# PEN-H essential guidance for NCD care in humanitarian settings 13 April 2020 The Package of Essential NCD Interventions for Humanitarian Settings (PEN-H), published by the International Rescue Committee (IRC) in 2020, remains a valuable but underutilized resource for humanitarian health practitioners. This guide addresses specific challenges in delivering care for non-communicable diseases (NCDs) in crisis situations. It was launched during a lively special event hosted by The Geneva Learning Foundation (TGLF) on April 13, 2020, with PEN-H’s leader author and TGLF co-founder Dr. Shanthi Mendis and IRC’s Dr. Laura Miller responding to questions from 754 health workers, primarily from developing countries. Dr. Shanthi Mendis, who is also the principal author of the original WHO Package of Essential NCD Interventions (WHO-PEN), explains why this guidance remains relevant: “When humanitarian emergencies occur in any part of the world, people caught in these situations will include many with NCDs, some diagnosed and some undiagnosed. The stressful situation itself will make people develop acute exacerbations.” Current data shows hypertension affects approximately 25% of populations globally, while diabetes prevalence ranges from 6% to 15%. These conditions become particularly challenging in crisis situations where healthcare systems are disrupted and resources are limited. ## Specific challenges in humanitarian settings Laura Miller from IRC identified three persistent challenges that make the PEN-H guidance essential: “Several countries affected by conflict have had a higher burden of NCDs. Specifically Syria, Libya, Yemen – these conflicts have continued for many years, meaning that there have been many more people who have died unnecessarily due to NCDs.” She highlighted particular concerns in refugee settings: “In refugee camp settings, such as in Kenya and Thailand, where refugees have been living for two to three decades, we have seen increasing rates of NCDs due to exposure to unhealthy risk factors – inability to access healthy foods, lack of space to be physically active, and increased stress resulting in use of tobacco and alcohol.” The third challenge involves healthcare delivery systems. Miller noted: “The clinical guidelines and standards really vary in countries and contexts. In some places where we work, there are Ministry of Health clinical guidelines. In other places, clinicians use MSF guidelines. But in many countries where you have extremely weak health systems or failed states, the clinical guidelines have not been updated in many years.” ## Practical guidance for critical care PEN-H provides specific protocols for managing NCD emergencies in resource-limited settings. Dr. Mendis detailed the most critical scenarios: “When you take non-communicable diseases, there are certain emergencies that are likely to occur, particularly in the acute response stage in the first week or so. People will die from NCDs within the acute phase from conditions like acute coronary syndrome, acute heart failure, stroke, hypertension emergency, diabetic ketoacidosis, acute asthma exacerbation, and status epilepticus.” The guide includes practical interventions for situations where hospital referral is impossible: “If the patient is breathless, you could sit the patient up. You can give oxygen if available. If the blood pressure is very low, you can raise the foot end of the bed. An intravenous line is set up for most acutely ill patients, ensuring they receive intravenous fluids when unable to take anything orally.” ## Supporting community health workers PEN-H includes eight specific protocols for community health workers, recognizing their essential role in crisis response. These protocols cover patient counseling, advice on tobacco cessation, guidance on harmful use of alcohol, diet, physical activity, and medicine use. ## Development implications The guide addresses broader societal impacts of NCDs in humanitarian settings. “If you let people die prematurely under the age of 70, you are losing breadwinners of families,” Dr. Mendis explained. “This affects family income and creates long-term healthcare costs. By prevention, you save money, and this is a major development issue for countries.” ## Accessing the guidance The PEN-H guide remains available in English, French, and Arabic. The 2020 launch event provides additional context and implementation insights from humanitarian health practitioners. IRC developed this resource to address a critical gap in humanitarian healthcare delivery. As Miller stated: “We had to prioritize this as part of our mission of ensuring people remain healthy within humanitarian contexts.”
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