Keywords

29.1 Introduction

A humanitarian crisis is a situation of human emergency causing physical, economical or environmental damage that overwhelms a community’s potential to tend to its population’s needs [1]. Although crises may be natural: geophysical (earthquakes, volcanoes), meteorological (storms), hydrological (floods), climatic (droughts), or biologic (epidemics), the most commonly encountered humanitarian emergencies are man-made [2].

Conflicts are defined as violent struggles between at least two groups resulting in at least 25 battle-related deaths per calendar year [3]. They usually develop within the context of long-standing inequalities and social quarrels that intensify with the breakdown of civil authority [4]. In a battle for power and resources, where predatory social domination fuels existing tensions, and fluid local identities are manipulated, sectarian differences arise, intensifying societal fragmentation [5]. Conflicts torment populations, causing loss of lives and infrastructure plus profound health effects. Civilians face dislocation and migration or stay becoming victims of violence, political turmoil, hunger and illness [6].

Multiple countries of the Arab world are in a state of humanitarian crisis because of armed conflict. Conflicts distress the entire region, affecting countries of active combat as well as adjacent host countries with already frail economies. These countries include Syria, Iraq, Lebanon, Somalia, Sudan, Yemen, Libya and the occupied Palestinian Territory [7]. The past decade has witnessed a surge in numbers of people in humanitarian crises with non-resolution of present conflicts, as well as the uprising of new conflicts [8]. The more protracted conflicts are, the larger the health-related deficit grows as countries fall short on medical supplies, equipment, infrastructure, and personnel.

A devastating impact on health systems, daily life, and well-being of civilians is noted, with an increase both in communicable and Non-Communicable Diseases (NCDs) such as cancer in conflict-affected zones as well as in host countries to displaced populations [9,10,11]. With the escalation of the humanitarian situation, the number of civilian casualties renders too high, and international response becomes vital. The WHO Constitution, formulated in 1946 [12], mandates protection of human rights as well as the security and maintenance of proper healthcare. Its commission emphasizes the fundamentality of providing all human beings with “the right to the highest attainable standard of health” [13]. Furthermore, the United Nations ascertains “the global community’s responsibility for everyone’s welfare” with a doctrine of the “responsibility to protect” [14]. Although humanitarian action often provides short-term requirements of food, shelter and trauma relief, longer-term humanitarian aid focuses mainly on communicable diseases, with relative control of infectious diseases. Nevertheless, an increase in NCDs, cancer particularly, has been noticed in the context of ageing populations and collapsing health systems [15, 16].

Available studies in the region led by international collaborators show an increased incidence of NCDs with increased disease burden and increased morbidity, elaborated by higher disability-adjusted life years, and higher mortality [11]. As part of 2015’s established Sustainable Development Goals (SDG), the United Nations focused on ensuring healthy lives and promoting well-being for all at all ages (SDG 3) [17]. SDG 3.4 further elaborated the need to reduce by one-third premature mortality from NCD by the year 2030, including cancer, through prevention and treatment [17]. Moreover, the World Health Assembly in 2019 discussed a 5-year global action plan to promote the health of refugees and migrants, focusing on aid organization and delivery, with the strengthening of health policies and information systems [18]. The humanitarian community, based on collaborations between international and local organizations, re-directed forces towards coordinated humanitarian reform to fill the gaps achieving a more comprehensive, effective, and sustainable needs-based relief effort. The humanitarian reform aims to dramatically enhance humanitarian response capacity, predictability, accountability, and partnership. It is empirical to identify and integrate key interventions for NCD care into humanitarian programmes, to conceptualize and empower local healthcare systems through capacity building and strengthening. Thereby, available resources and the resilience of populations can be harnessed to attain present as well as future well-being.

