Closing the Cancer Divide: an Equity Imperative

Monday, August 22, 2011

Cancer Detection and Diagnostics Technologies for Global Health National Institute of Health Washington, DC

Felicia Marie Knaul

Drectior, Harvard Global Equity Initiative Founder, Tmatelo a Pecho

From anecdote
to evidence

January, 2008 June, 2007

Harvard School of Public Health

Con jf en harvard

Global Task Force on Expanded Access to Cancer Care and Control

From anecdote

to evidence

Challenge and disprove the minimalists: myths about cancer& NCD

M1. Unnecessary: Not a health priority for the poor M2. Impossible: Nothing we can do about it M3. Unaffordable: .for the poor M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor

The Cancer Divide: disparities in outcomes

between poor and rich directly related to inequities in access and differences in underlying socioeconomic and health conditions.

The divide is the result of concentrating risk factors, preventable disease, suffering, impoverishment from ill health and death among poor populations.
fueled by progress in cutting-edge science and medicine in high-income countries.

The Cancer Divide: An Equity Imperative

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:
Exposure to risk factors Cancers of infectious origin Death from treatable cancer Stigma and discrimination Avoidable pain and suffering Impoverishment

For children & adolescents aged 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

Distribution of childhood cancer globally by income level (< 15)

Income Level Low Low middle Upper middle High Incidence 21% 50% 15% 15% Mortality 27% 55% 15% 5% Population 20% 57% 13% 10%

More than 85% of pediatric cancer cases and 95% of deaths occur in developing countries.

Distribution of mortality, 1-15 years Mexico, 1979-2008

40%

1-4

40%

5-14
16%

5% 0 0

1979

2008

1979

2008

Malignant tumors Infectious and parasitic diseases Respiratory infections

The opportunity to survive (M/I) should not be defined by income.

Yet it is.
100%

Children

Adults

Survival inequality gap

Leukaemia
Cervix

Prostate
HL N HL

All cancers

Breast Testis

LOW INCOME

HIGH INCOME

LOW INCOME

HIGH INCOME

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

Concentration curves of incidence and mortality by type and country income

Children (<15 years)
Non-Hodgkin lymphoma
1

Leukaemia
1
0.8

0.8 0.6 0.4 0.2 0

0.6 0.4 0.2

0 0.2 0.4 0.6 0.8 1

0.2

0.4

0.6

0.8

Incidence

Mortality

Concentration of I and M Example: Cervical cancer

275,000 deaths worldwide; 88% in LMICs: 160,000 in Asia 53,000 in Africa, 31,700 in LAC

HPV Vaccine
Source: Paul Farmer., 2009

Children orphaned by cervical cancer

Avoidable cancer deaths

Income Region Low income Lower middle income Upper middle income High income % of deaths considered avoidable

65 53 46 29

LMICs: 83% of avoidable deaths

Challenge and disprove the minimalists: myths about cancer& NCD

M1. Unnecessary: NECESSARY M2. Impossible: Nothing we can do about it M3. Unaffordable: .for the poor M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor

Initial views on MDR-TB treatment, c. 1996-97

In developing countries, people with multidrug-resistant tuberculosis usually die, because effective treatment is often impossible in poor countries. WHO 1996 MDR-TB is too expensive to treat in poor countries; it detracts attention and resources from treating drugsusceptible disease. WHO 1997

Outcomes in MDR-TB patients in Lima, Peru receiving at least 4 months of therapy

failed therapy died 8% 8%

abandon therapy 2%

cured 83%

Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

Source: Paul Farmer., 2009

Harvard, Breast Cancer in Developing Countries Nov 4, 2009; Nobel Laureat Amartya Sen, Cancer survivor

Mortality from breast and cervical cancer in Mexico,1955-2008: less death from cervical
16

Age-adjusted rate per 100,000 women

12

1995

2006: BC>CC.
For the first time in more than 5 decades.
Source: Lozano, Knaul, Gmez-Dants, Arreola-Ornelas y Mndez, 2008, Tendencias en la mortalidad por cncer de mama en Mxico, 1979-2007.
FUNSALUD, Documento de trabajo. Observatorio de la Salud, con base en datos de la OMS y la Secretara de Salud de Mxico.

