 OK. Good afternoon. Welcome to the final session. It's an impressive number that has managed to stay throughout the whole thing. I'm sure there's nothing to do with the drinks that we promised at the end of this session. So I'm stepping in for this session to chair this session with Helen by Grape who spoke earlier. And the plan is to explore some of the key topics that have come up during the day, what our stellar panel of speakers have thought about during the day, the key messages that they've reflected upon. So they're going to be sharing those. The good news is we have no more PowerPoint presentations, just discussion. So we are looking for some good questions and observations from the audience, including our online audience. They seem to have gone very quiet this afternoon. Some time differences may account for that, but we're looking to you, Belarus, Ukraine, Sudan elsewhere. No excuses. Good. So how are we doing this? I'm going to hand over to Helen. So Helen is going to say a few words more and then we will get stuck into the panel. Exactly. I'm going to talk very briefly because I want to hear really what the panel has to say. But I just wanted to kind of wrap up some of the gaps that I think have been brought out over the course of the day. And what I'm hoping the panel is going to do is try and prioritize some of these gaps and come with some concrete action points that maybe we can all together as a community take forward. The first one that I think came out from a lot of the presentations was this issue of the guidelines. What do we mean by guidelines? Is that how do we standardize this, coordinate this, but actually also have a user-friendly in-the-clinic version that enables our healthcare workers to put this evidence-based medicine into practice? How do we take that coordination forward? And also guidelines around the how-to. How do we deliver services? Do we decentralize? Is it safe to tar shift? And what are the important research questions we need to have answered to persuade ministries of health to do that and donors to fund that? Second gap, the monitoring and evaluation chestnut. We haven't cracked it in HIV, that's for sure. But how can we work as a community to come up with the minimum set of indicators for these very difficult settings that we're working in? That dilemma between the information we need to improve the service that we're working in face-to-face with the patient versus the big data we need to understand what's going on at a population level. What hasn't been talked about so much, and I see as quite a big gap in this topic, is the advocacy agenda, the funding agenda, and the access to medicine agenda. What is happening with that? Because quite frankly, where I go, these medicines aren't on the shelf. So what is the global community doing in terms of trying to improve or ensure a sustainable medicine supply for non-communical diseases? Finally, how do we piece together or prioritise a research agenda to answer the key questions that the field is asking to improve the care for the patients? What co-ordination mechanism again is needed to put together the advocacy and a research agenda to push this work forward? So what we've asked each panel member to do, they've got three minutes, so we've given them a strict time. We want to hear from them what their take-home message from today is. What they see as the priority gap that the international community should be doing to address these challenges of providing NCD care in humanitarian settings, and what is their specific organisation doing to address some of these gaps? OK, so I'm going to hand back over to Bayard. Good. Thank you. So first up, we have Slim Slammer, who's already had made important contributions today. So Slim works for WHO MRO, and he's really led a lot of the work on non-communical diseases, and particularly given the region with humanitarian crisis affected populations, and has really, I think, been really behind a lot of the work on pushing NCDs up the agenda, and most recently helping with developing emergency health packages for NCDs, kits for NCDs, so it's been really valuable work. So your observations, please. Well, thank you first for the invitation, and let's say for me it's double pleasure first because I was an alumni sitting here about 10 years ago, so it was nice to be back as a WHO staff, and also because of many of the faces that are here. I mean, we are a bit of a usual suspect now. We see each other in several occasions, and I have been sitting on the board of MSF Switzerland for many years and saying that also MSF is moving forward, professionalising what was for me a bit of an advocacy message for years, and thinking that things are really moving from just the kind of playdway and advocacy to really implementation. I think it's an important aspect. I would like to maybe respond to some and highlight some of the question from a WHO perspective. I mean, we are a technical agency that produces normative guidance, and I would say in this field we need to look at two things. I come from a region, as you mentioned, where we have half of the population displaced in the world in our region at the moment. We have major emergency and conflict settings, probably the region where we have the most important conflict situation at the moment. We have three, grade three, which is the highest level of emergency at the moment, and also all the more protected situations like in Somalia. So we have a huge immediate response to countries. So I think the work on research, the work on normative guidance should not hinder our technical response that need to be taken down now. So sometimes the data gathering, the issue that require a bit of a delay, of thinking, of conceptualization, of operationalizing through a UN system as a WHO, the process sometimes a bit longer to occur. So this should not prevent us to respond. So I think one of my take home message is that if you want to work in this field, you need to know what is happening there. I think the disconnection that I see sometimes in discussion, you need to know what emergency response means, how they operate at the moment between the various agencies, and not just as an NGO perspective or as a UN agency perspective, but how this relates to a ministry of health that have to respond at the first place to the need of the population. I think this is the first message, understanding the context in which you operate. I think it's an important aspect. From a WHO perspective, the mandate actually we receive