On 24 February 2022, the Russian Federation invaded Ukraine and commenced one of the largest humanitarian crises of the 21st century. Within 5 weeks, by 1 April 2022, the Russo-Ukrainian war had displaced >7 million Ukrainians internally and >4 million abroad, an estimate representing more than one-fourth of the Ukrainian population (1).
Attacks during armed conflicts not only cause direct physical harm, but also impair the management of chronic diseases. As of 13 March 2022, Pandey et al. (2) estimated that, among the displaced Ukrainian population, >2.63 million Ukrainians have cardiovascular disease and >615,000 people have diabetes. These numbers represent individual humans struggling to manage their health in the context of extreme suffering and trying to complete disease management tasks that are difficult at the best of times while surviving in a war zone.
Joseph Stalin reportedly said of the state-inflicted Ukrainian famine of the early 1930s, in which he himself was complicit, “A single death is a tragedy; a million deaths are a statistic,” illustrating our reduced ability to comprehend the suffering of those with whom we do not have a personal connection. Although the existing work on this topic discusses the challenges of managing diabetes during humanitarian crises, previous work has not considered the fates of those who are directly experiencing military conflict. It is up to us to allow these people who are managing diabetes in a situation unimaginable to most who reside in regions unaffected by conflict to teach us through their individual stories.
TeleHelp Украïна (TeleHelp Ukraine) (3) is a nonprofit organization founded by the medical faculty and students of Stanford University, providing free telemedicine to those who are situated in Ukraine and Poland; its services are unavailable to anyone outside of those regions. TeleHelp Ukraine is one of many telemedicine projects that currently exist worldwide (4–6). Most of the active 161 volunteer specialists, generalists, psychologists, and talk therapists are practicing in the United States, Canada, Western Europe, or Australia. Collectively, they had completed >2,400 consultations as of April 2024.
During the time period accessed by the authors, there had been 61 consultations with people with diabetes, from whose consultation notes the following quotes are taken. Notes from consultations conducted with practitioners around the world through this program offer us direct insight into the impact of conflict on people with diabetes, especially those managing type 2 diabetes, who represent most of the TeleHelp Ukraine client population. Consultations are conducted with medically trained interpreters, with treatment notes being recorded by clinicians in English in purpose-specific practice management software (Cliniko, Melbourne, Australia). This quality improvement exercise for the program used de-identified clinical notes recorded by program clinicians, with potentially sensitive information redacted; therefore, review by an institutional ethics review board was not required. Redaction of geographical locations served to protect individuals caught in an active conflict zone, where violence and persecution are ongoing.
The known theoretical challenges and needs for diabetes care during humanitarian crises, based on the six building blocks of health systems described by the World Health Organization (WHO), are shown in Table 1 (7–12). Additionally, suggestions for measures that may address these challenges are listed in the right column in Table 1. However, by exploring the experiences of people with diabetes in the Russo-Ukrainian war, we may understand the effects of conflict on diabetes management in reality. Moving from theory to practice through the documented experiences of Ukrainians with diabetes, this evidence-based understanding of the issues will bolster existing literature on providing health care in humanitarian crisis settings (13–18), enabling better targeting of health care resources during the current conflict and improving planning for crisis assistance to people with diabetes in future conflicts. Relevant evidence from consultation notes has been organized to align with three of the six WHO building blocks (4): medical products and technologies, service delivery, and health workforce.
