Dear Editor,
We present a local experience concerning the dilemma of chronic diseases in crisis situations and war. The large number of casualties and the unpredictable nature of war zones underscore the urgent need for specialized emergency medicine measures. These conditions are multifaceted and attributable to numerous extraneous variables that directly affect hospitals, which face particular difficulties in providing emergency care, especially during mass casualty incidents (MCIs). Under routine conditions, the Emergency Severity Index (ESI) is typically used for patient prioritization and triage to identify the most critically ill patients and provide prompt medical care. However, during MCIs and emergency situations involving large numbers of patients, the standard protocol shifts to the Simple Triage and Rapid Treatment (START) and JumpSTART triage systems, which are intended to maximize survival. Although this change is operationally necessary, it presents substantial challenges for chronic patients, who are often undertreated and receive comparatively limited clinical care.
The burden of chronic illnesses among populations affected by natural disasters and conflict is a growing but largely unrecognized public health emergency. Chronic conditions, such as diabetes mellitus, hypertension, cardiovascular disease, and chronic respiratory disease, are frequently overlooked during humanitarian crises, despite being major causes of death worldwide. Maintaining continuity of care for chronic patients has therefore been identified as a major, under-addressed challenge.
Despite strong evidence regarding the effectiveness of disease-control protocols, a critical lack of both the quantity and quality of research persists in this field. In a landmark systematic review, Blanchet and colleagues examined interventions for chronic patients in humanitarian settings in low- and middle-income countries (1). According to a 2025 systematic review and meta-analysis of 12,037,279 participants in the conflict-affected Amhara region of Ethiopia, 60% of health facilities were non-operational and 70% of the population was affected by the conflict, with chronic disease management suffering the most (2). Neglecting chronic patients during humanitarian crises has measurable, serious, and avoidable consequences. A 2015 commentary summarizing World Health Organization, United Nations, and peer-reviewed evidence from the Gaza conflict in 2023 - 2025 reported that more than 90% of primary health care facilities had critical shortages of insulin, anesthetic agents, and dialysis supplies. The proportion of patients with chronic diseases attending health clinics decreased from 96.7% before the conflict to only 40.7% during the conflict (3).
Infrastructure and worker safety are also at risk under these conditions, requiring appropriate actions to minimize damage and improve readiness, including prompt medical attention, START- and JumpSTART-based triage, stress debriefing, recovery, and continuous monitoring. In non-wartime settings, standard triage, such as the ESI, is prioritized to identify the most critically ill patients and provide definitive care. During war and crisis, however, START and JumpSTART triage are prioritized. Their main objectives are to save as many casualties as possible, control bleeding, secure airways, and enable rapid evacuation. This approach supersedes traditional protocols. Accordingly, pilot crisis-readiness exercises and preparedness models have been developed and implemented (4, 5).
In practice, these emergency measures may marginalize chronic patients unless specific planning is undertaken. For inpatient bed management, clinically stable, nonemergent patients may be discharged more rapidly, while elective admissions and outpatient visits are minimized. As a result, patients with long-term illnesses may be discharged in a state of partial rather than complete recovery. As the clinical course evolves, several contributing factors may worsen clinical status and consequently increase indirect war-related morbidity and mortality. These factors include inadequate patient education, potential medication shortages, restricted access to specialists, logistical barriers to hospital admission during war, and the predominance of START and JumpSTART protocols in these settings.
Given the unpredictable nature of crisis and war situations and the possibility of MCIs, emergency medicine plays a crucial role in managing and coordinating hospital services. Incorporating this experience into future operational guidelines and providing ongoing training for medical teams should be regarded as a strategic necessity (6). Morbidity can be reduced and survival improved through preventive measures, adequate crisis-response readiness, thorough and professional coordination among medical staff, and attention to factors beyond hospital administration and management that affect treatment, such as obstruction of emergency routes by unforeseen events and physical barriers to access. In addition, developing homegrown hybrid models that combine on-site mass-casualty triage with internal triage procedures, tailored to each hospital's equipment and resource level, may be a valuable approach (7).