it already from an NCD perspective more at the development level. Even as you might know, I mean the NCD global agenda have been moving for more than a decade now, including with an action plan that is going to be revised 2013-2020. In that action plan there was already a mention and a mandate given to WHO to deploy an interagency kit for NCD management. And this has been a bit the entry point. Nothing has really been operationalised so far. So our entry point for guidelines was also to say how we can link the minimum standards of treatment with guidelines and with the rational use of drugs drawing on what exists in development-stable settings. And as many of you are aware, I mean there has been a publication of this WHO package of essential intervention for NCD prevention and control in low-income settings with implementation tools. So we are trying to draw as much as possible from this guidelines. But to take it one step further, in terms of guidance, I think, there is the normative guidance about how you discuss NCD in emergency in general in terms of prioritisation. There is the clinical aspect of it where we are trying now to develop an NCD emergency kit. We are in the process of piloting a set. It's a set of essential drugs and supplies and equipment for 10,000 people for three months, a bit like similarly to the interagency kit. Some of you might be familiar that there is, for the last two decades, a kit that has been proposed that many countries are purchasing in emergency settings for the general basic PhD needs. So we are trying to adapt it with an NCD specific focusing on the most common conditions, mainly hypertension, diabetes, as we have said, asthma, and the colleagues for mental health who have developed also a kit, a guidelines for mental health in humanitarian settings. So all the drugs that are in the MHGAP H, which is the humanitarian, will be also included in the kit. So we don't want to make that distinction because there are a lot of trainings and support and capacity building so the kit will contain those basic drugs, mainly for PhD level. So we are now in the process of having a finalisation of the kit. An invitation to bid will be sent next week and by three months probably will have the first kit ready for pilot testing in Syria, Iraq. So this is one aspect that will influence a bit what are the priority drugs that countries should also foresee in the reconstruction phase if they want also to integrate primary healthcare and trying also to align a bit and influence the donors because there is a lot of donors saying we are a lot of requests on NCD but we don't know we should invest in dialysis in cancer and of course there are a lot of needs that are mentioned but trying to standardise and rationalise a bit the approach about a package of at least primary care intervention for NCD management this is one of the first steps that we try to assess but of course we are addressing only one aspect of the building blocks the human resources, the aspect of what type of trainings and we are partnering with many agencies working in this environment including MSF and others to try to see what could be the guidelines adaptation and for this I'm not sure that we need necessarily to change everything on how we manage diabetes and cardiovascular existing international guidelines for most of the NCDs I mean have a rational approach that are evidence based I think the most important questions are more about tellering it to emergency settings in terms of the frequency of lab testing some of the chains of drugs so I think we will really look at what the HIV colleagues have done in terms of the how and making maybe an approach to see if there are specific questions that need some adaptation of existing guidelines that Helen mentioned maybe one or two pages colleagues from primary care international that have to leave now have already come out for UNRCR to have a commission work with very simple guidelines very nicely put together actually in terms of reading I think it's really adapted to emergency settings I think they need a bit of tweaking to change perhaps the questions about the frequency of monitoring but I think there are elements that are already good in the practices that we foresee here of course from a WHO perspective we have a kind of stringent process sometimes to really endorse guidelines so we are going through maybe those questions to the guidelines review committee but as I mentioned it would be more on the how I'm not sure that we will commission systematic review and even if we commission them they will not come out with I mean a lot of information about what we need questions might be more on how to reflect on the how rather than on changing the content of the treatment I will stop there for the guidelines yes thank you I'm just going to go through the panel then we'll take a load of questions at the end so can I turn to Difford? so we are very grateful to Jay Begaria who has stepped in really the last minute to cover for Chris Lewis to offer some perspectives from Difford it's also difficult for Jay because due to work commitments you can come earlier today but I'm sure she'll be able to wing it so Jay is a public health position who's worked in a range of international and domestic public health jobs and she's been at Difford for the last five years including work in south Sudan and also in the Ebola response in Sierra Leone and she previously worked for Save the Children so just a few words would be great from Difford's perspective so hi and I'm sorry I couldn't make it earlier today it sounds like it's been a fascinating day and I spoke to one of my Difford colleagues at lunchtime and she gave me a brief on how things have been going and I guess when I think about the priorities I'm going to divide it into three or four possibly and I guess the first so starting with context and then thinking about lessons we can learn different ways of delivering and the kind of evidence base and cost effectiveness base so in terms of context thinking beyond my time at Difford and in Paho we used to have cyclical emergencies due to hurricanes and there we started a piece of work on older people in disasters and part of the rationale was that older people suffer from different types of NCDs and we weren't planning for them so they weren't during an emergency they were more seriously affected by an emergency and we weren't able to kind of ensure they remain productive and healthy and happy after an emergency and so I think there's a thing