Elsevier

The Lancet Oncology

Volume 15, Issue 7, June 2014, Pages e290-e297
The Lancet Oncology

Policy Review
Cancer in refugees in Jordan and Syria between 2009 and 2012: challenges and the way forward in humanitarian emergencies

https://doi.org/10.1016/S1470-2045(14)70067-1Get rights and content

Summary

Treatment of non-communicable diseases such as cancer in refugees is neglected in low-income and middle-income countries, but is of increasing importance because the number of refugees is growing. The UNHCR, through exceptional care committees (ECCs), has developed standard operating procedures to address expensive medical treatment for refugees in host countries, to decide on eligibility and amount of payment. We present data from funding applications for cancer treatments for refugees in Jordan between 2010 and 2012, and in Syria between 2009 and 2011. Cancer in refugees causes a substantial burden on the health systems of the host countries. Recommendations to improve prevention and treatment include improvement of health systems through standard operating procedures and innovative financing schemes, balance of primary and emergency care with expensive referral care, development of electronic cancer registries, and securement of sustainable funding sources. Analysis of cancer care in low-income refugee settings, particularly in sub-Saharan Africa, is needed to inform future responses.

Introduction

In 2012, the United Nations High Commissioner for Refugees (UNHCR) recorded 35·8 million displaced people, including 10·5 million refugees, 17·7 million internally displaced people, and several million other civilians who were stateless, repatriating, or seeking asylum worldwide.1 Protracted armed conflicts in the Middle East, particularly in Afghanistan, Iraq, Libya, and Syria, have led citizens of these countries to seek asylum, or be forced to migrate, to several neighbouring countries. These conflicts uprooted healthy and ill civilians alike.

For many decades, refugee crises happened mainly in low-income and less-developed countries. Infectious diseases and acute malnutrition were managed and treated by straightforward health interventions such as antibiotics, vaccinations, and nutritional supplementation. Although these interventions are important in emergency and postemergency settings, refugee situations in the 21st century are increasingly diverse and substantially long-lasting, and occur in camp and non-camp settings, and in low-income and middle-income settings alike.2

Worldwide, non-communicable diseases have received little attention despite their overall burden.3, 4 In refugees, such diseases present specific challenges, including continuity of care and avoidance of treatment interruptions due to displacement, the need for expensive and regular treatments, dependence on specialty physician skills, multimorbidities, and harm reduction through regular screening and lifestyle modifications.5 In some patients, chronic disorders become emergent or evolve into acute presentations if disease is unaddressed or their treatment suddenly stops.

Information on refugees with cancer in low-income and middle-income countries of first asylum is particularly scarce.6 Epidemiological studies of cancer have not been undertaken in many countries affected by humanitarian emergencies, even before conflict. In many locations where there are refugees, there are few data for cancer surveillance, cancer registries, or cancer patterns and outcomes in populations at risk. In this Policy Review, we present data for cancer care in refugees in Syria and Jordan to draw attention to the challenges, trends, costs, and patterns of cancer care to inform priority setting and improve outcomes in displaced people in humanitarian emergencies.

Section snippets

The Exceptional Care Committees of the UNHCR

UNHCR and its partners provide primary health services, and some secondary health services, to refugees registered with the UNHCR, to a maximum cost that varied between US$1000–2000 per person per year from 2009 to 2012. Refugees with serious medical problems that require costs beyond these amounts are referred to the UNHCR's Exceptional Care Committees (ECCs). The ECCs are composed of a UNHCR medical doctor and local doctors with varying specialities. The ECCs decide whether to support or

Data sources and analysis

Data for cancer in refugees were derived from the UNHCR's ECC records that included all registered refugees in Jordan or Syria whose applications were referred to the ECC. Iraqi refugees in the ECC records with a diagnosis of cancer were referred to the Al-Bayroni hospital for treatment in Damascus, Syria (between 2009 and 2011). Refugees of Iraqi, Syrian, and Sudanese origin were seen in multiple locations in Amman, Jordan (data between 2010 and 2012).

ECC data for cancer cases were assessed

Demographics

In Jordan, between 2010 and 2012, the ECC reviewed 1989 applications for treatment of any disease, of which 511 (25·6%) were specifically for cancer. For 2011 and 2012, when complete data were available, the mean age for cancer submissions was about 49 years (range: 0·4–94). 149 (50·3%) of applications for cancer treatments were for women, 29 (10·5%) were for patients younger than 20 years, and 100 (36·3%) of applications were for patients aged older than 60 years. In 2011, 114 (82·6%) of

Interpretation

Non-communicable diseases, particularly cancer, are an important disease burden in low-income and middle-income countries,3, 4 and cause huge challenges in humanitarian settings. So far, the response framework in humanitarian emergencies is built mainly on experiences in refugee camps in sub-Saharan Africa where communicable diseases have predominated.2 The prevalence of non-communicable diseases, including cancer, is higher in middle-income countries than in low-income countries, prevalence is

Future directions for cancer care in refugee settings

Cancer diagnosis and care in humanitarian emergencies typifies a growing trend towards more costly and chronic disease care that needs a multifactorial approach. International partnerships are needed to improve and support cancer disease surveillance and prevention, service availability, and delivery of the standard of care, and to reduce overall costs. Important next steps in cancer surveillance and care in humanitarian settings include the following measures.

First, health system capacities

Conclusion

Non-communicable diseases, including cancers, are increasingly recognised as an important disease burden that needs to be addressed in humanitarian emergencies—and prevention, diagnosis, and treatment of non-communicable diseases are important targets. This Review uses refugee data from the recent conflicts in Iraq and Syria to show the importance of cancer as a public health issue in crises in middle-income countries. Together with the suffering of refugees and their families who are affected

Search strategy and selection criteria

We searched PubMed (Medline) for English-language articles published between Jan 1, 1983, and Sept 30, 2013, that contained the words “cancer,” “neoplasm,” “malignancy,” “tumour,” “health policy”, “chronic disease”, and “oncology,” with the words “refugee,” “armed conflict,” “war,” “displacement”, “humanitarian emergency”, “violence”, and “armed conflict”, and the geographical names, “Iraq,” “Syria,” “Afghanistan,” “Lebanon,” “Jordan,” “Iran,” and “the Middle East.” Additional sources of

References (18)

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