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GLOBAL ALLIANCE FOR DIABETES IN CRISES (GADiC)

Diabetes is a major cause of death, disability and suffering in lower and middle-income countries, particularly amongst marginalized groups such as refugees.  Humanitarian crises put people with diabetes at high risk of death and complications from the disease, and yet provision of diabetes care in humanitarian settings remains scarce and lacks coordination. The Global Alliance for Diabetes in Crises (GADiC) is an alliance of international organizations from various sectors working to collectively improve diabetes care in humanitarian crises.

Diabetes is one of the most common non-communicable diseases (NCDs) with approximately half a billion people affected globally, of which 80% live in lower- and middle-income countries (LMICs).

Individuals with diabetes are particularly vulnerable in humanitarian crises due to disrupted health services, medication supplies, and unpredictable food supplies, which exacerbates the disease and can lead to complications or death. Type 1 diabetes is arguably the most life-threatening NCD in the context of service disruption, since lack of to access insulin and continuity of care in place them at immediate risk of death. Type 2 diabetes is responsible for a vast burden of suffering and disability in low resource settings and contributes substantially to cardiovascular disease related mortality. Moreover, diabetes is associated with greater susceptibility to infections and worse outcomes, including tuberculosis and other respiratory infections, which is of great concern, considering humanitarian crises and infectious disease outbreaks often go hand in hand.

The geography and nature of humanitarian crises today put people with diabetes at greater risk than ever. Forced migration has reached record high levels in recent years, with 85% of those affected being hosted in LMICs and 65% living in protracted refugee situations, which markedly reduces access to follow up care resulting in very poor health outcomes.2 On top of this, the current COVID19 pandemic highlights many of the challenges for diabetes care on a global scale: reports show more severe disease and increased mortality in people with diabetes due to COVID19, and the delivery of healthcare is challenged due to limited work force, disrupted supply chains, and difficult access to basic and essential medical supplies, such as insulin.

Despite projections of a 48% rise in diabetes prevalence globally over the next 25 years and expected increase in humanitarian crises due to climate change, conflict and epidemics, the provision of diabetes care in humanitarian settings remains scarce and poorly coordinated. This was highlighted at a symposium at Harvard in April 2019, which led to the Boston Declaration which was signed by 64 signatories from over 40 international organizations.5 The Global Alliance for Diabetes in Crises (GADiC) was consequently established to coordinate and tackle these goals collaboratively.

GADiC is a partnership of over 50 international organizations with an interest in diabetes from different sectors ranging from humanitarian organizations, intergovernmental and UN agencies, to academic institutions, civil society, philanthropic organizations and the private sector. GADiC is developing concrete collaborative initiatives that will increase access to and quality of care for people with diabetes in humanitarian settings. The partnership leverages the unique skills, expertise and capacities of both public and private member organizations, to develop and implement bold initiatives that improve services for the most vulnerable populations who lack access to quality diabetes care

Our mission is to improve access to and quality of diabetes care for vulnerable people in humanitarian crises and stop the preventable disability and death of people living with diabetes in these settings.

Member organizations of the alliance are motivated by universal medical ethics and the humanitarian principles of impartiality and neutrality. We work collectively to improve the delivery of diabetes care to save lives, reduce suffering, promote dignity, reduce disability, and strengthen resilience of people living in low- and middle-income countries and affected by crises. To do this, member organizations contribute their distinct skills, experience and capacities to develop and implement effective multi-sectoral approaches that address the operational and policy challenges that limit provision of care to the most marginalized people.

We envision a world where vulnerable people living in humanitarian settings have access to quality diabetes care and no one dies from lack of care.

By 2023, we will be able to demonstrate a substantial increase in access to insulin and meaningful improvements in quality of care for people with diabetes living in humanitarian crises.

OBJECTIVE 1. Increase the global health profile of diabetes, and consciousness of access to insulin as a humanitarian priority, through unified and strengthened advocacy.

