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The rise in non-communicable diseases and their contribution to COVID-19 is prompting a shift in priorities. Sharmila Devi reports. Ahmad* a 32-year-old Syrian refugee, presented with diabetes, but he refused to take insulin. “He had very high blood pressure and oedema and no response to oral medications so I counselled him to take insulin”, said Noor Al-Khazali, a doctor who works for a non-communicable diseases (NCDs) project run by Médecins Sans Frontières (MSF) in Jordan. But Ahmad was worried about the trouble of taking insulin every day: “he said it would ruin his life even more”. With the help of a health educator, who is also part of the NCD project in Irbid, northern Jordan, Al-Khazali persuaded the man to take insulin under their monitoring. “3 months later, he was so happy and said his life was completely changed. This is why I love this work”, she told The Lancet. Aid agencies and donors have traditionally focused on emergency assistance, but a massive rise in NCDs, which make people more vulnerable to severe COVID-19 and death, have made these diseases impossible to ignore. The prevalence of NCDs including diabetes, high blood pressure, respiratory disease, and heart disease is increasing around the world. These diseases are costly to treat because of the need for long-term medication and monitoring. But early treatment is cheaper than treating the complicated conditions that can develop without care, such as kidney failure.

etes, high blood pressure, respiratory disease, and heart disease is increasing around the world. These diseases are costly to treat because of the need for long-term medication and monitoring. But early treatment is cheaper than treating the complicated conditions that can develop without care, such as kidney failure. Globally, approximately 463 million adults have diabetes, projected to increase to 700 million by 2045, according to 2019 data from the International Diabetes Federation (IDF). NCDs were seven of the top ten causes of death in 2019, up from four of the top ten causes in 2000, according to the latest global health estimates by WHO. In lower-middle-income countries, the number of deaths from diabetes has nearly doubled since 2000. “The case to act has never been more urgent”, said The Lancet's Commission on diabetes, published November, 2020. MSF has focused on diabetes as one of the most common NCDs in the organisation's clinics in countries from South Sudan to Iraq where insulin is often not available in public health facilities or private pharmacies. In Jordan, MSF treats approximately 3600 Syrian refugees and uninsured Jordanians with diabetes, including around 600 using insulin, with a package of care that includes counselling and education about diet and lifestyle as well as prescribing and monitoring insulin. “Patients can call us at any time and we even distribute insulin to their homes if they cannot visit the clinic”, said Al-Khazali.

ans with diabetes, including around 600 using insulin, with a package of care that includes counselling and education about diet and lifestyle as well as prescribing and monitoring insulin. “Patients can call us at any time and we even distribute insulin to their homes if they cannot visit the clinic”, said Al-Khazali. In Lebanon, MSF has a continuous glucose monitoring (CGM) programme for children with type 1 diabetes who are refugees. The children wear a sensor on their arm to measure blood glucose concentrations. As part of the programme, approximately 100 children have insulin pens, which are fast-acting and easier to use than syringes. Houssam, aged 12 years, one of MSF's patients on CGM in north Bekaa, Lebanon, said that he had become used to living with the disease with the help of his parents and medical team. “I dream of travelling to Sweden to study to become a doctor”, he told MSF. © 2021 Mohammed Sanabani/MSF2021 Insulin ranks in the top five most expensive medicines in NCD programmes, said MSF. Government procurement prices of different types of human and analogue insulin in vials were between US$6 and $34, according to a study by the Addressing the Challenges and Constraints of Insulin Sources and Supply group.

© 2021 Mohammed Sanabani/MSF2021 Insulin ranks in the top five most expensive medicines in NCD programmes, said MSF. Government procurement prices of different types of human and analogue insulin in vials were between US$6 and $34, according to a study by the Addressing the Challenges and Constraints of Insulin Sources and Supply group. “Diabetes is still a challenge at the primary care level and often there aren't any guidelines for health workers. We have provided NCD care in 14 countries so far”, Lilian Kiapi, senior technical adviser for the International Rescue Committee, told The Lancet. The agency has provided almost 1 million NCD patient consultations in humanitarian settings from Bangladesh to Yemen. Kiapi was among the authors of a guide, Integrating Non-communicable Disease Care in Humanitarian Settings, published last November by the International Rescue Committee and the UN High Commissioner for Refugees, which highlighted the challenge of the changing nature of humanitarian emergencies including conflicts occurring in higher income countries, increasing number of protracted crises, and more people being internally displaced compared with refugees. People have had to resort to unorthodox measures to protect their insulin supplies. “In Kenya, people have kept their insulin in a thermos flask with a blanket wrapped around it. In Somalia, they have kept insulin under a clay pot”, said Kiapi. “Donors are now understanding the need for NCD resources in emergency settings.”

