Improving MHPSS has been a continuous goal for humanitarian community. The development of global standards such as sphere and the inter-agency standing committee guidelines for MHPSS in emergency settings are one part of these and are widely used and accepted as a standard to achieve in humanitarian settings. As a result of the guidelines, humanitarian actors are able to plan, establish, and coordinate a set of standardized multi-sectoral interventions to improve people's mental health during an emergency. But do these guideline ensure the integration of MHPSS and NCD prevention and care? To what extent is traumas and prevention mentioned in those guidelines? What are the challenges and opportunities to this integration? To learn about those guidelines in humanitarian response, I'm joined by Dr. Sigiriya Aebischer Perone and Dr. Carla Satie Kamitsuji from the International Committee of the Red Cross, Geneva. As a part of humanitarian response, one of the key recommendations of international humanitarian guidelines is to ensure MHPSS is available for local communities. Could you please let us know what the main principles of these guidelines are? One of the key principles, it's really the continuum of care. Meaning that people in humanitarian settings, they need to have access to care on two levels. On one side, they have to have access to different levels of care, meaning they have to have access from primary health care and then if they have complications, they have to be referred to secondary care or even rehabilitation. That's the one. The other one, they need to also have continuous access to care over time. Because people in humanitarian settings, they are even in far more difficult conditions than usually people with chronic conditions due to the stress, loss of livelihood, and all security constraints. In order to avoid complications, really the key principle actually for chronic care and care for non-compliance diseases and mental health is the continuum of care. Then as these diseases are not clearly visible, they need to be followed up over the long time. There needs to be set up some safety nets. Meaning also big work with the community and also to set up a system actually to follow up the patients. If they cannot come, to go out, to reach out to them, to trace defaulter, to bring maybe medicines to them to make sure that they have all the time access to care. Just continue with what are these main principles. Mental health and psychosocial needs they often arise or worsen when we think of conflict and they need to be included in any multidisciplinary response. Also another main principle are the determinants of health. There are numerous determinants of health that can be considered social. The social determinants of health for example, housing, education, social support, family income, employment, access to health services, food and security, which means inadequate or uncertain access to food. Given an example, the life expectancy can be reduced by 15-20 years for people living in low and middle-income countries due to the increased risk of chronic conditions such as diabetes and heart disease. Poverty can limit the access to healthy food, limit the ability to afford safe neighborhoods, and then the person might be more likely to be victim of violence. The response needs to take all these elements into consideration, the social determinants of health. It's beyond health, meaning that there is a need of an integrated approach. For example, cash programs, links with nutrition, livelihoods, gardening. Do you think this has been effectively implemented? It's a complex intervention which needs time. It requires a mind shift, not work in silence, and also consider not only emergency interventions, but also chronic conditions like mental health and other NCDs. It requires training our staff, supervision, provision of medicines and diagnostic tools, and reorganizing the care, introducing follow-up systems and referral pathways. Do these guidelines mentioned the integration of both MSPs and NCD prevents non-care? Yes, they do. Actually, they are mentioned that this integration in ICRCs operational guidelines for the management of non-communicable diseases and also mental health, the same applies to [inaudible], UNHCR and also the guidelines of the International Rescue Committee, IRC. To what extent is promotion and prevention mentioned in these guidelines? Essentially, it's secondary prevention, and secondary prevention would be when the disease, the illness, is already diagnose, and to prevent that it can't worsen. As we work in conflict settings, persons usually consult once they already have the mental health condition or the non-communicable disease. Another part that it's very important is reducing daily stressors is essential. When we're working in conflict settings, many people have gone through traumatic experiences that have impacted their lives, but also once they are displaced or after being through war, the daily stressors, their current living conditions can be as stressful and have an impact on their well-being as the traumatic situation they went through. Imagine an acute humanitarian emergency. That is very difficult actually to promote healthy lifestyle. This is essentially done in most stable settings. What is very important to take into account it's about the choices patients have. Meaning very often they have very little choice of what kind of foods they would have, because they depend on food aid. There we have really to take a very individualized approach to see what are really the needs of the patients and what are the capacities, and to adapt the answer to very specifically to each person and to each setting. But we could do also about food, it's for example, to work beyond health actually, with agencies who provide the food aid. They have to make sure that the food basket also do not contain too much sugar and salt. Actually, this would benefit not only to patients who have already a non-communicable disease, but to all persons in general. Because in many settings where we work actually, patients depend for many years on food aid, and we can see that this can have a very bad effect on them on the long term, with a lot of food which is provided essentially consisting of carbohydrates and also lipids. Where community programs exist, the promotion of healthy behavior can be integrated into all health programs, including outreach activities, and be part of community engagement and empowerment efforts. Well, actually, the health promotion which we do, it's essentially also to prevent complication of the long-term for there, things which are quite easy to do. For example, a patient who is diabetic would be for them to look at their feet, to diagnose early any problems, and to be able then to consult. The same it's also about prevention for people who had a myocardial heart attack, who we would need to give them aspirin to prevent a new heart attack. Are there any barriers that complicate the deliverance of MSPSS and NCD prevention and care? There is a need to focus also on the indirect victims of the conflict. The indirect victims of the conflict are those with disabilities due to restricted medical care related to the conflict or post-conflict situation, such as people with acute or chronic conditions like diabetes and other congenital deformities so focusing also on these indirect victims. In the contexts where we work, one of the obstacles is the setup of the health system where mental health and non-communicable diseases are traditionally treated by the specialist, not the primary health care physician in primary health care settings, so this is also one obstacle. The patients, they are used to seeing the specialist, and they trust less the general practitioners in the primary health care setting and another obstacle is the lack of trained workforce to deal and manage mental health and non-communicable diseases. There is another thing, that many humanitarian organizations are reluctant to engage in interventions that require long-term investment. One additional barrier, actually, it's also the lack of research. There is a lack of evidence what is actually the best way to approach non-communicable diseases and mental health. This leads also to a lack of standardized guidelines across also organization and patients very often in these settings they can go one day to an ICRC clinic, next day to MSF and then to UNHCR. It's very important to standardize the approach and also to work, as we said before, along the continuum of care. Then in the settings where we work, there is very often a disruption of the health system. There are also many security constraints, so the patients has difficulties to reach the health facilities. There is also very often a lack of health professionals and the health infrastructure can be also destroyed. The big challenge also, it's the continuous access to medicines, and not only medicines because these chronic conditions they need also monitoring, so it's also the access to diagnosis. For example, a patient who is diabetes, you have to be able to measure the blood sugar level to be able to adapt the treatment. How can MSPSS be better incorporated within NCD prevention and care? There is more and more a consensus across all organizations that there is a need to indicate mental health and non-communicable diseases in essentially also at primary health care, and there are also regular meetings between the different agencies and where this is addressed. A big help was also in 2018 when the WHO said that mental health is included in non-communicable diseases, so now it is part of the five main non-communicable diseases, so it's not only about diabetes, hypertension, cardiovascular diseases, chronic respiratory diseases, and cancer. Now, mental health is a full part of the non-communicable diseases, so it makes it far easier to work together and to address problems of patients.
