Refugees in Conflict: Creating a Bridge Between Traditional and Conventional Health Belief Models

Considering the increased migration from Middle‐Eastern countries to Europe, this article reports on the related challenges to European health care professionals, including the communication gap created by differences in health care beliefs. The conclusions of the MERGIO research workshop are presented.

Abstract

The recent wave of migration from Middle Eastern countries to Europe presents significant challenges to the European health profession. These include the inevitable communication gap created by differences in health care beliefs between European oncologists, health care practitioners, and refugee patients. This article presents the conclusions of a workshop attended by a group of clinicians and researchers affiliated with the Middle East Cancer Consortium, as well as four European‐based health‐related organizations. Workshop participants included leading clinicians and medical educators from the field of integrative medicine and supportive cancer care from Italy, Germany, Turkey, Israel, Palestine, Iran, Lebanon, Jordan, Egypt, and Sudan. The workshop illustrated the need for creating a dialogue between European health care professionals and the refugee population in order to overcome the communication barriers to create healing process. The affinity for complementary and traditional medicine (CTM) among many refugee populations was also addressed, directing participants to the mediating role that integrative medicine serves between CTM and conventional medicine health belief models. This is especially relevant to the use of herbal medicine among oncology patients, for whom an open and nonjudgmental (yet evidence‐based) dialogue is of utmost importance. The workshop concluded with a recommendation for the creation of a comprehensive health care model, to include bio‐psycho‐social and cultural‐spiritual elements, addressing both acute and chronic medical conditions. These models need to be codesigned by European and Middle Eastern clinicians and researchers, internalizing a culturally sensitive approach and ethical commitment to the refugee population, as well as indigenous groups originating from Middle Eastern and north African countries.

Implications for Practice.

European oncologists face a communication gap with refugee patients who have recently immigrated from Middle Eastern and northern African countries, with their different health belief models and affinity for traditional and herbal medicine. A culturally sensitive approach to care will foster doctor‐refugee communication, through the integration of evidence‐based medicine within a nonjudgmental, bio‐psycho‐social‐cultural‐spiritual agenda, addressing patients' expectation within a supportive and palliative care context. Integrative physicians, who are conventional doctors trained in traditional/complementary medicine, can mediate between conventional and traditional/herbal paradigms of care, facilitating doctor‐patient communication through education and by providing clinical consultations within conventional oncology centers.

Refugees' Journeys Across Health Belief Models of Care

The recent wave of migration from Middle Eastern countries to Europe has presented a number of challenges to oncologists and European health professionals. These include the inevitable communication gap, which is created by differences in health care beliefs between European health care practitioners (HCPs) and their refugee patients. The urgency of addressing these challenges cannot be emphasized enough, especially in light of the large numbers of refugees from countries such as Syria and Iraq, and with the world watching images of their desperate attempts to reach the shores of countries such as Greece and Italy, among others [1]. Concepts such as compassion, survival, and conscience have been re‐emerging in the conversations of more and more HCPs who are devoted to saving and rehabilitating refugees, many of whom have undergone traumatic experiences and lost their sense of security in the psycho‐social‐cultural‐spiritual context of medical care.

Although the rescue efforts on the shores of Europe have been characterized by a paternalistic doctor‐patient interaction, the doctor‐refugee dialogue in mainland Europe requires a shift in the communication paradigm to one of a shared decision‐making process that addresses the culture gap between the HCPs’ and the refugees’ health belief models. The cultural gap that exists between the Eastern collectivistic approach with that of the Western individualistic one has been described by Dwairy et al. and tends to be under‐recognized in the Western conventional medical setting [2]. An example of this communication gap is the high prevalence of complementary and traditional medicine (CTM) use among patients of Middle Eastern origin [3]. This population has a high affinity for herbal medicine use within the context of traditional Muslim and Arab medicine. This is especially true for cancer care, in which CTM is often used in conjunction with conventional chemotherapy [4]. Indeed, in Middle Eastern and northern African countries, herbal medicinal products are reportedly being used by over half of patients undergoing chemotherapy [5].