about thinking across different regions of the world where and different types of emergency so I think the NCD agenda in kind of humanitarian settings has really moved on particularly since the crisis in the Middle East but that's not to say that other types of humanitarian context also need us to think about NCDs in a different way while I was at Save the Children it was as the Libya war crisis started and there as you said the NCDs is a hugely broad range of conditions and can range from things that can be fairly simple to treat and fairly simple for people to control to much more complex so the requests for chemotherapy or the requests for renal dialysis were significant during that crisis and so I think we need to think about well what can we do within a limited resource base what is cost effective what can be supported in challenging context and learn from the HIV context as well and I currently work on HIV, TB and malaria and one of the things we've been thinking about is how do you maintain people on treatment for chronic diseases in the event of an emergency what kind of packaging can you give people so that they have more longer access to their drugs or can you preposition things or can you have community members with access to these commodities that they then take with you so the different ways of delivering so it's probably reflecting a lot of what you've discussed during the day I know that we've got it right in the HIV world either and we are still working on it and trying to think of how you test and treat people but also prevent kind of the sort of problems from emerging following the humanitarian crisis and so then I think it comes to kind of different role in thinking in non-communicable diseases if we think about it outside of a humanitarian context we very much merge it into our health system strengthening work so at country level it's part of our primary healthcare programming in some countries and there are some pilots that are happening thinking about how to integrate it into the essential medical kits that are often ordered particularly in chronic settings like Saeddan so the essential medical kit there did have basic drugs it didn't have complex drugs but it did have basic drugs for some non-communicable diseases so thinking about what you can do in those contexts in the humanitarian setting obviously our work in Syria does include some programming around non-communicable diseases but I unfortunately don't know the specifics of that and more broadly I think part of the challenge for us has been the limited data and evidence around it to actually make really good decisions around non-communicable diseases so I think that's probably my three minutes up eh? Great, top three minutes I didn't need to come at all and thank you for bringing up the issue of older populations we have done a systematic review currently under review on the health needs of older populations in humanitarian crises I'll let you guess how strong the evidence base is it's even weaker for anything related to NCDs so thank you for that so moving on to our third panelist I've made here the classic chair's failure of not getting the pronunciation beforehand so we'll do a test of what I say to what it actually is so it's a pleasure to welcome Sejeria Avisha Peroni so I'm judging by the laughing I'm guessing that's 0 out of 10 for the pronunciation could you share with us what you should be pronounced Yes it's Sejeria Avisha Peroni in French but you can do it however you want because it's just not pronounceable That's very gracious of you so please share with your perspectives so I share with you from the ICC perspective I'm also working at the University Hospital where both had so I think the issue is access to basic essential medicines like insulin mainly if you think about conflict settings where we are still not able all the time to deliver insulin like in places like Yemen and demands are very very high I think that's really something very important and also the definition also WHO is stating of basic and essential medicines for diseases where we are currently on the list which WHO is working issuing also our own list of medicines so to be able to guarantee continuity of care across health structures I think also that's something we have to see because the patients in emergency settings in crisis and conflict they are not bound to one health center so if they move from one place to the other they have to find the same type of treatment so I think this is a key priority in the humanitarian world one other issue is for the continuity of care to draw the lessons from HIV and TB programs and also mental health programs and also in this highly vulnerable population who move from one place to the other you know one you have them once in consultation but you don't know when you will have them next time so one key issue will be to develop in some way this golden first encounter where you have really to put the package on the patient and to give him clear red flags when to seek help for complications where and also to give a package of medication if possible because you don't know when the next time he or she will have access to health care for non-communicable diseases it's chronic life long diseases so it's very important once we start something that we think also on the long term to have the idea of sustainability of interventions and there we will need also guidance and to come and to have a common approach how to deal with complications of conical diseases like dialysis because these are big issues and where we will need to to work together I think also something very important for the ICRC it's that there will be no screening or active kinds finding in crisis settings because it would be not at all ethical to diagnose a condition where for which it's not yet symptomatic and you have no access to health care and also highly burden to the current existing health system I think that there is a lot of advocacy to be done to work together on this very important topic and to have really a common approach with similar medication where you can move from one centre to the other and also to think about how to have the medical information stay with the patient again patient move from one place to the other so we have to find a way to have the medical information available at the time where you have to make medical decisions so that's many areas where we will have to work on and also there is more research needed in for example thermostability of insulin where first research