Forced Migration And Foot Care In People With Diabetes Reply

1 Kehlenbrink S, Smith J, Ansbro É, et al. The burden of diabetes and use of diabetes care in humanitarian crises in low-income and middle-income countries. Lancet Diabetes Endocrinol 2019; 7: 638–47. 2 Boulle P, Kehlenbrink S, Smith J, Beran D, Jobanputra K. Challenges associated with providing diabetes care in humanitarian settings. Lancet Diabetes Endocrinol 2019; 7: 648–56. 3 Kehlenbrink S, Jaacks LM, on behalf of the Boston Declaration signatories. Diabetes in humanitarian crises: the Boston Declaration. Lancet Diabetes Endocrinol 2019; 7: 590–92. 4 Shahin Y, Kapur A, Seita A. Diabetes care in refugee camps: the experience of UNRWA. Diabetes Res Clin Pract 2015; 108: 1–6. 5 IDF. IDF diabetes atlas, 8th edn. Brussels: International Diabetes Federation, 2017. 6 Rigato M, Pizzol D, Tiago A, Putoto G, Avogaro A, Fadini GP. Characteristics, prevalence, and outcomes of diabetic foot ulcers in Africa. A systemic review and meta-analysis. Diabetes Res Clin Pract 2018; 142: 63–73. 7 Abbas ZG. Diabetic Foot—an African perspective. JSM Foot Ankle 2016; 1: 1005. 8 Abbas ZG, Archibald LK. Epidemiology of the diabetic foot in Africa. Med Sci Monit 2005; 11: RA262–70. unattended, callouses, cracks, fissures, and ulcers provide a gateway for bacteria and foot infections that spread rapidly to underlying tissues, bone, and the central circulation. Under the pressure of forced migration, foot assessment for people with diabetes needs to be prioritised early in any contact with the health-care system, no matter how rudimentary. Of all the complications of diabetes, life-saving foot care can be instituted by health-care workers and taught to displaced people. Living conditions can be optimised by providing cots to eliminate the need to sleep on the ground and risk exposure to rodent bites. Education about not walking barefoot, especially at night, to latrines can be provided. Clean water for wound care can be prioritised. In short, even in the absence of glucose control, antibiotic therapy, and surgical care, hygienic practices reinforced by education can be implemented. However, education is not an easy approach because people are not always aware they have diabetes, the concept of insensate feet and the danger they present can be difficult to teach, and walking barefoot might be both cultural and habitual. Furthermore the stress of harsh and uncertain circumstances can limit the ability of people to focus on self-care. Foot infection provoked by walking due to forced migration is an acute and potentially deadly consequence of a chronic complication of diabetes. The Series on diabetes in humanitarian crises and the associated Boston Decla ration describe the urgent need for research, resources, and protocol development for diabetes care for populations exposed to catastrophic events. In view of the potentially important link between forced migration and foot injury, particularly in African populations, in people with diabetes (both diagnosed and undiagnosed), we propose that foot care protocols should be an area of primary concern. Author’s reply We thank Arsene Hobabagabo and Anne Sumner for highlighting the urgent issue of foot care in people living with diabetes in humanitarian settings. We agree that this is an often neglected and underappreciated component of diabetes care in populations undergoing forced migration, including in Africa. Unfortunately, data on this topic are scarce. This limitation was evident in the first Series paper on diabetes in humanitarian crises, in which none of the studies identified in our search of the scientific literature reported on foot care in this region. Only five studies included any mention of peripheral neuropathy, diabetic foot, or amputations. Four of these studies assessed data from UN Relief Forced migration and foot care in people with diabetes