The Middle Eastern Research Group in Integrative Oncology (MERGIO), a group that works under the auspices of the Middle East Cancer Consortium, has been examining ways in which the fostering of a culturally sensitive approach can bridge the HCP‐patient communication gap [6]. This is an important objective, especially in light of the potential risks associated with the unmonitored use of CTM therapies such as herbal medicine, while providing significant relief to patients for quality‐of‐life‐related outcomes [7]. The research being conducted by MERGIO has led to a recommendation for the establishment of an integrative model of supportive cancer care within the conventional oncology setting [8]. The model is currently being implemented in a number of clinical settings, under the direction of integrative physicians who are dually trained in supportive care and CTM and whose services are providing patients with culturally sensitive, patient‐centered, nonjudgmental, and evidence‐based guidance [9].

Meeting the “Other”

The activities of MERGIO have also led to a number of collaborative initiatives in the Middle Eastern arena, led by leading figures from the fields of palliative, oncology, and integrative care in Europe. In May 2017, a MERGIO research workshop took place as part of the World Congress on Integrative Medicine and Health in Berlin. The workshop was titled “Refugees with Chronic Diseases between the Middle East and Europe: The Role of Traditional and Integrative Medicine in Bridging Gaps.” The success of the workshop was enhanced by the participation of 14 clinicians, researchers, and medical educators from Italy, Germany, Turkey, Israel, Palestine, Iran, Lebanon, Jordan, Egypt, and Sudan. The participants’ commitment to advancing the healing process among their patients was the prime factor that motivated them to overcome the conflicts and diverse settings of medical care in their countries. However, organizing such a meeting of this unique group of scholars presented a number of challenges to the workshop organizers. These included the numerous international conflicts taking place in the Middle East and increasingly strict European security‐related constrictions. As a result, three of the Middle Eastern lecturers were unsure of their ability to procure visas that would enable them to attend the workshop, and one scholar from Iraq was indeed prevented from attending as a result.

The MERGIO‐led workshop identified a willingness on the part of the participants to share the responsibility for the refugee “problem.” The presenters each described their own unique perspective in addressing the suffering experienced by their patients. The challenges they faced in their daily work were found to apply to countries such as Lebanon, which is struggling with a 30% increase in its population, as well as numerous Palestinian refugees [10]; in Jordan, where a third of its population now includes refugees from Syria and Iraq [11]; in Turkey, where there are more than two million refugees and where free medical care is provided to all refugees and to refugee children with cancer [12]; in Iran, where HCPs are providing care to 8.5% of the entire registered refugee population worldwide, primarily from Afghanistan [13]; and in Sudan and Egypt, where oncologists and palliative care practitioners face many challenges treating their own refugee populations [14], [15].

The workshop participants also shared an understanding that the refugees’ health‐related challenges are not merely a European “problem” that needs to be addressed by European clinicians and health care policy legislators. The approach taken was one of a shared responsibility and decision‐making process, acknowledging that clinicians from both Europe and the Middle East should be involved in codesigning interventions for the refugee population. The European HCPs were thus able to benefit from the knowledge and experience of their Middle Eastern colleagues, who could help them identify significant psychological‐social‐cultural‐religious‐spiritual gaps, enhancing doctor‐patient communication in a culturally sensitive approach.

The interaction between Middle Eastern HCPs and their European counterparts can have a significant impact in specific locations as well, such as the shores of the Greek and Italian islands of Lesbos and Lampedusa. It is at these places that conventional medical care needs to be integrated within a culturally adjusted approach to the treatment of refugee patients, many of whom faced the challenges of long journeys, unwanted pregnancies, and gender‐based violence, among others. The need for this type of interchange becomes even more important later on, when refugees begin their settlement and acclimatization in the new host country. This process can be accompanied by chronic illness, such as pain and other somatic symptoms, as well as a rapid rise in cardiovascular and cancer morbidity as a result of the often intensified acculturation processes [16].

Role of Integrative Medicine in Mediating Between Models of Health Care

The MERGIO workshop meeting also emphasized the need to promote comprehensive care in the refugees’ communities, with elements that correspond with their health belief care models, specifically relating to CTM. Middle Eastern patients often express seemingly conflicting expectations from Western health care. They may seek a conventional medical approach, while at the same time turning to CTM practices, particularly the use of Arab and Islamic‐based herbal remedies. Once in Europe, many refugees may feel disappointed by what their European HCPs consider to be medical care. They often have difficulty understanding the relevance of what they may perceive as “nonmedical” practices, such as the emphasis placed on lifestyle changes, stress management, “watchful waiting,” or even discussing treatment options in a shared decision‐making process [17]. Their disappointment in conventional care can be exacerbated by the doctor‐patient communication gap and other sociocultural elements and may lead to reluctance to disclose the use of CTM practices such as herbal medicine.

