Cancer care for refugees: time to invest in people and systems
Authors: André Ilbawi, Slim Slama
Journal: The Lancet Oncology (2020)

Almost 5 million refugees are living in Jordan, Lebanon, and Turkey, most of whom originated from Syria.1UNHCROperational portal: refugee situations: Syria regional refugee response.https://data2.unhcr.org/en/situations/syriaDate: 2020Date accessed: February 18, 2020Google Scholar The health and wellbeing of refugees are matters of international concern, enshrined in political declarations recognising the right to health for all. However, as highlighted by Rima A Abdul-Khalek and colleagues in The Lancet Oncology,2Abdul-Khalek RA Guo P Sharp F et al.The economic burden of cancer care for Syrian refugees: a population-based modelling study.Lancet Oncol. 2020; 21: 637-644Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar the response to deliver on these political commitments to finance cancer care might be inadequate. Cancer and other non-communicable diseases are a severely neglected dimension of refugee health. Predominant reasons are misperceptions of cancer as being too complex and too expensive to treat, a lack of consensus on cost-effective interventions, an inability of host health systems to expand cancer services, and chronically underfunded humanitarian responses.3UNHCRHealth sector humanitarian response strategy: Jordan 2019–2020. Health Sector Humanitarian Response Strategy.https://data2.unhcr.org/en/documents/download/68348Date: February, 2019Date accessed: February 18, 2020Google Scholar The consequence is thousands of potentially avoidable deaths from cancer among the refugee population living in Jordan, Lebanon, and Turkey.4WHOWHO report on cancer: setting priorities, investing wisely and providing care for all.https://apps.who.int/iris/handle/10665/330745Date: 2020Date accessed: February 18, 2020Google Scholar What needs to be done? We propose three actions: formulate a compelling narrative and integrated plan; invest effectively to make an impact; and monitor implementation and promote accountability. In 2019, governments at the World Health Assembly agreed to a 5-year global action plan to promote the health of refugees and migrants, focusing on how services are selected, organised, and delivered, while also enabling health through integrated policies and strengthened information systems.5WHOPromoting the health of refugees and migrants: draft global action plan, 2019–2023.https://www.who.int/publications-detail/promoting-the-health-of-refugees-and-migrants-draft-global-action-plan-2019-2023Date: May, 2019Date accessed: February 18, 2020Google Scholar The global focus has now shifted to put national plans, rather than international strategies, into action. To include cancer in humanitarian responses or general government expenditure, a stronger, more detailed justification is needed when juxtaposed against other priorities. As a starting point, the 2019 WHO report on cancer found that for every US$1 invested in cancer, there is a direct productivity return of $2·30 and full social return of $9·50.4WHOWHO report on cancer: setting priorities, investing wisely and providing care for all.https://apps.who.int/iris/handle/10665/330745Date: 2020Date accessed: February 18, 2020Google Scholar These estimates are compelling arguments for action but can only be achieved if the highest priority, resource-appropriate interventions are selected. External development assistance must thus initially focus on early diagnosis and treatment of curable cancers (such as childhood cancer or early-stage breast, cervix, or colorectal cancers) to optimise expenditure. In parallel, ministries of health, UN agencies (particularly WHO and the UN Refugee Agency), and stakeholders involved in service provision should better align efforts when designing and implementing essential services packages. This alignment entails reaching a consensus on priority cancers, clinical pathways, and financial protection mechanisms. A compelling, unambiguous narrative can then be elevated to the highest possible public and political levels. Cancer care for refugees is feasible and is a personal and political matter. Can we accept a refugee child dying avoidably from cancer while neighbouring children who bear national citizenship are able to access care? To invest wisely, commitments to scale up capacity must include broader health system investments. Investments focusing only on treatment of individual patients and not system requirements or structural reforms will not advance broader public health. Health system readiness in host countries determines what can be made available for