Aid agencies in Lebanon shift focus to chronic illnesses
MSF in Lebanon is shifting away from emergency aid and focusing on long-term support. (AFP/File)
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Samira Khalaf, 57, waits in the hallway of a Doctors Without Borders clinic in the northern town Abdeh. A Syrian refugee, she suffers from diabetes. Such chronic, noncommunicable diseases represent one of the greatest health challenges of the refugee crisis. Lebanon’s largely private health care system can mean patients face prohibitive costs for the drugs they need. Before she heard about the clinic, Khalaf was forced to borrow money to pay for her insulin.
“I couldn’t not buy [the medications], I really needed to buy them, because I knew I could not stay alive if I didn’t, so I was trying anything,” she said.
She now gets her medication free at the clinic.
The center conducts up to 30 consultations a day and the team of health care professionals not only diagnoses and treats patients, but also educates them on how to better manage their conditions alone. Staff give presentations in the waiting room on monitoring blood sugar and nutrition and lifestyle choices. Khalaf’s sons are on their way to the clinic so a nurse can make sure they are injecting their mother with the correct levels of insulin.
The facility and others like it across the region are part of evolving medical response to the Syrian refugee crisis. Doctors Without Borders, which goes by its French initials MSF, is best known for providing medical care in war zones and battling endemic diseases in developing countries, but the protracted nature of the current refugee crisis and the changing needs of its victims have required it to broaden focus.
“It’s really just a response to a clearly identified need in the population to whom we provide care,” said Philippa Boulle, noncommunicable diseases adviser and chronic disease team leader at MSF. “Even in those [areas] affected by conflict, natural disasters and other humanitarian crises of recent times, these have been among the diseases which patients are presenting.”
She said the reasons were twofold. Global epidemiology is rapidly evolving – cardiovascular disease is now the leading cause of death, diabetes is on the rise and NCDs are having a greater and greater impact on global mortality. Such afflictions, including hypertension, asthma and pulmonary disease, have seen a particular increase in low- and middle-income countries, including those in the Middle East. Before the civil war, the World Health Organization estimated NCDs accounted for some 77 percent of all deaths in Syria.
“We’re talking about people that move with their [condition],” said Fouad Fouad, assistant professor in the Faculty of Health Sciences at the American University of Beirut.
“For the first few months, people suffered from problems of clean water, diarrhea, vaccinations, and the aid system responded to this, because they know how to do that. But quickly after, when people started to settle, they returned to their original diseases. ... Unfortunately the system wasn’t well organized to respond quickly to that.”
He said the lack of adequate care meant refugees suffered gaps in treatment which led to complications, necessitating expensive hospitalizations. A nurse at the Abdeh clinic said initially 30 percent of their patients arrived with complications, though the number has declined over time.
MSF has offered treatment for NCDs since the onset of the crisis. But the large-scale provision of medication and comprehensive patient education constitutes new ground.
“There’s not a lot of global experience in terms of how to treat these types of diseases in humanitarian settings,” Boulle said. “They’re very different kinds of diseases to manage. ... You need to be able to follow up with patients, you need to have reliable, consistent sources of medication, and then the other specificity of these diseases is that patients need a capacity of self-care, so we need to incorporate the education of patients into the response.”
Many refugees had their treatment interrupted when they fled while others are arrested or detained without their medication. Stress and psychological trauma can also aggravate their conditions, as can poor nutrition and a lack of exercise. All of these things are a reality for many refugees in Lebanon.
Living conditions is a worrying factor for professionals. “If they’re living in very crowded conditions, they need to have adequate space to store their medication; if they’re injecting insulin they need a safe and clean space to inject it,” Boulle said. “They will be also more exposed to diseases which could exacerbate their disease.”
Despite a number of organizations providing treatment for NCDs, the need is by no means met. “This has been one of the bigger gaps,” Boulle said. “There are still not many providing care for the chronic diseases. It’s a clear gap where we think we can have added value.”
MSF works continually to simplify and adapt its approach in order to provide essential care to the largest possible number of people, establishing protocols for the prescription and provision of drugs, and engaging with patients to preempt complications. But there is not enough money to provide everyone with affordable care.
“Refugees access care through a network of primary health care centers [PHCs], where they can access treatment for NCDs,” explained Michael Woodman, senior public health officer at the Beirut office of the UNHCR.
“The major challenge is scaling up access. ... Around 100 PHCs have subsidies in place, but at other PHCs, costs may vary from $5 to $10, which may well be unaffordable.”
There are also legal hurdles to expanding treatment.
Ironically, while MSF educates patients to take better care of themselves, fully trained Syrian health care professionals are not allowed to practice in Lebanon, according to Fouad.
“Culturally, Syrian doctors may address people’s needs better than Lebanese ones, and it would cost less, significantly less.” He noted that Syrian doctors have successfully set up clinics in Turkey, which has no such prohibition.
Restrictions on the importation of pharmaceuticals also drive up costs.
“In Lebanon we have to buy locally, and that makes it a bit more expensive,” Boulle said. “One of our key drugs at one stage was very difficult to purchase from our supplier, so that was quite a challenge for us.”
Woodman said the delivery of drugs also needs to be scaled up. “There is additional funding to purchase more drugs due to the refugee crisis, but this funding by donors needs to be increased and sustained over the medium term to meet needs.”
With international aid organizations effectively functioning as a subsidiary health care service, Fouad argues that large-scale reform is needed to add permanent capacity.
“We have to have a system that addresses the needs of those people or there will be more tension, more wasting of resources, more wasting of money, more wasting of aid.”
Fouad also called for more research. There remains limited data on NCDs in humanitarian situations. Woodman said WHO is currently performing a nationwide survey to look at the prevalence of risk factors in the population.
For now, MSF plans to continue to refine its model for treating these diseases, demonstrating its feasibility and sustainability.
“One of the real objectives was to develop this kind of model ... that we think is rationalized in terms of the cost, but still providing very good quality care,” Boulle said.
The hope is that such programs can inform the ongoing response to humanitarian crises and stand ready to be implemented whenever the next one comes.
By Ned Whalley
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