Closing the Cancer Divide: An Equity Imperative 220811

8/2/2019 Closing the Cancer Divide: An Equity Imperative 220811

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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 KnaulDrectior, Harvard Global Equity Initiative

Founder, Tmatelo 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

Harvard School of Public Health


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Global Task Force on ExpandedAccess to Cancer Care and Control


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From anecdote

to evidence


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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/orChallenging cancer implies taking resources away

from other diseases of the poor


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The divide is the result of concentrating riskfactors, preventable disease, suffering,impoverishment from ill health and deathamong poor populations.

fueled by progress in cutting-edge science andmedicine in high-income countries.

The Cancer Divide:disparities in outcomes

between poor and rich directly related to inequitiesin access and differences in underlying socio-

economic and health conditions.


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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

The Cancer Divide:

An Equity Imperative


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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


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More than 85% of pediatric cancer cases and

95% of deaths occur in developing countries.

Income Level Incidence Mortality Population

Low 21% 27% 20%Low middle 50% 55% 57%

Upper middle 15% 15% 13%

High 15% 5% 10%

Distribution of childhood cancer

globally by income level (< 15)


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Distribution of mortality, 1-15 years

Mexico, 1979-2008

0

40%

1979 2008

1-4 5-14

Malignant tumors

40%

5%

16%

Respiratory infections

Infectious and parasitic diseases

%

1979 2008

0


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Adults

Breast

Cervix Prostate

Testis

HL

N HL

Leukaemia

All cancers

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

Children

LOW

INCOME

HIGH

INCOME

Survival

inequalitygap

LOW

INCOME

HIGH

INCOME

100%

The opportunity to survive (M/I)

should not be defined by income.

Yet it is.


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Concentration curves of incidence and

mortality by type and country income

0.2

0.4

0.6

0.8

1

00.2 0.4 0.6 0.8 1

Non-Hodgkin lymphoma

0.2

0.4

0.6

0.8

1

0 0.2 0.4 0.6 0.8 1

Leukaemia

Children (


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Children orphaned by cervicalcancerHPV VaccineSource: Paul Farmer., 2009

275,000 deaths worldwide; 88% in LMICs:160,000 in Asia

53,000 in Africa,

31,700 in LAC

Concentration of I and M

Example: Cervical cancer


23/47LMICs: 83% of avoidable deaths

Avoidable cancer deaths

Income Region % of deaths consideredavoidable

Low income 65Lower middle income 53

Upper middle income 46

High income 29


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minimalists:


M1. Unnecessary: NECESSARY

M2. Impossible: Nothing we can do about it


M4: Inappropriate: either/or

Challenging cancer implies taking resources away

from other diseases of the poor


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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

cured

83%

abandon

therapy

2%

failed

therapy

8%

died

8%

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

Outcomes in MDR-TB patients in Lima,

Peru receiving at least 4 months of therapy

MDR-TB is too expensive to treat in poor countries; it

detracts attention and resources from treating drug-

susceptible disease. WHO 1997

H d B t C i D l i C t i


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Harvard, Breast Cancer in Developing Countries

Nov 4, 2009; Nobel Laureat Amartya Sen, Cancer survivor


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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.

Mortality from breast and cervical cancer inMexico,1955-2008: less death from cervical

2006: BC>CC.For the first time in more than 5 decades.

Age-adjusted rate per100,000 women

0

4

8

12

16

1955

1965

1975

1985

1995

2005

P di t i t t t


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Severely resource-constrained settings:

PIH-DFCI-BWH Financial protection/insurance: Mexico

International partnership: St Judes IOP

Survivorship: Sigamos Aprendiendo en

el Hospital

Pediatric cancer treatment:

innovations

PIH DFCI BWH


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Rural Rwanda, Burkitts lymphoma

Source: Paul Farmer., 2009

Regimen ofvincristine,

cyclophosphamide,

intrathecal

methotrexate

Status post-CHOPin Central Haiti:

Still in remission

three years later

Central Haiti

0o

ncolo

gists

PIH, DFCI, BWH


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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/AIDS2006: All pediatric cancers

2007: Breast cancer

2011: Testicular cancer and NHL

Access and equity: evidence from a pharmacy

St J d I t ti l O t h P


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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


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MOH+MOE

65 Sigamos Aprendiendo

classrooms in 23 statesThe majority of tertiarylevel hospitals

Survivorship care

through education

Ch ll d di th


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minimalists:


M1. Unnecessary NECESSARY

M2. Impossible POSSIBLE



Challenging cancer implies taking resources

away from other diseases of the poor`


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`5/80 Cancer Disequilibrium

Almost 80% of the DALYs (disability-adjustedlife-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 health64% of new cancer cases

15% of the global population.


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Source: Paul Farmer, 2009

Drug % Decline in price 1997-9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%

Ofloxacin 98%

Reduced prices of second-line TB drugs


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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


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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

Ch ll d di th


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minimalists:

Myths about cancer& NCD



M3.Unaffordable AFFORDABLE


Challenging cancer implies taking resources

away from other diseases of the poor

Th di l h


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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.


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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 communityhealth 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.

Diagonal Strategies


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Horizontal Coverage: BeneficiariesWOMEN

A diagonal approach to women and

health and cancer care and control


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br

Juanita:Advanced metastatic breastcancer is the result of a seriesof missed opportunities


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Mexico: Harnessing the primary level of

care for improving BC detection and care


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minimalists:

Myths about cancer& NCD



M3.Unaffordable AFFORDABLE

M4. Inappropriate : APPROPRIATE


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Be an

optimistoptimalist


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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 KnaulDrectior, Harvard Global Equity Initiative

Founder, Tmatelo a Pecho

Closing the Cancer Divide: An Equity Imperative 220811

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