The CANCERLESS Project has been funded by the European Commission’s Programme Horizon 2020, GA 965351
The death of a child under the age of five in Europe is primarily a family tragedy, the death of hundreds of thousands of children under the age of five in the world due to easily preventable diseases is a tragedy for all, and some doctors are not willing to look the other way.
This is just one of the examples that experts give when they explain what social medicine is about. It is not only the genes that make us sick, often economic problems, the difficulty of accessing prevention systems, even the lack of access to culture are responsible for many deaths.
Social medicine was born to take all this into account: the environment makes us sick, and some environments more than others. It is an old medical discipline that was inaugurated in the 19th century to investigate how social and economic conditions impact health and disease, and to find remedies so that prevention and cure became truly universal goods.
Igor Grabovac is a social doctor at the Institute for Social and Preventive Medicine of the Center for Public Health of the Medical University of Vienna. He is coordinating an international consortium to adapt and apply the “Health Navigator” model to prevent cancer among the homeless population in Europe. The project is called CANCERLESS and is funded with 2.8 million euros by the HORIZON 2020 program of the European Union.
In this interview, Igor Grabovac explains what CANCERLESS is, and why it is so important that the invisible count.
Q: The latest United Nations global study, conducted in 2005, estimated that 100 million people were homeless. Is there a more up-to-date figure? Has it increased significantly or decreased? What is your perception of the current situation?
A: It is very difficult to offer real estimates on the homeless since it is a dynamic concept. Some people are, what is called, “chronically homeless” (meaning they are homeless for long periods of time – several years) and there are those who are “acutely or intermittently” homeless. This means that each time a measurement is made, different figures for the number of homeless will be obtained.
However, taking into account the increase in housing costs, the fall in subsidized housing, the decrease in investments in the social sector, the economic crisis and austerity measures, the wave of refugees and migrants of the last years (especially in Europe), there are signs that the number of people needing accommodation is increasing year after year.
The COVID pandemic that we are experiencing has caused new social problems and an increase in unemployment, and will surely have an additional effect on the number of homeless people.
Q: Are we talking about a population that does not go to the doctor, or goes less often than the rest?
A: I have to say that homeless people go to the doctor and seek medical health quite often. The use of health services by the homeless can be quite high, according to some data. What is different is the way they use health services. Specifically, they tend to go more to the emergency services and tend to stay longer in hospital. However, they do not have general practitioners or family doctors and make very little use of community health services. And that is precisely the problem, that, for example, they do not receive a pregnancy follow-up, or a cough check to see if the syrup has worked, nor do they undergo regular checks for their depression.
Q: Does the model that you are going to apply in CANCERLESS, the Health Navigator, try to facilitate access to diagnosis, treatment, etc.? Is it about breaking down the barriers that make it difficult for them to come out of their isolation?
The health navigator model that we have devised focuses on the one hand, on increasing the empowerment of the homeless, and on the other hand on offering a tailored service that can provide exactly the support they need to “navigate” healthcare systems, which are often very confusing and fragmented.
The model will seek to increase their knowledge of various issues relating to their health, which we hope will enable them to make better and more informed decisions about aid and also provide a service that supports them in finding the right pathways within the healthcare systems.
Q: You have received funds to implement this model, the Health Navigator, for cancer prevention in homeless people in different European cities. Do you have data on the incidence of cancer among the homeless in Europe?
A: Unfortunately, there is very little data on the health status of homeless people in Europe, but also globally. So, we hope that our study will also shed some more light on the prevalence of cancer in the homeless population. Some existing data suggest that the prevalence of cancer is roughly double in the homeless population compared to the general population. This is probably due to increased exposure to chronic stress, various environmental factors, an increased risk of infectious diseases, but also poor nutrition and a higher prevalence of smoking.
Q: How many homeless people die from a type of cancer that could have been prevented?
Unfortunately, it is impossible to know, since we do not have this type of data. Very few countries have specific data on the homeless population. However, the data support the fact that homeless participation in primary and secondary prevention services is very low. This would mean that, probably, when they are diagnosed with cancer, it is at a later stage, which may be associated with a more complicated clinical course and treatment.
Q: In 1971, President Richard Nixon declared war on cancer and signed the National Cancer Act. Since then, a lot has been invested in research, prevention and treatment, and the number of deaths from cancer is declining. But can we be cancer-free if a population of 100 million people does not have access to the latest advances?
.A: Unquestionably many things have changed since 1971 and much progress has been done in understanding cancer, its development, diagnosis, treatment and, most importantly, prevention. The European Union has also drawn up a Plan to fight cancer and has also named the fight against cancer as one of its main priorities for the next period.
To move towards the goal of reducing the burden of cancer, cancer mortality, and improving the lives of people living with and beyond cancer, we need to focus on equity and ensure that everyone has the same rights and access to preventive and curative services.
The goal of CANCERLESS is that no one is left out of advances in research, treatments, etc. The homeless must also be taken care of.
