healthcare reflections

I noticed an inconspicuous piece on my BBC news feed yesterday that has made me think again about equality, access to health care, economics, and how we put a value on human life.
The report was about the problem of health care amongst refugees, and the study that was discussed had looked at refugees in Jordan over a 12 month period. Jordan has taken the vast majority of refugees from Syria, significantly increasing its native population, and placing a huge financial burden on its government (over $50m in the first four months of this year).
In the past healthcare provision for refugees has been concentrated on treating malnutrition and infectious diseases, but what the study showed was an unmet need for diagnosis and treatment of cancer, particularly breast and bowel cancer. Application can be made to the UNHCR for exceptional funding to treat chronic disease; during the study period 50% applications had been accepted, and the largest amounts given for treating any single individual was slightly over $2000.
Criteria for successful applications included good prognosis and no need for very costly treatment.
The authors of the study suggested that there was a strong case for simple screening procedures in refugee communities as well as advice about prevention.
I would be interested to read the original study for more detail, but the bare reported facts are provocative.
The most striking thing of course is that this is unlikely to cause even the tiniest ripple on the surface of UK consciousness, either in political circles or in our general society. The success of UKIP (of which more in another blog) has made it clear that a substantial minority of British citizens are xenophobic, and most others have far greater concerns than the fate of Syrian refugees in Jordan.
The combination of xenophobia and government’s fear of losing votes has ensured that the health of any refugees who actually enter the UK is not a priority. Several reports about the failure to recognise or treat the mental health needs of asylum seekers suggest to me that it is very unlikely that screening for cancer is on anyone’s agenda.
The UK government assuages its conscience (and our collective conscience) by repeatedly telling us and the international community that it has given more money than other countries towards helping the Syrian refugee crisis.

However, that money is inadequate for the healthcare task described in the report. When hundreds of thousands of people are displaced their pathologies, whether manifest, developing, or nascent, do not go away. Refugees are human beings like every British citizen, and unfortunately some of them will get the same diseases as we do. The question posed by the report is, how do we respond to this?
In the situation described, funding is available from UNHCR (although presumably this is not unlimited), but as with all applications for funding a case has to be made. The basic requirements appear to be a good prognosis and affordable treatment. The highest costs of treatment on this basis seem extremely low – just over $2000 a patient.
Of course I know nothing of outcomes, or details of treatment. Nevertheless the comparisons with cancer treatment here are striking. I have no idea of the cost of treating one person with breast or bowel cancer but obviously it is many fold more than the refugee costs. In one sense it is unfair to even attempt to draw a parallel, but perhaps we should question the morality of providing increasingly expensive treatment to try and prolong life. Over the course of my professional career in medicine I saw a trend towards a ‘we’ll try one more thing’ mentality which I believe says more about doctors’ fears of failure – the only way that they can view death – than of a careful, collaborative decision on a course of action that is best for the patient. Expense should not just be measured in financial terms, but also in emotional currency.

I can hear my critics saying ‘ but they are refugees, they are lucky to be out of a war zone, they can’t expect first world medicine’. The unpalatable fact is that of course many of Assad’s opponents had every expectation of high quality medicine before the civil war. Likewise I have met asylum seekers who were doctors in their countries of origin, practicing good quality medicine. The labels ‘refugee’ or ‘asylum seeker’ are completely dehumanising, enabling us to treat people in ways in which we would dream of treating our own families and friends.

The moral, ethical and philosophical dimensions of healthcare for refugees could be debated endlessly. I have a few simple questions:
How do we decide how much to spend on the health (or protracted death) of any one individual?
Why do we implicitly decide that refugees and asylum seekers are, de facto, not entitled to basic healthcare screening and preventative treatments?
Who decides what a human life is worth?

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