Global Cancer Care and COVID-19

July 27, 2020

Information

July 26, 2020

Yale Cancer Center

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00:00Support for Yale Cancer Answers
00:03comes from AstraZeneca, dedicated
00:05to providing innovative treatment
00:08options for people living with
00:13cancer. Learn more at astrazeneca-us.com.
00:14Welcome to Yale Cancer
00:15Answers with your host
00:16Doctor Anees Chagpar.
00:18Yale Cancer Answers features the
00:20latest information on cancer care by
00:22welcoming oncologists and specialists
00:23who are on the forefront of the
00:26battle to fight cancer. This week
00:27it's a conversation about global
00:29cancer care with Doctor Kaveh
00:31Khoshnood. Doctor Khoshnood
00:32is an associate professor
00:34of Epidemiology and microbial
00:35diseases at the Yale School of
00:38Medicine where Doctor Chagpar is
00:40a professor of surgical oncology
00:42Maybe we can start off by you
00:44telling us a little bit about yourself
00:46and your background and how you got
00:49interested in global health.
00:51I am, as you mentioned,
00:54a professor at the Yale
00:57School of public health.
00:59I came to United States as an
01:02immigrant and got interested in public
01:05health and pursued a Masters degree
01:08and a PhD degree at Yale and ended up
01:11staying here and joined the faculty and
01:16I always had this interest in what
01:19used to be called International Health,
01:21and now we are referring to it at
01:24global health and particularly health
01:26issues in low middle income countries
01:28where they have limited resources.
01:30So that's been a long interest of mine and
01:35that's where I got started.
01:37When we think about
01:40international health or global health,
01:42I think that there's a few things there.
01:45One is that
01:47oftentimes it's difficult to see
01:48beyond the kind of health issues
01:51that we have in our own borders.
01:53So what was it about global health that
01:55really sparked your interest rather than
01:58kind of thinking about public health
02:00issues that are right here at home,
02:02was it your background?
02:03And coming here as an immigrant?
02:06Was it something else that
02:08kind of turned you on to
02:10thinking about all of these
02:12health issues that might be unique
02:15or might actually be more
02:17ubiquitous that we can study in
02:19a global context?
02:20Yeah, I would say my interest in
02:23global health is very much personal.
02:26Having been born in Iran, I
02:30left the country in my teenage years
02:32right after the Iranian revolution
02:35and the Iraq war and seeing some
02:38of that devastation caused by that.
02:40I think some of those experiences
02:43and memories stayed with me and
02:45I could try to forget about them,
02:48but I came here, so I think it is
02:51very personal for me, frankly.
02:56I think that that's
02:59so important because you
03:00know we see conflict on the news all
03:03the time and oftentimes we think about
03:07this as having political ramifications
03:10or perhaps even social ramifications.
03:12But rarely think about the real human
03:15health consequences of these conflicts.
03:18So can you talk a little bit
03:21more about that?
03:29I'm sitting at Yale
03:31School of Public Health and here we are
03:34obsessed with issues of prevention.
03:36That's all we think about.
03:38How do we prevent bad things from
03:41happening in the first place?
03:42But when it comes to issues of conflict
03:46and their negative health consequences
03:49there was not a single course that I could take.
03:52There wasn't any research projects
03:54that I could get involved with and
03:57so I was asking myself as an epidemiologist,
04:00as a public health person,
04:02what do I bring to the table?
04:06What is it that I can do about these
04:10devastating consequences of conflict?
04:13And so that got me started
04:16and I had an opportunity a few
04:19years ago when I had a sabbatical,
04:22and I really wanted to sort of dig
04:24deep into what's the role of a public
04:28health professional in prevention
04:30of conflict in the first place.
04:32Who are mitigating its negative consequences.