Practical Challenges Associated With Diabetes Care in Humanitarian Crises in Low- and Middle-Income Countries, Based on Six Building Blocks of Health Systems described by the WHO (7–12)
| Challenges . | Actions for Improvement . |
|---|---|
| 1. Information and research | |
| Insufficient baseline epidemiological data on diabetes in LMICs | Implementation of surveillance and health information systems in LMICs for baseline prevalence data (e.g., International Diabetes Federation) |
| Diabetes and other NCDs not included in rapid crisis assessment tools | Development of standardized tools and methods to assess diabetes and NCD burden in crisis-affected populations |
| Lack of evidence-based guidelines for diabetes management | Development of evidence-based guidelines for diabetes management in emergencies (e.g., the WHO PEN guidelines, which provide resources and information on diabetes care delivery in LMICs) |
| 2. Service delivery | |
| Lack of knowledge of optimal diabetes management models of care* | Development of diabetes crisis models of care (e.g., 2019 UNHCR operational manual, which includes management of acute diabetes complications where emergency room and inpatient services are not readily available) |
| Priority of diabetes care given to those at greatest risk | Development of stratification systems for detecting high-risk patients on whom to focus access efforts |
| Access to physical health services (e.g., hospitals) during acute phase* | Resourcing to restore health infrastructure |
| Inadequate patient education because of disruption in care continuity, lack of human resources, and lack of culturally relevant education materials* | Development of simple and visual cross-cultural patient education resources (e.g., CardMedic resources that provide patient education on common health care topics that overcomes sensory impairments) |
| Lack of patient control over dietary intake* | Increased food diversity in nutritional aid to address the needs of people with diabetes |
| Housing insecurity† | Focus on restoring infrastructure and shelters† |
| Lack of standardization of interagency emergency health kits* | Standardized minimum service package for crisis diabetes care (e.g., the WHO stand-alone emergency NCD kit, which provides medicines for 10,000 people for 3 months, including metformin, sulfonylureas, insulin, and urine and blood test strips) |
| Lack of care continuity after hospital discharge because of mass displacement* | Establishment of a “patient passport” to facilitate care continuity during humanitarian crises |
| Competition for access between internationally displaced individuals and local nationals | Integration of displaced populations within host country health systems |
| 3. Health workforce | |
| Exacerbation of pre-crisis workforce limitations* | Task-sharing with nonphysician providers (e.g., the Pocketbook for Management of Diabetes in Childhood, Adolescence in Under-Resourced Countries, WHO PEN guidelines, and the Tactical Combat Casualty Care program in Ghana) |
| 4. Medical products and technologies | |
| Diabetes medical devices that are not robust because of a lack of supporting infrastructure* | Development of point-of-care devices for key diabetes investigations adapted to emergency settings (e.g., point-of-care laboratory tests and temperature-stable device strips) |
| Limited availability and affordability of medications* | Development of a sustainable and resilient medication supply |
| Insulin provision difficulties, including high cost, requirements for test strips, and requirements for refrigeration* |
|
Notes on specific diabetes medications during humanitarian crises:
| |
| 5. Financing | |
|
|
| 6. Governance | |
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| Challenges . | Actions for Improvement . |
|---|---|
| 1. Information and research | |
| Insufficient baseline epidemiological data on diabetes in LMICs | Implementation of surveillance and health information systems in LMICs for baseline prevalence data (e.g., International Diabetes Federation) |
| Diabetes and other NCDs not included in rapid crisis assessment tools | Development of standardized tools and methods to assess diabetes and NCD burden in crisis-affected populations |
| Lack of evidence-based guidelines for diabetes management | Development of evidence-based guidelines for diabetes management in emergencies (e.g., the WHO PEN guidelines, which provide resources and information on diabetes care delivery in LMICs) |
| 2. Service delivery | |
| Lack of knowledge of optimal diabetes management models of care* | Development of diabetes crisis models of care (e.g., 2019 UNHCR operational manual, which includes management of acute diabetes complications where emergency room and inpatient services are not readily available) |
| Priority of diabetes care given to those at greatest risk | Development of stratification systems for detecting high-risk patients on whom to focus access efforts |
| Access to physical health services (e.g., hospitals) during acute phase* | Resourcing to restore health infrastructure |
| Inadequate patient education because of disruption in care continuity, lack of human resources, and lack of culturally relevant education materials* | Development of simple and visual cross-cultural patient education resources (e.g., CardMedic resources that provide patient education on common health care topics that overcomes sensory impairments) |
| Lack of patient control over dietary intake* | Increased food diversity in nutritional aid to address the needs of people with diabetes |
| Housing insecurity† | Focus on restoring infrastructure and shelters† |
| Lack of standardization of interagency emergency health kits* | Standardized minimum service package for crisis diabetes care (e.g., the WHO stand-alone emergency NCD kit, which provides medicines for 10,000 people for 3 months, including metformin, sulfonylureas, insulin, and urine and blood test strips) |
| Lack of care continuity after hospital discharge because of mass displacement* | Establishment of a “patient passport” to facilitate care continuity during humanitarian crises |
| Competition for access between internationally displaced individuals and local nationals | Integration of displaced populations within host country health systems |
| 3. Health workforce | |
| Exacerbation of pre-crisis workforce limitations* | Task-sharing with nonphysician providers (e.g., the Pocketbook for Management of Diabetes in Childhood, Adolescence in Under-Resourced Countries, WHO PEN guidelines, and the Tactical Combat Casualty Care program in Ghana) |
| 4. Medical products and technologies | |
| Diabetes medical devices that are not robust because of a lack of supporting infrastructure* | Development of point-of-care devices for key diabetes investigations adapted to emergency settings (e.g., point-of-care laboratory tests and temperature-stable device strips) |
| Limited availability and affordability of medications* | Development of a sustainable and resilient medication supply |
| Insulin provision difficulties, including high cost, requirements for test strips, and requirements for refrigeration* |
|
Notes on specific diabetes medications during humanitarian crises:
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| 5. Financing | |
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| 6. Governance | |
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*Challenges described by referenced literature that are also represented in the treatment notes.
