Global Health and Cancer: Evidence based Advocacy 140311

8/2/2019 Global Health and Cancer: Evidence based Advocacy 140311

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Global health and cancer:evidence-based advocacy

Felicia Marie KnaulDirector, Harvard Global Equity Initiative

Secretariat, Global Task Force on Expanded Access to Cancer Care and Control inDeveloping Countries

Associate Professor, Harvard Medical SchoolFounder: Tmatelo a Pecho

Global Health and Cancer:a Seattle Perspective

Seattle

March 17, 2011


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From evidence

to anecdote


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July, 2007


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January, 2008


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March 2008, Launch, Cncer de mama: Tmatelo a Pechosurvivor


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Harvard, Breast Cancer in Developing Countries, Nov 4, 2009;Drew Faust, President Harvard University, Cancer survivor


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Harvard, Breast Cancer in Developing CountriesNov 4, 2009; Nobel Laureat Amartya Sen, Cancer survivor


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Global Task Force for Expanded Accessto Cancer Care and Control in

Developing Countries


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From anecdote

to evidence


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Challenge and disprove themyths about cancer/NCD

M1. Unnecessary:

Not a health priority in LMICs/not a problemof the poor

M2. Impossible:

Nothing we can do about it

M3. Unaffordable: .for the poor

M4: Inappropriate: either/or

Challenging cancer implies taking resourcesaway from other diseases of the poor`


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More than 85% of pediatric cancer cases and 95% of deathsoccur in developing countries that use less than 5% of the

world resources.

Level ofIncome

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 globallyby level of income (< 15)

For children & adolescents 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

C i f li


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Concentration of mortality:example Cervical cancer

Children orphaned by cervicalcancer

HPV Vaccine

Source: Paul Farmer., 2009

275,000 deaths worldwide; 93% in LMCs


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Lethality by cancer type and country income

Adults (15+)

Casefatalityapproximatedby

mortality/incidence

Breast

Cervix uteri

Prostate

Testis

Hodgkin lymphoma

Non - Hodgkin lymphoma

Leukaemia

All cancers

0

0.2

0.4

0.6

0.8

1

Low income Lower middleincome

Upper middle

incomeHigh income

0

0.2

0.4

0.6

0.8

1

Low income Lower middle

income

Upper middle

income

High income

Source: Knaul, Arreola, Mendez. estimates basedon IARC, Globocan, 2010.

Children


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The opportunity to survive should not be an accident of geography or definedby income.

Yet it is.But . there is scope for action.

Source: Author estimates based on IARC, Globocan, 2008 and 2010.Quote: HRH Princess Dina Mired

0

0.2

0.4

0.6

0.8

Low incomecountries

Lower middleincome

Upper middleincome

High incomecountries

All cancers, < 15

~casefatality(mo

rtality/incidence)

Leukaemia,


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Fuente: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 laSecretara de Salud de Mxico.

Mortality and age at death: breast andcervical cancer in Mexico 1955-2008

Rate per 100,000 womenadjusted for age

0

4

8

12

16

1

955

1

960

1

965

1

970

1

975

1

980

1

985

1

990

1

995

2

000

2

005


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Cancer is a disease of rich and poor.

Yet, the burden is increasingly polarized so thatit is the poor and only the poor who suffer:

The cancer divide

Preventable cancers: Incidence and death. Treatable cancers: Death.

Avoidable pain and suffering.

Financial impoverishment from the costs of careand effects of the disease.

Will the burden be even more

concentrated in women and children?

C


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M1. Unnecessary: NECESSARY

M2. Impossible:

Nothing we can do about itM3. Unaffordable: .for the poor

M4: Inappropriate: either/or



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In developing countries, people withmultidrug-resistant tuberculosis usuallydie, becauseeffective treatment is oftenimpossible in poor countries.WHO 1996

MDR-TB is too expensive to treat in poorcountries; it detractsattention and resources fromtreating drug-susceptible disease.WHO 1997

Initial views on MDR-TB treatment, c. 1996-97

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

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

cured

83%

abandon

therapy

2%

failed

therapy

8%

died

8%

Peru, Lima: All patients

initiated with at least 4months therapy between Aug

96 and Feb 99

Source: Paul Farmer, 2009

PIH/DFCI/BWH:


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PIH/DFCI/BWH:Rural Rwanda: 0 (zero) oncologists

Source: Paul Farmer., 2009

Burkittslymphoma

EmbryonalRhabdomyosarcoma


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St. Jude International Outreach Program:Global Partnership Innovation Model

Institutional commitment: St. Jude Hospital dedicates a1-3% of their budget to International Outreach Program Strategy: Partnership and twinning Evaluation and implementation research

15 + countries

El Salvador

5-year survival rate for children with ALL increased from 10%to 60% during the first five years of collaboration

Recife, Brazil

Since 1994, the cure rate for childhood cancers in increasedfrom 29% to 70%

Cure4Kids

Over 24,000 users in more than 175 countres

Ch ll d di h


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M2. Impossible:POSSIBLE

M3. Unaffordable: .for the poorM4: Inappropriate: either/or



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

Almost 80% of the DALYs (disability-adjusted life-years) lost worldwide tocancer are in LMICs, yet these countries

have only a very small share of globalresources for cancer ~ 5% or less.

