I will spend the rest of my life developing a philosophy of being. Complexity challenges and refines what we believe. Involvement in the lives and health of people continues to be the greatest privilege and professor.
A young university student told me she “commutes” between her studies in Damascus and her family’s safe haven in Lebanon. We discussed bombs and daily realities. She clearly understood the risks. What she communicated to me about the choices she makes perhaps cut to the heart of the reality of refugee life: no discernible future; at least not in any way that can be planned.
That night I read on Al Jazeera of July recording the highest number of air strikes in Syria (Al Jazeera 2015), with a particular focus on the suburbs of Damascus. I wanted to ask her to reconsider. Risk analysis is fascinating business. For each of us individually, the consideration of why we do what we do. I don’t understand much, but I think I understand the freedom this young woman is demanding. Freedom that she will take, regardless of whether it is given.
Al Jazeera (2015). "Highest number of Syria air strikes recorded in July." Retrieved 23 August, 2015, from http://www.aljazeera.com/news/2015/08/highest-number-syria-air-strikes-recorded-july-150801142450925.html
The World Bank. "Data: Syrian Arab Republic." Retrieved 23 August, 2015, from http://data.worldbank.org/country/syrian-arab-republic.
UNHCR (2015). UNHCR Global Trends 2014: World at War Geneva, UNHCR.
World Health Organization (2014). Global status report on noncommunicable diseases 2014. Geneva, World Health Organization.