Closing the cancer divide: Lessons from Mexico

Jill Bennett Academic Community Lecture Seattle, WA June 19, 2013

Dr. Felicia Marie Knaul

Director, Harvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control Assoc Professor, Harvard Medical School Sr. Economist, Fundacin Mexicana para la Salud Founder and President, Tmatelo a Pecho Board Member, Union for International Cancer Control

January, 2008

From anecdote

to evidence

GTF.CCC = global health cancer care

Closing the Cancer Divide:

A BLUEPRINT TO EXPAND ACCESS IN LMICs

Applies a diagonal approach to avoid the false dilemmas between disease silos -CD/NCD- that continue to plague global health

Closing the Cancer Divide:

An Equity Imperative
Expanding access to cancer care and control in LMICs:
M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate

I: Should be done II: Could be done III: Can be done

1: Innovative Delivery 2: Access: Meds, Vaccines & Tech 3: Innovative Financing 4: Evidence for Decision-Making 5: Stewardship and Leadership

The Cancer Divide: An Equity Imperative

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:
1. 2. 3. 4. 5. Exposure to risk factors Preventable cancers (infection) Treatable cancer death and disability Stigma and discrimination Avoidable pain and suffering

Facets

The Opportunity to Survive Should Not Be Defined by Income

100%

Children

Adults Survival inequality gap

Leukaemia

All cancers LOW INCOME HIGH INCOME LOW INCOME HIGH INCOME

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

In Canada, almost 90% of children with leukemia survive. In the poorest countries only 10%.

Cancer especially in women and children - adds a layer of discrimination onto ethnicity, poverty, and gender.

Insidious injustice: lack of access to pain control

Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain: Poorest 10%: 54 mg per death Richest 10%: 97,400 mg per death

Global Burden,Cancer: 1990-2010

Deaths
6 5 Deaths (Millions) 4 3 2 1 0 DALYs (Millions)

DALYs
160

5.3

140 103

140
120

3.6
2.2

2.7

100 80 60

45

49

40
20 0

LMIC

HIGH INCOME

LMIC

HIGH INCOME

LMIC

HIGH LMIC INCOME

HIGH INCOME

1990

2010

1990

2010

1990

2010

Deaths DALYs lost LMICs, % of DALYs lost to cancer

5m 148m, 5.9% 62%

8m 188m, 7.6% 69%

For children & adolescents 5-14 cancer is

#2 cause of death in wealthy countries #3 in upper middle-income #4 in lower middle-income and # 8 in low-income countries
More than 85% of pediatric cancer cases and 95% of deaths occur in developing countries.
Fuentes: WHO, 2008

The Cancer Transition

Double burden for health systems
Mirrors the epidemiological transition LMICs increasingly face both infectionassociated cancers, and all other cancers. Cancers increasingly only of the poor, are not the only cancers affecting the poor
LMICs account for >95% of cervical and >60% of breast cancer deaths. Both are leading killers of especially young - women.

Cancer transition in Mexico: Breast and Cervical mortality

Mortality rate adjusted by age

16

Mxico

12
8 4 0

1955

1960

1970

1980

1990

2000

30

Nuevo Len
(Wealthiest)

30

Oaxaca
(Poorest)

20

20

10

10

1990

1980

2000

1980

1990

2000

Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez.

2010

2010

2010

Women and mothers in LMICs face many risks through the life cycle Women 15-59, annual deaths
- 35% in 30 years
Mortality in childbirth Breast cancer Cervical cancer Diabetes

342,900

166,577

142,744

120,889

= 430, 210 deaths

Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.

The Diagonal Approach to Health System Strengthening

Rather than focusing on either disease-specific vertical or horizontal-systemic programs, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps and optimize available resources Diagonal strategies: X = > parts
Bridge disease divides: respond to patient needs, lifecycle Generate positive externalities: e.g. womens cancer programs also combat gender discrimination

Diagonalizing Cancer Care: Financing & Delivery

Integrate cancer care and control into national insurance and social security programs beginning with cancers of women and children Harness platforms by integrating breast and cervical cancer prevention, screening and survivorship care into MCH, SRH, HIV/AIDS, social welfare and anti-poverty programs.

Positive Externalities
Promoting prevention and healthy lifestyles: Reduces risk for cancer and many other diseases Reducing stigma around womens cancers: Reduces gender discrimination Pain control and palliation Reducing barriers to access is essential for cancer as well as for for other diseases and for surgery.

Investing In CCC: We Cannot Afford Not To

Tobacco is a huge economic risk: 3.6% lower GDP Total economic cost of cancer, 2010: 2-4% of global GDP

1/3-1/2 of cancer deaths are avoidable: 2.4-3.7 million deaths, of which 80% are in LIMCs

Prevention and treatment offers potential world savings of $ US 130-940 billion

Challenge and disprove the myths about cancer

M1. Unnecessary M2. Unaffordable M3. Inappropriate

M4: Impossible

Mexico: The Human Face of Financial Protection for Cancer: Abish Romeo

Guillermina Avila Trujillo

Juanita:

Effective financial coverage of a chronic disease: breast cancer

Cancer Control-Care continuum
Primary Prevention Early Detection

Diagnosis

Treatment

Survivorship

Palliation

Mexico: Large and exemplary investment in financial protection for cancer prevention and treatment for women, yet a low survival rate. Opportunities to improve delivery

Diagonalizing Delivery Tmatelo a Pecho, INSP, Seguro Popular Harnessing the primary level of care

Results: 000s promoters, nurses, doctors