has shown that you could give insulin for one month to the patients so this will have to be confirmed and I think also the ICRC will be able to go into this area Thank you very much for that Can I just pick up on one point before we move on which I don't think it's come up earlier today on this side just switched off with this idea of not active case finding in acute emergency which is entirely understandable and right from many perspectives but at what point do you what criteria do you have for deciding ok now we are in a position to be doing active case finding because it's very difficult to it's easy for there to be a sort of long term creep and never to be starting to do active case finding So we wouldn't do in our health facilities active case finding if a patient comes with symptoms like polyurea where we suspect diabetes of course then we would check and also where we would go it's for example in places where we have physical rehabilitation programs with patients who have been amputated and there we found out actually that sometimes up to a quarter of patients are amputated not due to war and conflict but to diabetes and there we will really have to find a way to refer them if you just have physical rehabilitation into the health system to get appropriate care for diabetes because otherwise all the rest doesn't make really sense ok, thank you moving on to Ann from UNHR who's nodding away so you may have something also to say on that but please go ahead well maybe on the issue of the active case finding I actually think it's a very good question and I think it's some we are really lacking guidance on this there is for TB like for example you don't do active case finding until you can be sure of achieving a certain level of cure I think obviously you need to have those services available and they need to be a reasonably good standard and you need to be sure that you have the resources to do this as well we are actually considering doing active case finding for diabetes and hypertension in one clinic in Zaatry camp through the clinic and then actually evaluating that so that is something that I think we do need more guidance on but just on I think a lot of it has been said I think we can also learn from other humanitarian guidance I think somebody mentioned this morning about the MISP the Minimal Initial Services package and I I think there it would be beneficial to have an agreed set of prioritized actions that regardless of the prevalence or regardless of the you know the population that we agree that we are going to carry out these actions and I think the most important thing is to continue those that are already on treatment and this is certainly something that we have been doing with new arrivals in the Middle East and then as the situation stabilizes you go on to a more comprehensive set of services which is based on which would vary by the prevalence and also the level of services that's available to the host community people are talking a lot about you know do we offer cardiac stance or do we do we dialyse but this also is determined by the level of services in a refugee situation by the level of services that's available to the host to the host community on the issue of what UNHCR has been doing before before I start to talk about the indicators is we we have been working with PCI since 2014 they've conducted a number of TOT trainings in Jordan and in other countries including Kenya and Bangladesh and then they have and then they've also developed a training manual for the integration of primary of NCD management into primary healthcare which we are currently translating or will soon be translating into Arabic as Slim mentioned there is also the field guides the clinical guides it's a two page guide it's a desktop aid that is for primary care managers for the main NCDs we also as we've heard various times today heard about this informal NCD group in Geneva and what we are actually going to do is develop a operational guide for the integration of NCDs into primary healthcare in humanitarian settings and we will be hiring a consultant to do that and I know that many of you are actually part of that group and I think I hope that some of these questions about screening will also be in that guidance but what I think also is really needed is I think gaps in quality of care are clear that's very very clear but what is needed as well is an agreed set of indicators what information do we need and what information should we be collecting and what stage of the emergency should we be collecting it and it may be worth while having an interagency group to work on that and this is I believe that the Sphere Guidelines are being revised starting next next year and I think it would be a good opportunity to put to expand that component of Sphere based on the experience of recent emergencies Thanks Thanks very much Moving on to Tomam Aludat who is an alumni of University of Damascus and also LSHTM and for nearly 15 years he's been working in emergency and humanitarian responses both in providing care but also important contributing to some of the leading guidelines guidebooks and other publications so it's great to have you here Thank you I need to make three points but under a couple of headlines one is that NCDs is an artificial construct there are diseases that have nothing to do with each other except that they aren't caused by an infectious agent and the second is humanitarian circumstances aren't equivalent to low resource settings so in that my first worry isn't about things we see very clearly which we talked about most of the day which is the high prevalence of NCDs in middle income country emergencies that's the Middle East my worry is that very little other than Kiran's example on DRC has been said about places where the prevalence is not as high and we are prone to ignoring patients who come and reach our door because we haven't decided yet that NCDs in their context are significant enough and here we need to not learn at least as MSF from what we've done with HIV because we've ended up at one point with vertical HIV programs with hundreds of thousands of patients yet failed to admit a single HIV positive patient in an integrated project and until we can integrate NCDs properly regardless to the burden we'd still be treating it in a way that will disadvantage some of our most vulnerable patients in the world those are the kids who have diabetes in very low income countries and as you heard from Philippa the countries where we see most of our