e have had to resort to unorthodox measures to protect their insulin supplies. “In Kenya, people have kept their insulin in a thermos flask with a blanket wrapped around it. In Somalia, they have kept insulin under a clay pot”, said Kiapi. “Donors are now understanding the need for NCD resources in emergency settings.” Alongside greater access to insulin, advocates are also calling on manufacturers to provide cheaper blood-glucose monitoring. While some devices might be affordable, the price of proprietary test strips to check for blood sugars are beyond the means of many people. “The insulin market is dominated by three companies [Eli Lilly, Novo Nordisk, and Sanofi] and their pricing isn't transparent in different markets. We're looking at overall costs, approaching manufacturers, and generating evidence on what's needed”, Amulya Reddy, NCD adviser at MSF, told The Lancet. © 2021 Maya Abu Ata/MSF2021 WHO is taking measures to increase the affordability of insulin, including its prequalification programme launched in 2019, when manufacturers were invited to submit insulin and insulin biosimilars for quality assessment. WHO is hoping to receive the first formal submissions by this summer, Gojka Roglic, medical officer at WHO's diabetes programme, told The Lancet. “Our aim is to broaden the insulin market, which is currently pretty unique given its domination by three companies.”

WHO is taking measures to increase the affordability of insulin, including its prequalification programme launched in 2019, when manufacturers were invited to submit insulin and insulin biosimilars for quality assessment. WHO is hoping to receive the first formal submissions by this summer, Gojka Roglic, medical officer at WHO's diabetes programme, told The Lancet. “Our aim is to broaden the insulin market, which is currently pretty unique given its domination by three companies.” WHO will also be reviewing data on the thermostability of insulin. “We will be looking at the whole body of accessible evidence”, said Roglic. “Back in the 1960s and 1970s, insulin was advertised as being heat stable, but by the 1980s it was stopped being marketed as such.” A study by MSF and the University of Geneva, Geneva, Switzerland, published in PLoS One on Feb 3, 2021, showed that a range of insulins could be kept at temperatures of 25–37°C for up to 4 weeks. This finding means that existing strict cold-storage recommendations might not be necessary, freeing patients from clinic visits and allowing home injections, and could be especially important for diabetes care in difficult settings. On April 14, WHO will be launching a Global Diabetes Compact to address barriers to care and to start dialogues with the private sector on improving access to medicines and technology. “We need to strengthen diabetes diagnosis and care. In rural Africa, it can be easier to test for HIV than measure blood glucose”, said Roglic.

14, WHO will be launching a Global Diabetes Compact to address barriers to care and to start dialogues with the private sector on improving access to medicines and technology. “We need to strengthen diabetes diagnosis and care. In rural Africa, it can be easier to test for HIV than measure blood glucose”, said Roglic. Advocacy groups, including the IDF, were disappointed when WHO member states at January's executive board meeting failed to adopt a resolution on any recommendations or targets on access to insulin, adopting only a decision to address diabetes as a “public health concern”. The Global Coalition for Circulatory Health, which includes the IDF, has called for the World Health Assembly to include NCDs in a resolution on health emergencies that is expected to be adopted in May. The coalition has stated that the resolution should include the commitment to “strengthen WHO's capacity to include and tackle NCDs and their multi-morbidity/co-morbidity implications in its response to health-emergencies”. At present, the EU-led draft resolution calls on member states to strengthen the response to infectious diseases based on lessons learned from COVID-19 among other communicable disease recommendations. “We're disappointed that a WHO resolution calling for access to insulin appears to be on hold. We wanted this in 2021, the 100th anniversary of the discovery of insulin”, said MSF's Reddy. For more on insulin storage see PLoS One 2021; 16: e0245372 For more on insulin storage see PLoS One 2021; 16: e0245372