In 2018, cancer incidence was estimated at 18.1 million people worldwide, with cancer mortality reaching 9.6 million [19]. Surveys showed cancer to be the culprit of 30% of all premature deaths from NCD in young adults, with lung cancer being the most common (11.6%) and most lethal (18.4%) [19]. However, numbers differ significantly according to the socioeconomics and Human Development Index (HDI) of countries. Despite all efforts to control the growing incidence of NCD and their corresponding premature deaths, specifically due to cancer, responsible for about 70% of all deaths, SDG 3.4 is far from being achievable given the currently slowing progress [20, 21]. In 2020, 1 out of 6 individuals dies because of cancer. These numbers are expected to increase by about 60% over the next two decades, with the greatest increase in Low- and Middle- Income Countries (LMICs), significantly burdening already struggling health systems [22]. By 2040, the predicted global cancer incidence will reach about 29–37 million cases, and LMICs will be the most affected, harbouring about 67% of all new cases [19]. Not only is cancer incidence not equitable, but also cancer death seems to affect more countries of the lowest socio-economic status, even more so, conflict-affected countries.

Cancer care in this region has been long considered too costly and complex, with a lack of consensus on cost-effective interventions as well as an inability of host health systems to expand cancer services [23]. Patients already diagnosed or with a new possible diagnosis of cancer face deficiencies in healthcare facilities, resources, and treating specialists [24, 25]. They are often forced to migrate seeking expensive cross-border therapy that occasionally proves to be unaffordable; given limited international aid available [26]. In an attempt to decrease NCDs and premature death rates, thereby achieve SDG 3.4, as well as integrate SDG 3.8 tackling universal health coverage where the provision of medical assistance and access to quality healthcare services including cancer care is available to all, the international community established the need to accelerate action against cancer and decrease its imposed global health burden, especially in territories most in need [17, 27]. In this review, we discuss the challenges facing cancer care in conflict situations, with a focus on vulnerable populations where humanitarian assistance is fundamental to fill the gaps, build local capacities, and strengthen healthcare systems to improve health-related outcomes at all stages of disease: primary prevention, screening and early diagnosis, multi-modality management and importantly palliative care.

29.2 Challenges Facing Cancer Care in Conflict-Affected Regions

“Cancer is a deeply personal disease, with tremendous physical, emotional and financial strains, on individuals, communities and countries”, a statement eloquently made by Mr. Tedros Adhanom Ghebreyesus, director of WHO [22]. Cancer can affect anyone anywhere in the world, regardless of wealth, social status, security, or humanitarian situation. Given its immense burden on global health, with a growing number of cases as a function of increased life expectancy worldwide, the international community rushed to accelerate global cancer control, with more effective means of prevention, screening, diagnosis, management, surveillance as well as palliation. However, cancer care remains uneven and inequitable across the globe.

What seems easily attainable in high-income countries (HICs) leading the way for the “moon-shot” approach of cancer care, having easy access to new expensive technology and drugs, is far from attainable in countries struggling with conflicts that prohibit them from accessing basic healthcare, where even the “groundshot” approach to cancer care may be difficult to provide due to extremely limited resources [28]. Inequity in access to effective means of diagnosis and management is mirrored in the much higher estimated mortality rates amongst vulnerable populations of conflict-affected countries of the Arab world. Underprivileged populations in conflict regions are faced with multiple challenges that delay diagnosis, hinder care, and make screening almost impossible. Treatable diseases become incurable with late diagnoses causing advanced stages, lower-quality care, and incomplete treatments, all of which are detrimental to patient outcomes [29,30,31].

Because of destroyed health facilities, non-operational infrastructure, exodus of medical staff and experts corresponding to the progressive Arab world brain drain [32], as well as the lack of much-needed diagnostic material, medications, or technology due to insufficient funds [33], people find no option but to seek medical care in other regions, cities and very often other countries. Displaced populations embark on paths loaded with military checkpoints and expensive “out-of-pocket” payments every step of the way, and despite selling all their worldly possessions, they still fall short of successfully managing to access appropriate care [24, 34]. Humiliation, violence, abuse, morbidity, and death are no strangers to refugees and migrants. International and national stakeholders are attempting to improve healthcare. However, it remains beyond the capacities of host countries or regions to manage the magnitude of such influx of ill people, especially when it comes to complex entities such as cancer requiring multi-disciplinary action and close follow-up [35, 36]. Optimal management of cancer requires the integration of multi-modal interventions including surgery, chemotherapy, radiation therapy, targeted and biologic treatment as well as immunotherapy, much of which is not available in conflict-affected LMICs of the Arab world.

