 Our next presenter to have Philippa Bould, who is the NCD advisor and leader of chronic conditions at MSF in Switzerland, and she has previously worked in MSF operations as the medic responsible for interventions in Iraq, for medical interventions, in Iraq, Syria, Lebanon, Sudan and South Sudan. Thank you very much Philippa, thank you. Hi everyone. So I'm going to give you a little bit of an overview of the burden of disease that MSF is seeing, particularly looking, giving a few examples of things that we're seeing, but I'm not going to go into so much detail of the examples of programs. I'll leave that to Q and in the next session. What I want to really focus on is some of the programmatic challenges that we're facing. So Kwaku has given us a nice overview of some of the more political or country-level challenges and I'll look more at the programmatic challenges we're facing. So just for those of you who don't really know MSF so well, and also just to set up a bit the discussion of the angle that we take and the approach from which we come, MSF is an international medical humanitarian organization and we deliver emergency aid to people affected by conflict, epidemics, natural disasters and an exclusion from health care and that's really based on the need of the population. And so I think the important thing about this is that we're seeing the need of the population change both as the demographics, the global epidemiology changes and then also as the nature of the places in which we intervene has been changing over time, particularly recently. So in 2014 MSF, so just MSF works as a, has five different operational sections and in 2014 we were working in 62 different countries with 384 projects and particularly of interest 59% of those were in unstable contexts so that frames a lot of what we do. Some of those are in what we controversially call remote control but that means we're really forced to use, we're only able to use just staff that we're able to find locally and so if there's other expertise that we need it can be more difficult to provide it on the spot and we need to provide that from afar. And then we have a small amount of projects where we provide support to different places. You can see that the majority of the projects are in African context but a wide variety of other ones and the Middle East quite a big one at the moment. Out of those you know most of our NCD care is provided within primary health care on an outpatient basis and so we had over eight million consultations in 2014 and you can see that the bulk of those are in African contexts and particularly in conflict affected countries. Most of those down the bottom have significant conflict over recent years. So what's the burden that we're seeing in these places and this is a patient leaving a clinic in the Ukraine where we're dealing with a lot of NCD. Well it depends a bit on the context so certainly we have a lot of variation by the depending on the different types of context. So we work in unstable contexts as I've mentioned and increasingly those are in places that have a high burden of NCD so the Middle East gets a star because I mean Quaker has already given a nice overview of the challenges and the burden that's faced there and that's where the bulk of our NCD patients are so far. Ukraine being another example and then we have a number of unstable contexts where there are you know lower burden of NCDs but we're increasingly having our teams needing to create a response for it and certainly in our primary health care settings we're not necessarily have been used to you know having the system that's required to manage these diseases. We'll talk a bit about that later but from places like Sudan to Kenya to working with refugees in Tanzania in all of these places now our teams are really trying to set up a system to address the particular challenges of the NCDs and then we have what we call our more stable contexts where we are for longer periods of time addressing a particular need and so for NCDs what's especially relevant is the HIV and TB projects and we'll Helen will talk a bit about those in the next session. Also urban slums so in these settings we're you know having particular groups who have high risk for NCDs that we're addressing amongst the normal projects and then you know importantly in all of these contexts I mean around the world now globally there's you know the biggest displacement the world has ever seen so 65 million people and that we're seeing in many of these different contexts and that brings particular challenges from managing these diseases. So when I look to give a bit of an overview of the proportion of the burden in fact we have from point zero two percent in an Ethiopian project to 82 percent of primary health care consultations in our Ukraine context where we're managing non-communicable diseases so it's a huge variation where we are and I think you saw in Kweku's presentation even within the Middle East and it's the same for us depending on the setting the proportion of primary health care that's that is taken up by NCDs can vary quite a lot depending on the acuity of the context and in some contexts we've seen that the longer we're there in fact the increased proportion of consultations due to NCDs. So which of the diseases we're managing and again we've seen in the previous two presentations certainly what predominates is cardiovascular disease and diabetes and then we're also seeing quite a lot of asthma and epilepsy and so then sometimes we're dealing with diseases like hypothyroidism, sickle cell anemia, chronic renal failure and when I the disease I put is sometimes it's either because sometimes we decide we have capacity within our program to manage them or sometimes because this is a particular issue in the area. Cancer for the most part is is really addressed related to HIV so Kaposi sarcoma and cervical cancer and then we deal with some others rheumatological disorders chronic liver disease and and and the choice is often depending on certainly the burden of disease but also the the capacity to respond in a cost effective manner in that setting and then mental illness I put on its own and really I mean this is something we're seeing in all of our context often it's dealt with on its own but we're really starting to look at how we can address this in conjunction with chronic disease because of course it's often you know comorbidity with chronic disease. So just to point out as well that the the predominance of diseases varies certainly between countries so for example as we've seen in the Middle East it's primarily cardiovascular disease and type 2 diabetes whereas in Tanzania with the Burundi