OPINION: Ability to store insulin without refrigeration a game-changer in refugee camps

By Sharon Kiburi

Management of diabetes, a condition requiring daily injection of insulin, is much easier with development of drugs that can be stored without refrigeration.

Qamar Ismail Yussuf has lived at Dadaab Refugee camp in Kenya for 22 years.

She first came to Dagahaley in 2009 with her mother and seven siblings to seek education and health services.

“UNHCR did not register us as refugees, so life in the camp became a little challenging, though it was a lot safer than in Somalia,” says Qamar.

Qamar’s father had stayed in Somalia to look after his business, but in 2011 he fell sick, and his wife returned to look after him, taking five of her children with her.

Back in Somalia, Qamar began having frequent bouts of feeling unusually thirsty, feverish and nauseous.

“I would feel thirsty a lot and go to the toilet frequently. I’d have high fevers and feel nauseous. We went to the local pharmacy, and they gave me some intravenous fluids, but nothing changed. I would faint a lot, and my family started saying I was possessed. Some of my relatives requested that I should be brought to Dagahaley in Dadaab Refugee Camp, where I was diagnosed with diabetes,” she says.

Qamar was unconsciousness when she was brought to MSF’s hospital in Dagahaley in 2017.

“I wasn’t even aware that we were here; I don’t know how we left Somalia,” she says. “A random blood sugar test was done, and it turned twenty-seven [mmol/L], from what I was told,” she said.

Qamar was admitted to the MSF hospital for seven days while her blood sugar levels were monitored.

“I felt a huge relief when I was put on treatment. After being discharged, I had to go to the emergency room every morning and evening to get insulin injections. It didn’t take long before we were trained and given a portable cooling box. It saved me a lot of time. Going to the ER every morning and evening, leaving my young children at home was difficult. Now I am okay, and nobody even knows that I have diabetes,” she says.

“After I got this, it’s like I gained independence. I can inject any time I feel like my sugars are high. Many people are injecting, and it’s something that people have come to understand. I carry my syringes and portable cool box whenever I go visiting my friends or relatives. I never leave them behind. There was this time I went home to Dhobley and Kismayu, and I carried it. My relatives there were so fascinated to see me inject myself. They’d ask: ‘How do you inject yourself? Can you do it now so that we can see?’” she poses.

Qamar says MSF provides all the supplies she needs, including insulin and syringes. She has follow-up visits at the hospital every 14 days when she collects more supplies. She says she has not faced any stigma since she started taking insulin, in contrast to the stigma she faced before being diagnosed with diabetes.

Despite being on insulin for more than two years, Qamar says that pricking her finger to test her blood sugar levels is what she dreads most. “Pricking the finger every time is painful and injecting can lead to soreness. But it never stops me from carrying out my daily activities, she adds.

Seeking to explore ways to improve diabetes care in resource-poor settings, a joint study by Médecins Sans Frontières /Doctors Without Borders (MSF) and the University of Geneva published in PLOS ONE, has demonstrated that one can store a range of insulins at temperatures ranging between 25-37 degrees for four weeks of use.

This study confirms the possibility for people living with diabetes in similar temperature conditions to use insulin, for up to four weeks, even in the absence of refrigeration access.

¨The ability to self-inject insulin is a fundamental aspect of diabetes self-management and the power of people with diabetes to be empowered for their health,”says Philippa Boulle, Non-Communicable Diseases Advisor at MSF.

Diabetes is a chronic, progressive disease that can be controlled with effective treatment. However, in many countries, people living with diabetes do not get the treatment they need to stay healthy and alive.

It is a shameful fact that only about half of people requiring insulin have access to it. Access to insulin has been primarily prevented due to high prices which again poses a challenge in terms of storage requirements and complex treatment protocols.

Strict storage recommendations for insulin are challenging to follow in tropical regions and the situation is even worse in conflict and humanitarian emergency settings.

Regular insulin requires refrigeration until its expiry date or until it is open for use. Once in use, storage recommendations are indicated as temperatures below 25°C for 42 days.

In many settings, this results in people being asked to travel to the health clinic for injections and monitoring, at least twice a day for the rest of their lives.

Every morning, Qamar checks her fasting blood sugar before eating or injecting insulin and my random blood sugar.

“I can read and understand the glucometer well and know how much insulin to inject. I am prepared for the injections, so they never bother me. I don’t experience hypoglycaemia much, but if I don’t eat well and tell to eat, the sugar gets low. Only we know what it feels like to have diabetes and having the right diagnostics and treatment kits provides a huge relief.” says Qamar.

Qamar’s biggest concern is the lack of consideration she receives at the food distribution centres. There is no special consideration whatsoever, whether you’re sick or not,” she says. “We queue there and, when I feel dizzy, I just sit down.”

MSF works in over 70 countries worldwide, and in most of these settings, insulin is often not available in public health facilities or private pharmacies.

MSF has been providing treatment for diabetes patients in multiple projects across the world (including Jordan, Lebanon, Iraq, Syria, South Sudan, Democratic Republic of Congo, Tanzania, Kenya, Zimbabwe, and Bangladesh) for those living in resource-limited settings.

Sharon Kiburi is a freelance journalist