In addition to managing the massive number of casualties resulting from war and crises, a major secondary issue arising from such critical conditions is the lack of access to effective health services for patients with chronic conditions. When medical teams are required to focus on acute crisis response, chronic conditions such as lung disease, liver failure, renal failure, and transplant-dependent status create substantial barriers to health care access. First, chronic patients are not prioritized in START and JumpSTART triage protocols, which are designed to maximize the number of emergency cases treated. Second, rapid discharge from emergency departments may result in patients being released before full clinical recovery, increasing the risk of relapse and clinical decline.
Allogeneic rejection, worsening lung disease and severe hypoxia, progression of liver failure to encephalopathy, diabetic complications such as diabetic ketoacidosis, worsening cardiac failure, complications of other chronic conditions, and delays in routine dialysis for renal patients may all contribute to these outcomes and ultimately increase long-term morbidity and mortality in this population. In addition, long-term irreversible secondary complications can substantially and irreversibly affect the health care economies of the involved nations. This issue may create a major challenge for the management and control of chronic diseases in crisis situations, especially when combined with likely disruptions in pharmaceutical supplies, restricted access to physicians, limited access to health care facilities and services, and increased patient distress, all of which have well-established effects on disease progression.
Therefore, chronic disease care should be integrated into crisis-response guidelines. This approach may help prevent complications if the capacity to receive and provide services for chronic patients, who are deprived of regular health care access during crises, is maintained remotely, at least through telemonitoring, and if a dedicated chronic disease management mechanism is established in advance in a designated center. Measures such as the management and procurement of pharmaceutical resources, the use of telemedicine technologies, and pre-disaster preparedness initiatives may each play an important role in ensuring continuity of care for chronically ill patients under non-routine conditions such as warfare, humanitarian crises, and MCIs, in which standard clinical and hospital systems are primarily engaged in acute crisis-response operations (7, 8).
The evidence-based solutions we suggest are as follows:
1. Chronic patient pre-disclosure registers: First responders can prioritize patients with chronic diseases during triage and evacuation planning by systematically identifying and flagging them.
2. Integration of chronic disease protocols into MCI frameworks: Chronic disease management and trauma care must be clearly integrated into standard operating procedures. Validated clinical guidelines and flowcharts are available for this purpose in the World Health Organization package of basic interventions for non-communicable diseases (NCDs) in humanitarian settings (9).
3. Pre-positioned essential medications and supplies: According to national lists of essential medications, emergency supplies must include pre-positioned essential medications and equipment, such as insulin, antihypertensive agents, bronchodilators, and dialysis equipment (9).
4. Frontline staff training: Emergency medical teams (EMTs) require formal training to recognize and manage chronic disease exacerbations. The World Health Organization Blue Book establishes minimum requirements for NCD care for all EMT classes, but implementation remains insufficient (10).
5. Patient-held medical records: As tested in Lebanon and the Democratic Republic of the Congo, paper-based or digital patient-held records can help ensure continuity of care for displaced individuals in fragmented health systems (11).
6. Integrated psychosocial support: The psychological burden experienced by chronic patients during crises is substantial. Care for NCDs must be provided concurrently with mental health services (10). Neglect of chronic patients during MCIs is not an unavoidable result of disasters; rather, it reflects a failure of ethical commitment, planning, and foresight. The World Health Organization Global Compact on Non-Communicable Diseases and the 75th World Health Assembly in 2022 urged governments to ensure access to chronic disease care during humanitarian crises for the 1.7 billion people worldwide who suffer from chronic illnesses (12).
The comprehensive set of suggested solutions may include telemedicine, mobile temporary clinics, dedicated funding for the purchase of specialty medications, and self-care training for patients and caregivers. During crises and conflict, the marginalization of chronic patients must be prevented. Therefore, we call on the international medical community, humanitarian organizations, and policymakers to view chronic disease management as a primary responsibility rather than a secondary concern, because these conditions can be directly, systematically, and preventably deadly.