The challenges that were identified during the workshop demonstrate the need for including European integrative physicians in the conventional cancer care setting. These physicians, who are medical doctors with extensive experience and training in complementary medicine, should be playing a central role in mediating between conventional European oncologists and HCPs and Middle Eastern refugee populations. Many CTM modalities (e.g., herbal medicine, manual and mind‐body‐spiritual approaches) may even provide a venue for promoting a cultural interface between the conventional HCPs and refugees. The goals of this mediation should not be to downplay the place of evidence‐based medicine in patient care but rather to enrich the culturally sensitive spectrum that can then, in turn, enhance communication and rapport between the two. In recognition of this need, the World Health Organization has included the integration of traditional medicine in national health care systems as a core issue for its traditional medicine strategy (2014–2023) [18].

This initiative should not, however, be limited to Africa or other isolated areas around the globe. It should also include the promotion of collaborative efforts among integrative physicians and HCPs from Middle Eastern and European nations, including locations such as Berlin, London, and Rome. Supportive and palliative cancer care is an ideal setting in which the integration of a culturally sensitive approach, whose goal is to improve patients’ quality of life during active oncology treatment and survivorship, can be of great benefit. Practically, the workshop participants discussed educational initiatives in integrative and CTM palliative care, which would be targeted at a multidisciplinary team of HCPs, primarily physicians and nurses, from European and Middle Eastern oncology centers. The goals of the training programs would first be to educate Middle Eastern HCPs on the safe, effective, economically sustainable, and evidence‐based use of CTM therapies for reducing chemotherapy‐related toxicities [19], improving adherence to chemotherapy protocol by enhancing patients’ quality of life [20], and reducing the risk of herb‐drug interactions after integrative physician consultation to be provided within the conventional oncology setting [21]. A second objective of the training program would be to teach European HCPs about traditional medical practices prevalent in the Middle East and North Africa. This would enable them to adopt a culturally sensitive approach in the treatment of their refugee patients, enhancing their ability to communicate with these and other Middle Eastern and Muslim populations in their home countries.

Conclusion

There is a need to advance regional and international collaborative initiatives, designing educational and training programs for oncologists, nurse oncologists, psycho‐oncologists, and other HCPs from both European and Middle Eastern countries, with a focus on palliative and supportive cancer care. Such programs would expose HCPs from the two regions to patients’ health belief models; address their expectations from doctor‐patient communication; and provide safe, effective, and economically sustainable care, including evidence‐based CTM modalities that are popular in the Middle East and northern Africa. This process will require training in communication and clinical skills, which need to be focused on in the palliative care setting under the guidance and direction of integrative physicians. This process will, in turn, enable oncology HCPs to adopt a culturally sensitive approach in treating their patients, enhancing their ability to communicate with the refugee and other Muslim populations in their home countries.

Author Contributions

Conception/design: Eran Ben‐Arye, Massimo Bonucci, Michel Daher, Rejin Kebudi, Bashar Saad, Thomas Breitkreuz, Maryam Rassouli, Elio Rossi, Nahla Gafer, Omar Nimri, Mohamed Hablas, Gunver Sophia Kienle, Noah Samuels, Michael Silbermann

Manuscript writing: Eran Ben‐Arye, Massimo Bonucci, Michel Daher, Rejin Kebudi, Bashar Saad, Thomas Breitkreuz, Maryam Rassouli, Elio Rossi, Nahla Gafer, Omar Nimri, Mohamed Hablas, Gunver Sophia Kienle, Noah Samuels, Michael Silbermann

Final approval of manuscript: Eran Ben‐Arye, Massimo Bonucci, Michel Daher, Rejin Kebudi, Bashar Saad, Thomas Breitkreuz, Maryam Rassouli, Elio Rossi, Nahla Gafer, Omar Nimri, Mohamed Hablas, Gunver Sophia Kienle, Noah Samuels, Michael Silbermann

Disclosures

The authors indicated no financial relationships.