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Closing the Pain Divide Global Health Perspectives, Global Health and the Arts Conference Long Wharf

Theatre, New Haven; April 5, 2014 Felicia Marie Knaul

Harvard Global Equity Initiative Harvard Medical School Global Task Force on Expanded Access to Cancer Care and Control Mexican Health Foundation Tmatelo a Pecho Union for International Cancer Control

From anecdote

to evidence

January, 2008 June, 2007

The night of my high school prom visiting my father, Sigmund Knaul, at Mount Sinai Hospital, Toronto a few weeks before his death from cancer. May 1984.

From anecdote

to evidence

global health cancer care

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.

Exposure to risk factors Preventable cancers (infection) Death and disability from treatable cancers Stigma and discrimination

5. Avoidable pain and suffering

Pain Control and Palliative Care: the global scenario

8 out of 10 leading causes of death are associated with the need for treatment of severe pain and palliative care. Only 8% of the over 100 million people who require palliative care annually have access. Only 20 countries in the world have effectively integrated palliative care into their health system.

Access to Palliative Care at End-of-Life

Level 1: Unknown Level 2: Building Capacity Level 3a: Isolated provision Level 3.b: Widespread provision Level 4a: Preliminary integration Level 4b: Advanced integration Not applicable
Source: Based on WPCA-OMS, 2014, Global Atlas of Palliative Care at the end of life .

Pain: a Global Injustice

Every year, tens of millions of people suffer needlessly in moderate to severe pain, including 5.5 million from cancer 83% of people in the world live in countries with little or no access to medications for pain control High-income countries account for less than 15% of the world's population but over 94% of consumption of morphine

The Global Pain divide

Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain: Poorest 10%: 54 mg Richest 10%: 97,400 mg US/Canada: 270,000 mg 267,000 mg

37,000 mg

272,000 mg

China:1, India:71 276 7

Mexico: 2,300

Latin America

Opioid Consumption (medical) in The Americas, 1965-2010, Log Scale

1000 Morphine Equivalence (mg/capital)
Canada USA

Argentina Brazil Chile Costa Rica Mexico Colombia






Fuente: Pain & Policy Studies Group. Opioid Consumption Motion Chart. University of Wisconsin. ( )for 2007 (accessed April 22 2011).

Pain and Palliative Care: a missing agenda

Not associated with any particular disease A cause without advocates: The majority die leaving victims without a voice Fear of death and pain The survivorship dilemma: those who live avoid thinking of death or pain

The costs to close the pain divide are less than many fear:
The majority of pain control meds are off patent and cheap YET: The poor overpay because prices are higher in low income countries
1 month morphine: $1.80-$5.40 versus $60-180

BUT: WE CAN GET THE PRICE RIGHT AND INCREASE ACCESS THROUGH COLLECTIVE ACTION: Global regulation focuses on control of illicit use Delivery & financing platforms are underutilized Innovation is undeveloped Purchasing is fragmented, procurement is unstable

Recent Global and Regional Advances

2013: PAHO opens regional financing and purchasing platform to chronic and noncommunicable diseases meds including pain control 2014: The WHO Executive Board pre-approved an innovative resolution urging countries to ensure access to palliative care and pain medicine urging
Countries: integrate palliative care into health systems WHO: increase technical assistance to member countries to develop palliative care services.

Universal health care through reform that created Seguro Popular Innovative legal framework: 2009 Palliative Care Law: 2013 in General Health Law

Almost 80% - 65,500 - of the 83,771 registered deaths from cancer or HIV/AIDS in 2010, died in pain

Barriers to Access Palliative Care by Health System Function: Mexico

Health System Function

Components of the Health Care Continuum

Prevention Survival

Palliative Care, Pain Control and End of Life Care

Missig: National Plan / Program Weak, poorly defined and restrictive regulatory frameworks Absence evaluation and monitoring
NO explicit coverage of interventions in either the Comprehensive Package for Essential Services or the Fund for Protection Against Catastrophic Expenditure -Social Security there is an everything and nothing




Lacking units and levels for delivery Supply chain and distribution is sporadic and spotty
Lack of trained personnel Fear of prescription Topic not available in medical school curriculum No published research related to health system

Resource Generation and Research

Source: Adapted from Knaul, F. M., Gralow, J. R., Atun, R., & Bhadelia, A. (Eds.). Closing the Cancer Divide. Harvard University Press, 2012.

Delivery: Access to Services at state level in Mexico

# pain control clinics in each state; public system
>5 5 4 3 0 1

Public hospitals with access to morphine NA 0

1 4 3 5

N = 30 of 32 states

Fuente: Dr. Alfonso Petersen Farah, Presentacin: Clnicas del Dolor, Foro Internacional Promoviendo las Oportunidades de los Cuidados Paliativos en Mxico. Octubre 11, 2013

Comprehensive and Systematic Solutions are required:





All-Society Solution is Required:

Supreme Court The National Congress Ministry of Health COFEPRIS (food and drug regulation) Insurance system: Seguro Popular, IMSS, ISSSTE and others Tertiary care hospitals Associations of Physicians and Health Professionals Private business sector Civil society Academic and teaching institutions Appropriate regulatory frameworks at the international level

Big Steps Forward:

International seminar, October 2013 Working group in the Supreme Court, 2013 Launched the public-private-civil societyacademia joint committee coordinated withCOFEPRIS, 2014 Development of training materials Support for international WHO resolution and INCB Participation in international workshops and application of knowledge in Mexico Establishment of working group to develop a National Program

Be an optimist optimalist

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