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Closing the Cancer Divide:

Global Health Catalyst Cancer Summit


March 20, 2015
Boston, MA
Felicia Marie Knaul, PhD
Harvard Global Equity Initiative, Global Task Force on Expanded Access to
Cancer Care and Control in LMICs
Harvard Medical School
Tmatelo a Pecho A:C. Mxico
Mexican Health Foundation

January,
2008
June, 2007

From anecdote

to evidence

Global Task Force on Expanded


Access to Cancer Care and Control
in Developing Countries

= global health + cancer care

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: Affordable Meds, Vaccines & Techs
3: Innovative Financing: Domestic and Global
4: Evidence for Decision-Making
5: Stewardship and Leadership

Did you know?


LMICs face a growing burden of both
infection-associated cancers, and all
other cancers.
Women in developing regions
account for >90% of cervical and
70% of breast cancer deaths.
Both are leading killers especially
of young women.

For kids 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 LMICs.

The Cancer Divide:


An Equity Imperative

Facets

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

100%

100%

Children

Breast
Cervix

Adults

Testis

India

Zimbawe

China

Prostat
e
Tyroid

Zimbawe
India
China

Leukaemia

Canada

Canada

LOW
INCOME

HIGH
INCOME

LOW
INCOME

HIGH
INCOME

Almost 90% of Canadian


childhood leukemia patients survive
In the poorest countries only 10% survive.

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

Survival inequality gap

The Opportunity to Survive


Mortality/Incidence
is largely defined by income

The most insidious injustice:


the pain divide
Non-methadone, Morphine Equivalent
opioid consumption per death from HIV
or cancer in pain:
Poorest 10%: 179 mg
Richest 10%: 99 mil mg
US/Canad: 344 mil mg
355 mil mg

India: 467 mg
333 mil mg

Mexico:3
,500 mg

Africa
Latin America

Source: Estimaciones propias Knaul F.M. Arreola H, et.al.,


basado en datos de: Treat the pain and INBC
(http://www.treatthepain.com )

Challenge and disprove the


myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE

The costs to close the cancer divide


are less than many fear:

Only 3 of 29 LMIC priority


cancer chemo and hormonal
agents are on-patent (2011)
Prices drop: HepB and HPV
vaccines
Pain medication is cheap

The costs of inaction are huge:


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

Champions the economics of hope:


Drew G. Faust
President of Harvard
University 25+ year BC
survivor

Nobel Amartya Sen,


Cancer survivor diagnosed in
India 60 years ago

Challenge and disprove the


myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APROPRIATE

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

Mitnick et al, Community-based therapy for multidrug-resistant


tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

Source: Paul Farmer., 2009

Women and mothers in LMICs


face many risks through the life cycle
Women 15-59, annual deaths
- 35%
in 30
years

Mortality
in
childbirth

342,900

Breast
cancer

Cervical
cancer

166,577

142,744

Diabetes

120,889

= 430, 210 deaths


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

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

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:
Exploit existing platforms e.g. ICTs
Compound to increase effectiveness at a given cost
Bridge disease divides using a life cycle response
Avoid the false dilemma of disease silos

Diagonal Strategies:
Positive Externalities
Promoting prevention and healthy lifestyles:
Reduce risk for cancer and other diseases
Reducing stigma for womens cancers:
Contributes to reducing gender discrimination.
Investing in treatment produces champions
Pain control and palliation
Reducing barriers to access is essential for
cancer, for other diseases, and for surgery.

Challenge and disprove the


myths about cancer
M1. Unnecessary NECESSARY
M2. Unaffordable AFFORDABLE
M3. Inappropriate APROPRIATE
M4: Impossible
POSSIBLE

Impressive Decline in Mortality from


cervical cancer in Mexico,1955-2012
Mxico
Age-adjusted rate per
100,000 women

16

2012

2005

1985

1955

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.

Expansion of Financial Coverage:


Seguro Popular Mxico
Affiliation:

Benefit package:
2004: 113

2014: 285
59 in the
Catastrophic
Illness Fund

Benefits Package

2014: 55.6 m

Vertical Coverage
Diseases and Interventions:

2004: 6.5 m

Horizontal Coverage:

Beneficiaries

Seguro Popular now includes


cancers in the national,
catastrophic illness fund
Universal coverage by disease with an effective
package of interventions
2004/6: HIV/AIDS, cervical, ALL in children
2007: pediatric cancers; breast
2011: Testicular, Prostate and NHL
2013: Ovarian and colorectal

Seguro Popular and breast cancer:


Evidence of impact
National Institute
of Cancer:
treatment
adherence
2005: 200/600
2010: 10/900

The human faces:


Guillermina Avila

Breast Cancer detection:


Delivery failure
% diagnosed in Stage 4 by state

# 2 killer of
women 30-54
5-10% detected
in Stage 0-1

RIch

Poor

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

Diagonalizing Delivery:
Training primary care providers in
early detection of breast cancer

Health Promoters
Risk Score (0-10)

6
5
4

Significant increase in
knowledge, especially among
health promoters and in clinical
breast examination
(Keating, Knaul et al 2014, The Oncologist)

3
Pre

Post

3-6 month

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.

HGEI-Lancet Commission on Global Access to Pain


Control and Palliative Care

=
Global
Health and
Health
Systems

Palliative
care
specialists

Goal:
Alleviate Avoidable
Pain & Suffering
Inaugural meeting of the Commission held September 22-23, 2014, in New York City Lancet Office

Be an
optimist
optimalist

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