Diabetes Care During Armed Conflict
By Anna Brooks
Ongoing hostilities and violence across the world leave people with diabetes in crisis and without access to essential resources. What can be done to help?
“For war, no one is prepared.”
This comes from Dr. Waseem Alzaanin, a doctor currently volunteering in Gaza with the Palestine Red Crescent Society.
Alzaanin was one of many who had to flee his town on the border of Gaza after the escalation of violence within the Israel-Palestine region. Alzaanin also lives with type 1 diabetes and is both experiencing and witnessing firsthand the devastating effects of war on people with chronic health conditions like diabetes.
“From the first day of the war in Gaza, all of the clinics that provide medical care for people with diabetes are closed,” said Alzaanin. “There is an extreme shortage of all medical supplies. I know a lot of people with diabetes who do not have drugs, insulin, or glucometer sticks to check their glucose levels.”
Roughly two billion people now live in areas of armed conflict, according to the United Nations. In war-torn areas like Palestine, Ukraine, Iraq, Yemen, and many more, people with life-threatening conditions are especially vulnerable without access to even basic medical care.
If you live with diabetes, what can you do when facing the unexpected?
Self-education and stress management are critical
In the face of violence, innocent civilians – including those with diabetes – are consumed by extreme feelings of fear and helplessness. With severe stress plus limited access to medical care and supplies, managing diabetes becomes an incredibly challenging task.
Despite the lack of security during times of armed conflict, there are a few things experts say you can do for yourself or loved ones with diabetes. The first step is educating yourself on self-management, said Dr. Brij Mohan Makkar, a leading senior diabetologist and obesity specialist based in Delhi, India.
If you’re a medical professional, educating patients on self-management during routine visits is essential. For example, diabetes self-management education and support (DSMES) services offer people with diabetes the power to make informed choices about managing their condition. Studies have found that those who utilize DSMES have improved health outcomes related to diabetes compared to individuals who don’t.
It might seem impossible for those in the midst of a humanitarian crisis, but maintaining your prescribed medical regimen the best you can is also important, said Makkar.
“Adhere to your usual medications, recommended diet, and lifestyle as much as possible,” said Makkar. “Regularly self-monitor blood glucose and blood pressure, and perform other forms of self-management, such as wound care.”
While research identifies diabetes outcomes during crises as suboptimal, it’s also important for patients and healthcare professionals to acknowledge and accept a significant relaxation in blood sugar control.
Of course, the impacts of war on mental health are unfathomable. Like other physical or environmental stressors, this may impact diabetes; studies suggest that the hormones that flood the body during times of stress can cause blood glucose levels to rise.
“Another aspect is the distress from the nonstop bombing of Gaza and leaving our homes,” said Alzaanin. “We are continuously worried and stressed. This makes our diabetes spike most of the time. So, stress relief activities sometimes help to gain control of our diabetes.”
It can certainly be much easier said than done in times of turmoil, but examples of stress-management techniques include exercise (like jumping jacks or running in place), deep breathing, progressive muscle relaxation, resting when possible, and maintaining social connections with others.
Protect medications and create an emergency supply kit
It can be impossible to predict when violence will break out or a natural disaster will strike (even for those already living in a war zone). No one wants to imagine the worst, however, current crises and the myriad of past ones are confirmation that putting emergency plans in place is critical.
“Of course, when war erupted we faced immediate challenges. Ukraine was absolutely not prepared,” said Dr. Boris Mankovsky, a Ukraine-based endocrinologist and president of the Ukrainian Diabetology Association. “It was a very sad surprise for me and all my colleagues because we didn’t expect that so many patients wouldn’t have any supply of insulin.”
Due to disruptions to supply lines and resulting shortages of medical supplies seen during armed conflicts, the first thing to put in place is a backup supply of whatever medications you need. Based on his own experience working as a doctor during the war in Ukraine, Manvoksy said it’s an “absolute necessity” for diabetes patients to have an insulin supply that will last at least 2-3 months.
If you’re in a situation where medical facilities are closed or about to lose power, as is the case currently in Gaza, there are strategies for storing and preserving medicine. For example, try to keep insulin vials cool by placing them next to a bottle of cold water or wrapping them in a wet cloth. In preparing for future crises, medical facilities may look into utilizing new, cheaper options for storing insulin, such as battery-operated, 3D-printed coolers.
In addition to an emergency medical kit, Makkar suggested (if possible) having a backup food supply. Due to either lack of access to food or increased carbohydrate intake from what food aid is available, people with diabetes can expect a disruption in their typical dietary patterns during an emergency.
“Meals in shelters can be inappropriate for diabetes patients and impair glucose control,” he added.
Along with medications, Makkar said emergency medical kits should also include:
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A diabetes identification card
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Personal evacuation plan
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Physician and emergency contact information
What healthcare workers, governments, and aid organizations can do
For healthcare workers on the front lines, treating people with chronic conditions can be challenging. If possible, experts suggest aid workers without prior diabetes knowledge undergo specialized training about how to manage diabetes in environments where resources are restricted.
Especially in places susceptible to violence or natural disasters, volunteer medical staff should be trained and equipped ahead of time with things like glucometers and rapid-acting insulin so they’re ready at all times for diabetes-related emergencies.
Language barriers can also be an issue for volunteers and medical professionals working in foreign countries or with masses of displaced people. Especially if translators are unavailable, finding ways to simplify communication is critical – for example, adding visuals or symbols (like the sun and moon to indicate the time of day a medication should be taken) to medication labels. In Ukraine, Mankovsky said leaflets in different languages with basic information on hyper- and hypoglycemic emergencies were available at the borders.
For healthcare organizations and workers who want to help from afar, offering online consultations is another treatment option. While this might be difficult in areas where access to electricity is scarce, endocrinologists, physicians, and mental health specialists volunteering to do online visits could fill in some of the gaps in care on the ground.
If internet access is available, apps like CardMedic offer a large library of digital flashcards with easy-to-read explanations on different healthcare topics. To improve communication between healthcare workers and patients, the app also offers sign language videos and speech-to-text translation services.
Federal agencies can play a massive role aiding in emergencies by providing free medical care when possible. For example, during the war in Ukraine, co-payments for insulin were canceled and regulations around prescribing medications were lifted, said Mankovsky.
“We allowed physicians other than endocrinologists to write prescriptions for insulin because we understood there are too many patients in some regions and too few endocrinologists,” said Manvoksy.
In war-torn regions like Palestine and Ukraine, a major problem is accessing life-saving medications like insulin. Because roughly 50% of pharmacies in Ukraine stopped operating, Manvoksy said they relied on non-conventional carriers to deliver insulin like post offices and supermarkets.
Of course, this is also why the cooperation of governments, international organizations, pharmaceutical companies, and other outside aid is so critical during humanitarian crises. They can help deliver medications like insulin in regions of heavy fighting through remote means, such as drones.
“People outside have a lot of ways to help,” said Alzaanin. “They can also support us by supporting healthcare and humanitarian aid.”
If you’re preparing for or are already in a crisis and live with diabetes, here is a list of resources that can help:
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Other diabetes organizations like the American Diabetes Association
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Local government council
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Evacuation centers
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Volunteers such as HAM radio operators and retired healthcare professionals
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Donors of medical aid overseas like pharmaceutical companies and Insulin For Life
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Non-government organizations like the International Federation of Red Cross and Red Crescent Societies, United Nations, World Health Organization, and Doctors Without Borders
Editor’s note: It is diaTribe Learn’s policy to ensure the accuracy of the information we convey to our readers. It has come to our attention that a quote used in this article made a claim that we could not verify, so we removed the quote. We regret this error.