†Challenge indicated in treatment notes that was not represented in referenced literature. DPP-4, dipeptidyl peptidase 4; GLP-1, glucagon-like peptide 1; LMIC, low- or middle-income country; NCD, noncommunicable disease; PEN guidelines, package of essential noncommunicable disease guidelines; SGLT2, sodium–glucose cotransporter 2; TZD, thiazolidinedione; UNHCR, U.N. High Commissioner for Refugees.
Medical Products and Technologies
During humanitarian crises, reduced availability and affordability of essential medications for diabetes and associated complications pose significant risks to glycemic control. According to a July 2023 U.N. report (19), one in three people have challenges accessing essential medications in active conflict areas of Ukraine, and one in five are experiencing the same difficulties in the nation overall. Treatment notes resonate with these difficulties and unfavorable actions that had to be taken as a result. For example, the following account reveals that oral antihyperglycemic agents vital to diabetes management are scarce, considerably affecting diabetes management.
“Metformin 850 – but due to the lack of supply, taking 100[0], rationing metformin 850.”
There are many accounts about the unavailability of insulin.
“Poorly controlled [type 2 diabetes] on gliclazide 80 mg a day and desires to know the correct dose. [Blood glucose] 170–180 [mg/dL] fasting. Used to be on insulin, but no longer available and trying to treat with oral medications. Has multiple toe amputations.”
“[Patient] states he ran out of his insulin, and there’s none available. He increased his metformin dose from 500 mg per day to 1,500 mg but his sugars are still high. He takes one other medication for [type 2 diabetes] but doesn’t know the dose. He has developed an ulcer on his right foot but states he was seen by a war surgeon and was given antibiotics. Requests thioctic acid pills – states he had it in [intravenous drip] in the hospital for ulcer to heal and was told he should take it in capsule form for 20 more days . . . . diabetic ulcers and multiple toes amputated.”
Consultation notes document that medications for comorbidities commonly associated with diabetes are also deficient.
“Blood pressure – the patient takes her blood pressure at home. It usually runs 135–145 mmHg systolic. Poor compliance due to inability to get the medication. Today, her blood pressure is 200/90 mmHg.”
“Hypertension on multiple medications and access to medications difficult.”
The impact of the armed conflict on mental burden is also apparent and worsened by the lack of available medications.
“Anxiety, started on paroxetine, no longer available. Needs substitution.”
“Anxiety – [history] had been on mirtazapine – Remeron, which helped, but it was stolen from her . . . . [Post-traumatic stress disorder] and anxiety due to the war with manifestations of shaking attacks . . . . shaking attacks lasting 3 days. Not consistent with a seizure. Triggered by anxiety and shelling of the town.”
Increase in mental burden and lack of resources for management during disastrous periods is especially worrisome because people with diabetes are more likely to suffer from depression, anxiety, and suicidal ideation (20).
In addition to essential medications for diabetes, there is a lack of screening tools for continued monitoring or new diagnosis.
“She does not have glucometer, does not check blood sugars . . . . Blood pressure has always been in 130–140 range systolic but has not checked for a long time.”
“Measures blood sugars approximately once per week. Has a glucometer but hasn’t had access to blood glucose test strips.”
“3 days ago, measured blood sugar, was 14 [252 mg/dL] (fasting). 3 days before that was 17.1 [308 mg/dL] (fasting).”