refugees we have a lot of patients with asthma we do have hypertension we have children with sickle cell anemia and then also within the diseases and so we see some phenotypic sort of variations so so whilst again the Middle East is type 2 diabetes then in in some of the African contexts we may be seeing a sort of type 1 or an insulin requiring diabetes probably related to malnutrition which manifests quite differently. So this is just an example from one country and thanks to my colleague from OCBA for this so 12 different countries ranging from the Middle East to sub-Saharan Africa to Central America where they manage a whole variety of chronic diseases within primary health care and you can see the spread of diseases there with you know hypertension in most settings would be number one asthma and diabetes quite high but they also dealing with a lot of arthrosis and musculoskeletal disorders and sort of some others. Now in some of our settings we really try to to specify what we consider part of our chronic disease program and so in a primary health care you might get a spread like this because you're dealing with whatever comes in but when you're specifically addressing with a specific system non-communicable diseases we tend to try and limit limited and it tends to be focused on on the diseases I mentioned previously cardiovascular disease diabetes, COPD asthma, epilepsy and we often include hypothyroidism which is very feasible to manage in most of our settings. So what's been changing over time? So as Quake has already pointed out there's huge challenges in data you know analyzing data for this because certainly I mean traditionally we've not really been set up to look at you know the data related to NCDs within our primary health care so what I did instead because the data is not so reliable for that you know looking over time was to have a look at one of our supply main MSF supply centres that supplies four of the different operational sections and just to look at the the orders that have been placed for for insulin and also for enalapal so two key drugs for NCDs over time now there'd be lots of biases and ways of interpreting this but I think it still shows quite an interesting trend and so you can see for the different insulin orders that you know they from 2008 quite low numbers of quite low amounts of insulin which slowly increased a little bit over time and then really an exponential increase over the last couple of years but what I looked at as well as not just an amount of insulin that's been ordered but also the number of projects and number of orders that have been placed and I think this is quite an interesting trend because that's more of a steady increase so it shows to me two things you know one is that the number of places that are starting to order and need insulin is increasing but also within those the amount that's needed is increasing so as I said not not a good statistical analysis but an interesting trend and similarly for enalapal you can see also that the the number of projects and orders for that has been increasing whereas the amount of it has increased much more exponentially recently so as I said I'm going to focus a lot more on the challenges that we face and I'm going to sort of classified into two things one is the patient challenges and one is the more programmatic challenges and the patient challenges really come down to sort of the vulnerabilities of the patient so these become challenges both for the patient to manage their disease and for us as an organization to help them to to support the patient with the management of that disease and in these settings there's you know it's a very complex pattern and very many risk factors so the sort of risk factors around livelihood meaning of course in a conflict situation or in a in a displacement situation you will have you know pressing needs like food and water and not just access to that but also suitability of the food and of the shelter to being able to self manage their disease and so quick who already mentioned a bit the lifestyle issues but certainly you know if patients have very limited access to food that can be quite challenging and we've seen that in a number of settings such as with with the refugees in Tanzania where you know access to appropriate food to be able to then manage a patient with type 1 insular diabetes and certainly even to enough food can be quite a challenge then of course loss of livelihood loss of pensions income to be able to manage the ongoing requirements of a chronic disease and the loss of care and social networks and this is something that we see quite a bit for example I was recently in the Ukraine where we're working with people in the buffer zone of the conflict area it's primarily elderly people who've been left behind the younger people and those who've been able to have already fled so a lot of elderly people with with non communicable diseases who've really lost their social support structure they don't have people to help them young people who can take them to to health to access health care for example and it's also caused a lot of fragmentation within the community so that there's a lot of mistrust within the community and so the whole social network has broken down which makes it very challenging for the population who are suffering from medical illness and we see particular vulnerable groups so so those with disability mental health will be an issue that will come up many times I think today there's a lot of multi morbidity associated with NCDs and these ones are more challenging to manage we see you know the last two categories I've already mentioned the housebound elderly that we see in the Ukraine and then another context so in Congo for example it's young mothers who have you know complications due to their diabetes for example a blind patient I've been told about who's still needing to care for her four children so there can be some great variations in the vulnerable groups that we've seen and as well as and this really alters their ability to self-care as I've mentioned as well as the difficulties in trying to provide the right care for them so in terms of the challenges related to implementations I'll look you know at the programmatic challenges the challenges related to the technical delivery of the care and then the model of care and how we address that so for the programmatic challenges the first challenge and will is that of prioritization so in these complex contexts when you're in a conflict situation when people have issues of livelihood where you know what are the most important needs so the first thing we need to do is assess what those needs are and that in itself