outpatients are DRC Central African Republic South Sudan and Niger so this is my first point to the point of I think saying it's unethical to diagnose is a bit too harsh because it would have worked if you have a self-contained camp where people can go nowhere and are immobile but we've talked about mobile populations and their ability to I don't feel that it's my place to decide for them that you shouldn't know what you have and maybe make decisions that affect your treatment people might want to sell something travel somewhere seek help it's different from what we've done 15 years ago and I think we need to revisit that concept because it applies in some places but not in others so my first take home message is we need to learn how to integrate NCDs in primary healthcare and take it from the point of view of the physician who treats it and the patient who suffers it not only the policy makers who make the bigger choices the second one is something that hasn't been mentioned at all today what about those we cannot treat I give you we can't treat cancers effectively we can't treat so the patients that come and you can't treat what happens now more often than not is we send them home and I've heard it from field colleagues oh they have terminal cancer we send them home to die in dignity and dying in pain is not dying in dignity we talk not about palliative care and that is not appropriate and you'll find more often than not that when we design kits we ignore pain medicines and we ignore we ignore the ability and our physicians are scared of giving pain medicines because it's illegal because it's hard because they're not trained on it and if we're going to simplify we might as well simplify a dignified treatment for terminal patients I think in MSF at least we've ignored it because we're too focused on saving lives and things that do not save lives sort of drops of the radar the last thing I want to say is on humanitarian isn't low resource prioritisation is extremely different from one place to the other the second one is cost effectiveness doesn't mean to us nearly what it means to developmental people cost effectiveness is irrelevant at least in MSF we're lucky we have money but we do treat hepatitis C at large cost we do treat as you've seen in the video reconstructive surgery for war victims we do treat extremely drug resistant TB I wouldn't drop treatments for NCDs just because they are expensive as a single point and the last one is you have to forgive us but sustainability also isn't as much on our radar we have moved from not treating HIV patients because we are not guaranteed to stay there for the rest of their lives into saying that if we've been there six months and we will stay six months initiating patients and then someone else might take it someone else I think it's more relevant in NCDs because there's no resistance a diabetic patient who gets treated six months survives six months and then in Arabic we say God creates where you don't know something will happen you hand it over you stay there more often than not we will stay there for 20 years anyway so sustainability sustainability is important but it's not a reason to not treat patients and just to finish that I'll quote an ICRC icon Jean-Piquetet said in 1979 explaining what a humanitarian principle said we will never sacrifice the life of a patient today for the hope of saving another life in the future and that's probably how significantly different humanitarians think about issues like this thank you very much brought up a huge range of issues it also brought up one that's sort of barely been touched on as in a way the some of the ethics that these topics bring up which I don't think we have time to explore today but we'll do another symposium next time last but by no means least we have Carl Blanchet who's associate professor here at LSHTM and Carl is also the director of the new health in humanitarian crisis centre here at LSHTM Carl has a huge experience working in the humanitarian sector and also in research thank you I'm going to bring you back to research that's my field and I'm going to talk about data so today we learn a lot about the fact that we don't have enough evidence in this field the good news is that the same sectors in humanitarian crisis and we've done a lot of systematic reviews and that is not exhausted it continues its hard work and producing a lot of systematic reviews we always have the same messages we have been commissioned by the sphere project actually to document whether the standards and indicators were evidence based so we're just in the process of doing that and we emphasize a lot on we're going to insist a lot on the NCD indicators actually that are very very weak so we hope that we're going to influence the sphere project as well and I'm sure you're going to be involved in this process I think we've got two different types of evidence that we need one is about what works and the second one is about how to implement what works and what does that mean depending on the context depending on the phase of the crisis depending on the type of crisis and so on we're going to have different types of implementations what is important about evidence that evidence is needed it is ethical we need it, good intentions are not enough we need to avoid to damage the safety of the patient we need to avoid to do harm but secondly it's important as well I agree with you to know the cost effectiveness of interventions because we're going to make choices on the most cost effective interventions between one and the other it's important to know that we know that conducting research in conflict affected countries is quite challenging we know that but there is a lot of evidence from stable settings and Pablo you know that on NCDs there's a lot of evidence so how can we use better the evidence we have that has been generated in stable countries and settings and then trying to understand a little bit more about the lessons learned from these areas as well and I'm glad to hear that Helen took the example of HIV there's a lot to learn from other sectors that's important when we talk about integration for example a lot has been done on family planning on HIV and so on what can we learn from these sectors if you go back to what is the definition of evidence and what we mean when we mean about evidence in the humanitarian sector I think I would like to go back to the basics and I think to me is about systematically collect the right data that is going to be analysed and I think