Imagine a resident physician working at a low-resource hospital in sub-Saharan Africa. A young patient presents to her clinic with the symptoms of diabetic ketoacidosis resulting from uncontrolled type 1 diabetes, a complication which is easily treatable with insulin and fluid replacement therapy. But resource scarcity hinders the delivery of care, and the patient dies — a death considered to be largely preventable by modern medicine. The same scenario repeatedly plays out, with the resident unable to save her type 1 diabetes patients from death or adequately manage those with chronic, unresolved complications from type 2 diabetes. While this harrowing experience may have discouraged many from pursuing a career in global health, this resident was moved to action. Galvanized by what she had seen, she has dedicated her career to helping the millions of people living with non-communicable diseases (NCDs), such as diabetes, in low- and middle-income countries (LMICs). This former resident, Sylvia Kehlenbrink, MD, is now a physician and the director of Global Endocrinology at the Brigham and of the Non-Communicable Diseases (NCDs) in Conflict Program at the Harvard Humanitarian Initiative.
“I get this question a lot: ‘Don’t you go to bed depressed every night because you can’t fix the problem?’” says Kehlenbrink. “That’s just not the right way to look at this. We have to start somewhere, and any small movement in the right direction is progress.”
Thoughtful, humble and dedicated, Kehlenbrink is a pioneer of a new wave of health: global endocrinology. Diabetes is estimated to affect one in 11 — 425 million — adults worldwide. Of those, one in two — 212 million — adults with diabetes remains undiagnosed. This chronic disease, which is perceived as largely controllable in developed nations, kills more people each year than HIV, tuberculosis (TB) and malaria combined.
“I found it really notable that if someone walked into the hospital with a fever, or a cough, or a new diagnosis of HIV or TB — we could treat it,” she said. “So many resources have been invested into HIV and TB, which is fantastic. However, in the process, the diabetes epidemic has soared, and people are not getting care.”
Kehlenbrink attributes part of this discrepancy to the differences in treatment and disease etiology. “Unlike HIV and TB, diabetes is not directly transmissible, generally progresses slower and complications often don’t arise until years later, so I think it isn’t perceived as an immediate threat. In addition, advocacy efforts have not been as strong, and funding has been scarce, considering all NCDs combined currently only receive less than 3 percent of the overseas development aid.”
Examining the Perilous Intersection of Disease and Conflict
The burden of diabetes is disproportionately high in developing nations, with reports estimating that up to 77 percent of individuals with diabetes reside in LMICs. In parallel, LMICs are also disproportionately affected by humanitarian crises. Global forced displacement is at an all-time high — more people must leave their homes for longer periods of time. The United Nations High Commissioner for Refugees (UNHCR) estimates that 68.5 million people were forcibly displaced at the end of 2017, for an average duration of 20 to 29 years.
The intersection of chronic disease and forced displacement creates a perfect storm.
“Individuals with NCDs are more vulnerable in crisis situations,” writes Kehlenbrink in a PLOS blog post. “Emergencies exacerbate NCDs, and there is invariably a health care gap for those with chronic disease. Despite these massive global changes, the problem of NCDs in humanitarian emergencies and conflict settings has been largely neglected.”
With the growing burden of forced migration and the persistence of NCDs, the landscape for humanitarian initiatives is beginning to shift. “Historically, the main causes of death and disability in humanitarian crises were infectious diseases, malnutrition and trauma,” says Kehlenbrink. “However, as crises are increasingly becoming protracted, humanitarian actors are now starting to take care of longer disease processes.”
Pursuing Advocacy and Collaboration
How do we begin to address such a complex and large-scale issue? There is no easy answer, but Kehlenbrink envisions an approach that combines public advocacy with global collaboration. These features will be reflected in the inaugural “Diabetes in Humanitarian Crisis” symposium that Kehlenbrink has organized for early next month at Harvard Medical School, which unites a range of humanitarian and non-humanitarian actors, including leaders in global health from organizations such as the World Health Organization, UNHCR, and Doctors Without Borders, to philanthropic organizations, government agencies, executives from global insulin and oral antidiabetic manufacturers, and academic institutions. Ultimately, Kehlenbrink hopes to reach the same advocacy and collective mobility that was achieved by the HIV and TB communities.
“To my knowledge, it’s the first symposium specifically looking at diabetes in humanitarian crises,” says Kehlenbrink. “The symposium seeks to bring everyone together from different sectors to build partnerships and prioritize next steps as an international community. We must ask ourselves: What are the most immediate needs? What are the most significant barriers? How can we work together to move this field forward? How can we best fund this global crisis? No single institution can to fix this issue, and we need to collaborate and work together.”
Harnessing the Power of Information
Kehlenbrink lights up as she talks about her work at the newly established Global Endocrinology Unit at the Brigham and Harvard Medical School. The program uses a three-pronged approach consisting of research, education, and clinical care to address the global management of endocrine disorders, particularly in low-resource and humanitarian settings.
In terms of research, Kehlenbrink is currently working with the HUmanitarian NCD InTeragency study in Emergencies and Disasters (UNITED) Consortium, which is comprised of seven humanitarian organizations, including the UNHCR, Doctors Without Borders, and the International Committee of the Red Cross, to improve diabetes care in humanitarian contexts.
Kehlenbrink notes that data on the epidemiology and management of diabetes in many parts of the world is scarce. To address this, UNITED is currently doing a retrospective “landscaping” study to assess the current practices, challenges, and barriers to diabetes care in over 100 humanitarian sites.
They are also jointly developing a set of NCD-specific core indicators to equip NGOs to effectively monitor diabetes and other NCDs over the course of their clinical and humanitarian efforts. These indicators will then be used to establish a data repository that will guide future efforts to plan and evaluate NCD care in humanitarian settings.
“The Brigham has a long history of leadership in global health,” says Kehlenbrink. “With the Global Endocrinology Unit at the Brigham, I’m really hoping to tap into the incredible resources we have here in terms of knowledge, skill and research capacity, and build that out to advance the field.”