Produce a high-level World Health Assembly declaration that supports the provision of insulin to all those in need in humanitarian settings
Strengthen unified advocacy campaigns and global awareness, particularly among governments and donors, to ensure access to insulin and inclusion of diabetes care in humanitarian responses
Improve processes for dissemination of findings and publications about diabetes care and prevention in humanitarian crises to all audiences, such as via social media, websites, and news releases.
Advocate for the use of all available tools to reduce prices of essential medicines and diagnostics

OBJECTIVE 2. Improve access to insulin and other essential medicines and diagnostics for glycemic and cardiovascular risk reduction in humanitarian crises

Routinely include essential medications and diagnostics for diabetes in humanitarian response systems, with insulin as an immediate priority
Advocate for transparent procurement and prices for insulin used in humanitarian settings, reflecting the known cost of production
Advocate for the pre-qualification of biosimilar insulins to introduce further market competition and aim for price reductions
Improve availability, affordability, coverage, quality, and field suitability of diagnostic equipment for diabetes and hypertension in humanitarian settings
Develop a consensus statement and identify needs for further research on insulin thermostability, to inform international guidelines on the storage of insulin and blood glucose test strips in humanitarian settings

OBJECTIVE 3. Establish a unified set of clinical and operational guidelines for diabetes in humanitarian crises

Develop and test evidence-based clinical guidance and educational materials on diabetes care in humanitarian crises
Develop and test different cost-effective models of care that take local health systems and food supplies into consideration and develop differentiated emergency preparedness plans.
Develop new tools and support innovation around treatment, monitoring and education to facilitate care and coordination between humanitarian organizations.
Clarify the potential role of insulin analogues in humanitarian settings.

OBJECTIVE 4. Generate an evidence base to support advocacy, through improved data and surveillance

Systematically assess current data collection processes to form a baseline understanding of context, capacity, needs, and barriers as regards collection of diabetes related indicators
Develop and implement standardized indicators of the prevalence of diabetes, access to care, patient burden and patient-centered outcomes in humanitarian crises for program monitoring and evaluation, and to make these data available to stakeholders.
Expand the diversity of qualitative and quantitative studies of diabetes in humanitarian crises across regions, types of crises and crisis stages.
Include crisis-affected populations in studies of the economic and social implications of diabetes in host countries.

Estimate the cost of diabetes care in humanitarian crises incurred by the health system and out-of-pocket expenditures, and the cost of inaction.

Members of the Alliance connect, share and collaborate both bilaterally and through events and activities provided by the GADiC secretariat, hosted at the Harvard Humanitarian Initiative in Boston and linked to Brigham and Women’s Hospital. At present, the main collaborative activities of the members have been grouped into the four workstreams, each of which has appointed a working group lead.

The work of the secretariat is governed by an advisory board made up of geographically diverse representatives from WHO, NGOs and academic public health institutes. Members of the advisory board receive no compensation or incentives for their work and have no competing interests.

Leadership Team

Chair of the Secretariat

Sylvia Kehlenbrink, Brigham and Women’s Hospital and Harvard Humanitarian Initiative, Boston, MA

Advisory Board

Stéfane Besançon, Santé Diabete, Mali

Kiran Jobanputra, Médecins Sans Frontières OCA, UK

Kaushik Ramaiya, Shree Hindu Mandal Hospital, Tanzania

Bayard Roberts, London School of Hygiene and Tropical Medicine, UK

Slim Slama, World Health Organization, Egypt

Working Group Leadership

Advocacy

Arjan Hehenkamp, Stichting Vluchteling

Amulya Reddy, Médecins Sans Frontières OCA

Access to Medicines and Diagnostics

Helen Bygrave, Médecins Sans Frontières Access Campaign

Christa Cepuch, Médecins Sans Frontières Access Campaign

Katy Digovich, Clinton Health Access Initiative (Insulin Thermostability Sub-Group)

Jing Luo, University of Pittsburgh

Clinical and Operational Guidance

Philippa Boulle, Médecins Sans Frontières OCG

Sylvia Kehlenbrink, Brigham and Women’s Hospital/Harvard Humanitarian Initiative

Data and Surveillance

Éimhín Ansbro, London School of Hygiene and Tropical Medicine

Angelica Cristello, UNC Gillings School of Public Health

Ruth Hunter, Queens University Belfast

Kathrine Souris, UNC Gillings School of Public Health

IDF Diabetes Atlas Ninth Edition 2019
UNHCR Figures at a Glance 2019. https://www.unhcr.org/figures-at-a-glance.html (accessed 12-05-2019)
The human cost of natural disasters 2015: a global perspective. Brussels: Centre for Research on the Epidemiology of Disasters, 2015.
Kehlenbrink S, Smith J, Ansbro É, et al. The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries. Lancet Diabetes Endocrinol. 2019;7(8):638-647. doi:10.1016/s2213-8587(19)30082-8
Kehlenbrink S, Jaacks LM, Aebischer Perone S, et al. Diabetes in humanitarian crises: the Boston Declaration. Lancet Diabetes Endocrinol. 2019;7(8):590-592. doi:10.1016/S2213-8587(19)30197-4

CONTEXT

Diabetes is one of the most common non-communicable diseases (NCDs) with approximately half a billion people affected globally, of which 80% live in lower- and middle-income countries (LMICs).

