 that crisis affected countries, so he's going to be presenting on the perspective of experiences of international medical costs. Thank you. Nathan Heyser, thank you be act, good morning ladies and gentlemen, so this is just to give a quick overview of international medical courses work in the spirit crisis and some anoddiadau ar y cyfnod o'r cyfnod. Yn ymddir y cyfan cyd-i amwyaf, ydy'r cyfnod arall ymddiadau ar gyfer y cyfnod, er fydd o'r cyfnod ar y cyfnod yma, yma yw'r cyffredin iawn yn ogymell ar y cyfnod o'r cyfnod yma, a'r cyfnod ar gyfer y cyfnod ar gyfer y cyfnod, mewn yw'r cyfnod yma yw'r cyffredin iawn, head home, ac y sgwp sy'n gweld ychydig o gweld, ac y ddweud y llennid yn gweld gan hynny'n ddiddordeb Gwyrwch yn gweld gan hynny o'r ddiddordeb. Mae'n gweld rôl o'r sgwp, mae'n wedi gweld cyd-gwyrdau a'r mynd ditblygu o'i'r gwahanol o'r ailfig, yn ôl cyfrifoedd o g佐atau yn gwahanol. Mae'r cyfrifoedd o'r cofnillyddau, r�ffarnio, sgwp, a'r ailfig o'r cyfrifoedd o'r sgwp yn gweld gyda'i lwyddiol iawn. we try as much as possible to have an integrated approach looking at some of these areas. Maternan, newborn, child-held, primary and secondary care, adolescent health, etc. We also try to look at the systems that support these types of services. ac the capacities, if I say capacities talking about the human resource capacity financial capacities, et cetera related to how these services are provided, so we also look at some of these areas, especially highlighting the fact that we have quite a strong focus on human resources for health and some of the things that we do around that pre-service, trainees, in-service trainees, et cetera. So, with the Syrian crisis, without going into all the details, I think we all know the serious story, what has transpired so far. This map is from the UN, both elements from Ocha, from WFP, et cetera. This is the last map from July this year. So, you have a total refugees coming out of this crisis of almost 4.8 million. And as you can see to the top left, about 2.7 million of them are in Turkey and other parts of the region. So, it's quite a major issue as we all know. It's classified as the biggest humanitarian crisis we've seen so far. And for us who are actors on the ground, we don't see any, let's say, solutions, if you like, to address some of these things, because the political aspect, et cetera. So, we are just helping as much as we can with those people who are displaced in the situation whereby they didn't actually ask for it. So, it's quite dire. And if there's any one listening from the political angle, please do something to try to stop this, because it's really sad. And from there, if you continue the map to the left side, those in Turkey trying to get into Europe and those going through Cyprus also trying to get into Europe, and then the whole gamau of issues around the Mediterranean Sea crosses and the crisis that has spilled over into Europe and the fallout of that across the whole of European continent. So, it's quite a major thing. Now, hwnnw nw y bit more on the NCDs. As we know, NCDs is quite a major disease burden across the world actually. I think with all the WHO regions, it's only the sub-Saharafrican region that is still, you have a communicable disease as the main sort of mobility mortality. But for the rest of the regions, it's NCDs. Anything with sub-Saharafrica, which is projected that within a few years, is it up to 2030 or 2050 that NCDs will take communicable diseases? So, it's a major issue for the globe, for the world. And there's a whole host of sort of discussions led by WHO, et cetera, to try to come up with a way of addressing some of this because most systems, most systems, especially where the burden is the highest or the burden is getting to a point whereby it's not manageable, the systems are not set up to properly deal with NCDs. And here we are talking about four of them, but there's a whole gamut of it, which especially in emergencies is really difficult to address. So, for the Middle East region, these are the four main NCDs that WHO is reporting. This is data from WHO from 2016. The chronic respiratory diseases, COPD, the diabetes and your cancer, cardiovascular disease as well, your ischemic and heart attacks, et cetera. 1.7 million people die here in the region just from their bare four diseases. So, if you include the others, you can see the burden. And from these mortality figures, it's projected to reach 2.4 million by 2025, which is just around the corner. That is if agent action is not taken. Now, this agent action is, of course, if the action plan is there, which I think there's a framework for the region, those of you who work in the region, the gentleman from the EMRO maybe can say something about it. There's a framework to try to address the NCDs in the region. However, with this crisis, whether that can be actually implemented and see through is a big question. So, this projected mortality most likely is going to be rich given the problems going and of course the cardiovascular disease