In the presence of frail social, economic, and political instabilities, in addition to already burdened and fragmented healthcare systems, host countries are overwhelmed. From social taboos of insecure cancer patients fearing discrimination, to governmental labelling of malignancies as “helpless”, and international organizations such as the UN limiting financial support to individual cases [37], curability and treatment-quality rates remain low. Patients, if ever reach the clinic, get deferred, never continue the requested work-up, or fail to find the needed support to access and complete treatment [36]. In another scenario, the continuity of care of a patient already on active treatment is compromised after displacement. With no data documentation and no transfer of medical records, patients are confronted with significant delays and imposed repetition of work-up, indicating potentially avoidable waste of resources [31]. The absence of national policies to regulate healthcare and cancer access for these patients is just the start of the wider problem. Humanitarian aid may be targeting sound investment in immediate cancer control; yet substantial global heterogeneity in leading cancer types ought to be taken into consideration, and regional responses must be contextualized accordingly to the epidemiologic burden of disease [19, 38, 39]. Therefore, the presence of proper tumour registries, population-based guidelines, and need-based research is of utmost importance, all of which are deficient in LMICs of the Arab world. Figure 29.1 summarizes the challenges leading to poor cancer care in the region.

Fig. 29.1
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Challenges leading to poor cancer care in the region

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Cancer occurs in more than 300,000 children annually worldwide, and the rate is expected to increase, more so in LMICs. Most paediatric cancers have a cure rate that can reach up to ≥80% in some HICs [40, 41]. The burden of paediatric cancer has shown wide inequality among countries, as children in countries with low HDIs are significantly less likely to access care or receive successful treatment with high morbidity and mortality rates [42]. Why would a child be deprived of possibly curable treatment because he or she was born in an inconvenient time and place?

In conclusion, delays in effective cancer control become increasingly costly with increased morbidity, preventable life loss, as well as significant economic and social burdens. Highly effective National Cancer Control Plans (NCCPs) based on affordable and feasible interventions are suggested as an integral component of Universal Health Coverage (UHC) that would fall under the banner of SDG 3.8 promoting access to high-quality essential healthcare services [43, 44]. UHC aims to protect people and improve their outcomes [45], through the strengthening of existing healthcare systems, as well as local capacity building [46]. Cancer diagnosis and management have developed rapidly in recent years. However, in many crisis-affected countries of the Arab World, cancer control strategies, if existent, are inefficient, uninformed, do not adhere to best practices, and are not adapted to national health systems’ capacities with an inappropriate allocation of available resources. Implementation of NCCPs through collaboration with national and local organizations would strategize priorities and cancer care investments so as to efficiently fulfil unmet needs, reduce suffering, save lives as well as aid in promoting economic productivity through evidence-based policies [47,48,49]. Coordination of governmental figures such as ministries, public health institutes or social securities, private insurance companies as well as health providers, civil society stakeholders and several voluntary organizations is inevitable for proper healthcare workers’ training, not to forget the creation and monitoring of national policies and specific population-based guidelines.

Finally, it is worth mentioning the ongoing COVID-19 pandemic that has affected the entire globe [50]}. It has been a particularly tough challenge for cancer patients who are immunosuppressed, immunocompromised or simply fatigued and in need of assistance in daily-living activities. All these characteristics render cancer patients more vulnerable to infectious diseases [51, 52]. Strategic planning, capacity building and policy creating have been paused, with attention re-focused towards virus containment. Some diagnostic and even therapeutic modalities are halted. Furthermore, travel difficulties and long waiting periods are driving patients away from consulting with their primary physicians. An international cross-sectional study was done in 54 countries across six continents to evaluate the impact of the pandemic on cancer care worldwide. It showed a devastating impact, with reported harm from interruption of cancer-specific care reaching 36.52%, up to 80% in some centres, and worse in lower-resource countries. Challenges included patients missing therapy in >10% of cases, medication restriction in 10% of cases and overwhelmed medical systems in 20% of cases {[53]}.

Despite all these challenges, some conflict-affected economically drained communities in the region managed to issue pragmatic need-based recommendations for daily practice in cancer patient care during the COVID-19 pandemic, as well as establish proper means for distant/telemedicine and tele-education, so as to follow and manage cancer patients according to the best updated data with extremely limited resources [54, 55].