that's important what does that mean that means first we need to agree all of us on what kind of data we need to collect and the type of data we're going to collect is going to differ depending on the context depending on the type of crisis and so on if we talk about surveys for example that's going to be different from if we talk about health services management or health services data or user utilization of services so I think that's one of the task for us is to work together academics, policy makers UN agencies and NGOs on the type of data we need to collect systematically and routinely secondly I think evidence is not enough to influence policies and practice and I think what we need what we have now is a forum of academics and practitioners discussing together and I think that's important to continue this dialogue because we have a wide vision on what research needs to be done and how this research or this evidence can be translated into practice and policies we know that most of the sphere standards maybe 20% of them are not evidence based we know that most of the international guidelines are not evidence based they are based on something else expect consultation and so on it's important to agree on how we can translate that I had one of the 56 bullet points what I would like is to I think to invite people to continue the dialogue and I think what we can offer at the London school is to offer some space and a forum to do that so Pablo, Bayer and I discuss about the fact that this year what we should do is to organize with you a seminar series on NCDs and humane crisis every two months we can invite some of you invite you for open discussions and to present some of the data or some of your latest findings or innovations that can be shared with the panel or a public the second idea I think is to continue the dialogue virtually I think there are plenty of virtual forums we can use on platforms in order to continue the dialogue between practitioners academics and policy makers to define research priorities to define what kind of data we need to collect but as well to look at all the innovations we have not only in terms of practice or guidelines but as well in terms of research or ideas for methodologies like David developed earlier, thank you great, thank you Carl for raising those last few points we are going to try and make sense of today thankfully that doesn't really fall to me Kieran is going to give a summary of today just before the end but we're also looking at trying to produce a short summary a written summary of what's come about but also looking at how we can take this forward in terms of future activities and not just academic seminars but also active forums for sharing data information experiences and so on so moving swiftly on to the questions there are lots of key issues that were raised in these discussions around developing the importance of developing and use of guidelines and importantly adapting and tailoring those to specific context the need for developing agreed indicators what else with the importance of continuity of care and highlighting gaps in the quality of care learning lessons from mental health and HIV the critical importance of integrating NCD into primary healthcare the issues around active case-finding and diagnosis the role of palliative care which hasn't really been addressed much today importantly the issue of sustainability and different perspectives on the role of cost effectiveness and lastly that we're all talking about an artificial construct anyway none of it really matters so are there any questions from the online terrible terrible thankfully there's going to be some great questions from us so we got someone with a microphone again thanks if we just take the first one it was one at the back is there another mic that we can I think there's someone at the woman up there just say who you are sorry John we'll just start with the woman up there hi hi I just want to start by thanking you it's been a really interesting day my name is Nina Rajani and I'm a East London GP and I also I've been a field doctor for MSF as well and I guess I just want to something that sort of popped up as I was listening to you make a comment is that there's definitely been an acknowledgement of the fact that this sort of this idea of a non-communicable diseases being a bit of an artificial construct and the issues that arise with that but also I was just also thinking about this idea of just like kind of lumping together humanitarian settings as well because and what made me think about it is I was working in Jordan this year and the main project that I went out to work with was on the Jordan-Syrian border emergency intervention where we were very much focusing on NCDs as well as reproductive health care and dermatological diseases and the rest of it but also while I was while we were waiting for the permission from the Jordanian Government to to have access to the border I also spent some time working at Zatterie refugee camp and you know those two those two areas those two environments are very very different from each other I mean when we were seeing Syrian refugees on the Jordan-Syrian border in the middle of the desert that we had to drive three and a half hours every day to get to and it was absolutely crazy you were really I mean you basically almost certainly going to see those people just just the once right and you've got to do what you can do in that time and you know where as opposed to seeing seeing Syrian refugees in Zatterie refugee camp some of them have been there you know since it was open like perhaps up to what is it three or four years something like that four years yeah so I guess that's all I just wanted to great so the importance of context and the point that you made this morning as well this hugely sort of varied challenges in providing care in very very different circumstances and from a research perspective the bias that's really gone towards much more stable settings good John John Ydkin I just wanted to make a suggestion that case finding and diagnosis of a condition like diabetes may be unethical unethical in the humanitarian crisis situation and my construct is going to tie in cost effectiveness whether NCDs exist or whether they're an artificial construct and what works now I think that we've got completely stymied by what works that anything where you can do a trial and the P value is less than 0.05 for effectiveness it works and nice will prove it now risk factors are different from diseases risk