Individuals with diabetes are particularly vulnerable in humanitarian crises due to disrupted health services, medication supplies, and unpredictable food supplies, which exacerbates the disease and can lead to complications or death. Type 1 diabetes is arguably the most life-threatening NCD in the context of service disruption, since lack of to access insulin and continuity of care in place them at immediate risk of death. Type 2 diabetes is responsible for a vast burden of suffering and disability in low resource settings and contributes substantially to cardiovascular disease related mortality. Moreover, diabetes is associated with greater susceptibility to infections and worse outcomes, including tuberculosis and other respiratory infections, which is of great concern, considering humanitarian crises and infectious disease outbreaks often go hand in hand.

The geography and nature of humanitarian crises today put people with diabetes at greater risk than ever. Forced migration has reached record high levels in recent years, with 85% of those affected being hosted in LMICs and 65% living in protracted refugee situations, which markedly reduces access to follow up care resulting in very poor health outcomes.2 On top of this, the current COVID19 pandemic highlights many of the challenges for diabetes care on a global scale: reports show more severe disease and increased mortality in people with diabetes due to COVID19, and the delivery of healthcare is challenged due to limited work force, disrupted supply chains, and difficult access to basic and essential medical supplies, such as insulin.

Despite projections of a 48% rise in diabetes prevalence globally over the next 25 years and expected increase in humanitarian crises due to climate change, conflict and epidemics, the provision of diabetes care in humanitarian settings remains scarce and poorly coordinated. This was highlighted at a symposium at Harvard in April 2019, which led to the Boston Declaration which was signed by 64 signatories from over 40 international organizations.5 The Global Alliance for Diabetes in Crises (GADiC) was consequently established to coordinate and tackle these goals collaboratively.

WHO WE ARE

GADiC is a partnership of over 50 international organizations with an interest in diabetes from different sectors ranging from humanitarian organizations, intergovernmental and UN agencies, to academic institutions, civil society, philanthropic organizations and the private sector. GADiC is developing concrete collaborative initiatives that will increase access to and quality of care for people with diabetes in humanitarian settings. The partnership leverages the unique skills, expertise and capacities of both public and private member organizations, to develop and implement bold initiatives that improve services for the most vulnerable populations who lack access to quality diabetes care.

MISSION STATEMENT

Our mission is to improve access to and quality of diabetes care for vulnerable people in humanitarian crises and stop the preventable disability and death of people living with diabetes in these settings.

Member organizations of the alliance are motivated by universal medical ethics and the humanitarian principles of impartiality and neutrality. We work collectively to improve the delivery of diabetes care to save lives, reduce suffering, promote dignity, reduce disability, and strengthen resilience of people living in low- and middle-income countries and affected by crises. To do this, member organizations contribute their distinct skills, experience and capacities to develop and implement effective multi-sectoral approaches that address the operational and policy challenges that limit provision of care to the most marginalized people.

LONG TERM VISION

We envision a world where vulnerable people living in humanitarian settings have access to quality diabetes care and no one dies from lack of care.

PRIORITY AGENDA 2020-2023

By 2023, we will be able to demonstrate a substantial increase in access to insulin and meaningful improvements in quality of care for people with diabetes living in humanitarian crises.

OBJECTIVE 1. Increase the global health profile of diabetes, and consciousness of access to insulin as a humanitarian priority, through unified and strengthened advocacy.

Produce a high-level World Health Assembly declaration that supports the provision of insulin to all those in need in humanitarian settings
Strengthen unified advocacy campaigns and global awareness, particularly among governments and donors, to ensure access to insulin and inclusion of diabetes care in humanitarian responses
Improve processes for dissemination of findings and publications about diabetes care and prevention in humanitarian crises to all audiences, such as via social media, websites, and news releases.
Advocate for the use of all available tools to reduce prices of essential medicines and diagnostics

OBJECTIVE 2. Improve access to insulin and other essential medicines and diagnostics for glycemic and cardiovascular risk reduction in humanitarian crises

Routinely include essential medications and diagnostics for diabetes in humanitarian response systems, with insulin as an immediate priority
Advocate for transparent procurement and prices for insulin used in humanitarian settings, reflecting the known cost of production
Advocate for the pre-qualification of biosimilar insulins to introduce further market competition and aim for price reductions
Improve availability, affordability, coverage, quality, and field suitability of diagnostic equipment for diabetes and hypertension in humanitarian settings
Develop a consensus statement and identify needs for further research on insulin thermostability, to inform international guidelines on the storage of insulin and blood glucose test strips in humanitarian settings

OBJECTIVE 3. Establish a unified set of clinical and operational guidelines for diabetes in humanitarian crises

Develop and test evidence-based clinical guidance and educational materials on diabetes care in humanitarian crises
Develop and test different cost-effective models of care that take local health systems and food supplies into consideration and develop differentiated emergency preparedness plans.
Develop new tools and support innovation around treatment, monitoring and education to facilitate care and coordination between humanitarian organizations.
Clarify the potential role of insulin analogues in humanitarian settings.