Q: I suppose the issue of fairness is important in general, not just in cancer, but in all health policy issues.
A: Sure. For example, we will never be able to return to post-covid “normality” if we do not ensure that everyone has access to vaccines and is able to apply hygienic measures.
This means that we have to focus on all social structures and make sure that our politicians and policy makers understand this need for widespread access and ensure equity.
In this regard, I am pleased to quote Robert Virchow, known for his work in the field of pathology and microbiology, but also regarded as the father of social medicine, who said: “Medicine is a social science, and politics nothing but medicine at a larger scale”
Q: Robert Virchow fought for a “Universal Public Health Service” in the 19th century. How are we placed today? Are we closer or further to achieving this goal?
A: Globally, I think we are very far away. And unfortunately, there have been political changes and movements that push us further apart. We are not moving towards equity, but rather in the opposite direction. We see it for example in the United Kingdom. Its National Health Service was very strong, and is now becoming more and more privatized. We are heading towards a model more similar to what happens in the US. In many countries, such as Austria, where we have universal access to healthcare and it is quite good and robust, more and more people tend to take out private insurance for certain things because they are afraid or because they want to have a better level of attention.
Unfortunately, I think privatization is definitely a trend.
In Austria it is quite common for pregnant women to take additional insurance to be able to give birth in private clinics, something that not everyone can afford. So even if everyone has access, the question is whether the quality of services is better in the private sector compared with the public one. I believe that we must actively work to avoid this. The things that everyone has access to and that we pay for with our taxes must be of the highest possible quality.
Q: How many people will CANCERLESS reach, in which cities and for how long?
A: The project has an expected duration of 3 years. The implementation of the Health Navigator model will take about 18 months and the rest of the time will be used to prepare the intervention and later on, to evaluate it.
We hope to include some 1,500 homeless people in the Madrid, London, Athens and Vienna. We will also involve stakeholders, policy makers, but above all professional groups who work with homeless people on the front line on a daily basis. It is very important to make their voices heard and to analyze what they perceive as the main barriers to doing their work more effectively.
Q: One of the cities chosen is Madrid, in Spain. Are the people who benefit from the project excluded from universal healthcare in Spain?
A: CANCERLESS will include homeless people who have access to health services, but also those who do not have health insurance and may not have access. This is also very important to analyze, especially in Spain, given the high number of immigrants and refugees that make up the homeless population but are not covered by universal health coverage. This issue is not only important for Spain, but also for the rest of the participating countries.
Q: What does CANCERLESS offer in practice? For example, a pioneering navigation project, developed at the Harlem Hospital Center in New York, offered homeless women mammograms to prevent breast cancer, and tracked the results. Does CANCERLESS include this type of actions?
A: The CANCERLESS project does not focus on a specific strategy or technique. Rather, it will focus on increasing the empowerment of the homeless so that they can make better and more informed decisions for their health. This means that we will launch workshops to stop smoking, we will try to improve vaccination rates, and we will see how we can generally increase the health status of the homeless population (which in turn will also have to be a prevention strategy cancer) and also include all homeless people in the screening programs (as a type of secondary prevention) that exist in the participating countries (such as mammography, or colonoscopy).
In this case, our navigators will help guide and find suitable ways for the homeless to attend their appointments and will help them when they need it on a case-by-case basis.
If there are people with a suspected diagnosis who need further testing or treatment, our navigators will also help them access the appropriate care and make sure they don’t get lost in the system. This holistic approach was also one of the reasons why the European Union awarded the grant to the CANCERLESS project, as we considered the problem from a systemic point of view rather than focusing on a specific intervention (such as mammography or colonoscopy among others).
Q: Finally, I would like to know your general opinion about the CANCERLESS project. How did you feel when you found out that you had received the European funds to make it happen? What response do you hope to get from the homeless people?
A: Obviously, we are very surprised and euphoric. I received a phone call when I was leaving the office from a colleague who was screaming with happiness; that’s how I found out. Personally, I was very happy at the beginning, but then I was also very scared, since I feel the tremendous responsibility that I have as a coordinator, and also that we have as a consortium.
It is a great responsibility and privilege to create a platform to give a voice to those who are normally invisible and unheard. We want to make a change and this project has a real opportunity to provide a change not only while it is implemented, but also later if it is implemented as part of the health care policy.
The people and organizations we work with are very happy, since none of them are driven by fame or financial gain, but rather a true passion for work and helping those who really need it.
During my first conversation with one of the organizations we are going to work with, they told me that they had recently lost a homeless patient due to cancer and that the entire staff was devastated as they had fought this disease together with the patient. CANCERLESS will not solve all problems, but it can solve some and this is what gives us hope and what motivates us to work as hard as we can to make real changes in people’s lives.
CANCERLESS has been funded by the European Union’s Horizon 2020 Programme under the Grant Agreement GA 965351. The contents of this publication are the sole responsibility of consortium and do not necessarily reflect the opinion of the European Union.