Palliative Care is a Useful Means to Overcome Intercultural Barriers Faced by Refugees in their New Host Countries

The unprecedented wave of refugee migration from Africa and the Middle East to Europe presents major challenges to European health professionals and to society at large. A recent workshop which took place in Syracuse, Sicily, brought together physicians, nurses and psychologists and managers of governmental agencies from Italy, Lebanon, Israel, Iraq, Iran, Sudan, Tunisia, Jordan, and the European Society of Medical Oncology, aimed to create a training program to formulate a dialogue between professionals in their regions and refugees in Italy. A major barrier refugees face is a lack of communication (verbal and cultural) which hinders their smooth absorption into society. Cultural mediators who speak Arabic and Italian and understand the refugees’ faith, tradition and beliefs, are paramount to successfully building bridges between such diversities. Predictably, most asylum seekers undergo anxiety, fear, and depression after arriving in Europe. Following intensive deliberations, all workshop participants agreed that applying palliative care methodologies, as practiced in cancer patients, would be therapeutically advantageous in overcoming the psychological suffering that refugees experience during their initial stay in Europe. Accordingly, all agreed to start with training courses, both in refugees’ countries of origin and in Europe, for representatives or mediators (preferably with some clinical background and experience); whereby tremendous efforts would be made to create a working palliative care model that includes bio-psycho-social elements. This model or paradigm will employ a culturally sensitive approach that takes refugees’ spiritual needs into consideration, relying on core ethical principles.


Commentary
Efforts to absorb refugees from African and Middle Eastern countries with different traditions and cultural backgrounds often cause increased ethnic and religious tensions, which frequently lead to the emergence of social violence. The realization of collective suffering forces communities and government health agencies to develop new programs that include social determinants to overcome the severe cultural gaps of the newcomers in their host countries [1]. Recognizing the refugees' culture serves as an important integration factor, as participation in cultural life creates a sense of belonging to society while assisting recovery from trauma and alienation [2]. By innovative styles in communication and cultural products that involve the refugee community, bridges can be built between the diversity of individuals, and host communities may share the task of integration and implementation [3].
At present, most healthcare provided to refugees by volunteers and nongovernmental organizations often reflects limited experience or few formal links with the healthcare system. Further, the migrant population from Africa and the Middle East is needy in many different areas, including social and economic aspects. These individuals have very limited access to health care, because approaching health care organizations may lead to imprisonment and deportation [4]. Thus, a new perspective and better training of healthcare staff are needed.
promoting immediate essential health interventions [4]. Furthermore, to familiarize refugees with existing health facilities, cultural mediators conduct group awareness and psycho-education sessions [5]. As the mediators speak the language of the refugees they are crucial in enhancing dialogue, trust, and transcultural understanding.

A New Initiative
In October 2017, the Middle East Cancer Consortium (MECC) organized a workshop entitled Health Care for Refugees in Europe, 2017, together with the MARELUCE Onlus Association, the Promuovere Onlus and Associazione Nazionale Oltre Le Frontiere (ANOLF) in Sicily, Italy. The goals of that workshop were to: • Affirm the ethical responsibility of hosting countries for the healthcare of migrants and refugees, based on the International Declarations on Human Rights. • Develop a model of "cultural sensibility" to be applied in the psycho-oncology support program. • Evaluate the correlation between psychological stress related to emigration (absence of caregivers, distance from family, encounter with a new culture and disease-related health issues), as well as exposure to a completely new environment, language, culture, religion, and society. • Monitor emotional stress. • Establish caregiver support programs, including healthcare providers involved in care programs. • Create a multidisciplinary group of researchers and clinicians from Europe, the United States, and the Middle East with the aim of promoting the integration of supportive psychological cancer care for refugee populations. • Raise awareness of the cross-cultural communication barriers between migrants, residents, foreigners and indigenous citizens. • Promote a participatory action research approach in fostering the active role of migrants and foreign resident communities for outlining effective access to health services.
The significant outcomes of the workshop were due to the fact that clinicians, researchers and medical educators from Italy, Israel, Jordan, Iraq, Iran, Lebanon, Sudan and ESMO took an active role in the workshop deliberations. All participants expressed unanimous commitment to improving the healthcare of refugees within their respective countries, along with creating an innovative training program for representatives of the refugees in Italy, all of Europe, and the Middle East. The palliative care model of health care with its holistic approach may be the most helpful in these circumstances because of palliative goals, low cost, personal and cultural aspects.
According to its WHO (World Health Organization) definition, palliative care is an approach that improves quality of life of patients and their families facing a problem associated with life-threatening illness. Prevention and relief of suffering is attained through early identification and impeccable assessment and treatment of pain and other problems: physical, psychosocial and spiritual. A large majority of refugees reaching Europe suffer from behavioral disturbances, and accordingly palliative care approaches can be adapted for psychological therapy, with emphasis on the spiritual care of refugees. Palliative care also offers a support system to help patients live as actively as possible. By applying palliative models, as we know them from treating cancer and other non-communicable diseases, we can enhance quality of life, and may also positively influence the course of initial stress that these refugees experience.
It should be noted that palliative care techniques as listed in Table 1 are adaptable and not limited to any particular care setting. Therefore, their integration alongside any other treatment is recommended. Palliative care is also a human right-the right of everyone to enjoy the highest attainable standard of physical and mental health, and this applies to refugees too.  Unfortunately, palliative care for cancer has become associated with the end of life; psychologically, most people fear and avoid anything relating to death. In most refugee population countries of origin, informing patients of their diagnosis and prognosis in life-threatening situations is prohibited or strongly discouraged. It would, therefore, be the cultural mediator's task to explain the European approach of cancer patients sharing diagnosis, prognosis and treatment planning to the refugees and their families. Further, refugees should not be afraid of the stigma associated with the need to receive psychological assistance.
Thus, healthcare providers interested in the community should focus on use of palliative care techniques, ranging from relief of suffering to management of cultural and emotional stress, in order to restore self-dignity and provide spiritual comfort. In addition, during the workshop, participants described the current situation in their own country, while addressing the major demographic changes due to the influx of millions of refugees from neighboring countries.
Moreover, all agreed that the most efficient way to face enormous challenges among refugees in Europe would be via a shared responsibility and decision-making process by clinicians from both Europe and the Middle East. Through this collaboration, the European partners would benefit from the knowledge and experience of their Middle Eastern colleagues, which would be of significant help in trying to overcome the psychological-social-cultural-spiritual gaps. Such a Euro-Middle Eastern interaction would undoubtedly facilitate integration and absorption, with less conflictual adaptation of refugees once they arrive in a new and safe land.
We believe that people who have worked in the palliative care of cancer patients in developing countries, in organizations such as the Middle East Cancer Consortium, are best positioned to lead this effort because of their experience in extending palliative care and its techniques to minorities and poverty-stricken people, not because cancer is a common problem among refugees and immigrants [6].