Valentina Ocheretenko can’t leave Ukraine.

Ocheretenko, the board chair of the Ukrainian Diabetes Federation, has an adult daughter who was diagnosed with Type 1 diabetes as a child. Her daughter has an amputation, making travel extremely difficult.

But staying has had its dangers. On the north side of Kyiv, where the two live, Ocheretenko said she could hear explosions and see soldiers. And on Monday, her daughter, who has access to insulin but not regular meals, had an episode of hypoglycemia and required an ambulance.

According to Ocheretenko, the situation for people with diabetes in Ukraine is growing increasingly complex. “We have problems now, and it will be more difficult in a moment,” she said. “There is not enough food…people with insulin can’t reach people who need insulin.” Test strips, used to measure blood glucose levels and an essential component of at-home care for many people with diabetes, are also in short supply.

In addition, Ocheretenko explained, hospitals are focusing on the most urgent cases, which means that people in need of diabetes care aren’t always able to get it. “People who need some care, some help, cannot get some,” she said.

According to Ocheretenko, insulin and high-quality medical care were readily available in Ukraine before the conflict. “The main problem was education,” she said. “Now, the situation is tremendously different. We have big problems with logistics.”

Direct Relief’s response

In addition to requests for oxygen concentrators, trauma medications, and much more, Direct Relief has also received several requests for insulin and other diabetes treatments.

Direct Relief’s Director of Pharmacy and Clinical Affairs, Alycia Clark, explained that diabetes monitoring and treatment are essential during a humanitarian conflict. “Insulin requirements can change in stressful situations, so being able to monitor blood sugar during the crisis is extremely important,” she said.

Direct Relief, working with the International Diabetes Federation, Ukrainian Diabetes Federation, Ukrainian Ministry of Health, Life for a Child, and the World Health Organization’s non-communicable diseases working group, is mobilizing insulin, blood glucose meters and strips for Ukraine and Ukrainians fleeing war.

Clark also explained that tight blood sugar control is needed in critically ill hospitalized patients to improve outcomes, even if they do not have diabetes at baseline, leading to even greater insulin need.  

Walking a tightrope

Humanitarian crises gravely disrupt health care, making it more difficult to get medications and receive treatments even for conditions that are relatively straightforward to manage.

But for people who have insulin-dependent diabetes, managing their condition requires a careful combination of monitoring, insulin, and diet. “These people walk a tightrope every day between high and low blood glucose,” said Dr. Graham Ogle, a pediatric endocrinologist and general manager of the NGO Life for a Child, which provides medical support, education, and other services to children with type 1 diabetes.

Ogle explained that insulin is a complex molecule that needs cold shipment and storage. Even when a patient receives it, it should be stored in the fridge – although research suggests that evaporative cooling techniques, such as employing a clay pot, may be effective. If a person with diabetes is displaced by conflict, keeping insulin cold may be near-impossible, if they’re able to access it at all.

But for many people with diabetes, especially those with type 1 of the disease, it’s an absolute necessity. “If you have type 1 diabetes, you’re insulin-dependent. Without insulin, you would die within a week or even less,” Ogle said.

In addition, “if there’s a crisis, you might be out of your normal routine, and you may not be eating as much. You may not be eating anything.”

Amid conflict, a growing need

Ethiopia has been experiencing an ongoing, violent conflict since 2020. While it began in the organization’s Tigray region, it has since spread to the neighboring regions of Amhara and Afar.

For Tenagnework Goshu, general manager of the Ethiopian Diabetes Association, the most challenging part of working during a conflict setting is the lack of information.

Although the association has been sending insulin and other supplies into the three conflict-affected regions, Goshu said they are forced to do so with relatively little knowledge of what the need is or how many people with diabetes are currently affected.

“I’m sure the need is huge, but we cannot say there is this amount,” she said. “We have to go through an assessment…or else we need to have some kind of communications.”

Complicating matters is that hospitals have been damaged and even looted in the conflict.

Goshu explained that, although her organization was able to send insulin to Tigray as recently as a month ago, “we cannot just go or send [medical aid] because the road is not open…It involves war, it involves politics, so it’s not an easy thing to deal with.”

And although Goshu said the circumstances in Ukraine are different from those in Ethiopia, she said that having as much information as possible – and working closely with humanitarian organizations that can access insulin and other medical aid – has been key to her organization’s response.

Over the long term, Ogle said, the question during and after an outbreak of conflict becomes, “how strong are the services to look after people with diabetes?”

But because much of Europe has been mobilized to respond to the crisis in Ukraine, “I think I am less worried about the ones who made it out.”

For now, Ocheretenko said, her organization is concerned with procuring insulin and other diabetes treatments. She’s concerned that people will be unable to find the type of insulin they’re accustomed to using and will have to learn how to switch to whatever is available.

She’s also concerned that over time, people will forget about Ukraine – which would have severe consequences for many people, including those with diabetes: “I think that the usual situation is when people forget about the difficulties of others.”

“Even now, I can’t believe that it’s happened,” she said. “It’s unbelievable.”