Felicia Marie KnaulHarvard Global Equity InitiativeHarvard Medical SchoolGlobal Task Force on Expanded Access to Cancer Care and ControlMexican Health Foundation Tómatelo a PechoUnion for International Cancer Control

Long Wharf Theatre, New Haven; April 5, 2014

Closing the Pain DivideGlobal Health Perspectives,

Global Health and the Arts Conference

From anecdote …

… to evidence

January, 2008June, 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.

… to evidence

From anecdote…

GTF.CCC= global health +

cancer care

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:

1. Exposure to risk factors2. Preventable cancers (infection)3. Death and disability from treatable

cancers4. Stigma and discrimination

5. Avoidable pain and suffering

The Cancer Divide: An Equity ImperativeFa

cets

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

Source: Based on WPCA-OMS, 2014, Global Atlas of Palliative Care at the end of life .

Level 1: UnknownLevel 2: Building CapacityLevel 3a: Isolated provisionLevel 3.b: Widespread provisionLevel 4a: Preliminary integrationLevel 4b: Advanced integrationNot applicable

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

Latin America

Africa

China:1,276

The Global Pain divide

Mexico: 2,300

272,000 mg

267,000 mg37,000 mg

Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain:

Poorest 10%: 54 mg Richest 10%: 97,400 mgUS/Canada: 270,000 mg

India:717

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

orph

ine

Equ

ival

ence

(mg/

capi

tal)

1000

0 1970 1980 1990 2000 2010Fuente: Pain & Policy Studies Group. Opioid Consumption Motion Chart. University of Wisconsin. (http://ppsg-production.heroku.com/chart )for 2007 (accessed April 22 2011).

CanadaUSA

ArgentinaBrazilChileCosta RicaMexicoColombia

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 cheapYET:

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 useDelivery & financing platforms are underutilizedInnovation is undevelopedPurchasing is fragmented, procurement is unstable ，

Recent Global and Regional Advances

• 2013: PAHO opens regional financing and purchasing platform to chronic and non-communicable 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.

Mexico….• Universal health care through reform that

created Seguro Popular• Innovative legal framework: 2009 Palliative

Care Law: 2013 in General Health Law

…Yet….• 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

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

Health System

Function

Components of the Health Care Continuum

Prevention…Survival Palliative Care, Pain Control and End of Life Care

RegulationMissig: National Plan / ProgramWeak, poorly defined and restrictive regulatory frameworks Absence evaluation and monitoring

Financing

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

DeliveryLacking units and levels for delivery Supply chain and distribution is sporadic and spotty

Resource Generation and

Research

Lack of trained personnelFear of prescriptionTopic not available in medical school curriculumNo published research related to health system

0

1

2345

>5

# pain control clinics in each state; public system Public hospitals with

access to morphine

01

234

5>5

NA

Fuente: Dr. Alfonso Petersen Farah, Presentación: “Clínicas del Dolor”, Foro Internacional Promoviendo las Oportunidades de los Cuidados Paliativos en México. Octubre 11, 2013

N = 30 of 32 states

Delivery: Access to Services at state level in Mexico

Comprehensive and Systematic Solutions are required:

LEGISLATIVE AND

NORMATIVE FRAMEWORK

REGULATORY

FRAMEWORK

SUPPLY CHAIN AND

DISTRIBUTION OF

MEDICATIONS

PATIENT AWARENESS

PREVENTION AND CONTROL

OF ILLEGAL USE AND MEDICAL SUPPORT FOR ADDICTIONS

EVIDENCE ON REAL DEMAND

AND BARRIERS

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 society-

academia 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