Closing the cancer divide: a new frontier for global health 160512

7/31/2019 Closing the cancer divide: a new frontier for global health 160512

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Closing the cancer divide:

a new frontier for global health

May 16, 2012

From Lab to Market SeminarUS Department of State, Bureau of Educational and

Cultural Affairs, Institute of International EducationCambridge, MA

Felicia Marie Knaul, PhDHarvard Global Equity Initiative,

Global Task Force on Expanded Access to Cancer Care and Control in LMICs

Mexican Health FoundationTmatelo a Pecho


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From anecdote

to evidence


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January, 2008

June, 2007


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Con jf en harvard


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From anecdote

to evidence


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Global Task Force on Expanded

Access to Cancer Care and

Control in Developing Countries

= global health + cancer care


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Applies a diagonal

approach to avoid

the false dilemmasbetween disease silos

-CD/NCD- thatcontinue to plague

global health

Closing the Cancer Divide:A BLUEPRINT TO EXPAND ACCESS IN LMICs


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Challenge and disprove the

myths about

cancer/NCD/Chronic illness

M1. Unnecessary

M2. Unaffordable

M3. Impossible

M4: Inappropriate

Should,

Could, and

Can..

be done

Expanding access to cancer care and control in

low and middle income countries:


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all Latin American nations, much of eastern

Europe and central Asia, China, India, many

other parts of south Asia, and even countries in

Africa, are facing a painful double burden of

diseasenot only the persistence of infectious

threats, child and maternal mortality, and

undernutrition, but also the emergence of newdangers, notably diabetes, obesity,

cardiovascular disease, stroke, cancer, mental

ill-health, and injuries.

JULIO FRENK & RICHARD HORTON

HEALTH REFORM IN MEXICO SERIESTHE LANCET, 2006


16/541955 2005

72%

22%

6%

73%

17%10%

Communicable

Chronic, Non-communicable

Injuries

Over 50 years,

Mexico will

complete an aging

process that tooktwo centuries in

most European

countries.

In 2050, one-in-four Mexicans will

be 65 or overa

four-fold increase.

Rapid andPround Demographic and

epidemiologic transition

Mexico


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Mirrors the overall epidemiological

transitionprotracted and polarized*:

LMICs increasingly face both cancersassociated with infection, and all other

cancers.

Cancers that were once considered only ofthe poor, now cease to be the only cancers

of the poor. (e.g. cervical & breast cancer)

The Cancer Transition

* Frenk et al


18/54Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

The cancer transition in LMICs:

breastand cervicalcancer

53%

20%19%

-31%

0%

LMICs High

income

% Change in # of deaths1980-2010LMICs account for

>90% of cervical

cancer deaths and

>60% of breast

cancer deaths.

Both diseases are

leading killers

especially of young

women.


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#2 cause of death in wealthy countries

#3 in upper middle-income#4 in lower middle-income

and # 8 in low-income countriesMore than 85% of pediatric cancer cases and 95% of

deaths occur in developing countries.

For children & adolescents

5-14 cancer is


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Cancer is a disease of both rich and poor;

yet it is increasingly the poor who suffer:

1. Exposure to risk factors

2. Preventable cancers (infection)

3. Death and disability from treatablecancer

4. Stigma and discrimination

5. Avoidable pain and suffering

The Cancer Divide:

An Equity Imperative

Face

ts

I id d t lit f


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MortalityIncidence

Incidence and mortality of

cervical cancer(adjusted rate per 100,000 women)


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Adults

Leukaemia

All cancers

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

Children

LOW

INCOME

HIGH

INCOME

Sur

vival

inequa

lity

gap

LOW

INCOME

HIGH

INCOME

100%

The Opportunity to Survive (M/I)

Should Not Be Defined by Income

In Canada, almost 90% of children with

leukemia survive.

In the poorest countries only 10%.


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Stigma:Cancerespecially in

women and children - adds a

layer of discrimination ontoethnicity, poverty, and

gender.

Survivorship

care is non-existent.

