 Now we're going to hear a little bit about the lessons learned from the MSF experience of implementing NCDs in humanitarian settings. So Kiran Javanputra is the Deputy Director of the Manson Unit in OCA, also a family physician, and my colleague is an NCD advisor for MSF Holland. Okay, thank you very much, Philippa, for the introduction, and thanks for the invitation to speak, although I am one of the organizers, so it's cheating to say that, but yeah, I feel I should. Now I just want to acknowledge that following on from what Helen has talked about, about learning from HIV, we are starting to learn from our NCD programs as well. I mean, this is new in MSF to some extent, and we've been treating NCDs since the inception of MSF more than 40 years ago, but it's relatively new that we are actually trying to systematically focus on developing models of care that are, to some extent, evidence-based, and so that is just in the, I would say in the last few years. So we're starting to learn some lessons from these programs, and I actually want to say that I want to acknowledge that actually teams from South Sudan, DRC, Jordan, Lebanon have all contributed to this presentation. Just to start off, I think it's just good for us to remember that explicitly we will take a focus as a humanitarian actor on reducing suffering, death, and disability, and that will mean making choices, that will mean providing treatment, especially for people who are acutely unwell and secondary prevention, targeting symptomatic patients, but explicitly not focusing on primary prevention, at least that's not in our immediate priorities. And I think also, just at this point, just to remember that we do make this point often that I think very obvious to everyone here, but humanitarian settings are not the same as low-resource settings. We, like many actors, have a tendency to try to generalize, and because there is some guidance on low-resource settings, we try to do copy-paste and apply that in our context, and it doesn't always work. We need to be conscious of those differences, because they range from everything from the demography, the epidemiology, and the comorbidity, I think, just not to say more on that. I want to share a couple of examples of coming from programs from across the movement of MSF, so programs in conflict-affected rural settings such as South Sudan and DRC, where diabetes is being treated, and then comprehensive NCD care in Jordan and Lebanon, and looking at a few key lessons at the end. So firstly, taking an example from DRC, this is a context with chronic displacement, continued violence in eastern Congo, and a significant number of patients with diabetes, and what we see here again is an epidemic that we haven't fully characterized. There's very little data about this. Of course, we are seeing demographic transition, a lot of patients with classic type 2 diabetes, but we're also seeing lean, younger diabetics who are instant-dependent but never present in diabetic ketoacidosis, so the kind of malnutrition modulated or related diabetes. It's a system where there is funded largely by cost recovery, so out-of-pocket payments from patients, very few doctors, little knowledge of diabetes among staff, because the medical training tends to focus predominantly on infectious diseases, the kind of opposite problem we're facing when we deal with UK or European trained doctors who have very little experience of the communicable disease, of course. Patients are traveling from far, people don't have fridges, and there's constant interruption of access by fighting. So these considerations obviously influence how the model of care that we have developed in that setting. The care is free. Now that, of course, is one of the principles of MSF and many humanitarian actors, and that is what we use our money for, to be able to deliver free care. The care is nurse-led. A doctor is available for complex cases. A lot of emphasis on staff training and standard operating procedures, as Helen said, where possible, these are one-page charts on the wall of clinics, and a strong focus on treatment literacy because we are talking about chronic conditions which will require self-management, even though these are conditions that people may not have extensive knowledge of, we need to be focusing on empowering the patients, especially because people will be cut off from time to time. So there is a strong focus on treatment literacy. And then taking a lesson from HIV, expert clients, or expert patients, something that we found seems to work quite well in this setting in eastern Congo. People who've lived with diabetes, for example, for many years, and are actually very happy to share their experiences and the techniques they've used to manage their condition. And especially in a busy waiting room of patients who are waiting all day to go through the process of having their disease managed, it provides opportunity for presentations from other patients. Looking at ways of spacing out appointments, again, thanks to the gradual emerging evidence on thermostability of insulin, I think that increasingly we feel very confident not to insist that patients come to facilities, to have insulin given, that we can give insulin for at least a month to be kept outside the fridge. And of course, we then focus on teaching people how to do that. And then finally, the line at the bottom, runaway packs and buffer stocks, again, something we take from HIV programming in insecure settings, the importance of especially anticipating those interruptions and seeing what you can do in terms of prepositioning stocks of drugs. And just to maybe say a few words about what we found with this cohort, it's a small cohort, currently 107 patients, 19% lost to follow-up each year, which actually means 81% staying in care each