Man-made and natural disasters have many elements in common regarding prevention, preparation, response and recovery and their consequences, affecting, in particular, vulnerable groups such as those with diabetes and major comorbidities, pregnant women, children and older people. During man-made disasters there may be risks of radiation, biological warfare and use of weapons of mass destruction. There may also be deliberate blockades of humanitarian aid, including essential medicines such as insulin. Two examples of man-made disasters, the wars in Ukraine and Ethiopia, are discussed in the following sections.

Case study: the Russia–Ukraine war

Ukraine, the largest country in Central Europe, with a prewar population of approximately 42 million, had a diabetes prevalence in 2021 of about 7.1% among adults aged 20–79 years, representing about 2.3 million people [2], of whom about 200,000 required daily insulin injections, provided free by the state. In 2014, the Crimean Peninsula, part of Ukraine, was annexed by Russia and fighting between the two countries in two eastern regions of Ukraine began. These political and military events caused a significant migration of people, including individuals with diabetes and doctors, from affected areas to other parts of the country, mainly to regions nearby (including Kharkiv, Dnipro and Kyiv). The healthcare system adjusted and continued to operate at efficient levels. However, on 24 February 2022, a full-scale war started with the rapid movement of Russian military forces deep into Ukraine. The healthcare system and supply chains were not prepared and dramatic problems were evident from the very first hours and days of the war. A major challenge was the severe shortage of insulin, other glucose-lowering medications and diabetes devices (e.g. glucose meters and insulin pumps), as well as medications for treating other chronic conditions, for example l-thyroxine for treating hypothyroidism. Most people who needed insulin had enough supplies for only 2–3 weeks. About half of the pharmacies in the country closed because of a lack of supplies and staff, and delivery of insulin and other medications to areas affected by heavy fighting was severely limited and often impossible [40, 41]. During the first few weeks of the war, many people and medical personnel had to move. The chaos led to a very uneven geographical distribution of individuals with diabetes, with the number of people with diabetes in western parts of Ukraine increasing two- to threefold in the first few weeks of the war, which overwhelmed local facilities [42,43,44]. An estimated 11 million people had to leave their homes and >6 million people found asylum in other countries [45, 46]. However recent reports related to Ukrainian refugee children with type 1 diabetes in their host countries show good uptake of diabetes technology and relatively good metabolic control.

Ukraine received humanitarian aid from government and non-governmental organisations worldwide. With regard to diabetes, insulin delivery became the main priority early on and was mainly solved by the joint coordinated efforts of government, national and international non-governmental organisations and volunteers and donors. Pharmaceutical companies and non-governmental organisations (including many Insulin For Life affiliates [https://www.insulinforlife.org] and Direct Relief [https://www.directrelief.org]) provided insulin for free, which, as the traditional channels for supply of insulin had stopped, was successfully delivered by non-conventional carriers (supermarkets chains, postal workers and volunteers). Any co-payment for costly insulin analogues was immediately cancelled. A special order of the Ministry of Health, including a list of insulins approved for use, was prepared, and insulin swapping charts were made available, which were very helpful for clinicians who were not very familiar with diabetes management pre war. As many individuals with diabetes had to be treated by different healthcare providers from those normally treating them, the following actions were implemented:

Doctors other than endocrinologists or general practitioners were able to write prescriptions for insulin and glucose-lowering medications.

Webinars suitable for healthcare professionals who were relatively new to diabetes care commenced.

Involvement of diabetes-related pharmaceutical company representatives was encouraged without commercial promotion to assist with information regarding the availability of their products and humanitarian aid.

Collaboration with colleagues in European countries treating refugees with diabetes facilitated knowledge transfer.

With the help of the European Society of Endocrinology, leaflets in Ukrainian including basic information on the management of hyper- and hypoglycaemia emergencies were prepared and were freely available for refugees at the borders.