04:34And I was fortunate to be able to get
04:37connected to colleagues at the American
04:40University of Beirut in Lebanon,
04:42where Lebanon has gone through its own
04:45long civil war and it's next to Syria,
04:50where over a million Syrians have
04:53been displaced into Lebanon, and so
04:56the school of Public Health
05:00at the American University Beirut,
05:01they can't afford not
05:03to be thinking about issues of
05:06conflict and displacement,
05:07so I felt like that was the
05:09right place for me to go,
05:11and I had the good fortune of being able
05:14to connect with a number of faculty there,
05:18including faculty who came from
05:19Iraq themselves or came from Syria,
05:21and now they were in Lebanon
05:24at the American University,
05:25and I learned a lot from them.
05:28Tell us more about that experience
05:29and what you learned in terms of
05:32the health consequences because
05:34I don't think that people
05:37fully appreciate the public health
05:40consequences of conflict that go
05:42beyond the fact that
05:45yes, people die in wars,
05:47but people may not really
05:50understand the health impact of
05:52being a displaced population.
05:54Being in a refugee camp,
05:56and all of the factors that go
06:00into that which have real Health
06:03and Human consequences.
06:05Tell us more about your experiences
06:08in Beirut and what you learned.
06:10I completely agree with you.
06:13I think when we think of a conflict,
06:16we think about people who died directly
06:19as a result of war and conflict.
06:22But unfortunately the indirect
06:25consequences are far greater and could
06:28last long after the conflicts end.
06:31And so that was one of the
06:34first things I learned.
06:36The other thing is, I'm
06:38an infectious disease Epidemiologist.
06:40So I had a focus on HIV,
06:44aids, tuberculosis,
06:45both when it comes to health issues of
06:48refugees and other displaced populations.
06:50There's a variety of health issues they're
06:53dealing with, it is not just infectious disease.
06:56In fact a lot of it is chronic conditions,
07:00some of them already had
07:02these chronic conditions
07:03before they were displaced,
07:05and then some of them developed this while
07:08they came to this new country,
07:12and I realized that even though non
07:15communicable diseases and chronic
07:16conditions were not my expertise,
07:19I needed to learn more about them and
07:21ended up getting involved in issues
07:24such as cancer prevention treatment,
07:27which frankly I had no background in.
07:30I was very much focused on
07:33infectious diseases, including HIV/aids
07:38and the consequences,
07:39including mental health issues,
07:41which is another huge issue that
07:44I've come to appreciate,
07:46which again can last
07:47sometimes decades after conflict
07:52and if we care about the health of
07:55refugees and other displaced populations,
07:58we can't just focus on Infectious Diseases.
08:02We need to have a kind of a broad interest.
08:07I think that
08:08we're beginning to see
08:11that more and more, even when we
08:13think about non displaced people.
08:15But when we think about global
08:17health as a whole so often in the
08:20past when we were thinking about
08:22load middle income countries,
08:24a lot of the focus if we think
08:27about the goals and
08:30now the work of major foundations,
08:34it's really been on malaria, TB, HIV,
08:37kind of the Big Three and I have to
08:40say that you and others who have been
08:43so deeply involved in infectious
08:46disease and global health have
08:49really made an impact in those areas.
08:53But we're beginning to find
08:55now that the non communicable
08:57diseases and cancer in particular,
09:00are really claiming a lot more
09:03than those big three.
09:06I think it's absolutely true and
09:09the data and statistics prove that.
09:11The other thing about conflicts, I realize,
09:14is that they're often protracted.
09:16They can last a long time.
09:18When people are displaced,
09:20they're not just displaced for a few
09:22days or a few weeks or a few months,
09:26their often displaced for years,
09:28sometimes decades,
09:28which means the kinds of health issues they're
09:31dealing with are noncommunicable diseases.
09:33They have hypertension they can have diabetes,
09:37and they can have cancer, so these are
09:40the health issues of concern to them.
09:43And frankly,
09:44the humanitarian organizations are
09:45often ill prepared to deal with these
09:48sort of long-term chronic conditions.
09:51They are very much focused on sort
09:54of coming in and intervening on
09:57short term health issues and leaving.