29.3 Potential for Development & Improvement of Cancer Care in the Arab World

Countries in the region find themselves facing immense challenges of intractable conflicts with a pertinent increase in cancer burden. In addition, with the absence of standard guidelines or clear national policies for much-needed developmental reforms in the provision of cancer care to citizens as well as refugees and displaced people, the international society shed light on the importance of the establishment of NCCPs [56]. NCCPs are based on the principle of governance to provide the population’s needs and set norms with focused agendas for strategic investments in local resource-stratified healthcare [57]. Given the scarcity of cancer registries, the lack of quality cancer prevalence data as well as the absence of proper conflict-adapted population-based studies to inform programming and care delivery, strategic planning for cancer care development seemed to be a difficult target [58]. Therefore, international aid emphasized the importance of strengthening the quality of tumour registries, quality of data collection as well as the importance of crisis-contextualized research. Means of electronic data collection were sought and implemented by multiple NGOs, helping make documentation and transfer of medical information easier for better continuity of care [59,60,61]. Technology was also noted to be of utmost importance in communication among healthcare workers, improving coordination, multi-disciplinary care, and implementing distant training and education, staying in line with all international information updates.

Despite shouldering a significant proportion of the global cancer burden, these countries of the Arab World notably lag in knowledge yield and production of resource-stratified evidence-based cancer research [62,63,64]. Table 29.1 as well as Fig. 29.2 retrieved from Abdul-Sater et al. [65] show an example of barriers to cancer research and researcher training needs in the region [65]. These gaps in obtaining population-based research impede nations from reaching target care goals, more so with drastic impact in conflict-affected settings. In fact, focusing on creating unified health research structural regulatory frameworks that embark on building research capacity through training of researchers and healthcare professionals, helps identify actual population needs. They bridge the gaps to the provision of high-quality cancer care [66], as well as develop profound networks and enhance communication among physicians, technicians, healthcare workers, social workers, civilians, media, academia, policymakers, governmental organizations as well as national and international non-governmental stakeholders [67, 68]. These networks facilitate access to information, as well as dissemination and implementation of knowledge by addressing questions that cannot be otherwise addressed in non-crisis settings.

Table 29.1 Themes, subthemes, and their share of mentions of research barriers form participants’ responses [65]. Used with permission from Abdul-Sater, Zahi, Elsa Kobeissi, Marilyne Menassa, Talar Telvizian, and Deborah Mukherji. “Research Capacity and Training Needs for Cancer in Conflict-Affected MENA Countries”. Annals of Global Health 86, no. 1 (2020)
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Fig. 29.2
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(a) Radar chart highlighting the difference between the importance to job and ability to perform regarding activities related to cancer research and care. Tree map chart showing the themes mapped from participants; responses to the research (b) and training (c) barriers. Used with permission from Abdul-Sater, Zahi, Elsa Kobeissi, Marilyne Menassa, Talar Telvizian, and Deborah Mukherji. “Research Capacity and Training Needs for Cancer in Conflict-Affected MENA Countries”. Annals of Global Health 86, no. 1 (2020)

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Task Forces have emphasized the absolute necessity for priority-setting and policymaking at all stages of the cancer continuum [69, 70]. For example, specific exposure-related cancers, more common in these regions, can be approached more conclusively. Hepatocellular carcinoma related to hepatitis viruses B and C (HBV, HCV), cervical cancer related to human papillomavirus (HPV), lymphomas as well as head and neck tumours related to Ebstein-Barr virus, are all diseases that can either be prevented by vaccination (HBV, HPV) or caught at an earlier more curable stages by screening [71]. Nation-wide screening and early detection programmes can help minimize cancer burden, especially in common malignancies such as lung, breast and colon cancer [72]. Awareness campaigns regarding tumour-related signs and symptoms, as well as tobacco-cessation programmes and informing of the whereabouts of screening/detection programmes should be incorporated in all physician clinics and media.