can be a challenge and traditional methods of assessing the needs in these in humanitarian settings haven't necessarily included looking at the needs or how to look at the needs related to non communicable diseases and then you need to make some choices and sometimes some difficult choices on what are the priorities in that setting and once those choices have been made something that that I think is often interesting is then defining the objectives of that so if you have if it's clear that non communicable diseases is something that you need to address if you're in a conflict situation as an emergency organization what is your objective in addressing that need and sometimes that can be a challenge certainly for the people in the field and particularly when we look at the scope of the response so so the issue is you know how far do we go who is it that we admit to the program is it those who have complications and are most severe is it those who just who need continuity of care do we go so far as to screen for patients with hypertension and diabetes and I can tell you as MSF so far that is not something that we normally are doing do we look at preventative measures and how much can you you know ignore the important issues of prevention related to these kind of diseases and and and what what is the scope of medication that you provide given that this is a broad range of diseases with many different diseases that you're addressing in medications what is the scope of what you're going to provide how much does it fit in with what exists in the country and as quick who's already mentioned this can vary a lot in different countries there's not a lot so far in terms of what we've seen of a sort of harmonious list of medications that's used and so when you go in as an humanitarian organization how much do you try to harmonize that and how much do you try and go in with the essential list that's yours and that you think is important and then that that issue of sustainability and continuity of care which is always one of the huge challenges in any humanitarian setting but even more so when you're looking at diseases that need continuity of care and then the challenges of resources and I think I could already mention this but but one of the things is that the human resources of course and so what are the competencies that you need and what are the ones that you have locally and they may be very they may be quite different do you need particular expertise or do you try and deal with you know the competencies that you find there and then how do you support that staff from afar or on the spot and for supply we've already mentioned some of the challenges of the medications but of course you and the issue of it being relevant to the context in which you're working but as well as that trying to make sure you have a continuous supply since one of your objectives is often going to be continuity of care I have to skip this because it's in another presentation so just an issue on the challenge of comorbidity okay so for the model of care so as I mentioned previously often we're trying to implement this care and in an integrated manner so integrated into our primary health care but our traditional approach to primary health care is not so adapted to a chronic care model and so with the model of care the challenge is how do you organize the care particularly if you're in an emergency setting if you're in a mobile clinic you know going from place to place how do you actually organize care for this kind of the chronic care that's needed and how do you adapt that to the type of setting whether that be a more stable setting whether that be a mobile clinic secondary health care and so on and then what you do in terms of the staff roles and so one of the challenges if you don't have exactly the human resources you need or if you have you know a big need to address is this issue of whether you can task shift to nurses or to lower levels of staff to provide some of the care in the setting and then within that that organization you need two specific things and one is the follow-up of patients and this is what primary health care is not normally adapted to how do you provide follow-up care for patients with a chronic condition do you trace the patient if you lose them in the program what if you're unable to access the location and that has certainly happened to us in a couple of contexts where we've been running a regular clinic and then for security restrictions we're unable to go for a period of time so what do you set up in place to be able to allow that continuity of care for patients and what if people are moving and as we've seen there's a huge movement of population these days and so you know how do you address that if there's a population that's on the move and and they're needing this continuity of care and then the other specificity again which Quaker has already talked about is this need for patient education and patient self-management and this is extremely challenging in conflict and humanitarian settings to find the time firstly to give the patient the information they need to have staff who are competent to give that or who have the skills rather than competence to give that information but also I think you know prioritizing what the education is that you give and so it's always this we have this discussion a lot about the challenges around the education what is the most important thing you know if you're in a conflict situation is it really to be you know addressing with patients stopping smoking and changing their diets and exercising or should we prioritize the education and look at things like taking their medication appropriately keeping themselves safe and knowing you know the danger signs and symptoms and so these are really interesting challenges to see how we then address the education in these situations and of course the challenge of then making it culturally specific and relevant and meaningful to the population with whom you're working and then lastly the technical challenges so I won't dwell too much as Craig has already talked a lot about the guidelines and so they are very different in different places and as we've all and and we try to really have an evidence-based guidelines but the problem is there's really not a lot of evidence as we've already heard from humanitarian settings so it's often a case of trying to adapt existing international guidelines to our context but then the challenge of having that you know harmonious guidelines and different between different organizations and with the national guidelines as well and then with the tools again having these adapted to the chronic care model in terms of patient