Access to cancer care for Syrian refugees

Background 

Since the outbreak of the civil war in the Syrian Arab Republic in March 2011, over 11 million Syrians fled their homes. The majority have sought refuge in neighbouring countries such as the Republic of Turkey, Republic of Lebanon and Kingdom of Jordan. Over 1 million refugees have settled in Lebanon since the outbreak of the war, making it the country with the highest per capita concentration of refugees in the world. This large influx of refugees has exacerbated the political, economic and security challenges of the country. Furthermore, it has equally placed a considerable burden on the Lebanese health system. The health system has fragmented due to alternate options provided by aid organisations and poor coordination of the health system response to the refugee crisis. Due to irregular funding, many Syrian refugees have died of cancer. 

No Access to Legal Status 

In Lebanon without the necessary documentation, refugees are considered to be there illegally and this gives them a restricted legal status in the country. In a new Refugee Policy adopted in 2015 with the aim to reduce the number of refugees, the law stated that refugees now had to pay a $200 USD annual fee to maintain legal status. This did not decrease the number of refugees in Lebanon, but merely stripped more than 60% of refugees of their legal status, and as a consequence it limited their ability to move without restraint because of the fear of being arrested. Without this legal status they can no longer obtain gainful employment, have no access to health care, cannot go to school, and cannot register births and marriages. This lack of legal status contributes to widespread poverty, risks statelessness for children born in Lebanon, presents a barrier to schooling and prevents marriage. 

Economic and Financial Hardship 

Due to their illegal status, refugees in Lebanon are not allowed to work. Therefore, most refugees have no access to the labour market, and are completely dependent on international aid. As much as 58% of Syrian refugee households are living in extreme poverty, at less than $2.87 USD per person per day. On this meagre salary they are unable to cover the cost of basic necessities. 

Poor Living Conditions 

Syrian refugees in Lebanon live predominantly in urban and rural areas in informal settlements. Some refugees have started building informal settlements on privately owned land and dividing the cost of the rent. These informal settlements are usually makeshift tents comprised of wood and plastic. As these structures do not meet basic safety conditions, they are at a high risk of fire which can break out suddenly and spread to other closely packed tents in minutes. The conditions in which these Syrian refugees live are squalid. They have insufficient food, no safe drinking water and hygiene standards are exceedingly poor. 

Access to Health Care 

As refugees with illegal status are fearful of being arrested, detained or deported, they limit their movements within the cities, and this restricts their ability to access basic services, such as health care. In addition, even if they were able to find basic services, their financial situation means that they would be unlikely to be able to pay for any kind of medical treatment. Syrian refugees with cancer are one category of this population that is at risk of not being able to have access to health care. 

Local NGOs such as Karma Association, that works for equal access to healthcare, has been able to raise funds to afford treatment for young Syrian refugees. However, assistance is heavily dependent on funding and several people have been unable to receive treatment due to insufficient funding. People think first about whether they can afford the treatment before going to the doctor, so doctors see several children refugees who are in the late stage of the disease, making treatment that much more difficult. Furthermore, in some instances, as a consequence of restricted access to food and potable water they are equally in a malnutrition status. In addition, if patients with cancer live in poor conditions they are increasingly susceptible to infections, potentially with fatal consequences. Parents sometimes contact doctors to sell their organs in order to afford treatment for their children. In some cases, refugees with cancer are able to start treatments for their diseases, however, because of insufficient funds they have to stop the treatment. According to local NGOs, the lack of funding prevents refugee children from accessing early diagnosis and healthcare. The funding depends mostly on individual donors, not on long-term sustainable solutions. Other challenges in providing care concern the restriction of movement and the refugees’ illegal status. 

International Human Rights Law 

Although Lebanon has not ratified the 1951 Refugee Convention, all refugees have the fundamental right to the enjoyment of the highest attainable standard of health. The failure to sign or ratify the Refugee Convention is mitigated in some respects by the customary law principle of non-refoulement and other international human rights treaties that it is a signatory to.4 For example, Lebanon has ratified the International Covenant on Economic, Social and Cultural Rights (ICESCR), which article 2.2 states that States Parties “(…) undertake to guarantee that the rights enunciated in the present covenant will be exercised without discrimination of any kind as to (…) national or social origin (…)”. By virtue of these treaties, the state is legally obliged to comply with and implement all necessary measures to guarantee the safety and well-being of the refugees under its jurisdiction. 

Recommendations

The NGOs signatories to this statement suggest that the United Nations and the government of Lebanon exert all possible efforts to ensure the protection, safety and the needed care for the Syrian refugees, and take the necessary measures by the government, such as: 

• Sign the 1951 Refugee Convention in order to ensure the full legal protection for refugees and asylum seekers in Lebanon; 

• Develop a comprehensive refugee policy grounded in refugee rights and clear and appropriate administrative procedures for refugees from Syria in Lebanon. Include refugees who have entered through unofficial border crossings; 

• Abolish the annual fee of $200 USD for the renewal of stay; 

• Address refugees’ exclusion from health care services and their unmet health needs; 

• Do not require a legal stay document to access local health service providers and hospitals; 

• Establish a sequence of health services, “the cancer continuum of care”; 

• International community and humanitarian actors should strengthen their information and services outreach to refugees, lobby the Lebanese government and provide support for the new comprehensive refugee policy reform; 

• International and local organizations should coordinate their actions with the government to ensure the continuum of care; 

• Explore the option of public-private initiatives to address the care continuum, support infrastructure development, capacity-building initiatives, and introduce price initiatives;