refugees. Financial costs must be considered—not only how much services cost, but also the purchases required and programmes needed as the number of people requiring services increases. Deficits in primary care and cumbersome clinical pathways encountered by refugees result in more advanced disease, greater costs, and worse outcomes.6Marzouk M Kelley M Fadhil I et al."If I have a cancer, it is not my fault I am a refugee": a qualitative study with expert stakeholders on cancer care management for Syrian refugees in Jordan.PLoS One. 2019; 14e0222496Crossref Scopus (13) Google Scholar Therefore, programmes for early diagnosis of cancer must be well resourced as part of a broader response. Investments in services and systems have previously improved access to cancer services even in fragile states.3UNHCRHealth sector humanitarian response strategy: Jordan 2019–2020. Health Sector Humanitarian Response Strategy.https://data2.unhcr.org/en/documents/download/68348Date: February, 2019Date accessed: February 18, 2020Google Scholar, 7WHO Regional Office for the Eastern MediterraneanWHO responds to the cancer care crisis in Yemen.http://www.emro.who.int/yem/yemen-news/who-responds-to-the-cancer-care-crisis-in-yemen.htmlDate: May 7, 2018Date accessed: February 18, 2020Google Scholar In monitoring implementation, data should drive decision making. Existing information systems do not capture the number of refugees affected, how cancer is diagnosed, if and when treatment is received, and the outcome. Without this information, the ability to mobilise partners and maintain momentum could be lost. Current registries in Jordan, Lebanon, and Turkey are population-based, but data about refugee status are generally not captured or reported.2Abdul-Khalek RA Guo P Sharp F et al.The economic burden of cancer care for Syrian refugees: a population-based modelling study.Lancet Oncol. 2020; 21: 637-644Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar Since the onset of the Syrian refugee crisis in 2013, the number of Syrian refugees in all countries reached more than 5 million in April, 2017, and continues to increase.1UNHCROperational portal: refugee situations: Syria regional refugee response.https://data2.unhcr.org/en/situations/syriaDate: 2020Date accessed: February 18, 2020Google Scholar Time will not resolve the cancer care needs of refugees and thousands will continue to be diagnosed each year.2Abdul-Khalek RA Guo P Sharp F et al.The economic burden of cancer care for Syrian refugees: a population-based modelling study.Lancet Oncol. 2020; 21: 637-644Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar Abdul-Khalek and colleagues have rightly drawn attention to the economic requirements of providing cancer care for refugees.2Abdul-Khalek RA Guo P Sharp F et al.The economic burden of cancer care for Syrian refugees: a population-based modelling study.Lancet Oncol. 2020; 21: 637-644Summary Full Text Full Text PDF PubMed Scopus (8) Google Scholar This paper is only the beginning of the research and political agendas; to deliver on the potential of universal health coverage, greater health service and implementation research is needed, focusing on how services are organised and delivered, and also documenting best practices in financing. Inequalities in cancer have become a predominant theme in this era characterised by rapid progress and innovation for some populations and lack of access, premature death, and financial hardship for many more people.3UNHCRHealth sector humanitarian response strategy: Jordan 2019–2020. Health Sector Humanitarian Response Strategy.https://data2.unhcr.org/en/documents/download/68348Date: February, 2019Date accessed: February 18, 2020Google Scholar, 8World cancer report: cancer research for cancer prevention.http://publications.iarc.fr/Non-Series-Publications/World-Cancer-Reports/World-Cancer-Report-Cancer-Research-For-Cancer-Prevention-2020Date: 2020Date accessed: February 18, 2020Google Scholar Developing stronger systems for cancer care is a global public good. It is time to make a collective investment reflecting this reality. We declare no competing interests.The views expressed are those of the authors and not necessarily those of their affiliated institutions. The economic burden of cancer care for Syrian refugees: a population-based modelling studyCancer among the Syrian refugee population represents a substantial financial burden for host countries and humanitarian agencies, such as the UN Refugee Agency. New ways to provide financial assistance need to be found and must be coupled with clear, prioritised pathways and models of care for refugees with cancer. Full-Text PDF Open Access