file that enables you to follow up the patient data is a huge challenge and that's something we're really working on a lot because you know in in a in these kind of you know emergency context to be able to collect the right data really does take time and effort and it's different data that you need for a chronic disease compared to an acute to acute conditions because you need to somehow look at the impact and the follow-up of patients patient education tools laboratory and so this is also a discussion that we have about what you know what are the minimum levels of laboratory requirements how much do we are we able to do and in terms of point of care tests how much do we need to set up a bigger level of laboratory and then adapt to the context monitoring and evaluation I haven't really in fact data should have been under there but I but I haven't put much there because that is a whole session that we're going to talk about in but that's one of the biggest challenges I think that we face so the challenge of patient education and making it relevant and then the other challenge so this is a lunchtime at community a mobile clinic in the Ukraine where the community provided lunch for us so you can see straight away if the clinic is providing us is our lunch we're going to have a huge challenge with the lifestyle education and this is a little training session we did recently on educating our staff on how to teach patients so that's a very very quick summary that's certainly not all of the challenges that we face and hopefully some of our colleagues contribute some of these but these are just when we're looking to implement programs what of the things we face so far and then in the next session we'll look a little bit at some of the examples of how we've tried to address some of the challenges and what we've implemented but as I said already you know a lack of evidence on how to go about it is one of the things that really is facing all of us and so there's a lot of work to try and you know look at what different different models and different technical methodologies we can use to address the challenge of entities and humanitarian settings so we'll now move on to some time for questions including questions of clarification for Philippa if there are any if we can ask our speakers to come up some stools have been specially prepared for the older amongst us it's all getting a bit Valdunacan and just while we've got a brief gap do people have to sit at the back do you want to are you okay please come and grab some seats this is a fairly dreadfully designed lecture theatre in the sense of just blocking people from getting seats but you're okay okay great so thank you for the three presentations deep breath time in terms of enormous range of challenges that have been being presented here and thanks quickly for offering some solutions and recommendations for those and certainly the challenge that James presented and Philippa mentioned as well and also quickly around that the lack of evidence and data is really one that has sort of motivated much of the work for this symposium and and the work that we're doing with MSF in trying to sort of work together on looking at how we can improve evidence on NCDs and NCD responses in humanitarian crisis and definitely there'll be more examination exploration of this in particularly the session this afternoon so moving on to some questions should we start with the online audience yep so we have one question from Eva for Philippa and it's the burden of consultations for NCDs in line with the burden of disease for NCDs and can you comment upon the health literacy of these people on NCDs so I guess in general for the first question the answer is yes so certainly in in kind of the sub-saharan African context where we see that you know there's still large rates of things like malnutrition like infection infections vaccine preventable or vector-borne diseases then the proportion of NCDs that we'll see is less whereas in the Middle East obviously there was already a pre-existing high burden of disease and so that's what we see in somewhere like Ukraine again it is a pre-existing high burden of disease but it's also further skewed by the fact that some of the population who've been able to live with a younger and more well population who may have been the ones more likely to have infectious disease and so on coming with those and what we're seeing is the population left with the chronic conditions. Any more online questions? John, if you could also just say who you are and what you're from. I'm John Yudkin retired academic from UCL I think what I like to do is to suggest that there's not only the burden of disease that should prioritize interventions there's also the concept of how much difference an intervention can make and that's very much to do with the context. For example the burden of disease for cardiovascular disease is huge and yet if somebody is displaced and has to interrupt taking their statin for a day or a week or a month they may get a proportionate increase of about point something percent in their cardiovascular mortality. Somebody with type 1 diabetes whose insulin supply or syringes are not able to be taken with them on a boat journey across the Mediterranean will die so even though the burden of cardiovascular disease is huge burden of type 1 diabetes is tiny the acute case fatality from an interruption of medication is vastly different between those two so could I suggest I mean Philippa addressed this neatly because she was implying there's a sort of matrix that's not only to do with disease burden and the number of consultations but the acuteness or chronicness and the impact of interrupting medication epilepsy somebody who has it chronically but if they miss their medication they have an acute status epilepticus type 1 diabetes similarly and what I would then suggest is one needs a sort of matrix for the chronicity of the condition the prevalence of the disease the case fatality of an interruption of medication and the programmatic necessity to think five and ten years in advance if one's got a chronic situation as in many of the refugee camps in his to Mediterranean and elsewhere thank you John yeah no I just thank you very much that comment I think it's a very important point and I am and I guess that we certainly when MSF is looking at you know intervening in a place we do look at more than just what are the predominant diseases we look at the added where the gaps are in terms of treating those but particularly who are the most vulnerable and so relating to NCDs this may be often the ones with died with type 1 diabetes for example and so in context where the burden