account for about 54% of this. 43 million people have diabetes in the region, which is the highest prevalence in the world. Now, the India subcontinent is really competing with this one. So, we also know that that's a big thing waiting to happen. Diabetes is almost exploding on the Indian subcontinent. And once again, if it's not addressed in the next few years, probably to overtake this figure here. So, our response, we work in these areas, these countries, and this mainly targeting refugees from the Syrian crisis, alternative displays, persons, et cetera. And these are some of the health facilities. These health facilities are sort of a mixture of health centers, primary care centers, care hospitals, medical mobile units, et cetera. With a mixture of all kinds of levels of staffing that we use. And this support that we give is mainly through local partners. So, that has got also its own challenges. And some of the key areas we try to address. So, primary health care, secondary health care, maternal care, et cetera. Trauma care, emergency medicine, obviously. Mental health, sexual support, charcoal testing, general peace balance, nutrition. And across all this, we try as much as possible to try to engage communities on life-side choices. Now, this is a major thing, which once again, those of us or the colleagues who have worked in the region before cannot attest to that changing behavior and trying to address some of the risk factors around NCD is a major problem. Even in this country, where everything is relatively calm, very, very stable, fifth biggest economy in the world, et cetera. Getting people to change diet or stop smoking or cut off alcohol is a big issue. It has taken its ages and we are still struggling with it. So, imagine such a contest trying to get people to change behavior. It's a major challenge. And I think also, who know the region also very well, people tend to like medicines as against healthy life choices. So, overview of the data that we've come across so far. Now, as the gentleman James mentioned a bit earlier, these are program data. This is just data from our program. So, with what I've described, you take this with a pinch of salt, okay? So, data quality, accuracy, reliability is a major problem. We know that. We know that. So, gathering data from the health facilities, from the activities we do through our local partner, et cetera, is a major challenge. It's a big challenge. It is such a sort of fluid, precarious situation. So, all of us here who have worked in crisis setups, et cetera, low research setup, you know the challenges around data, some of the challenges you are facing. But this gives a little bit of an idea which more or less fits with the disease bed in the region and part of what James also presented. So, if you look at the total, these are sort of the average monthly consultations. The total is the blue bar and then the numbers for the NCDs is the red bar and then the percentage associated with that. So, if you look at the total, we are looking at somewhere around 95,000 consultations across all those countries and those facilities. There are around roughly 15% of the consultations being NCDs. So, it's a snob. And if you look at it, various countries, it's biased significantly. And with Syria, we are looking at almost 50% of the consultations being done to NCDs, which is quite an interesting one. So, once again, if you compare that to the rest of the countries, example of Turkey, we are looking at the same displays. Mainly Syrians. So, how that difference is? We are describing that as part of that being the quality around reporting. But it's quite an interesting observation there. And the top NCDs that we've been seeing so far are these ones. Hapitension being quite high there, followed by diabetes and asthma. asthma here is also related to other respiratory conditions like the COPD. The others, the 30% others, is mainly looking at issues around, for example, mental health, epilepsy, et cetera. Mental health is a big one in the relation with other chronic diseases. It's a big one. I remember a discussion we had in the NCD groups headed by UNHCR. How mental health has got its own category and resources to address that. But with the same crisis, it's clear. Mental health is a big thing there. And then part of the others, we have the ischemic heart diseases. It's in there. Some cancers. Lebanon. In a Lebanon program, we see cancers. However, the issue around cancers is that it's more around clinical provisional diagnosis. Because we don't have the systems to do proper follow-up and diagnosis of cancers. And most importantly, if you do that, addressing it, treating it, et cetera, is a major problem. Refering displaced persons, refugees into the existing system for care is a major problem. It's a big one. Cost is a major thing. So once again, cancers is something that I don't know what the NCD group is going to do about it. But it's a big one, especially in emergencies. It's a big one. So some snapshots. This is a Zatari refugee camp. Some