factors are a continuous variable that goes has a distribution in the population and above a certain level you call it hyper something rather cholesterolemia, tension, glycemia hyper cigarette smoking lungemia they're risk factors but when you turn that risk factor into a disease what does it mean okay if you've got diabetes sorry if you've got hypercholestrolemia and you put somebody on a statin the 4S trial took 4,444 people after my cartil infarction and showed that there was a significant benefit from similar statin the big studies now are 15,000, 20,000 people and you get a P value of less than 0.05 now what does that mean it means numbers needed to treat 50 or 100 or 200 people for 5 years or 10 years for one person to benefit from a non-fatal my cartil infarction diabetes treatment works but it works UK BDS what is the end point microbiome and urea not clinical renal disease there's never been a study to show the clinical renal disease is prevented in type 2 diabetes yet if you're going out in case finding people with type 2 diabetes put them on a treatment where NNT equals 200 for 10 years to prevent a non clinical disease taking care away from people who need it sorry to interrupt there because it's an important point I'm conscious of time but I know there's people that want to respond to that so it's just to give them time to respond Pablo did you want to I mean it's related with the some of the last comments I mean we were now querying well NCDs is a construct of human Italian settings we don't agree and even diseases because actually I mean that argument could be I mean put even for diseases so what are we discussing and we spend the whole day here and I think that's part of the challenge we have I mean we have here UNHCR we have ICRC we have WHO we have MSF we have DFID we have people from CDC I mean definitely we are I mean we are all facing I mean something it exists we are not making it up and what I hope we can at least try together to get some key questions and some strategies to keep this discussion and working together with concrete examples and I think we will not argue in everything and I think I mean Tama raise some ethical issues that also I mean could be and will be really interesting to discuss but I hope and that's I'm repeating what I said at the beginning of the day the I mean the expectation of this impossible is not just to have a academic discussion but if we can identify key issues that we want to work together and the way we're going to tackle some of the problems we are facing defining them is already seems one of the problems we have. I need to qualify my statement at this point. It was absolutely important to put NCDs on the agenda ten years ago to talk about after the global burden of disease of 2004 and the changes to say okay this is important enough for us to talk about it seriously now staying there is not necessarily productive because we've told why isn't there any activism about it or the simplicity of advocacy it's probably easier to advocate about type one diabetes and access to insulin than it is to talk about 20 different diseases with multiple different problems with access and so is access to medicines issues and so on and so on in parallel we don't talk about the hepatitis in the humanitarian settings we talk about hepatitis E causing outbreaks because of water we talk about hepatitis C and the access to the new generation of treatments that's what I'm not advocating the ignoring them I'm advocating the going a little bit deeper into knowing exactly what we want with them. On John's point you're absolutely right and I don't think anyone proposes us going and leaving the mass mortality we're facing from nutrition or infections and dealing with risk factors we've rolled that out long time ago in our discussions we aren't going to treat asymptomatic undiscoverable risk factors we're going to treat life risking very symptomatic and painful diseases and probably the symptoms is the line we're drawing between the risk factor and the disease and just one last word because you're absolutely right we've drawn this in a recently in a discussion about humanitarian ethics what is humanitarian is a philosophical decision that is made in a headquarters but how you deal with it is a different issue who decides whether a certain population movement is a humanitarian crisis or not should not necessarily affect the way as physicians we perceive our patients when we deal with it because there are way too many confounding politics in what we describe as humanitarian or not did anyone else want to respond to these points we do have some more questions as well well maybe some aspect I mean working with member states is a bit different when you work with an NGO or from a programmatic perspective the sustainability the issue of cost effectiveness are part of the equation I mean I'm an internist by training that issue of the human being the patient centeredness the people centeredness rather than the patient I think is an important component of it but for Ministry of Health also they need to make decision and for those countries at the moment I'm dealing with that have both a kind of development and emergency agendas that are blurred and have to respond to many challenges and to put forward for them I mean supporting them in making those choices the choices I mean need to be perhaps made explicit in how we decide at the moment like I give you an example in we are supporting Yemen Yemen didn't come out to us with diabetes type 1 as the first request it was a request on 150 medicine for cancer how do you respond to that I mean in term of how you prioritize those conditions when the Ministry of Health comes with something that for you might see irrational but you still need to respond to it and trying to make I mean those decision together I think so this is also the approaches from a WHO perspective putting that normative guidance of how you explicitly think about things that sometimes you have uncertainty you don't have the right evidence you still need to formulate a response I mean understanding my introduction that we need to respond now the urgency is now while at the same time building from that experiences the future response so that we can improve together this is where also agencies advocacy I mean someone mentioned about NCD alliance we contacted them some of them IDF are training people I mean some diabetes even specialists are training I mean some colleagues in the emergency response so to make a sense of what kind