is perhaps lower and where we have many many other challenges such as for example in in in our project in in South Sudan in fact it's primarily the patients with type 1 diabetes that we manage and and as I mentioned it in Tanzania with the refugees we see lots of patients with epilepsy and so so I think that is a very important point and I had something else to say that I forgot okay we're just gonna pass the mic around we just got there I'm also just I'm just gonna take a question from I'm just gonna take a question from the online audience first so we have one for James as well from Ionis and asking in your review if you saw any prospective studies comparing TB in people with diabetes versus the general population did we I don't think we did certainly not that I can remember no I mean we do need to look at the data and a little bit more detail but certainly from the work we've done so far there's there's nothing who's gonna who's got the mic let's just start with Barbara hi my name is Barbara Lopez Cardoso I'm from the Centers for Disease Control and Prevention in Atlanta I just want to make a comment thank you very much for the great presentations but I wanted to clarify something about the definition of mental health and how it's included in NCDs or not included because several of you you know like I am seed does seem to include it in NCDs and MSF sometimes does but I think in order to get a better handle on the magnitude of the problem of NCDs we also need to define better what we really mean with NCDs and if mental health is or is not included in it of course you know the mental health the global mental health field is a whole field in itself in a way but it's also very closely related and maybe it's part of NCDs and on the other hand NCDs in terms of your hypertension IB is also very closely related to mental health issues in terms of comorbidity etc so I think if we want to get a better idea about the the prevalence and the magnitude of the problem first we need to define what we really mean with NCDs and if mental health is or is not included and you know just to throw it out there that I discussed yesterday also with Kieran that I think it would be not that difficult to do some better cross-sectional surveys to get a better idea you know what really the prevalence is and at that point of course we can also define if we're going to include mental health in those kinds of surveys and certainly CDC would be very much willing to you know assist us then. Yeah just I'm glad you raised that point so from I think from our perspective and putting this symposium together we we were viewing in a sense that mental health is and psychosocial support is slightly separate only in the sense that it is a field unto itself and there's been a lot of work on it whereas there's been less work on on diabetes, cancers, cardiovascular disease, hypertension so on so I think that was part of the logic behind it but absolutely that there should be the links between them the comorbidities the potential for for integrated services is something that really needs to be born in mind. I know there's some hands coming up here but I just want to ask the panel members if they have any responses on that point. Yeah thanks yeah very important point on that but as Bea had mentioned I think from our perspective it's more about the integration of the services you want to avoid the situation whereby if you have a health center where you have consultation going on for for some form of NCD if you like and the co-mobility that you mentioned then if you have a sort of a separate location for for mental issues then it becomes quite a difficult challenge for the client especially in situations whereby movement is a little bit restricted so if you have a situation where you can have the so-called one-stop shop like your your HIV TB approach for example whereby it's all integrated so if you have someone who has got an issue related to the NCD which is a factor to the to your mental health or vice versa then it's easy to to provide a service in an integrated approach so that's the way we look at it but certainly there's a lot of discussion I think in the NCD group headed by UNSCR is also being discussed this particular issue I remember the discussion very well and the fact that mental health has got sort of quite a bit of focus there's a tendency to try to separate them. Yes just on this topic it's it's interesting because what we do now is simplify it and do mental health as if it's a harmonious group of diseases and NCDs as if it's harmonious group of diseases we end up addressing the NCDs as we talked and mental health go to psychosocial support what falls in the crack is psychiatric disorders that then very few people acknowledge or address and this we've seen there has been a quite forceful push in some of sections of MSF to just accept that you have mental health conditions that need treatment that is chemical treatment not psychosocial support and that get ignored and done off with because they are not included practically in any of the two groups. Thanks for that point. Karen you had a question. Polyuria as a medical condition for saying that they would present for health especially in a context that has not known diabetes significantly in the past so I think it's really just to say that maybe it's more a comment and a question to the panel about how how we can address this and do we need to actually rely more on surveys of disease burning in the context of working rather than relying on what we're seeing. Yeah just a quick comment on this. This ties in very well with what the gentleman mentioned. So in the situation of displaced population in the humanitarian context I think we also discussed in the NCD group at some point is do you sit back passively and wait for clients to get to you or you actually seek them as you mentioned if you seek you may find. However if you have a context whereby you know previously that you may have people for epilepsy or may have a client with type 1 diabetes etc and if you sit back and they don't seek care then your mortality in that particular case it goes up. So there's a fine balance between passively sitting back and actively seeking clients to go out in terms of what is out there etc. We related to what the gentleman said as to the level of risk and mortality if you interrupt treatment something that I think it needs to be sort of be part of the whole package of NCD care in emergencies. Sure I mean not much more to add but it was certainly something we discussed as part of this review and it's unsurprising that we see a lot of papers that look specifically at hypertension because it's diagnosed with a blood