10:00Whereas the kinds of chronic conditions
10:03that these individuals are dealing with
10:06require sustainable health services,
10:08and that's one of the major challenges
10:12that these humanitarian organizations
10:14kind of develop a parallel system to
10:18the health system of the host country.
10:22So, for example,
10:24in Lebanon you have local and international
10:27humanitarian organizations that offer
10:30all kinds of Health Services.
10:32But often that's in parallel
10:34to the Lebanese health system,
10:35so the two are not well integrated,
10:38which makes it quite complicated
10:40for people with chronic conditions.
10:41Tell us more about that because
10:43I think that
10:44you make a really good point about
10:46the fact that when we look
10:49at the conflicts that have gone
10:51on in the Middle East and that are
10:53continuing to go on in the Middle East,
10:56it seems like this has
10:59gone on for decades and
11:03almost half a century if not more so
11:07when we think about people who have
11:10pre existing conditions or are at risk
11:13for conditions that are non communicable,
11:17like cancer, and they're in a refugee camp,
11:20they've been displaced from their home,
11:23tell us more about how
11:26they access health care.
11:28I mean, can they
11:29go and seek care at at a Lebanese hospital?
11:36What humanitarian and NGOs can
11:39offer in terms of Health Services?
11:42I mean how do they get those health services?
11:48There are major barriers for refugees
11:51and other displaced populations
11:54to access cancer prevention
11:56and treatment and screening.
11:58As I mentioned,
12:00these organizations often don't
12:02have cancer prevention and treatment
12:04as one of their top priorities.
12:07They considered that beyond the
12:10scope of their work.
12:12So it's often neglected.
12:14The way I learned about this
12:17was I just went to one of these clinics
12:21that was being done by a humanitarian
12:24organization and
12:27happened to meet this wonderful breast
12:30cancer physician from Syria who had
12:33been displaced himself into Lebanon.
12:35And because of his interest and passion,
12:38he really wanted to do whatever he could
12:42through breast cancer screening
12:45and Prevention and treatment,
12:47and he managed to do some
12:52fundraising and began to do
12:55breast cancer screening
12:58and I heard his story and what he was
13:01doing and I was so moved by his passion
13:05and by the way I want to just emphasize that
13:10in these kinds of humanitarian settings,
13:12often there are these unbelievable heroes
13:15who step up and do the kind of work that
13:19you just have never seen before.
13:22I mean this man himself is
13:24a displaced individual.
13:25He's not legally allowed to work.
13:28He could work under the table
13:30of a Lebanese physician,
13:32who is willing to sign off on patients,
13:36but he was actually seeing
13:38quite a few patients,
13:39both Syrians and Lebanese.
13:41So I learned a lot from him and I
13:45asked how we could potentially
13:48support what he was doing.
13:51I connected with my colleagues
13:52at the American University in Beirut
13:54I connected him
13:55with colleagues such as yourself and
13:59others at Yale just to see what we can do.
14:02This was only one NGO of the many,
14:06many in Lebanon that decided to
14:09have a focus on breast cancer.
14:12And frankly,
14:13it was entirely because of this one man
14:16who saw how this was being neglected,
14:20ignored, and he had been screening
14:23at the time I met him, hundreds
14:26and hundreds of women and unfortunately
14:29he had been identifying quite a few
14:33Syrian women with breast cancer and
14:35many of them were advanced stages
14:38because they had been ignored.
14:40They had not had access to screening, and
14:45that's how I got interested in that,
14:49and I ended up working with former
14:51Yale students to just begin
14:54to understand what's the level of
14:56cancer awareness and knowledge,
14:58and also barriers to seeking medical
15:00treatment among Syrian refugees,
15:01but also among some of the low
15:04income Lebanese citizens in Lebanon.
15:06That's such important work and
15:08we're going to pick up on all of
15:11that work right after we take a
15:14short break for a medical minute.
15:17Please stay tuned to learn
15:19more about global cancer care
15:21with my guest doctor Kaveh Khoshnood.
