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Skip to 0 minutes and 13 seconds BAYARD ROBERTS: The priority NCDs in these settings are really those that are feasible and affordable to treat. So those principally relate to diabetes, cardiovascular disease, and risk factors for cardiovascular disease, such as hypertension. And the models of care to treat NCDs in these settings really rely on a staged process of priority, is to find and maintain treatment for those that are already on treatment for NCD such as diabetes or cardiovascular disease, to ensure there is no interruption of treatment. Secondly, there is a process of case finding and raising awareness within the communities around NCDs, to ensure that those with NCDs are able to access care before severe complications set in.

Skip to 1 minute and 8 seconds What we’re also seeing is the need to improve operating procedures, guidelines, essential packages of medicines for NCDs in emergency settings to increase the availability and access to NCDs in these settings. What we’ve observed in areas where we’ve been doing work and research on NCDs is that people are accessing care far too late, because levels of knowledge and awareness are low often. So for example, in a study we’re doing in diabetes in Democratic Republic of Congo, we were witnessing people that are coming to the diabetes services quite late. And as a result, complications were setting in, leading to things like foot amputations, premature blindness, and so on.

Skip to 1 minute and 56 seconds And so the challenge is really raising awareness in the communities, but also improving access to that care, both through increasing the availability of that care, the quality of that care, and trying to overcome many of the challenges inherent of working in a very insecure environment.

Skip to 2 minutes and 13 seconds KIRAN JOBANPUTRA: The programmatic challenges around NCDs in the settings that MSF works in, very much relate to the fact that non-communicable diseases are chronic diseases. So it requires implementing a chronic care model in settings where the health system is fragile, and maybe it struggles to adapt to the specific needs of chronic care programmes. So the sort of thing I’m talking about are training staff in chronic disease management, so these chronic diseases maybe have not featured very significantly in the curricula in some of these countries. Or maybe those chronic diseases were only managed by hospital specialists.

Skip to 2 minutes and 53 seconds And in the Syrian context, for example, the mass influx of refugees to surrounding countries, we now have to deliver that care at primary care level. There isn’t enough secondary care. So training staff who are not familiar with those conditions, implementing guidance protocols, tools, simplified SOPs for primary care settings, looking at treatment support, multi-disciplinary team working. So in other words, not just having a clinician, but also maybe a lay health worker or someone that can spend time with the patient exploring their specific issues. All of these are parts of chronic care that are standard in many developed or high income settings, but have infrequently been implemented in the settings we’re working in.

Skip to 3 minutes and 38 seconds And then, of course monitoring and evaluation and patient registration to be able to monitor, assess, and improve the quality of the care you’re delivering. Now, those are the implementation challenges around NCDs, but there are challenges relating to NCDs in these settings that are broader than that. We lack information. We need to better understand not just the epidemiology and the demography of these diseases, which parts of the population they’re affecting and how the needs of those different parts of the population differ. We need to have a good understanding of the health system, which often includes detailed gap analysis. And we need to understand people’s perceptions of these diseases, and what will make them seek care, or what are their priorities.

Skip to 4 minutes and 22 seconds Because we have very little understanding of that. And until we understand that well, we’re unlikely to have optimal services.

Skip to 4 minutes and 30 seconds BAYARD ROBERTS: There are a number of challenges in mental health care and humanitarian settings. One is a quite fundamental one, of how mental health is conceptualised and understood. Because it’s so locally and culturally bound, that it’s not simply possible to impose a simple set of services or an understanding of what mental health is in different cultural contexts, in the way that you could, for example, with NCDs and diabetes or cardiovascular disease. And so it really requires a much more grounded, culturally sensitive approach to understanding how that population understands mental health and mental health disorders, and what are culturally appropriate responses to that. So that’s a really fundamental issue in providing appropriate and sensitive mental health services in emergency settings.

Skip to 5 minutes and 26 seconds Other challenges include simply the availability of services in these resource-poor settings, and access to those services, particularly in insecure environments. Other challenges relate to the stigma and discrimination which is really inherent in the issues around mental health in whatever context, but equally applied to mental and to emergency contexts. So that’s something the agencies have to work towards to support people being able to understand mental disorders, and then feel free to access mental services. So there are barriers there. Other issues around providing mental health services and care include the availability and the quality of provision of care, and also, the long term and sustainable nature of it.

Skip to 6 minutes and 22 seconds In many settings, we see protracted crises which go on for years and even decades. And so there has to be an attempt to try and integrate services within the communities and within the local health system. So that will often mean providing mental health care and services through, for example, the primary health care system, rather than setting up standalone vertical programmes which are generally not sustainable and reduce access in many cases.

Non-communicable diseases and mental health

The burden of non-communicable diseases (NCDs) is becoming more pronounced in humanitarian settings as more crises occur in high- and middle-income countries. Awareness of mental health needs in emergency settings is also increasing, placing greater emphasis on interventions appropriate to address each.

Dr Bayard Roberts and Kiran Jobanputra explore the role of health services in preventing and reducing the impact of NCDs and mental illness in the wake of a humanitarian crisis. They also examine the challenges of implementing care in complex and fragile environments, and highlight gaps in current provision.

In the video, Bayard raises the issue of cultural and social understanding of sensitive health issues. If you think about your own personal background or professional environment, how might the norms or customs of your culture affect someone who wanted to seek help for a health issue?

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This video is from the free online course:

Health in Humanitarian Crises

London School of Hygiene & Tropical Medicine