pressure cuff and it's very simple and straightforward. I mean it was it was also quite surprising that we were seeing an increase in the number of papers that were looking at cancer and that raises some interesting questions in terms of what you go where you go with with that information once you've you've made a diagnosis. Certainly in the context I worked in most recently we saw a lot of hypertension diabetes because it was simple and straightforward to pick up on them in some ways to treat. We were treating cardiac disease somewhat presumptively on occasion and then we were seeing cancer but unable to do anything about it. Yes certainly and of course it's absolutely true that you we find what we look for and I and I it's certainly I wonder whether the fact that we're starting to have more requests from some of these kind of sub-Saharan African context for how to support patients with NCDs is because there is an increasing awareness of it and they're more likely to do something with the high blood pressure they find than perhaps ignore it in the past but I guess there is also this issue of the prioritization and so that the question of then what we look for will depend on the priorities and the context and how far we go and so in some contexts it's been that we don't have the capacity to be sort of screening as such for patients with these diseases but certainly having our team alert to them and certainly doing training of our teams to make sure that they recognize symptoms if they present and in some situations doing some some sort of health promotion in the community particularly you know to make people in the population aware of these diseases. Okay thank you I'm conscious quite a few hands being raised but let's first go to the online audience. Yep there's another one for Philippa from Francesca in Italy and she wanted you to comment a bit about the cost of a project on NCDs in comparison to other projects so in terms of the team and drugs and then if we know something about the impact of results of these kind of projects on mortality. Okay so yeah relating to the costs I mean certainly a chronic you know a chronic disease program brings with it a huge number of different costs to what we may have in other settings but I mean firstly the cost of the medications is is one of the big burdens because you're needing to provide patients with usually multiple numbers of drugs on a continuous basis. One of the benefits though is that with with many of these conditions there are generic and cheaper forms of the drugs available insulin though is still an issue and so that's certainly a cost and with insulin there's also a lot of extra costs you may not necessarily think about you need to provide the equipment you need to provide the glucose monitoring how far do we go in terms of providing that and the other cost that that is a challenge is is this the setup and that you know these patients may take more time to see in consultations and so you may not the clinicians may not be able to see as many patients per day because each patient is more complicated and that you need to think about these other components like like following up patients and like providing education to patients and so that and that brings an extra cost. There was another question on the impact. Yeah and just to add to that another person want to also know about the impact on morbidity as well so disability long-term disability as well as mortality just to answer. Okay so so just very quickly because we're running a bit short of time as I've said we've had to sort of look at how we collect our data because definitely what is important is to measure the impact in terms of the morbidity so we look at certain measures like patients blood pressure and blood sugar but we also look at the complications sustained by patients and so on but that's really a work in progress and that's something I don't have some good figures on unfortunately at this stage but hopefully we'll come. Okay thank you we've got loads of questions coming up now I'm going to take two questions here so if you could yeah. Just I want to speak my name is Ali from Oroa. Just I want to to to mention one of the important challenges facing humanitarian organization in the field which is the sustainability of their interventions and the handover of cases after they leave. Usually there is an immediate response during a humanitarian crisis that usually become less relevant less important. Usually the humanitarian organization comes through a project for one or two years they create dependence of patients after that they leave and those people are left without any care. Thank you. Did you also? Dr. Slama from WHO MRO I'm the NCD focal point for NCD in emergency for our region that cut across 22 countries so we have two three great three countries Iraq Syria and Yemen at the moment where we are facing those problems plus Libya plus other countries but I wanted to link the the discussion about the burden of the priority element because of course I mean the health information system in emergency settings is different from a traditional health information system and from NGOs perspective I mean what you capture as you mentioned is sometimes not directly I mean the reality on the ground and there are various providers as you mentioned as well more and more we see humanitarian providers asking the Ministry of Health mainly to mainstream the services for displaced population and they do it as well so you have a mixed health system within you the humidity and context so what you are capturing doesn't say much sometimes of the reality on the ground in terms of service delivery from a burden perspective I mean in my region in particular we have a quarter of the population that have hypertension prevalence we have 14 percent of the population with diabetes this is one of the highest in the highest in the world and the treatment gap is huge we know that even more than half of the people are not receiving any treatment even they are diagnosed so the purpose here is not to link just the burden because the burden we know that is there have received a lot of proposals in the last three years about conducting studies on the burden and prevalence of those condition among Syrian refugees I don't see the sense to that I mean the pre-existing condition that we know in Syria we will find them in those people I mean in other neighboring countries the main issue is what are the priority action that need to be taken and what are the subgroup of those patients that need specific attention in term of minimum standards like the sphere standards I mean recommendation on NCD are I mean give some orientation but they are