year, which I actually think is a pretty positive finding, especially in a very insecure setting. And quite a young cohort, as you see, at median age 45, this is not an actually only 19 children, so this is not a diabetes epidemic affecting the 60-year-olds and 70-year-olds. You have a full age range, including some people developing diabetes in their 20s and 30s. The graph below just shows that the median blood sugar level in this cohort was sitting around 200, which is perhaps not ideal, but actually, again, I think we would feel that this is not so bad for a setting such as Eastern Congo, which is very difficult to maintain regular access. And where the graph goes a little crazy at the end, this was actually where the team had to evacuate. There was a security incident and the service had to be put on standby. And I think it just is a reminder, and there you can see that people are presenting acutely, so they've got very high blood sugar levels. It's a reminder of the difficulties of providing this care in those contexts. I think I will skip this slide, but it's just to say that we were able to do a qualitative study on the experience of patients and health workers. And I think it just brought home some of the challenges of this sort of program. I mean, the fact that the dietary advice we recommended was not affordable. Patients relied on a family member or a treatment supporter to some extent, and those that were isolated that didn't have that tended to struggle much more with adherence. So again, another lesson from HIV or TB, is there a role for including systematically a family member or a treatment supporter to help people manage their chronic illnesses in these settings? Just then comparing this to diabetes management in South Sudan, here MSF, this is the Paris branch MSF has set up a outpatient pediatric diabetes service because pediatric diabetes represented such a significant burden of, well, a proportion of acute admissions, and these were children presenting in DKA. So again, a project, an MSF intervention in a very unstable setting, which did not set out at the start to provide chronic disease management, but where they realized that actually they couldn't keep not responding to this patient group. A cohort of 49 cases, seven lost to follow-up over two years, so again, very good retention in care, and again, providing four weeks in insulin at a time. I think one of the challenges here is a context with marked food insecurity, very significant poverty, unreliable mealtimes because basically people don't have food and you can't tell people to eat three times a day, so the decision was made to only treat with long or medium acting insulin, not to give biphasic insulin, and so to try and manage type 1 diabetes with NPH insulin, and due to the risks of hypoglycemia associated with fast acting insulin, if you don't have reliable access to food, and of course that doesn't produce the best outcomes in terms of blood sugar control, and the project would see those children still coming back in with diabetic ketowacidosis, sometimes even with hypoglycemia, but again, this is a sort of trade-off we have to think about if we're working in these contexts. In addition, the patients are generally, the parents are generally illiterate, so you have to find new ways, well, different ways of providing treatment support and treatment support materials, and again, once again, the long distances to walk to reach the hospital, a clear access barrier, do we need to be looking at decentralization and the sort of more community models such as Helen presented? Now, I think just to have a look at now at a very different context, again, this is one we've talked about a lot, and I actually won't, I don't need to present the context at all, so there's a slide on Lebanon and Jordan there, I just want to draw attention to the fact that I think as was said earlier, these are health systems that have absorbed vast numbers of new arrivals, and I think that as MSF, we sometimes get frustrated at working in these countries when funding for NCDs is withdrawn by the Ministry of Health, at the same time, I think it was, as was pointed out by Quaker, I mean, let us actually see that in perspective, I mean, they have had an influx of up to 10% or more of the equivalent of the population, so NCDs were managed in secondary care generally in these contexts, and now the countries had to rapidly scale up NCD care at primary care level. General practitioners work at primary care level do not have that much experience of NCD management in these contexts. I think PCI and organization is here who's been involved in trying to work with the UNHCR to capacitate primary care physicians. I just put this slide up because it's just to show what a patient has to negotiate to get access to NCD care in Jordan. The system, of course, I said that the system is overwhelmed, there are plenty of actors, and so although there's a huge MSF logo on there, it's not to say that we are the only actor. There's actually hundreds and, of course, this is an attempt to sort of patch together a health system response. So looking at, I'll give an example, both from Lebanon and Jordan, this is the model of care that the MSF team set up together with the Ministry of Health in Lebanon. Again, you can see that it's a, we're trying to achieve a somehow simplistic and somehow simplified and sustainable model of care. There is joint consultation, the first visit as in a consultation with a doctor focusing on medical care and then a consultation with a nurse focusing on patient support and education. At the second visit, that's repeated. And if the patient is stable after three visits, then the care becomes nurse led and with referral to a doctor for complications. And then the doctor will see the patient every six