Th t i idi l f


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The most insidious example ofinjustice is 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

E di t


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A) Should be done:

B) Could be done:

C) Can be done

Myth 1. Unnecessary

Myth 2. Inappropriate

Myth 3. Unaffordable

Myth 4: Impossible

Expanding access to cancer

care and control in LMICs:

W d th i LMIC


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Women and mothers in LMICs

face many risks through the life cycle

Women 15-59, annual deaths

Diabetes

120,889

Breast

cancer

166,577

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

Cervical

cancer

142,744

Mortality

in

childbirth

342,900

- 35%in 30

years

= 430, 210 deaths


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The Diagonal Approach to

Health System Strengthening

Rather than focusing on disease-specific vertical

programs or only on horizontal system

constraints, harness synergies that provide

opportunities to tackle disease-specific priorities

while addressing systemic gaps.

Optimize available resources so that the whole ismore than the sum of the parts.

Bridge the divide as patients suffer diseases over a

lifetime, most of it chronic.


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Why diagonal delivery?

Shared risk factors

Co-morbidity

Common need for strong health systemsplatforms

Efficiency

Knowledge sharing

Economic developmentSocial justice


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Delivery: Harness platforms byintegrating cancer prevention,

screening and survivorshipsupport into MCH, SRH,

HIV/AIDS, social welfare andanti-poverty programs.

A Diagonal Strategy:

Diagonal Strategies:


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Diagonal Strategies:Positive Externalities

Promoting prevention and healthy lifestyles:

Reduce risk for cancer and many other diseases

Reducing stigma for womens cancers:

Contributes to reducing gender discrimination

Promoting access to education for children w/ CI

Reduces poverty, contributes to social development

Pain control and palliation

Reducing barriers to access is essential for cancer as

well as for for other diseases and for surgery.

E di t


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A) Should be done: necessary

and appropriate

B) Could be done:

C) Can be done

Myth 3. Unaffordable

Myth 4: Impossible




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`5/80 cancer disequilibrium(Frenk/Lancet 2010)

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.

I ti I CCC


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Investing In CCC:

We Cannot Afford Not To

Health is an investment, not a cost

Tobacco is a huge economic risk: 3.6% lower GDP

Total economic cost of cancer, 2010: 2-4% of global GDPPrevention and treatment offers potential world savings of

$ US 131-850 billion mostly due to productivity gains and

reducing suffering

1/3-1/2 of cancer deaths are avoidable:

2.4-3.7 million deaths

Of which 80% are in LIMCs

In esting In CCC:


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Investing In CCC:

The costs to close the cancer divide

may be less than many fear:All but 3 of 29 LMIC priority, candidate cancer chemo

and hormonal agents are off-patent: many < $100 / course

Cost of drug treatment: cervical cancer + HL + ALL(kids)in LMICs / year of incident cases: $US 280 m

Pain medication is cheap

Prices drop: HPV 2011 from $US 100 /dose to:GAVI $5

PAHO $14

N ti l R i l d


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National, Regional and

Global Financing: potentialRecognition of potential of existing markets

Leverage integrated, innovative, scalable

financing mechanismsDiagonal partnerships:pink ribbon red ribbon

Aggregate purchasing and sustainable

procurement through existing funds andplatforms

UNICEF

PAHO

E di t


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A) Should be done: necessary

and appropriateB) Could be done: affordable

C) Can be doneMyth 4: Impossible



Ch i


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Harvard Breast Cancer in Develo in Countries Nov 4 `09

ChampionsNobel Amartya Sen,

Cancer survivor diagnosed in India50 years ago

Drew G. Faust

President of Harvard University22+ year BC survivor

Champions from LMICs: M ico


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Champions from LMICs: Mxico

Initial views on MDR TB


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In developing countries,people with multidrug-

resistant tuberculosis usually

die, because effective treatment

is often impossible in poor

countries. WHO 1996

Initial views on MDR-TB

treatment, c. 1996-97

Source: Paul Farmer., 2009

MDR-TB is too expensive to

treat in poor countries; it

detracts attention and resources

from treating drug-susceptible

disease. WHO 1997


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Outcomes in MDR-TB

patients in Lima, Peru

receiving at least fourmonths of therapy

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

All patients initiated therapy

between Aug 96 and Feb 99

Source: Paul Farmer, 2009

Drug% Decline in

price 1997-9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%

Ofloxacin 98%

Making common

cause with WHO:

Reduced prices ofsecond-line TB drugs

Cured

83%Abandontherapy 2%

Failed

therapy

8%

Died

8%

Success in treating several


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Mexico: cervical cancer.

Source: Knaul et al. 2008. Re roductive Health Matters and u dated b Knaul Arreola-Ornelas and Mndez based on WHO data WHOSIS 1955-1978 and Ministr o Health in Mexico 1979-2006

0

4

8

12

16

19551965

1975

1985

1995

2008

Success in treating severalcancers.

R l R d 0 l i t


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Rural Rwanda: 0 oncologist

Source: Paul Farmer., 2009

Burkittslymphoma

Embryonal

Rhabdomyosarcoma

St Judes International


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St. Jude s InternationalOutreach Program

20+ countries

El Salvador

5-year survival rate for children with

ALL increased from 10% to 60% during

the first five years of collaboration Cure4Kids/Oncopedia

Over 31,000 users in more than 183

countres

Financing innovations:


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Financing innovations:

DomesticIntegrate CCC into national insurance and

social security programs to

express previously suppressed demandbeginning with cancers of women and children:

Mexico, Colombia, Dominican

Republic, PeruChina, India, Taiwan

Rwanda, Kenya

A diagonal approach to social


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Horizontal Coverage: Beneficiaries

A diagonal approach to socialinsurance and cancers

I i l ti


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# of covered services

Source: Comisin Nacional de Proteccin Social en Salud, 2012

Increase in population coverage +

expansion of package of services

Households affiliatedto Seguro Popular

2006

2004

~100%

2012

2005

~17.2

millonesdefamilias

9%

30%

20%

42%

1.5 3

.5millones

5.1millones

7.3millo

nes

53%

9.1m

illones

2007

2008

61%

10.5

millones

2009

85%

14.7

millones

2010

+113

146

249262

266

2006

2004

2

012

2005

2007

2008

2009

2010

275

2011

89%

2011

15.4millones

Mexico Seguro Popular:


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Mexico Seguro Popular:financial protection for catastrophic

illnessAccelerated, universal, vertical coverage by disease

with a package of interventions

2004/5: ALL in children, cervical, HIV/AIDS

2006: All pediatric cancers then all children and

newborns for almost everything

2007: Breast cancer

2011: Testicular cancer, prostate and NHL

Seguro Popular and cancer:


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Seguro Popular and cancer:

Evidence of impact

Since the incorporation of childhood

cancers into the Seguro Popular

30-month survival ALL: 30% to almost 70%

Breast cancer adherence to treatment:

2005: 200/6002010: 10/900

J it


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Juanita:Advanced metastatic breast

cancer is the result of a seriesof missed opportunities

Program to reduce


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Program to reducebarriers:

Breast cancer, Mexico

Results: promoters nurses doctors


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Results: promoters, nurses, doctors

Challenge: from survival to survivorship


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Be anoptimist

optimalist

Expanding access to cancer care and control in

LMICs: Should, Could, and Can be done


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Available @amazon

http://www.amazon.com

Fall @harvard U Press

http://www.hup.harvard.edu/


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Closing the cancer divide:

a new frontier for global health

May 16, 2012

From Lab to Market SeminarUS Department of State, Bureau of Educational and

Cultural Affairs, Institute of International EducationCambridge, MA

Felicia Marie Knaul, PhDHarvard Global Equity Initiative,

Global Task Force on Expanded Access to Cancer Care and Control in LMICs

Mexican Health Foundation

Closing the cancer divide: a new frontier for global health 160512

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