not specific enough but which group of patients like those who are already under treatment and within those who are under treatment maybe the subgroup of those who might present life-threatening complication if we interrupt suddenly the treatment this is a kind of reasoning that we are trying to implement with the I mean an agency group at the moment to come out with some outline of a proposal of a strategy to really prioritize NCD in emergency because we are trying to mingle everything together I think as as Philippa have said we need a bit to prioritize and also in terms of settings when the settings are different if you have implementing partners working with UNHCR if you have like in Turkey the Ministry of Health being directly I mean providing care and situation like Syria acute emergencies and more protected situation with displaced population are a bit different in terms of the ability to retry it something that I've seen a bit missing from the presentation in Syria Iraq Yemen for instance the main determinant is access and conflict related and direct attacks and all those elements that are protection issues and entitlement rather than the programmatic area related to NCD and this is a bit I mean one an important distinction to be made with Lebanon Jordan Turkey which are more situation of chronic condition a chronic situation where we have displaced population thank you for those for those two points I think we've got that three three or four questions here let's just start with David just down here thanks I'm David from Alice HTM I wanted to ask about the definition of the diseases when you try to quantify disease I think the first thing is to define what it is is and I I have the impression I'm not a medical person I'm a statistician when speaking to Maddox they say well many of these definitions are drawn from countries and settings that are completely different from these like hypertension or diabetes so is it really reasonable to use the same definitions to quantify diseases in these settings to have any thoughts about that yeah I mean in general you know in our guidelines we would use for example the fairly standard WHO definitions for diagnosis of diabetes and diagnosis of hypertension for example so in my experience I haven't seen that to be a big challenge in terms of too much difference in the way that they're diagnosed there may be a challenge in whether people are actually sticking to those but in terms of the overall concepts I haven't seen too much of a challenge in that I don't know if you have a comment yeah for international medical core our default position is try to look at the existing definitions from the countries where we operate so Lebanon or whichever country we look at what are those definitely already exist and we try to use and adopt those if those are not available because of whatever the reason then the next level go to the global level WHO definitions etc which most of the time it needs to be sort of adapted to specific context but certainly they are there and I think the biggest challenge or one of the challenges related to that is is how you you convey that to to the staff especially situations whereby they are not very familiar with those and related to that is the the flow of of client care looking at the primer presentation I realized that for example that the flow of client care of diabetes was it in Jordan was completely different from the one in I think Lebanon or Iraq one of those so these are some of the things but certainly these definitions at least from the global level from the WHO level it's already there okay thank you yeah Dave Lee on from the London School of Hygiene Tropical Medicine I'm an epidemiologist I just first of all I think there's always a tension in these situations between saying the focus should be on what we do because action must be taken which obviously is what most people here feel I feel action has to be taken but on the other hand it is very important that action is taken on the basis of good evidence and so the notion that we know what's there and therefore just develop programs I think is slightly misguided I think in a number of settings particularly in Sub-Saharan African settings and some settings in the Middle East we actually don't really know what the burden of NCDs are even in the stable populations we really don't know there's data out there but it's very very it's very very thin so I think they're going back to the the first presentation the importance of surveillance are to objectively try and determine what are the important profiles of disease and NCDs communicable diseases in populations is absolutely crucial because that is the basis for then rational planning in terms of what you can anticipate having said that I think some of the remarks that John Yodkin made I think his idea of a matrix of what you know if you've got type 1 diabetes you're gonna have to have insulin otherwise you're gonna die for other things the intervention in an acute setting is is probably less important but one thing which has come up and been referred to on a number of occasions which I think is really central here is we one thing we do know and it seems I think there's relatively good data on particularly in emergency settings with refugees is age profile age profile is the key determinant of the balance of disease you're gonna find in that population particularly with respect to NCDs so for example according to UNHCR 3% of Syrian refugees are 60 years or more which is probably half the I think the latest data I've looked at 6% of the Syrian population are 60 plus so this is even a lower fraction than in the so someone I think said that the young people are moving younger people are moving out so and those younger people are moving are going to be ones who are relatively healthy and can undertake that trip so I think there are lots of ways in which we can use just the basic data on age to at least anticipate what the profile is going to be and so I would really my intervention is to say we need better data we need to interpret it more rigorously and I think I think the notion that of course you'll find it if you look for it makes it sound as though it's it there's something sort of biased going on I think clearly where services are provided you're going to get increases in what's what's apparent but there are ways of actually doing surveillance which actually independent of of clinics I think that's going to be dealt with this afternoon yeah thanks for raising that point and we will definitely explore a lot of these issues further I'm conscious of time if we just take a question from the online group yeah so this one is from someone from MSF