Childhood cancer among Syrian refugees: the need for new approach

Fouad M.Fouad MD World Cancer Congress Paris Oct.31-Nov.3, 2016

Syria Tragedy

• 10 p/ hour are killed since 5 years (mostly civilians)

• Half million death (direct violence) • 2 million injuries • 12 million displaced

Syria Tragedy 1. long term/protracted (almost 6 years)

• average length of major protracted refugee situations globally is now 26 years

• 23 of the 32 protracted refugee situations have lasted for more than 20 years. (UNHCR- 2015 )

2. massive influx (4.8 million Syrian refugees, 7 m IDPs) • 10 million refugees/21.3m worldwide are Syrians and Palestinians

(UNHCR/UNRWA) • 1.1 m in Lebanon-209 refugees/1,000 inhabitants, • one million have requested asylum to Europe

3. urban settlements; 85% of refugees are non-camps

4. middle income; NCDs are estimated to account for 77% of all deaths

5. multiple actors (state/ non-state) = multiple health systems 6. 2011-2015 life expectancy fell by 7.3 years (both sexes) 11.3

years (male) (Lancet 2015)

The framework of humanitarian aid system

Emergency OR

Protracted crises

The framework of humanitarian aid system • Built on the experiences of refugees living

• in camps • in low-income, • less developed countries where communicable, maternal,

nutritional, and newborn diseases are prevalent • Respond by straightforward interventions such as

• antibiotics • vaccinations • nutritional supplements.

Cavallo 2016

46% 37%

19%

34%

23%

59%

20%

62%

37%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% o

f tot

al d

eath

s cau

sed

by N

CDs (

both

sexe

s, a

ll ag

es)

Percent of Total Deaths caused by NCDs in the Largest Source Countries of Refugees in 2015

No data available

Rabkin, Fouad 2016

Morbidity and Mortality before 2011

• Mortality from CVD; coronary heart disease and stroke: over half of all-cause death in Aleppo (Maziak et al. 2007).

• Risk factors for CVD :two out of five were hypertensive, obese, or smokers (Maziak et al. 2007).

• overall rate of coronary heart disease morality rose by 64 % between the years 1996 and 2006, mostly due to increases in their risk factors (Rastam et al. 2012).

• The last two decades witnessed as well an increase in cancer morbidity and mortality in Syria perhaps due to a combination of increased risk factors and improved documentation (Deeb and Eid 2012). • top three cancers (incidence rate) in men were bladder, leukemia

and lung • breast, uterus/cervix and leukemia in women (Mzayek et al. 2002).

150-200 per 100.000 population Source: national cancer registry MoH

Childhood Cancer (0-14) -Syria Year # % 2002 921 9.1 2003 949 7.8 2004 939 8.4 2005 720 6.3 2006 1221 8.9 Total 4750

Source: national cancer registry MoH

Childhood cancer 2002-2006 top 5, age (0-14) Type # %

Leukemias 1480 31. 2 CNS 975 20.5 Lymphomas 894 18.8 Bones and soft tissues 689 14.5 Urinary tract 305 6.4 Total 4343

Source: national cancer registry MoH

NCDs among Syrian refugees in Lebanon (2011-2015)

• Chronic Health Conditions: The presence of hypertension, cardiovascular disease, diabetes, chronic respiratory disease, or arthritis in one or more household members was reported by 50% of Syrian refugee households

• 70% had an out- of- pocket payment • 76% of refugees were currently taking medicines; among

those not taking medication, the primary barrier was cost.

Health service utilization for non-communicable diseases among Syrian refugees and host communities in Lebanon

Hypertension CVD DM Ch.res dis.

Syrian refugees (n = 1376)

20.5 % 10.8 % 9.9 % 16.0 %

Host community (n = 686)

34 % 19.8 % 21.0 % 12.1 %

Age-specific chronic disease prevalence

Doocy 2016

Cancer among Syrian refugees in Lebanon-estimate • 1.5 m • No data available on cancer • Incidence rate per 100.000: 150-200 (Syria before 2011,

Jordan) = 2250-3000 new cases/annually • Childhood cancer • Incidence rate per 100.000: 18-20 = 270-360 new case/an

Cost • Treatment for every child with cancer costs (in Lebanon)

between $100,000 and $200,000 (CCC-Leb) • In 2015, CCC received $3.5 million from St. Jude and have

enrolled 25 patients, 21 Syrians, and 4 Palestinians into the program (Saghir, 2016)

UNHCR- Leb: policy of health services support of Syrian refugees • Refugees with serious medical conditions that require care

costing more than the $1,000 to $2,000 allocated in the -UNHCR’s budget for primary health-care services are referred to the ECC*, whose members include: • a UNHCR medical doctor • local doctors with varying specialties.

• The ECC decides whether to approve or reject treatment, based on • the necessity of the suggested treatment, • feasibility of the treatment plan, • disease prognosis, • cost of care, • eligibility as a registered refugee.

*Exceptional Care Committee

Examples from Jordan and Turkey

• 2010-2012 • Only 246/ 511 applications for cancer treatment—most

commonly for breast cancer were approved by ECC • The main reason for denial, “was poor prognosis” or ‘too

expensive” (UNHCR 2014)

• According to asylum law (April 2013); “People who have registered as refugees, including children, have been provided with free medical treatment as Turkish citizens, including cancer treatment and care at tertiary Government and university hospitals”. (Kebudi 2016)

Challenges • complicated and expensive ongoing care • mostly beyond the financial resources of relief organizations • the delivery of continuity care (cancer) is especially difficult for

persons who are • mobile, • unstably housed, • psychologically stressed, • lacking health coverage

New Approach • Mobile and online information campaigns focusing on

preventative health • New financing models such as crowd-funding and potentially

health insurance. • Universal health coverage: “structured pluralism” - integrating

the large humanitarian system into the hosting country health system (Frenk 2015. Blanchet & Fouad 2016)

• More research on cost-effective interventions • New guidelines to address cancer care in conflict context and

protracted displacement conditions

Thank you