of message we want to convey first to the member state to the entire community that respond given the fact that some agencies maybe are not concerned with sustainability but our member state I mean I like there was one report of the WHO that's really like in the title but also in the content for mental health people is building back better that takes actually example of in emergency setting in mental health response how we can use it to build better in terms of responding I think one aspect that I'm covering is both in emergencies but also NCD integration primary care from a system perspective we need to do that system analysis and help countries to understand beyond the crisis what could be the basis for a better response and glad you read that point of the broader health systems implications for this which hasn't necessarily come up easily so the good news is we've got a question from our online audience the bad news is it's already been answered by you so apologies for that so I think we have time for one final question and then Kieran is going to wrap up for us please that's a lot of pressure on me my name's Pete Skelton from handicap international thank you to the panel it's been a really fantastic afternoon and people have touched on points and we've heard I think age and disability mentioned very very briefly towards the closing and I just want to say that these vulnerable populations NCDs are inextricably linked the connection between the two is incredibly profound and that these groups are often very neglected in our humanitarian responses the focus of today has been on improving care of people with NCDs in humanitarian settings and until we as a humanitarian community I think get better at including these groups particularly people with disability and older people within our responses and I speak particularly from an emergency medical perspective we're going to fail to respond properly to the NCD issue so I wanted to open it up to the panel maybe to the room to see if anybody had any tips on how they've actually managed to better include those populations within their programs because I think even within the data that we've seen we've seen that they are neglected thank you for that experts so I can tell you from the physical rehabilitation programs so there we realized actually as I told before that NCD patients are unputated due to diabetes and now we are looking into how to refer them into the health system for proper diabetic care and also what we are looking into now to use the time when they are in our centres to be rehabilitated to work and that would be also on healthy lifestyle because there we have time because that's then in more stable settings so yes I think it's a priority because they are already there with complications so if you don't want them to go ahead with amputations we have really to do something for them any other comments on maybe just briefly I work with Petra Shruder from NDCAP International when we initially actually started the kind of informal group on NCD and emergencies I mean NDCAP was also involved and they raised the point of the issue of amputation in diabetic patients in particular but we were at the time also there was a convention for disability that came out I mean at the UN level so we are trying also to operationalise this with our member state at the regional level we have the next regional committee there was one specific element about assistive devices for disabled people including in emergency settings that we are talking about colleagues from HQ have already issued a couple of years ago there was amputation and a policy guidance on disability in emergency settings to what extent this is operational on the field I must say very little almost nothing apart from those groups like ICSC that have specific programmes at least from what we see from the member state this is still a very neglected field I think that's one of the issues and there are specific programmes and specific organisations but as with NCDs it's not mainstreamed into humanitarian and medical responses so as NCDs need to be mainstreamed so does disability and older populations and only by doing both at the same time can we really reach both goals Thanks for that point Kiran did you have something you wanted to add on that Just very quickly just to say that in programmes where we are delivering NCD care particularly diabetes care we do always include wound care and diabetic ulcer care so obviously thinking ahead in terms of preventing those the amputations but also teams in Jordan have set up home visits after they tried doing taxi consultations as they called it which meant people with mobility difficulties who couldn't physically get into the clinic were consulted in a taxi outside and that raised confidentiality issues so they then started actually doing home visits and have a 200 person home visit cohort I think this is one of our key interests is trying to identify the really vulnerable populations and these are some of the ways to do it but as Tamarn points out they might not always be considered cost effective and it's interesting because what's far from the eye far from the heart sometimes you don't see them you don't look for them unless that someone comes and for example our collaboration with the handicap international in Jordan is because we're actually effectively amputating them in the surgical hospital that deals with war surgeries so we have at least grown a step further and we have asked for the help of physical rehabilitation from handicap international looking effectively for people that we haven't you know is yet to be done and it's very interesting the parallel hydro is when we had refugees running from Sudan from South Cordofan one of the revelations I've seen that opened the eyes of people is when people couldn't carry on anymore walking they dumped the older people on the side of the street and when we figured that out we went and collected some and we didn't manage to get some no one would have thought about it until we seen it and then our international president wrote a paper with help agent international on the issue we need an eye opener sometimes things that we're subconsciously ignoring thank you for that I think that's perhaps the take home message from today it wasn't scripted I promise you so we're going to hand over to Kyra now he's going to give some concluding remarks and thinking about the sort of next steps going forward and I'd just like to thank our panel very much for participating thank you