Now in the fourth year of war, medical care in Ukraine, including diabetes care, has somewhat stabilised, and the supply of insulin and other glucose-lowering drugs has been restored to prewar levels. The migration of individuals with diabetes and medical personnel has also significantly reduced, even in areas close to the zones of fighting. For example, the number of people admitted to hospital with endocrine diseases (mainly diabetes) in the Kharkiv area was 410,203 in 2021, 294,489 in 2022 and 431,473 in 2023 (I. Smirnov, City Hospital, Kharkiv, Ukraine, personal communication, October 2024). Key lessons learnt to date from the war in Ukraine that can be applied to subsequent disasters are as follows: (1) people with insulin-treated diabetes need to have at least 2–3 months’ supply of diabetes medications; (2) non-conventional carriers can be used for insulin delivery; (3) partnerships with pharmaceutical companies are valuable for providing and delivering medications; and (4) simplified glucose drug regimens should be used when possible. However, challenges remain. Adherence to prescribed regimens is difficult because of disrupted lifestyles, ongoing attacks, long periods spent in shelters and severe stress. There is still limited access to care, including diabetes care, in areas near the zones of heavy fighting. Many new cases of diabetes and its complications are anticipated, and high rates of diabetes-related foot ulcers and related amputations have been reported [47]. Optimising diabetes care and health outcomes will be a major post-war task.

Case study: the Tigray war

Similar diabetes care-related challenges and solutions were experienced during the Tigray war in Ethiopia (3 November 2020–3 November 2022). Tigray is one of 11 regions of Ethiopia, with an estimated population in 2020 of 7.3 million [48]. The region, located in the north of the country, borders the Afar and Amhara regions, Sudan and Eritrea.

The Tigray war was fought between the Ethiopian federal government and Eritrea allied forces and the Tigray Defence Forces. The war resulted in a full-scale humanitarian catastrophe, with >70,000 refugees fleeing from Western Tigray to Sudan, >2 million displaced people sheltering in different parts of Tigray and approximately 518,000 civilian deaths [49]. During this period, Tigray was under siege and humanitarian blockade, with critical shortages of food and medicines leading to mass starvation and the complete collapse of the healthcare system.

Médecins Sans Frontières (Doctors Without Borders [https://www.msf.org]) teams in Tigray documented evidence of widespread, deliberate and targeted attacks on health facilities. Before the war, Tigray had >720 health posts, 224 health centres, 24 primary hospitals, 14 general hospitals and two tertiary specialised hospitals. However, of 106 facilities assessed between mid-December 2020 and early March 2021, 87% were no longer functioning or fully functioning [50]. The war led to the complete breakdown of healthcare delivery, with no health posts, only 3.6% of health centres and 13.5% of hospitals being fully functional in 2021 [51]. As expected, this had a major negative impact on chronic disease management, with only 21% of people using healthcare services from November 2020 to June 2021 compared with prewar data (September–October 2020) [48] (Fig. 4).

Fig. 4

Changes in the use of services by individuals with type 1 diabetes before and during the Tigray war (September 2020–June 2021). Reproduced from Gebrehiwet et al [48]. This figure is available as part of a downloadable slideset

In Tigray as a whole, although underestimates owing to underdiagnosis and limited access to diabetes care, there were 6726 people with type 1 diabetes and 17,627 with type 2 diabetes receiving regular follow-up at general and primary hospitals pre war in November 2020 [52]. About 80% of essential medications were available before the war, which plummeted to <20% by the start of 2022; similarly, the availability of routine laboratory tests, including blood glucose and HbA1c testing, dropped from 94% to <50% by the start of 2022 [53]. Insulin supplies declined sharply during the war and completely ran out by July 2021, resulting in avoidable deaths; doctors were forced to use expired drugs and individuals with diabetic ketoacidosis were treated with oral hydration because of a lack of i.v. fluids; and increased levels of malnutrition also complicated diabetes management, as individuals with diabetes had reduced resilience to fight communicable diseases [52]. In addition, deaths of dialysis patients doubled because of interruptions to dialysis sessions [54], and healthcare professionals worked without pay for 17 months while facing severe food shortages [55]. The IDF publicised this humanitarian crisis in January 2022 [52], forcing the Ethiopian government to send limited supplies of insulin to Tigray [56, 57]. Although the war ended after the Cessation of Hostilities Agreement in 2022, healthcare services in Tigray have not yet recovered, and access to insulin and other critical medications still remains limited. Unfortunately, many healthcare professionals left their posts, seeking employment in other countries, further exacerbating chronic disease care [58]. The war has had a major psychological impact on the public, including people with diabetes, with increasing levels of anxiety and depression [57, 58]. The Tigray war demonstrated that it takes only a few weeks for diabetes care to collapse and many years for it to recover. Almost all sections of society, including medical doctors, were seriously affected by the lack of insulin, with many deaths occurring, especially among children [57, 59]. The Tigray war highlights how strategies for rapid insulin access in areas hit by war and disasters need to be developed and ideally agreed at the United Nations and by all countries.