By Panu Eskola Saaristo, TGLF Fellow for Humanitarian Health
Somewhere in a flooded district this week, a woman is trying to work out where next week’s insulin will come from. A man is learning that the clinic where he had his cancer follow-up is closed. They are not thinking about the humanitarian system. They are thinking about whether they will still be here in a month. This article is about them, and about the person best placed to keep them alive: the local health worker who was there before the crisis and will be there after it. Investing in that person’s leadership is the single change that would do most for people living with noncommunicable diseases in a crisis, and noncommunicable diseases are where the case is clearest.
When the earthquake hits, funding follows the trauma. When cholera breaks out, logistics follow the cholera. When Ebola arrives, the emergency medical teams follow Ebola. The pattern is understandable, but it drains institutional memory with each new crisis and leaves out most of the people the response is meant to serve.
Noncommunicable diseases (NCDs) do not pause for emergencies. Hypertension does not resolve when floodwater enters the clinic, diabetes does not remit when the supply chain collapses, and epilepsy does not wait for the ceasefire. NCDs already cause around three-quarters of deaths worldwide, and their burden falls hardest on the low- and middle-income settings where most humanitarian crises occur. For a large share of every affected population, these conditions are the most pressing health threat people face, compounded rather than replaced by the disaster.
They are also clinical multipliers. A person living with uncontrolled diabetes who then contracts a respiratory infection, sustains a wound, or is displaced from their insulin supply faces a fundamentally different level of risk than someone without that underlying condition. Funding only the acute presenting emergency without addressing its chronic underpinning is incomplete medicine.
Two reasons are usually given for leaving NCDs until later, and both dissolve on inspection. The first is that chronic disease is simply not the humanitarian’s job. But a surgical team that agreed to operate on trauma while declining to perform a caesarean section would be judged to have abandoned its patients; declining to sustain insulin or antihypertensive treatment is the same abdication, made less visible only because its consequences arrive weeks later rather than on the operating table. The second is that NCD care means lecturing people about dieting and smoking cessation, which is indeed inappropriate when their homes are under water. But that is a caricature. In a crisis the task is not behaviour change; it is continuity – maintaining medication and monitoring the controls, blood pressure and blood glucose, that keep chronic disease from turning acute. That work is done by people who are already there.
Care that cannot wait
The argument that NCD management is care that can wait, or second-line care, deserves direct confrontation, because it is wrong on its own clinical terms. Acute complications of chronic disease – heart attack, dangerously high blood pressure, diabetic crisis – are immediate, life-threatening, and preventable with continuity of care. This is not care that becomes relevant once the emergency is over. It is emergency care.
The evidence is not marginal. Across several major earthquakes, the incidence of an acute heart attack has risen roughly two- to threefold in the weeks and months after the event, with the elevation persisting for years in the worst-affected areas. The population that absorbs that surge is disproportionately those already living with cardiovascular risk. The moment of crisis is precisely when uncontrolled NCDs turn fatal, not a moment when they can be safely set aside.
It happens that doing the right thing here is also inexpensive, and the figures are worth stating plainly because they remove the last excuse. The medicines and devices needed to treat the acute, life-threatening presentations of NCDs for a population of 10,000 people over three months have been modelled at approximately US$2,000; adding the resources to manage the chronic conditions underneath them as well brings the total to around US$22,000. Against the cost of a single heart attack managed in a referral hospital, an amputation following an infected diabetic foot, or a stroke that leaves a working adult dependent, these are trivial sums. The point is not that NCD care is a shrewd purchase. The point is that the thing standing between a person and a preventable death is small, cheap, and already designed – and still routinely left out.
Because there is a value judgment buried in that omission. A response that routinely excludes people living with NCDs has decided, without ever saying so, whose health is worth protecting. No serious humanitarian actor would state that judgment aloud. Many emergency health response plans nonetheless enact it. And it cannot be defended by pointing to another gap elsewhere – that the mothers in the next clinic are not getting the antiretrovirals that would prevent HIV transmission to their babies is an indictment of that omission too, not a permit for this one. Suffering is not a budget line to be traded against another. Each of these people is owed the care their condition requires, by virtue of being a person the response is standing next to.
The patient the system cannot see
A crisis produces a particular kind of casualty who never appears in the caseload: the person whose treatment simply stopped. The person displaced from the district where their blood-pressure tablets were dispensed, the one whose insulin was in a refrigerator that lost power – they present with nothing acute on the day the response arrives, so a system that counts consultations does not register them at all, until weeks later they arrive in crisis or do not arrive again. They are invisible not because they are hard to find but because no one is looking for them the way they would have to be looked for.
Finding them is not work an external rapid-response team is needed for. It is done by the community health worker who already knows which households have a member on insulin, who has the standing to ask, and who is trusted enough to get an honest answer. That relationship takes years to build and can be drawn on in minutes once it exists. It is the most effective way the system has of reaching the person whose care lapsed, and in most crises it is already in place. The reason the system underperforms is not that this capacity is absent. It is that the capacity is neither recognised nor invested in.
This is the missing key. The frontline worker is routinely treated as the last mile of a programme designed elsewhere – a delivery agent for other people’s protocols. A decade of listening to more than 80,000 of them says the opposite: they are the ones who know what works in their setting, who adapt when the protocol meets a reality it did not anticipate, and who hold the relationships on which everything else depends. Invest in that, and the concrete things that keep people alive – the refill that arrives, the record that travels with the patient, the referral that connects – actually happen. Fail to, and no amount of external surge capacity makes up for it.