In presence of proper guidance and informed planning, cancer care in conflict-affected regions should not be dreaded. Infrastructure can be provided [73], if not in regions of active conflicts, then in neighbouring countries, or in “cease-fire safe-grounds” with properly equipped specialized care centres such as in Kurdistan [74]. Eventually, there is truth to health being a bridge to peace where death and morbidity can trigger humanity [75, 76]. As for cost and cost-effectiveness, cancer care can be economically yielding rather than expensive. Taken up in the momentum, with investments properly placed into systems not individuals, seven million cancer deaths can be avoided in LMICs by 2030, at a cost of US$ 2.70 per person in low-income countries, and US$ 3.95 per person in LMICs [22]. When financial costs are calculated from estimated purchases, and programmes for pre-specified numbers of citizens and refugees are based on registries and databases for treatment, screening, and early primary detection, inefficient primary care and cumbersome clinical pathways leading to more advanced stages with greater costs and worse outcomes can be evaded [27]. Budgets for expensive targeted therapy or immunotherapy that benefit minorities can be deterred and privatized, focusing on effective chemotherapeutic agents or curative surgical interventions.

Neglecting the incorporation of palliative care in cancer control agendas remains a pertinent concern. Only half of the countries worldwide seem to include palliative care in their NCD plans [77]. Palliative care is an essential part of comprehensive cancer care. It revolves around the prevention, early identification, and relief of any suffering of cancer patients on the physical, psycho-social, and emotional levels, with proper control of symptoms, most importantly pain [47, 49, 78, 79]. Palliative care preserves patient dignity, improves the quality of life and improves survival [80, 81]. It includes home care sparing patients and families costly lengthy hospital admissions, while simultaneously preventing hospital overcrowding and cutting down healthcare expenses [82, 83]. Perhaps it is worthy to ensure adequate opioid pain relief and oral morphine supply whose availability barely reaches 10% in LICs and 29% in MICs [84].

Once more, we need to emphasize the importance of sustaining cancer care during the COVID-19 pandemic. Cancer patients have been particularly affected by the pandemic, not only because of their vulnerable immune status and the possibility of severe adversities but also because their diagnosis, management and follow-up have been deferred until after the storm abides. Different care strategies and approach algorithms have been suggested by major health institutions of the Arab world regarding resource allocation, screening methods and general diagnostic and management recommendations in the outpatient and inpatient settings of patients with suspected cancer as well as those on active treatment with high-risk of COVID-19 infection [54]. Awareness campaigns indicating the importance of preventive measures and reporting symptoms have been shown to play a significant role. Furthermore, online consultations replaced clinic visits in the era of “social distancing”, and oral treatments prevailed over lengthy chemotherapy sessions whenever possible. Nevertheless, many people needing hospital admission remain and they cannot wait long. Otherwise, the recession phase (phase III) of COVID-19 will not only witness overcrowding of hospitals due to ill COVID-positive patients but also sick cancer patients. Studies discussed hospital system re-organization to include COVID-free areas where cancer care can be safely provided along new situation-adapted guidelines [85]. On the other hand, when it comes to networking, education and multi-disciplinary opinions, healthcare workers have shown remarkable adaptability with an unprecedented “webinar fever” and innumerable free online courses and discussions that have simply brought the entire world closer together.

29.4 Conclusion

Cancer care in conflict-affected regions of the Arab World is very heterogeneous, inequitable, and uneven, with an increasing cancer burden. Obstacles to quality cancer care are numerous and finding one purpose-oriented care model fitting all is impossible. International organizations attempt to empower local capacities, all while trying to fulfil SDGs 3.4 and 3.8. Improvement of cancer care and delivery of cost-effective and sustainable high-quality care must be based on local knowledge and evidence-based regional resource-dependent research-informed guidelines, within the context of a regulatory body and policies focused on dynamic priority-setting.

Cancer prevention, screening, early detection, and optimal management provision within a groundshot approach are pivotal to achieving targeted milestones. Palliative care, moreover, needs to be incorporated into pragmatic cancer control plans, due to its important role in the improvement of survival as well as the quality of life. International and national collaborations are essential, and funding can only be provided within organized frameworks. Although COVID-19 put all plans on pause, and adversely affected cancer care across the globe, especially conflict-affected countries of the region; however, it helped improve communication among national and international collaborators and stakeholders, all while enhancing access to the most updated knowledge.

29.5 Funding Information

The authors are funded through the UK Research and Innovation GCRF Research for Health in Conflict in the Middle East and North Africa (R4HC-MENA) project, developing capability, partnerships and research in the Middle and North Africa ES/P010962/1.