2005

1955

1965

1975

1985

Pediatric cancer treatment: innovations

Severely resource-constrained settings: PIH-DFCI-BWH Financial protection/insurance: Mexico
International partnership: St Judes IOP

Survivorship: Sigamos Aprendiendo en el Hospital

PIH, DFCI, BWH Rural Rwanda, Burkitts lymphoma

0 oncologists

Regimen of vincristine, cyclophosphamide, intrathecal methotrexate

Central Haiti
Status post-CHOP in Central Haiti: Still in remission three years later

Source: Paul Farmer., 2009

Mexico Seguro Popular Insurance: Fund for catastrophic illness

Accelerated universal vertical coverage by disease with a specified package of interventions 2004/5: ALL in children, cervical, HIV/AIDS

2006: All pediatric cancers

2007: Breast cancer

2011: Testicular cancer and NHL

Access and equity: evidence from a pharmacy

St. Jude International Outreach Program: Global Partnership Innovation Model

Strategy: teleoncology + twinning Institutional commitment: 1-3% of budget 15-20 countries Evaluation and implementation research El Salvador: 5-year survival rate for ALL increased from 10% to 60% in first five years of collaboration

Survivorship care through education

MOH+MOE 65 Sigamos Aprendiendo classrooms in 23 states The majority of tertiary level hospitals

Challenge and disprove the minimalists: myths about cancer& NCD

M1. Unnecessary NECESSARY M2. Impossible POSSIBLE M3. Unaffordable: .for the poor M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor`

`5/80 Cancer Disequilibrium

Almost 80% of the DALYs (disability-adjusted life-years) lost worldwide to cancer are in LMICs, yet these countries have only a very small share of global resources for cancer ~ 5% or less.

Africa
1% of global spending on health 64% of new cancer cases 15% of the global population.

Reduced prices of second-line TB drugs

Drug Amikacin Ethionamide

% Decline in price 1997-9 90% 84%

Capreomycin
Ofloxacin

97%
98%

Source: Paul Farmer, 2009

We cannot afford not to

Health is an investment, not a cost World Economic Forum: chronic disease is one of the three leading global economic risks Total cost of cancer treatment: $217 billion. (Bloom, EIU 2009) Total cost of prevention (7%): $10.6 billion Economic value of lost DALYs: 943 billion (ACS/Livestrong, 2010)

Total economic cost of cancer, 2009 $US1.17 trillion= > 2% global GDP

Cost of inaction
Assuming that between 45 and 60% of deaths are avoidable: $434-567 billion Total annual cost: $297 billion
Economic cost of inaction: $130-270 billion

Economic cost of inaction, 2009 $US130-270

Challenge and disprove the minimalists: Myths about cancer& NCD

M1. Unnecessary NECESSARY M2. Impossible POSSIBLE M3.Unaffordable AFFORDABLE M4: Inappropriate: either/or Challenging cancer implies taking resources away from other diseases of the poor

The diagonal approach to health system strengthening

Rather than focusing on disease-specific vertical programs or only horizontally on system constraints, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps. Optimize available resources so that the whole is more than the sum of the parts. Bridge the divides as patients suffer diseases over a lifetime, most of it chronic.

Diagonal Strategies
1. Harness platforms: Integrate disease prevention, screening and survivorship into MCH, SRH, HIV/AIDs, social welfare/anti-poverty programs. 2. Delivery: Catalyze, employ and deploy community health workers and expert patients. 3. Financing: Social protection strategies that include horizontal and vertical coverage. 4. Stewardship: Improve regulatory frameworks to remove non-price barriers to pain control.

A diagonal approach to women and health and cancer care and control

Horizontal Coverage: Beneficiaries WOMEN

Juanita:
Advanced metastatic breast cancer is the result of a series of missed opportunities
br

Mexico: Harnessing the primary level of care for improving BC detection and care

Challenge and disprove the minimalists: Myths about cancer& NCD

M1. Unnecessary M2. Impossible M3.Unaffordable M4. Inappropriate : NECESSARY POSSIBLE AFFORDABLE APPROPRIATE

Be an optimist optimalist

Closing the Cancer Divide: an Equity Imperative

Monday, August 22, 2011
Cancer Detection and Diagnostics Technologies for Global Health National Institute of Health Washington, DC

Felicia Marie Knaul

Drectior, Harvard Global Equity Initiative Founder, Tmatelo a Pecho