snapshots here. Our person is in Turkey. Turkey is also an interesting one. So this is the green part is southern Turkey. And where most of the refugees have displays into that part of. And then the blue marks there with the H is where we have our facility support. And then the pinky bit down is northern Syria. And you have your Aleppo there, et cetera. And all the stuff going on there. I mean, I don't know where it cannot describe it from the humanitarian perspective. Where it cannot describe what is happening there. And the whole issues around the border crosses, et cetera, et cetera. The policies around that. And on the one hand, we have people like us here in UK saying that what is happening is not good enough, et cetera, which you do more, et cetera, et cetera. And then on the other hand too, you have the politicians telling the text authorities that you have to control the border crosses. So what is happening, at least from the humanitarian perspective, they take these authorities to do that. Oh, you cannot cross. You cannot cross. But then, in the northern Syria, you have cities that are going on, part of my language. And people are just stuck. So it's quite a serious situation. I just came from Turkey, that place. I visited all these places. Gasiantev, San Yuf, et cetera. And it's quite a dire situation there. I think I'll not go on. Otherwise, maybe I might say something that I shouldn't. So some of the challenges that we are facing is not new, but some of them is worth highlighting. The impact on the health infrastructure of the host nations. Now, I don't know how to say this to get a message across. Let's say here in the UK or let's say in Germany, et cetera, they are concerned about the immigration, et cetera, the impact, et cetera. But take a country like Jordan, take a country like Lebanon, and just consider the numbers that are displaced into these countries. And then consider a minute the impact of that, or at least of the area of healthcare. It's enormous. So it's not comparable. So sometimes it's a bit difficult for us humanitarians to get a grasp on why some of these things are happening in Europe regarding whether refugees should be accepted or not or supported, et cetera. So it's a huge burden. And for example, Jordan, we do free care for NCDs for the refugees because of the impact on the effort. Lebanon, the same thing. A large privatised system. And refugees, around 15% of what we've seen so far, have been unable to pay for treatment in the past six, 12 months. That's why UNS are doing all they can to try to subsidise. So it's a big challenge down there. Multiple protocols in Gala probably Filipa will touch on this one. Also, what I didn't say a little bit earlier is in all these countries there are different protocols and the gentleman, yeah, I can remember you now, yes. We met in that one of the meetings. Multiple protocols in Gala is, if you look at it, the algorithm or the floater for diabetic management is very, very different from, let's say, the global Gala in regards to some of the specifics of those countries. And it's quite a challenge. And well, if you have a stable condition or situation for each country as in one protocol, that is fine. But when you have such displaced population in such a situation, I think it's always good to have one standardised approach that you can use as a standard to train the professionals that you mentioned, or some of the mentioned, train professionals, et cetera, to try to do some of these issues. Poor integration of NCD services at the primary level. Once again, those of you who know the Middle East, Middle East primary care is very, very, it's almost non-existent. People don't buy into it. Everything is at the hospital level. Maybe simple deliveries is at the hospital level, et cetera. So getting people to accept that you can go to the primary care centre or to the health centre and go and get your diabetes managed there, it's a big challenge for us to do it. Those in the camps almost don't have a choice. But if they had a choice, they would rather go to the hospital instead of coming to a primary care centre to manage their diabetes. It's a big challenge for us. It's sufficient mental health support services. I've thought on that already. In the process of support of medicines. Tension, materials, communities, et cetera, which I've alluded to. And this one. This is a big one. This is a big one. People prefer just giving me the medicines. Let me go ahead and do it for diabetes and stop talking to me about lifestyle changes. Now, in the region, sugar consumption is a big thing. Smoking is a big one. So, et cetera. So once again, whether we can come up with a strategy to do that, if you take the example of the UK or the US, et cetera, well, your conclusions can be drawn related to mine. So we try as much as we can. We use peer support groups. Those who are willing to talk about their conditions, we use them to try to educate the rest of the population. We use community or resource persons to try to pass messages