15:24Support for Yale Cancer Answers
15:26comes from AstraZeneca, working
15:28side by side with leading
15:30scientists to better understand how
15:32complex data can be converted into
15:37innovative treatments. More information at astrazeneca-us.com.
15:38This is a medical minute about
15:41breast cancer, the most common
15:43cancer in women. In Connecticut
15:45alone approximately 3000 women
15:46will be diagnosed with breast
15:48cancer this year, but thanks to
15:51earlier detection, noninvasive
15:52treatments, and novel therapies,
15:54there are more options for patients
15:56to fight breast cancer than ever
15:59before. Women should schedule a
16:01baseline mammogram beginning at age
16:0340 or earlier if they have risk
16:06factors associated with breast
16:07cancer. Digital breast tomosynthesis
16:09or 3D mammography is
16:11transforming breast screening by
16:13significantly reducing unnecessary
16:14procedures while picking up more
16:17cancers and eliminating some of the
16:20fear and anxiety that many women
16:22experience. More information is
16:24available at yalecancercenter.org.
16:25You're listening to Connecticut
16:28public radio.
16:29Welcome back to Yale Cancer Answers.
16:31This is doctor Anees Chagpar
16:33and I'm joined tonight by
16:36my guest doctor Kaveh Khoshnood.
16:38We are talking about global cancer care.
16:41But more than just global cancer care really,
16:44the issue of displaced populations
16:46in low middle income countries and
16:48right before the break you were
16:51telling us a little bit about your
16:54experience with Syrian refugees in
16:56Lebanon and how this one individual
16:58that's a health care provider who
17:00was a displaced person himself a refugee,
17:04but had a background in medicine,
17:07started a clinic to really help
17:10people with breast cancer.
17:12Because these conflicts are long
17:15and drawn out, and whether
17:19you are a refugee or not,
17:22you're at risk of cancer.
17:25But the problem for displaced populations
17:28is really accessing quality health care.
17:32Tell us more about the lessons that
17:34you learned in terms of barriers for
17:37refugees to get the care that they needed.
17:41The refugee situation in
17:45every country is different.
17:47In Lebano there are no formal camps.
17:51There are these so-called
17:54informal tent settlements.
17:55So they are very poor,
18:00poor hygiene, poor sanitation,
18:02high density places all over the country and
18:08so it's not easy for them
18:11to get to a clinic.
18:13There are these remote areas often.
18:18One that I recall was a
18:20story told to me by the Syrian
18:24physician about this one woman who
18:26was diagnosed with breast cancer,
18:29early stage and she managed to
18:32go to see the United
18:36Nations refugee agency and they have
18:39exceptional care and she
18:41approached them and basically asked
18:44for support so she could get
18:48screening and treatment for
18:50her breast cancer,
18:52and unfortunately,
18:52what this committee does is
18:55they kind of look at each
18:57case by a case by case basis
19:00and they only provide financial
19:02support for late staged disease.
19:04So they told her that your
19:07cancer is an early stage,
19:09so unfortunately you don't
19:11qualify for treatment.
19:12Just keep
19:13your cancer until it becomes late
19:16stage and then we will help you.
19:18Right now it is curable, we won't.
19:21Unfortunately, it's exactly what they
19:23said. They said if things get bad in six to
19:27nine months and that was devastating to
19:30me and that is completely against every
19:33principle and public health
19:35that I've learned about. You would never
19:38say that somebody who managed to get
19:40to you and they are in early stages
19:42they are treatable,
19:45and you want to intervene immediately
19:46and unfortunately
19:47this woman literally came back six
19:49months later, advanced stage.
19:51I don't know
19:53the full story,
19:55but that story kind of stuck with me
19:58and I realized the systems in place
20:00are frankly
20:03problematic to say the least.
20:06These exceptional care committees,
20:08as I said, are only for late stage
20:13cancer care and they have very limited funds.
20:17They look at every case and they
20:20make this very,
20:22very tough decision about do they
20:25qualify for treatment or not?