France and they're just asking about some people who are in these settings have already medication from previous doctors and some of these are outside of the guidelines for MSF so just wondering if there are any things about updating your guidelines to adapt to these people who would have already been on certain medications that might not be on your protocols so we have a lot of discussion about our medication list but really we we try to work with an essential drug list based on what are the key medications so that if patients come on on medications outside of that we should have an equivalent that we're able to change them to and this is certainly a challenge and it's difficult for people and for patients in it you know if they've come from a traumatic situation and they're needing to then also confront other change in terms of their medications but in the end we need to really have evidence based and sort of cost effective model which includes an essential list of drugs and that's generally how we work there are some settings in which we need to adapt slightly depending on sort of for example the national protocols and so where we're working according to national protocols and we're purchasing locally it may mean that we have a few drugs outside of our list but in general we stick to quite an essential drug list okay thank you so I think we have overrun by five minutes I know there's at least three questions that people have been raising their arms extremely strenuously for the last few minutes so if you can make the questions but keep them very brief please thank you just to follow up on the question of protocols is there any attention being given to try and harmonize protocols across agencies and across the countries because there's been quite a bit of that on communicable diseases will cross-border work so I wondered if there was anything similar of NCDs and my other question was about a follow-up you know said how difficult it is to follow up patients when they're moving etc so are there any innovations in this field new things being tried etc it'd be interesting to hear thank you so in terms of how I think I have some colleagues here and from other organizations and we've had a lot of discussion about this about harmonizing protocols a lot of us base our guidelines on the WHO pen guidelines and so there are certainly a lot of similarities but I think as time goes on there is a lot more coordination between organizations and this will be something we move towards relatively soon in terms of the innovations and following up patients there are a few things that have been tried I personally can't give you any detail on some examples but there has been some work with for example all the migrants moving into Europe and in terms of looking at different things in terms of apps and technology to be able to have patients have patient held records to be able to follow them but I think there's still a huge amount of work that can be done on that I think that's a whole interesting field to explore yeah so on the issue of protocols I think probably the gentleman will have a comment I mentioned there is a group led by UNHCR for NCDs and this one of the things that has been discussed over and over again and the last I heard there was an attempt to try to harmonize the protocols based on the existing pen to adapt it to humanitarian situations so yeah hopefully I don't know where that is because the last time I attended a meeting with that group was sometime last year so if there's any update on that that would be good to hear but certainly that has been recognized and there's there's effort to try to address it and with the continuity of care and follow-up yeah I mean it's quite difficult if you look at the displacement and fluidity of the situation at least for the Middle East is hugely an issue for those who are relatively stable or not moving that much in the camps it's a little bit easy to follow up through the peer support groups and the outreach services through the committees because that we use beyond that if somebody moves from Camp A or from Turkey to Europe or from Northern Syria to Cyprus etc. I mean you try to give them records of the medicines they are on etc so that the next point they get to they'll be able to assess those medicines but it's really really difficult at this day to have a grasp on the continuity of care if people move. Okay thank you our final question Genswin at the back. Another quick question about prioritization something picking up on something a couple of people have touched on particularly for end-stage disease complex treatment requiring diseases like cancers renal failure as well people who require dialysis I wonder if you could just say a little bit about how that fits into your discussions around prioritization the way in which you guys have been able to manage that if at all in the field and practically what's being done for people who have for instance end-stage renal failure and need access to dialysis but find that practically very difficult to get access to. So yeah I mean so the prioritization is always a very complex issue and it depends not just on the burden but at the vulnerabilities and where we can particularly have added value so in some circumstances it's providing general primary health care but there have been examples where we felt that we can really have a concrete impact and particular added value on on some of those more complex things so we have some specific examples where we have supported dialysis services so Ukraine and Yemen being two recent places where we've also provided primary health care or emergency care but there's a very concrete need often with an existing service that needs our support and then dialysis has been something. There is one project where sort of more invasive cardiovascular disease management is provided as a specific example so so it's certainly something that we're open to and it's and it's a I mean it's a very complex algorithm of looking at the needs and the added value but but but they can be lifesaving examples and so that we do we have at times address those. And a very pertinent question too because we happen to have a video an MSF video I'm assuming so you're not going to say it's HM1 on dialysis and that's being shown at lunchtime. So thank you for your attention apologies not to be able to get all the questions in particularly for the online audience but stick with us we do have all day to ask lots of questions so the next session starts promptly at 11 15 tea and coffee is served right downstairs can the speakers for the next session please come to the front now and it just leaves me to thank our panel members thank you.