months or so. And I think having an appointment system seems very obvious, but that was a critical innovation for this to work. And then SMS reminders or telephone reminders for patients before their appointments. And what we can see in Lebanon, 2,562 patients in 2015, a default rate of 30%, which looks very high. But when you actually look at what is happening there, a very large proportion of these patients are moving on, they're either moving back to Syria or they're moving elsewhere in Lebanon. So again, we have to think about that in these contexts, humanitarian contexts are metrics such as defaults, lost to follow up, we need to think about the context and actually what what is what are people's normal trajectory. When I'm looking at those doing some an analysis of the of these defaults, we do see that a proportion of them had difficult clinic access. And this makes us think about, again, should do we need to think about home visits if we want to reach those most vulnerable people. But the other thing that's clear as well is that a lot of people just stop taking medication. And I think we've had to had to acknowledge the significant efforts we need to put into patient support counseling, especially that first visit, as Philippa mentioned, people many, many, many people with NCDs coming from Syria are on 10 11 or 16 medications. They they're often the very latest, the latest branded medications. Sometimes we would have maybe difference to opinion about the evidence base, supporting the use of these medications. So that first visit is a critical negotiation with the patient. And if you want them to stay, you need to take the time to explain, we're going to change your medication. This is why. And I think that's very much borne out in our experience in Jordan as well. Very expensive care. Patients have fear. At first, at least patients describe had had fear of accessing services. I think that they'll we realize that I think there was a telephone survey conducted by some colleagues in the audience that many patients would be concerned that if they didn't have the Ministry of Interior card, and they went to a Ministry of Health facility, they could get in they could cause trouble. And and of course, patients, as I said, are used to a very specific type of medical practice coming from Syria. And as has been mentioned many times, significant burden of mental mental illness, and social issues in this patient group. So once again, these sort of factors in, you know, govern the type of model which we've developed in this setting. Again, it's very collaborative model with Ministry of Health, but also with other private providers to address that that potential fear of access to services. And again, this is all with the acknowledge with the blessing and the support of the Ministry of Health that we partner with some private providers as well. So that people are not afraid to access care. A significant accent on training staff in NCD care, again, SOPs looking at how we get the counseling session, as I mentioned at the first visit in this clinic in in Irbid, the team actually implemented a 30 minute counseling session with the nurse at the first visit, which sounds very luxurious. But I get I suspect in the long term, this is this pays off. So just looking at the few outcomes, the top one isn't a clinical outcome. But just to compare with the Lebanon situation, 4% were lost to follow up at 12 months of astonishingly small number. And so it's moving on on its own. But I realize I've run out of time. So but just to say again, maybe this is a more static population, but also does that intensified counseling at the first visit help. And I think just these are very preliminary data, but just showing that as patients came back on to their medication, you do see the expected improvements in clinical outcomes. We can't say that this is shown this is a this because these are actually three month outcomes. But it's just obviously when someone hasn't been taking their medication for while you start giving them medication again, you expect to expect the outcomes to improve. And that's what we saw. I said that a strong emphasis on training. This was our first regional training in Middle East in Amman with attended by MSF staff and some administrative health collaborators from throughout the region, including Lebanon, Iraq, even Ukraine and Uzbekistan, Swaziland, so a little bit outside the region as well, and facilitated by PCI. Now, I think just to round up then thinking about some of the lessons learned so far from these these models of care, again, I'm going to reiterate a couple of messages that have been raised already. We need to be thinking about improving our understanding of the needs. Our programs in Jordan and Lebanon have evolved significantly from our first assessments because I think actually it's only gradually that we're starting to understand not just the epidemiology, but who are the most vulnerable groups in that population and what barriers they're facing. A strong accent on patient literacy, integration of mental health, and again learning as what we can from HIV and a number of those lessons we've already tried and sometimes with success to implement in unstable context for NCD care. And as often been stated today, guidelines, tools, training are needed for primary care level. We have now, within MSF, we've started to develop some guidance on NCD specifically in humanitarian settings because I think as was said earlier, it's the national guidelines we use them when we can, but in the emergency phase of a response it's not always the national guidelines not always actually adapted to that emergency response phase. So thank you very much, everyone, and thank you also to the people from MSF and also colleagues at London School who contributed to this.