Global health and cancer: evidence-based advocacy

Felicia Marie Knaul

Director, Harvard Global Equity Initiative Secretariat, Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries Associate Professor, Harvard Medical School Founder: Tmatelo a Pecho

Global Health and Cancer: a Seattle Perspective Seattle March 17, 2011

From evidence

to anecdote

July, 2007

January, 2008

March 2008, Launch, Cncer de mama: Tmatelo a Pecho survivor

Harvard, Breast Cancer in Developing Countries, Nov 4, 2009; Drew Faust, President Harvard University, Cancer survivor

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

Global Task Force for Expanded Access to Cancer Care and Control in Developing Countries

From anecdote

to evidence

Challenge and disprove the myths about cancer/NCD

M1. Unnecessary: Not a health priority in LMICs/not a problem of 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`

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

Level of Income 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 that use less than 5% of the world resources.
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

Concentration of mortality: example Cervical cancer

275,000 deaths worldwide; 93% in LMCs

HPV Vaccine

Children orphaned by cervical cancer

Source: Paul Farmer., 2009

Lethality by cancer type and country income

1

Case fatality approximated by mortality/incidence

Children <15

Adults (15+)

0.8

0.8

0.6

0.6

0.4

0.4

0.2

0.2

0 Low income Lower middle income Upper middle income High income Low income Lower middle income Upper middle income High income

Breast

Leukaemia

Cervix uteri Hodgkin lymphoma Non - Hodgkin lymphoma Prostate

All cancers

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

Testis

~ case fatality (mortality/incidence)

The opportunity to survive should not be an accident of geography or defined by income. Yet it is. But . there is scope for action.

0.8

73%

Leukaemia, <15

0.6

0.4

All cancers, < 15

18%

Survival inequality gap

0.2

0
Low income countries Lower middle income Upper middle income High income countries

Source: Author estimates based on IARC, Globocan, 2008 and 2010. Quote: HRH Princess Dina Mired

Mortality and age at death: breast and cervical cancer in Mexico 1955-2008
16

Rate per 100,000 women adjusted for age

12

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

Fuente: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.

2008

The cancer divide

Cancer is a disease of rich and poor.
Yet, the burden is increasingly polarized so that it is the poor and only the poor who suffer:
Preventable cancers: Incidence and death. Treatable cancers: Death. Avoidable pain and suffering. Financial impoverishment from the costs of care and effects of the disease.

Will the burden be even more concentrated in women and children?

Challenge and disprove the 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 drug-susceptible disease. WHO 1997
failed therapy died 8% 8%

abandon therapy 2%

cured 83%

Peru, Lima: All patients initiated with at least 4 months therapy between Aug 96 and Feb 99

Source: Paul Farmer, 2009

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

PIH/DFCI/BWH: Rural Rwanda: 0 (zero) oncologists

Burkitts lymphoma

Embryonal Rhabdomyosarcoma
Source: Paul Farmer., 2009

St. Jude International Outreach Program: Global Partnership Innovation Model

Institutional commitment: St. Jude Hospital dedicates a 1-3% of their budget to International Outreach Program Strategy: Partnership and twinning Evaluation and implementation research
15 + countries El Salvador 5-year survival rate for children with ALL increased from 10% to 60% during the first five years of collaboration Recife, Brazil Since 1994, the cure rate for childhood cancers in increased from 29% to 70% Cure4Kids Over 24,000 users in more than 175 countres

Challenge and disprove the 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`

Reduced prices of second-line TB drugs

% Decline in price 19979 90% 84% 97% 98%

Drug Amikacin Ethionamide Capreomycin Ofloxacin

Source: Paul Farmer, 2009

`5/80 cancer disequilibrium

(Frenk/Lancet 2010)
Almost 80% of the DALYs (disabilityadjusted 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. Worse in certain regions:
Africa: only 02% of global cancer medical costs, 1% of global spending on health, 64% of new cancer cases, and 15% of the global population

Challenge and disprove the myths about cancer/NCD

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

Existing `Categories do not work for developing systemic solutions

Infectious origin/communicable NonCommunicable

Chronic

AIDS, Cervical cancer, TB, liver cancer, Chagas, cardiopathy, rheumatic heart disease, gastric cancer,

Most cancers, most CVD, hypertension, diabetes, asthma, mental illness

Acute

Infectious diarrheal diseases, respiratory infections

Acute myocardial infarction

People are at risk for many reasonsvictims of success?

Maternal mortality

Breast and cervical cancer

Africa

207,000

79,184 87,691 =143,778

LMICs

355,000

772,728 478,640 =1,251,368

The diagonal approach to health system strengthening

Vertical programs refer to targeted interventions, proactive and disease-specific on a massive scale (HIV, maternal and child health), while horizontal programs refer to more integrated health services corresponding to functions of the health systems, guided by demand and shared resources. it has been discussed at length what the most

effective approach is to deliver health interventions: vertical programs or horizontal programs. This is a false dilemma, because both interventions need to coexist in what could be called a diagonal approach
Seplveda et al., Aumento de la sobrevida en menores de 5 aos: la estrategia diagonal

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

Horizontal Coverage: Beneficiaries WOMEN

Diagonal approaches
1. Integrating breast and cervical cancer screening into MCH, SRH, HI;, packages 2. Integrating disease prevention and management into social welfare and antipoverty programs 3. Financial protection/insurance strategies with horizontal and vertical coverage 4. Reducing non-price barriers to pain control 5. Developing effective health services research and monitoring 6. Disease-anchored advocates championing health system strengthening and global health
Service Platforms Advocacy Health Systems Platforms Functions

Provider vignettes; a series of missed opportunities

Breast cancer advocate, runs an international NGO. Concerned about funding for treatment but does not participate in debate about health care reform Patients are surviving to suffer other diseases (diabetes?), but her group cannot offer assistance they have no linkages to other groups Does not participate in advocacy about women and health more broadly, yet one of the main barriers to early detection of her patients is machismo and gender discrimination Policy maker in MOH office down the hall from women and cancer Manages the cash-transfer, family planning program Information on NCD and cancers are not a topic that is covered in the discussions bc it is not a problem and there are no materials Nurse and midwife Works on MCH, SRH and HIV/AIDS locally Has participated in global advocacy and training conferences Undertakes research and field surveys .has never considered including NCD or cancer bcthere is no treatment available and she has been told that it is not a problem for poor women

Vignette: a series of Missed Opportunities: Juanita

left breast substantially larger than right; arrived at Morelos Womens Hospital bc she could not move her swollen arm; father of children abandoned household at diagnosis History Part 1:
- Age 42; 5 children aged 7-18; breast fed all - Cartilla de la mujer: regular PAP and clinic visits - Has Oportunidades attends regular community health platicas

History Part 2:
Felt a breast lump 4 years prior fear kept her from saying anything Lump grew last year doctor at local clinic gave anti-b w/out BCE Is entitled to Seguro Popular and free care Cannot travel to Mexico City; seeking care locally; paying out of pocket

br

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

Global health and cancer: evidence-based advocacy

Felicia Marie Knaul
Director, Harvard Global Equity Initiative Secretariat, Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries Associate Professor, Harvard Medical School Founder: Tmatelo a Pecho

Global Health and Cancer: a Seattle Perspective Seattle March 17, 2011