Stop making refugees wait for cancer care

By the end of last year, nearly 120 million people around the world had been forced to flee their homes because of conflict and insecurity. According to the UNHCR , this figure includes 15.6 million people in the Middle East and North Africa. These people, displaced in their own countries or across national boundaries are only the tip of the iceberg – according to the World Bank about a quarter of the world’s two billion people now live in fragile, insecure and conflict-hit states. In addition, more than a third of the men, women and children who become refugees will develop or be at risk from cancer . In August, the recognition that cancer is now a serious issue for refugees and host countries led to an unprecedented manifesto being published in The Lancet medical journal. Led by Dr Tedros Adhanom Ghebreyesus , the head of the World Health Organisation, it called on the international community to integrate cancer care into its wider humanitarian efforts. This call was the culmination of a long campaign of advocacy and research that began in 2017 with the creation of the Research for Health in Conflict Partnership across the Mena region co-led by the King Hussein Cancer Centre in Jordan, Hacettepe University in Turkey, the American University of Beirut and King’s College London. The complexity of cancer care for refugees and those in conflict settings means many of our standard models simply do not work. As Dr Mac Skelton and Dr Omar Dewachi from the American University of Iraq – Sulaimani have described, cancer patients affected by conflict have unique therapeutic geographies. They move within and across countries in search of care, something that makes delivering the essentials of treatment – surgery, radiotherapy and chemotherapy – very challenging. The challenges of gender are even greater. Dr Debbie Mukherji from the Clemenceau Medical Centre in Dubai and her colleagues have shown how female refugees with breast cancer are particularly vulnerable to delays in diagnosis and treatment. Such delays are lethal. A meta-analysis published in the British Medical Journal four years ago showed that delaying breast cancer surgery for four weeks meant an additional 10 women out of 1,000 would die of their disease. This number rises to 31 additional women when surgery is delayed by three months. To give some context, most women who are refugees will experience surgery delays of between three and 12 months. The reality at present is that many refugees will present with advanced disease, requiring good palliative care. However, as Prof Omar Shamieh and his colleagues at the King Hussein Cancer Centre have shown, this also remains poorly integrated into care for refugees. Many of the current conflicts in Gaza, Lebanon, Sudan and Ukraine reflect the magnitude and complexity of delivering cancer care in conflict settings and to refugees. However, Ukraine has shown what can be achieved with political will and rapid action. Ukrainian refugees have been able to access high-quality cancer care across Europe through the EU ’s Temporary Protection directives and a huge international effort has been put into providing continuing care within the country itself. However, as radiation oncologist Dr Horia Vulpe has shown with his work with Ukrainian refugees in Romania and Moldova, the pathways and therapeutic geographies for displaced people seeking care remain as complex as those seen in conflict-hit parts of the Middle East. This means we have little idea about the quality of care delivered or its outcomes. Better-organised cancer patient evacuations have been provided for children through the Supporting Action for Emergency Response, or Safer, programme run by St Jude’s Children’s Research hospital in the US. Some adults with complex blood cancers have also been included. The case of Ukraine has also been instructive in just how sensitive modern equipment for treating cancer – imaging equipment and radiotherapy – is to power cuts. In all the conflicts mentioned the key lesson learnt has been that cancer treatment is rapidly degraded and destroyed by modern warfare. This does not require a direct hit on hospitals – shockwaves from explosions kilometres away are enough to disable high-tech medical equipment. Ukraine has been an outlier for conflict and cancer. For much of the world, conflict has meant the destruction of infrastructure – such as in Gaza or Sudan – the enormous migration of refugees, and competing demands on resources and personnel for other more basic health requirements such as trauma, reproductive and public health. The UN and the wider international NGO system does not currently have a way of adapting cancer care to these situations and serious gaps remain between what these patients and host countries need and what we know. The idea that cancer care is a luxury that can be addressed after the conflict has not yet been dispelled. Re-priortising cancer care for refugees and conflict zones will require affordable evidence-based guidelines, better cancer intelligence and horizon scanning, the hardening of technologies to reduce vulnerabilities and new models of care. Countries must adapt their services and systems, and we will need a new political and economic model for cancer care in conflict to support those nations that host refugees. One of the maxims of the great Muslim scholar and physician Ibn Sina – “In the end, I have learned that we have neither learned nor understood anything” – perhaps sums up best where we are in our understanding of how to deliver cancer care to refugees. Herculean efforts are still needed to properly examine, through research, the needs of refugees with cancer. Such efforts are needed to ensure that we develop the best practices and policies to support patients and countries that bear much of the burden not just across the Middle East, but the world.