20:28And they've published a couple of papers
20:32and often they prove about 50% of the
20:36applications for exceptional care.
20:38So that's a huge public health disaster.
20:41This lack of prevention programs,
20:44screening, etc.
20:45so that got me started
20:49and as I mentioned before,
20:51I ended up working with this one
20:54student with a very small budget,
20:57just a fellowship from Yale University
21:00to go and do the first study
21:04to look at knowledge,
21:06awareness and barriers to accessing
21:08cancer care among Syrian refugees
21:11and Lebanese citizens.
21:13And no study like that had been done before.
21:17And this one student worked with some of
21:21my colleagues at the American University in
21:24Beirut and some of the students there
21:27and managed to interview over 400
21:31Syrian refugees and over 300 Lebanese
21:34citizens who were coming for Primary
21:37Health care programs in centers and
21:40did this cancer awareness measure,
21:43which was a tool that has
21:46been used in Jordan
21:48in the past,
21:49looking at cancer awareness and the results,
21:54not surprisingly,
21:54where that both the Syrians
21:57and particularly the Syrians
21:59compared to Lebanese Nationals,
22:02had very low awareness of cancer symptoms,
22:05cancer risk factors and also
22:08they reported a whole host of
22:11barriers to getting treatment.
22:13And the most important was not having
22:16any sort of medical insurance.
22:19Lebanese health system is primarily
22:23private so government doesn't
22:26really have a whole lot of
22:29government run hospitals that
22:31provide cancer treatment and care.
22:33So if you're a displaced person
22:35with cancer in Lebanon,
22:37there is a whole host of
22:41barriers for you to get
22:42the treatment that you need.
22:45I wonder Kaveh,
22:48just listening to to the stories,
22:50you wonder whether the
22:53issue is primarily education,
22:55because even this lady
22:57who had enough education to
23:00find her cancer early,
23:03couldn't get it treated and
23:06thinking about the gentleman who
23:08started a screening clinic, that's great,
23:11but he'd be able to find these cancers early.
23:14But then when people applied for
23:17help to treat their early cancer,
23:19it would be to no avail.
23:22So, how do you intervene?
23:24What is the optimal strategy here?
23:27I mean, in most global health work,
23:30we always talk about education, right?
23:32Because it's
23:33cost effective,
23:35providing people education so
23:36that they know the symptoms.
23:38They can find things earlier and
23:40get them treated.
23:44But it seems to me that
23:46in refugee populations,
23:48even if you find things early,
23:50they tell you to come back when it's late.
23:54You're absolutely right.
23:55I think the kinds of barriers
23:58we are discussing with this
24:00populations are more structural,
24:02more system based institution level
24:05beyond the scope of what individuals can do.
24:08And frankly, these individuals
24:11don't have a lot of income.
24:14They usually have a couple $100 that
24:17they get from UN agencies per month.
24:20They have food insecurity issues.
24:23Or hygiene pollution.
24:24Smoking rates actually are quite high
24:26in the population, mostly in men,
24:29so there are few things they
24:31may be able to do on their own.
24:34But honestly,
24:35most of the changes that are needed are
24:38system level changes first and foremost,
24:41and that's why we ended up writing
24:43a short commentary just
24:45to bring attention to the issue
24:48of cancer care and treatment among
24:51displaced populations and refugees.
24:53Because it doesn't seem to appear
24:56on the priority list of a lot of
24:59the funders for humanitarian work.
25:03When they think of refugees cancer care
25:06doesn't immediately
25:08appear on the list
25:09so I feel like we
25:13need some high level
25:16interest in this topic.
25:22Tell us some of the interventions
25:25that you've been undertaking,
25:26cause it seems like for me,
25:28anytime it's
25:30a high level thing,
25:32it's a matter of changing bureaucracies
25:34or trying to change organizations and
25:37that's really difficult work?
