In conflict-affected areas, people experience significant challenges in health-care delivery, and this situation is even more extreme for patients with cancer. Until now, research on access to cancer treatment and care as well as cancer disparities in war-torn and post-war regions has been limited. Therefore, we advocate coordinated, global action to address this issue and implement evidence-based solutions.
In the developed world, millions of people are successfully treated for or cured of cancer; however, in many developing countries those chances of cure are extremely low1,2. A recent simulation-based analysis showed large variations in 5-year survival for childhood cancer dependent on the region, ranging from 8% in Eastern Africa to 83% in North America3. The situation is even worse for those in need of palliation and pain control. It is estimated that around 99.9% of patients with cancer who die in pain are in a low or middle-income region, and only 0.1% are in a high income one1.
Disparities in cancer, defined by the US National Cancer Institute as “adverse differences in cancer incidence, prevalence, cancer death, cancer survivorship, and burden of cancer or related health conditions that exist among specific population groups”, are more profound in war-torn and post-war regions. The majority of these regions are among the least developed and poorest ones in the world. War causes destruction: hospitals, roads, state buildings, economic systems are damaged or inaccessible. The political context and priorities change significantly, and usually the vast majority of the national budget shifts from public goods to security provision. In effect, when people are dying from injuries and illness related to weapons and bombs, care for patients with cancer is abandoned. But in the meantime, patients with cancer need to continue their treatment without interruption, new patients must get their proper diagnosis and therapy, and screening programmes need to continue to run efficiently. However, it is documented that the majority of patients in war-affected settings present with advanced stage cancer and, for many of them, appropriate care is not available2. Another major consequence of war is that affected regions become inaccessible, and this presents a challenging environment for data collection and research.
During the Syrian crisis, which started in 2011, about 45% of public hospitals were destroyed by the end of 20172. In many centres, which were still functioning, diagnostic imaging and radiation therapy modalities were not available, and many doctors and nurses were killed or injured. By 2013, around 70% (in some places 90%) of the medical workforce left the region; in 2015 alone, approximately 15,000 physicians left Syria; and medical education and training was interrupted2,4. Because of the exodus of qualified health-care personnel, medical students and residents frequently took over, exceeding their capabilities, which affected the quality of medical care. A survey conducted in eight hospitals from different governorates reported that only half of the patients were able to complete systemic chemotherapy and/or radiation therapy without interruptions4. Overall, during the first 5 years of the Syrian war, it was estimated that around 200,000 people died because of non-communicable diseases, including cancer, owing to a delay in diagnosis, a lack of access to and availability of qualified medical care and personnel as well as essential medicines2,4.
In Afghanistan, a country with decades of devastating war, most of the health-care infrastructure capable to diagnose, register and treat cancer was destroyed. Although cancer incidence was low (in 2015, 19,656 new cases for a population of 32.5 million), which is most probably due to under-registration and mis-diagnosis or under-diagnosis, in 2015 cancer-related mortality was high at 78%, while in the USA it was 38%.
In Gaza, as of August 2018, the shortage of cancer drugs reached around 85%, which stopped all cancer services. Cancer medications, radiotherapy machines and isotope scans were prohibited to enter Gaza. This made many patients travel across the border to get appropriate treatment; however, a little more than half of the patients were granted permission to exit the Gaza strip5.
War does not only affect the place in conflict, but the region as a whole. There is a high influx of refugees to neighbouring locations, which puts a huge burden on those locations economically and on their health-care systems. As of 2017, globally there were approximately 66 million displaced people, of which 22.5 million were refugees. Meeting the health-care needs of displaced people is a substantial challenge both for this vulnerable population, as well as for the host countries. The vast majority of displaced families have no insurance and financial means to support expensive treatment of cancer, and without additional support from non-governmental and international organizations, patients remain without appropriate diagnosis and therapy6.
King Hussein Cancer Center (KHCC), a leading comprehensive cancer centre in Amman, Jordan, reported that between 2011 and 2018, 356 Syrian patients received treatment at KHCC, which was covered by the King Hussein Cancer Foundation Goodwill Fund; the whole cost of treatment was approximately US$11,400,0007.
A study conducted among the refugee children with cancer between 2011 and 2017 in Lebanon demonstrated that of a total of 275 patients, treatment-related mortality and the rate of treatment abandonment was 1% and 2%, respectively, and approximately 78% of patients were in remission or on treatment. Despite these remarkable efforts, around 40% of non-Lebanese refugee children with cancer were not able to receive adequate care8.
Chemical weapons, considered weapons of war, not only cause direct deaths, but also contain chemicals that are carcinogenic. During the first 3 years of the Syrian war, more than 150 chemical attacks were documented, some of which used mustard or mustard-like gas, a well-known carcinogen from World War I, which causes lung cancer. Subsequently, there were reports about the significant rise of cancer rates in areas affected by chemical attacks.
Iraq, which before the 1980s was described as having one of the best health-care systems in the Middle East, after decades of conflict and instability, currently struggles with many challenges. Besides the ones similarly reported in other war-affected regions like Syria, a study showed a sharp increase in the number of childhood cancers, which was suspected to be due to possible chemical attacks using depleted uranium and white phosphorus9.
Prevention, another cornerstone of effective cancer control, is vastly affected as a result of war. Tobacco smoking, a major preventable cause of cancer, is rising in unstable regions. International tobacco companies, taking advantage of weakened governments, try to aggressively ‘invade’ war-affected and post-conflict markets10. Although several successful examples of tobacco control strategies in post-conflict settings (smoke-free environment policy in Vietnam and a ban on tobacco advertising in Iran) exist, in many other regions, the problem is still significant10.
To address the aforementioned problems, some solutions have been put forward, which range from creating no-fly areas for patients to receive diagnosis and treatment, increasing awareness about self-screening and educating people about cancer, using IT technologies, such as ‘telehealth’ for online consultations with specialists, to ‘empowering’ the United Nations (UN) and other humanitarian agencies to ask governments that escalate conflicts for the coverage of damages and medical expenses caused by war for those regions that are affected2,4. In particular, the role of the UN will be essential in the future, and strategies, which form part of the UN’s Sendai Framework for Disaster Risk Reduction, should be implemented as a global solution to tackle cancer disparities in war-torn regions2. This might include identifying patients who are most at risk and incorporating cancer care in mobile clinics.
While there are many similarities in the problems associated with cancer care between conflict-affected regions, there are also huge differences dependent on the specific region. Therefore, to address the problems, we first need to accurately measure them, understand them and then develop solutions, taking into consideration the specific social, economic and historical context that exists in that region.
How long does a region take to rebuild its health-care system and recover its cancer services, and what are the steps and the factors that influence this process? Which methods are most appropriate to use for conducting research into cancer disparities? These are just a few of the questions we need to answer, but they highlight the extreme need for global action to address cancer disparities in places affected by war. Coordinated, international research, involving cancer research and human rights organizations, local governments, academic institutions and patient advocacy groups, is urgently needed to investigate the aforementioned problems and to come up with evidence-based solutions.
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The authors declare no competing interests.
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Mired, D., Johnson, S. & Tamamyan, G. Cancer disparities in war-torn and post-war regions. Nat Rev Cancer 20, 359–360 (2020). https://doi.org/10.1038/s41568-020-0274-x