These accounts demonstrate the lack of access to necessary medicines and the impact this problem has on people in conflict regions. They call for increased attention to developing portable devices that allow point-of-care laboratory tests and international efforts to provide a sustainable supply of essential medications for diabetes and diseases often associated with diabetes.
Service Delivery
It is common knowledge among health care communities that ongoing diabetes care involves multilevel health care facilities. Issues with loss of electricity and infrastructural damage are not unfamiliar concepts in armed conflicts. However, consultation notes underline the individual stories of struggles related to these problems. One of the notes indicates the abrupt discontinuation of care.
“From [redacted location], displaced to [redacted location] since the war started . . . . Patient did not have any clinical documentation available to review, as this was all left in [redacted location].”
Some individuals faced power outages, leaving them unable to access telemedicine services.
“Unfortunately, there was a blackout in less than 5 minutes after the start of our visit, and I was not able to get any additional information.”
Although the Geneva Conventions on the Humanitarian Law of Armed Conflicts proscribe this practice, the WHO has confirmed >1,000 attacks on Ukrainian health infrastructure facilities—one of the highest numbers the WHO has recorded in a single conflict (8). Treatment notes describe the impact of such attacks on individuals.
“Patient stated he had an MRI of the abdomen in the Ukraine . . . . Unfortunately, the reports of the MRI and the scan/facility itself was destroyed in a fire.”
The importance of prioritization of health care access and laboratory testing is also emphasized in the notes.
“Unknown how well controlled her diabetes is, nor what medication she is on. Unclear if she actually should be on insulin as was not testing her blood sugars during that time. Levels she reports are too high. Needs labs.”
“Ideally, we should do official diabetic test on this lady as she possibly may have borderline diabetes, i.e., glucose tolerance test when feasible locally, and ideally should also have cholesterol and renal function blood testing and uric acid levels checked. Made patient aware that regular diuretic therapy increased risk [of] gout/renal stones.”
“Labs are expensive. Would like to get only necessary labs to be checked.”
“Friday traveled by car + walking (hitchhiked to get her pension – by car ∼1.5, walking ∼3 hours, was very hot that day).”
“No access to cardiac imaging or interventional treatment is anticipated in the near future because of war conditions.”
“[Patient] . . . has [history of peripheral vascular disease] and used to have [intravenous] medications twice per year. Recently, has not been able to have this therapy.”
“Ideally, if she had chest pain, she would seek medical evaluation, but not realistic, currently.”
Continuity of care involves adequate patient education and awareness of diabetes symptoms and management. Effects of conflict-induced discontinuity of provider-patient interactions on patient education is apparent in consultation notes.
“Once had blood sugar checked, found that it was 215 [mg/dL]. Denies polyuria or polydipsia . . . . Endorses history of episode of chest pain at work, for which she has never cathed [sic] . . . Likely [diabetes].”
“Was on metformin for [type 2 diabetes] but feels it did not bring her sugar down but never measured her sugar . . . . Denies any renal complications, but notes that her vision has gotten significantly worse.”
Even when patients can access health care, there is a lack of control over lifestyle factors crucial for diabetes management. For example, one note stated that a patient “was very active pre-war, but now sedentary with weight gain and increase[d] alcohol intake.”
Well-balanced nutrition is essential to the nonpharmacological management of diabetes, and poor nutrition is a risk factor for episodes of hypoglycemia. Unfortunately, food insecurity is also documented in some notes.
“Typical diet consists of buckwheat, soup, milk as available. Eats porridges such as millet and rice porridge.”
“Has difficulty adhering to diet due to limited access to food.”
Housing insecurity is also recorded.
“Lives with second husband in area of active shelling. Windows blown out, uses a portable gas appliance to cook. Looks after her [elderly] father who has dementia. Has . . . children and . . . grandchildren who have been evacuated. She would leave if she didn’t have to look after her father.”
“[Patient’s] house was shelled, and he had suspected concussion.”
The impact of this lack of safety and security on the rapid deterioration of health was frequently documented.
“. . . prior history of diabetes, who is presently a refugee from Ukraine in Poland . . . . For the past 5 months, since sitting in the basement in her home, she’s developed severe left-sided back pain radiating down to the sacroiliac joint and down to the leg. She has some numbness and is unable to walk sufficiently.”