25:39So ideally you would be able to go
25:41to the UN health agencies and say,
25:44you know you really ought to put
25:47early cancer care, all cancer care
25:49into your budget, to which
25:51they would likely say, well,
25:53we only have so much money and so therefore
25:55we're going to treat late stages,
25:58but I could go into a whole diatribe about
26:00how that's not really getting optimal
26:02bang for your Buck, but we won't go there.
26:06But how do you
26:07change these higher level,
26:10system institutional processes?
26:13Tell us a little bit about
26:16what your thoughts are there
26:18and maybe some of the work that
26:21you've been trying to do.
26:23This summer I'm working with another
26:25public health student who happens to
26:28be Lebanese American and what he's
26:30doing is mapping
26:33key stake holders and experts
26:35instead of cancer care in Lebanon to
26:38really try to get their perspective
26:40on what is it that can be done
26:43that has never been done before.
26:46Nobody has actually tried to get
26:48a mapping exercise of who are all
26:52the stakeholders.
26:53Frankly, this is a relatively new topic.
26:56It's just not being discussed,
26:58so you need to start there.
27:01But I've also been
27:03doing my best to push for prevention.
27:07Whether it's vaccination,
27:10HPV before cervical cancer,
27:12whether it's smoking cessation programs,
27:14there are cancer prevention
27:16strategies that can be adapted
27:19for use among refugees,
27:21and I just haven't seen any
27:24organizations doing that and that is
27:26sort of the direction I'm thinking
27:29of going, what is it that I can
27:32do as a public health person?
27:34I'm thinking more on the prevention side.
27:38I think certainly in terms
27:41of smoking cessation that would be huge,
27:44particularly given the high rates of
27:46smoking in these displaced populations
27:48with regards to vaccination,
27:50I agree with you, I think that it's a
27:52wonderful preventative technique, not
27:55only for cervical cancer but now for head,
27:58neck and all kinds of anal cancers.
28:01A whole variety of cancers.
28:03But my question is, let's suppose
28:06you're born in a refugee camp.
28:09Or you're brought there when you're very
28:12young, by the time you're 9 years old,
28:16you're still in the refugee camp
28:18and it's time for your vaccinations.
28:20For HPV, would these institutions
28:23offer vaccinations for HPV?
28:25Or is that not on their radar screen?
28:29And if not, how do you
28:31change that conversation?
28:35That's a very important
28:37topic as well, and in fact,
28:40that's another project that
28:41I worked on last summer with
28:44another public health student who
28:46happens to be Syrian American.
28:48And what she did was work with one of
28:51the large humanitarian organizations
28:52that has a lot of primary care centers,
28:56and offer vaccination,
28:57and basically try to understand
29:02what the Syrian women's
29:04understanding of vaccination coverage
29:06is and whether their children were getting
29:09vaccinated with barriers they face.
29:11And again, this was the
29:13first study of its kind.
29:16Nobody had actually interviewed
29:19Syrian women to understand
29:21what is going on with the
29:23vaccination of their children?
29:25And we are in the process
29:27of analyzing this data,
29:29but there seems to be also quite a bit
29:31of barriers that they're facing and
29:34getting their children vaccinated.
29:36I don't remember if there was a
29:38particular question about HPV but I think
29:45that the vaccination
29:46is another huge issue.
29:48Many of the children, as you mention, if you
29:51are born in another country,
29:53some of them are stateless.
29:56They don't have any legal
29:58documentation from Syria or
30:00Lebanon,
30:01so some of these children are not
30:04on anybody's registry so that they
30:06kind of fall through the cracks.
30:08So vaccination coverage is
30:11another huge topic
30:13of public health
30:15priority among displaced populations.
30:18Doctor Kaveh Khnoswood is an Associate
30:20professor of Epidemiology and microbial
30:22diseases at the Yale School of Medicine.
30:25If you have questions,
30:26the address is canceranswers@yale.edu
30:28and past editions of the program
30:30are available in audio and written
30:32form at Yalecancercenter.org.
30:33We hope you'll join us next week to
30:36learn more about the fight against
30:39cancer here on Connecticut public radio.