OBJECTIVE 4. Generate an evidence base to support advocacy, through improved data and surveillance

Systematically assess current data collection processes to form a baseline understanding of context, capacity, needs, and barriers as regards collection of diabetes related indicators
Develop and implement standardized indicators of the prevalence of diabetes, access to care, patient burden and patient-centered outcomes in humanitarian crises for program monitoring and evaluation, and to make these data available to stakeholders.
Expand the diversity of qualitative and quantitative studies of diabetes in humanitarian crises across regions, types of crises and crisis stages.
Include crisis-affected populations in studies of the economic and social implications of diabetes in host countries.
Estimate the cost of diabetes care in humanitarian crises incurred by the health system and out-of-pocket expenditures, and the cost of inaction.

ORGANIZATIONAL STRUCTURE

Members of the Alliance connect, share and collaborate both bilaterally and through events and activities provided by the GADiC secretariat, hosted at the Harvard Humanitarian Initiative in Boston and linked to Brigham and Women’s Hospital. At present, the main collaborative activities of the members have been grouped into the four workstreams, each of which has appointed a working group lead.

The work of the secretariat is governed by an advisory board made up of geographically diverse representatives from WHO, NGOs and academic public health institutes. Members of the advisory board receive no compensation or incentives for their work and have no competing interests.

Leadership Team

Chair of the Secretariat

Sylvia Kehlenbrink, Brigham and Women’s Hospital and Harvard Humanitarian Initiative, Boston, MA

Advisory Board

Stéfane Besançon, Santé Diabete, Mali

Kiran Jobanputra, Médecins Sans Frontières OCA, UK

Kaushik Ramaiya, Shree Hindu Mandal Hospital, Tanzania

Bayard Roberts, London School of Hygiene and Tropical Medicine, UK

Slim Slama, World Health Organization, Egypt

Working Group Leadership

Advocacy

Arjan Hehenkamp, Stichting Vluchteling

Amulya Reddy, Médecins Sans Frontières OCA

Access to Medicines and Diagnostics

Helen Bygrave, Médecins Sans Frontières Access Campaign

Christa Cepuch, Médecins Sans Frontières Access Campaign

Katy Digovich, Clinton Health Access Initiative (Insulin Thermostability Sub-Group)

Jing Luo, University of Pittsburgh

Clinical and Operational Guidance

Philippa Boulle, Médecins Sans Frontières OCG

Sylvia Kehlenbrink, Brigham and Women’s Hospital/Harvard Humanitarian Initiative

Data and Surveillance

Éimhín Ansbro, London School of Hygiene and Tropical Medicine

Angelica Cristello, UNC Gillings School of Public Health

Ruth Hunter, Queens University Belfast

Kathrine Souris, UNC Gillings School of Public Health

REFERENCES

IDF Diabetes Atlas Ninth Edition 2019
UNHCR Figures at a Glance 2019. https://www.unhcr.org/figures-at-a-glance.html (accessed 12-05-2019)
The human cost of natural disasters 2015: a global perspective. Brussels: Centre for Research on the Epidemiology of Disasters, 2015.
Kehlenbrink S, Smith J, Ansbro É, et al. The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries. Lancet Diabetes Endocrinol. 2019;7(8):638-647. doi:10.1016/s2213-8587(19)30082-8
Kehlenbrink S, Jaacks LM, Aebischer Perone S, et al. Diabetes in humanitarian crises: the Boston Declaration. Lancet Diabetes Endocrinol. 2019;7(8):590-592.

GLOBAL ALLIANCE FOR DIABETES IN CRISES (GADiC)

Diabetes is a major cause of death, disability and suffering in lower and middle-income countries, particularly amongst marginalized groups such as refugees.  Humanitarian crises put people with diabetes at high risk of death and complications from the disease, and yet provision of diabetes care in humanitarian settings remains scarce and lacks coordination. The Global Alliance for Diabetes in Crises (GADiC) is an alliance of international organizations from various sectors working to collectively improve diabetes care in humanitarian crises.

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