“She was active and athletic prior to the start of the war but has since had leg pain and swelling. She . . . was in [redacted location] at the start of the war and had to spend significant time in basements and bomb shelters, where she had to stay upright, unable to change shoes, etc. Since then, she’s had swelling of bilateral legs, which improves with elevation, as well as pain in bilateral knees. She states she’s been evaluated by local physicians in the city to which she evacuated who believe her leg swelling is due to varicose veins and recommend compression [and] Daflon.”
“Varicose veins and legs that worsened when traveled to [redacted location, internal displacement] to escape Ukraine war . . . . Is getting ready to take long bus back to [redacted location], will be driving to [redacted location], and is worried that the varicose veins will bother her again.”
As suggested in Table 1, integration of mental health services with medical management of diabetes is needed, and several notes highlight the effect of armed conflicts on mental health.
“. . . went through significant stress, lost 6 kg, was forcing herself to eat.”
“Her headache is constant and worse since 1 year ago, when she was forced to move. She says there is less light available in the place where she stays now . . . . She doesn’t sleep too well and sometimes uses melatonin.”
“Patient reports situational anxiety during wartime with significant palpitations/headache.”
“Patient reported several stressful situations during last year: death of . . . family members, finishing college, febrile illness in winter this year.”
“High blood pressure and insomnia. After a loud explosion last year, [patient] experienced loss of hearing [in right] ear . . . . He sleeps 4+ hours at night, hard to fall asleep, and wake[s] up after 4 hours.”
“Lives [with] son – daughter died. Lives very rural areas, small farm, appears very anxious and forlorne [sic], depressed regarding the war and her life and how things changed.”
Treatment notes demonstrate disruption of multidisciplinary services, including pathology laboratories, diabetes education programs, and mental health services, significantly affecting the quality of diabetes care. In addition, humanitarian crises can pose a greater strain on health care systems such as that of Ukraine, where there are already high out-of-pocket expenses for access to services despite the universal health care system (21).
Health Workforce
Armed conflict commonly displaces the civilian health workforce (2), which further deteriorates the health care infrastructure. One can glimpse this in the treatment notes.
“Chest pain is the patient’s biggest concern. She had a medication in the past that helped her pain, which was bisoprolol. Unfortunately, the medical team . . . [were] evacuat[ed] . . . prior to being able to get a full interview.”
“He states he has a psychiatrist, but he [the psychiatrist] is now in [redacted location].”
Kehlenbrink et al. (9) discuss the importance of task-sharing during emergency contexts. This practice involves developing guidelines on decentralizing diabetes care management and training nonphysician health staff to manage diabetes, especially with regard to diabetes-related emergencies. Although there are no explicit treatment note records of TeleHelp Ukraine being involved in task-sharing, treatment notes documenting active shelling, inadequate housing, and poor access to nutritious food suggest a potential increase in factors that put patients at greater risk of diabetes emergencies. In this regard, it is imperative to develop guidelines that the local nonphysician health workforce can use during humanitarian crises.
Conclusion
The direct quotes from the telemedicine consultations of TeleHelp Ukraine give us stories of individuals with diabetes directly affected by the war. People with diabetes are particularly vulnerable because displacement, food and housing insecurity, and lack of regular checkups and monitoring can easily disrupt diabetes management during armed conflicts.
One of the most significant limitations of telemedicine is that its availability is limited to individuals and families whose socioeconomic status gives them the ability to evacuate to areas with stable Internet access. Thus, these notes represent just the tip of the iceberg of hundreds of thousands of stories that may only be told through statistics.
Actions must be taken to expedite responses to current challenges and better meet the needs for higher-quality diabetes care during humanitarian crises. These should include undertaking measures to address the particular hardships experienced by people with diabetes, including limited access to medicines, laboratory investigations, and other treatment elements required for optimal diabetes care, as evidenced by the notes above. Let us learn from the narratives in these consultation notes and take action to reduce the burden of diabetes during humanitarian crises.
Duality of Interest
No potential conflicts of interest relevant to this article were reported.
Author Contributions
J.W.S.Y. wrote the manuscript. R.D.B. contributed to the discussion and reviewed/edited the manuscript. R.D.B. is the guarantor of this work and, as such, takes responsibility for the integrity of information provided.