across around some of these lifestyle choices. But once again, it's quite a challenge in getting any tangible result from these lifestyle changes approaches. Continue of care is very, very serious. Very, very full situation. So people move a lot, et cetera. So maintaining adherence to treatment, et cetera. Continue of care is also a major challenge that we face. Humor resources, which I've read to, is a big one. In Aleppo, in northern Syria, they understand some of these issues and so forth. We try to have some form of education, medical education for some of the doctors, et cetera. But it all fell apart with the recent surge in... So some suggestions which I probably, Philippa, will touch. And the group, the LCD group, will also allude to this. There's been a lot of discussions in that group. The group I'm saying is led by UNCR at the UN, Geneva, looking at LCDs in emergencies. There's been a lot of discussions around this, whether we can have a service package. Along the lines of MIS, those of you who know MIS, the minimum initial service package for sexual reproductive health. So with all these issues and the burden of disease, you cannot address everything in emergencies, especially emergencies. It's really difficult. So the discussion has been that, okay, should we have a specific package on NCDs during emergencies, whereby the priority diseases are targeted resources, aimed at those. Something that I'm not sure where that discussion is, whether it has moved on or not. Maybe some of you can... Related to that, you have your standard colours and protocols. All these specific to peoples of concern, emergency situations. Related to this, the standardised journey package, whereby if you have a defined package, there you know that, okay, when this situation arises, this is the package that we are going to train staff on to try to deal with this particular situation that is unfolding. Support to the national health systems, once again, the burden of all the impact of all this displacement, huge numbers of people on the health systems of the host countries, your Jordan's, your Lebanon's, et cetera. We shouldn't forget that. This is also with other emergencies, whereby sometimes I've seen it several times that the support received by the displaced population and the refugees, the support didn't get better than the host community. And because of the fact that, of course, people who are displaced are precarious, institutions, et cetera, so we pay attention to them and then we forget the host community. So this is something that also we need to bear in mind. And I think my last point on this is, once again, maybe Emeril, the gentleman from Emeril, can say something about this. Now, to see a coordinated NCD action plan in the region, and this coordinated action plan will look at some of the things I've already mentioned, the package of surveys, resources for that, et cetera, coordinated because if you don't coordinate it, then different agencies will come up with different things, which is exactly happening now, and it's quite a challenge to manage it if it's not coordinated. So Emeril, Ocha, et cetera, has already been done about this. But if you can have a coordinated approach to how to deal with the NCDs going forward, because from the political point of view, this crisis is not ending anytime soon, at least not in the next two or three years, but we need to deal with the burden of NCDs, which is getting worse and worse. Thank you. Thank you very much. Any quick questions of clarification? Sure. We just wait for the microphone. Thank you for presentation. I'm Dr Tjumar. I'm Health Advisor for HealthH International here in London. Look a little bit broadly about your presentation. Have you looked at the gender and age analysis? Have you kind of split them? Where's the big problem with NCD? We know statistically where they are, but from your point of view, you're from field to search and from your data. Thank you. Yeah, exactly that. It's not there, but of course, NCDs mainly affect the elderly people amongst us, but of course you also have some young people, especially the asthma part of it, some of the type 1 diabetes you also see in young people, but a bulk of it is coming in the older population group, et cetera. And that is seen across all the sites that you support. Gender is a big one. Once again, you have the Syrian population, well, in the region, they have their idiosyncratic processes around gender. Now, we try to, as much as possible, to try to offer services, to reach out to everyone, including the female part of the population. So we have specific areas, or we have specific activities that try to address females. So in the health facilities, we try to have female staff, for example, et cetera. In some of the community activities that we engage, we specifically target women group, et cetera. So it's not perfect, but at least we made attempt to reach out to try to address some of the gender issues around assistive services. Okay, I think if we can hold any other questions.