What already exists, and what is missing
None of this requires inventing new humanitarian medicine. The tools exist. The World Health Organization’s Package of Essential Noncommunicable Disease Interventions, known as WHO PEN, is a prioritised, low-cost set of protocols that lets primary-care staff – including non-physician health workers – detect, diagnose, and manage the main NCDs in resource-poor settings, and WHO states explicitly that it is suitable for emergency and humanitarian use. The Interagency Emergency Health Kit now has an NCD module. National essential medicines lists and treatment guidelines exist in most countries. The scaffolding is built.
What is missing is investment in three things, each of which is a capability of the frontline rather than a product shipped to it. The first is rapid participatory assessment of NCD need at community level, however rough, because the worker who can ask the community is the fastest way to make the burden visible and the cost of acting on it estimable. The second is preparedness built around harmonised medicine lists and the NCD kit, with the openness to align to the national system where one exists and adjust the standard kit to it, rather than arriving with a different formulary and creating prescribing chaos. The third is patient-held records and defined referral pathways, so that a person displaced across a border or into a camp continues treatment rather than restarting it – the mechanism that turns continuity from an aspiration into a handover that actually happens.
A word on scope, to be precise about the claim. This concerns the four classic NCD groups – cardiovascular disease, diabetes, cancer, and chronic respiratory disease – around which these tools are already built. Epilepsy is included pragmatically, because in a crisis it behaves like the others: medication-dependent, dangerous when interrupted, manageable with continuity. The broader mental health and brain health framings matter, but they are not yet settled by consensus, and stretching the argument to them here would cost clarity without adding force. The point of this article is not to widen the claim as far as it will go. It is to make sure the concrete, achievable things happen, because those are what reach the person waiting for insulin.
What donors and partners can do
Three commitments follow directly, and each is an investment in frontline capability rather than a substitute for it.
First, make NCD medicines and supplies a standard, non-negotiable component of every emergency health budget from the outset, using the interagency NCD kit as the baseline. At roughly US$2,000 to cover acute NCD needs for 10,000 people for three months, the question is not whether it can be afforded but why it was ever treated as optional. Supply chains are far harder to build mid-crisis than at the start.
Second, fund the preparedness phase, not only the response. Patient-held records and community health worker training in NCD recognition and first-line management are pre-crisis investments that pay their dividend in the crisis, at a fraction of the acute response they make more effective, and the benefit recurs with every subsequent emergency in the same setting.
Third, invest directly in the frontline leadership that carries continuity. This is the commitment that unlocks the other two. The nurse, the community health worker, and the district manager are adaptive leaders whose contextual knowledge and community relationships are the most durable assets in any health system. Investment in their capacity, in the peer learning networks through which they learn from and support one another, and in their ability to generate and share knowledge about what works in their specific setting, produces returns that outlast any single emergency. It is also the least fungible thing a donor can buy: medicines can be procured anywhere, but the relationship between a health worker and the community that trusts them cannot.
One caveat should be stated plainly, because a careful funder will look for it. The cost-effectiveness literature for NCD care specifically in humanitarian settings is still thin; the burden is well documented, the interventions less so. That is a reason to fund the care together with the evaluation that measures it, not a reason to wait. The sector does not lack the tools or the evidence of need. It lacks the decision to invest in the people who would use them.
What investment in local leadership actually means
The Geneva Learning Foundation’s forthcoming local leadership framework, built from ten years of structured dialogue with more than 80,000 frontline health workers, describes local leadership not as a job title but as a practice: the adaptive, cognitive, and relational capabilities that let a nurse, a community health worker, or a district manager solve complex problems where standard procedure runs out. For NCD management in a crisis, four of its nine domains are decisive, and each names something the frontline already does and is rarely credited for.
Adaptive leadership and critical reasoning. A nurse whose patient’s usual antihypertensive is not in the kit reasons through a substitution; a district manager facing a stock-out activates a workaround before the gap becomes a complication. This is not improvisation but trained adaptive expertise – knowing when to follow a protocol and when the protocol no longer fits the reality.
Community trust, social mobilisation, and accountability. This is what makes rapid, honest needs assessment possible at all. The worker embedded in the community is the way to find the missing patient that no external team can replicate, because the relationship it depends on takes years to build.
Entrepreneurial implementation and resource mobilisation. Peer support groups in protracted displacement have set up community pharmacies, pooled funds to buy medicines at lower prices, and registered as organisations in their own right. Supported rather than supplanted, communities generate solutions external actors never anticipate.
Adaptive clinical and public health practice. People living with NCDs in humanitarian settings are rarely managing one condition alone. They carry multi-morbidity, often with limited health literacy, under psychological stress, with social support disrupted. A clinical encounter that treats only the presenting condition misses the determinants of its outcome.
The image everyone already holds – the local health worker moving through the community – is not sentimental. It is an accurate picture of where the knowledge, the trust, and the continuity in a health system actually reside. The failure of the current model is that it has treated that person as an instrument and funded them last. The correction is to recognise them as the author of the solution and fund them first. NCDs are simply the clearest place to begin, because there the cost of getting it wrong is measured in the woman still looking for her insulin and the man whose follow-up never came – people the response was standing right next to when it let them go.
Panu Eskola Saaristo was inducted as The Geneva Learning Foundation’s first Fellow for Humanitarian Health on 1 June 2026.