Worse in certain regions:

Africa: only 02% of global cancer medicalcosts, 1% of global spending on health, 64%of new cancer cases, and 15% of the globalpopulation

Ch ll d di th


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M2. Impossible: POSSIBLE

M3. Unaffordable: .for the poorAFFORDABLEM4: Inappropriate: either/or

Challenging cancer implies taking resourcesaway from other diseases of the poor

Existing `Categories do not work


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Chronic

Acute

Infectiousorigin/communicable

AIDS, Cervical cancer, TB,liver cancer, Chagas,

cardiopathy, rheumatic heartdisease, gastric cancer,

Infectious diarrhealdiseases, respiratory

infections

Non-Communicable

Most cancers, mostCVD, hypertension,diabetes, asthma,

mental illness

Acute myocardialinfarction

Existing Categories do not workfor developing systemic solutions

People are at risk for many


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Africa

LMICs

Maternalmortality

207,000

355,000

Breast andcervicalcancer

79,184

87,691

=143,778

772,728

478,640

=1,251,368

People are at risk for manyreasonsvictims of success?

Th di l h t


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Vertical programs refer to targeted interventions, proactiveand disease-specific on a massive scale (HIV, maternal andchild health), while horizontal programs refer to moreintegrated health services corresponding to functions of thehealth systems, guided by demand and shared resources.

it has been discussed at length what the mosteffective approach is to deliver health interventions:vertical programs or horizontal programs. This is a falsedilemma, because both interventions need to coexist in

what could be called a diagonal approach

Seplveda et al., Aumento de la sobrevida enmenores de 5 aos: la estrategia diagonal

The diagonal approach tohealth system strengthening

A diagonal approach to women and


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Horizontal Coverage: BeneficiariesWOMEN

A diagonal approach to women and

health and cancer care and control

Di l h


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1. Integrating breast and cervical cancerscreening into MCH, SRH, HI;, packages

2. Integrating disease prevention andmanagement into social welfare and anti-poverty programs

3. Financial protection/insurance strategieswith horizontal and vertical coverage4. Reducing non-price barriers to pain control5. Developing effective health services

research and monitoring6. Disease-anchored advocates championing

health system strengthening and globalhealth

Diagonal approaches

Service

Platforms

He

althSystem

s

Functions

Advocacy

Platforms

Provider vignettes;


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Provider vignettes;a series of missed opportunities

Nurse and midwife Works on MCH, SRH and HIV/AIDS

locally

Has participated in global advocacyand training conferences

Undertakes research and field surveys .has never considered including NCD

or cancerbcthere is no treatment

available and she has been told that itis not a problem for poor women

Policy maker in MOH office down the

hall from women and cancer Manages the cash-transfer, family

planning program Information on NCD and cancers are

not a topic that is covered in the

discussions bc it is not a problemand there are no materials

Breast cancer advocate, runs an

international NGO. Concerned about funding for

treatment but does notparticipate in debate abouthealth care reform

Patients are surviving to sufferother diseases (diabetes?), buther group cannot offerassistance they have nolinkages to other groups

Does not participate inadvocacy about women andhealth more broadly, yet one ofthe main barriers to earlydetection of her patients ismachismo and gender

discrimination

Vi tt i f Mi d


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Vignette: a series of MissedOpportunities: Juanita

left breast substantially larger than right; arrived atMorelos Womens Hospital bc she could not moveher swollen arm; father of children abandonedhousehold at diagnosis

History Part 1:- Age 42; 5 children aged 7-18; breast fed all

- Cartilla de la mujer: regular PAP and clinic visits

- Has Oportunidades attends regular community health platicas

History Part 2: Felt a breast lump 4 years prior fear kept her from saying anything

Lump grew last year doctor at local clinic gave anti-b w/out BCE

Is entitled to Seguro Popular and free care

Cannot travel to Mexico City; seeking care locally; paying out of pocket


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br


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Mexico: Harnessing the primary level ofcare for improving BC detection and care


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Global health and cancer:evidence-based advocacy

Felicia Marie KnaulDirector, Harvard Global Equity Initiative

Secretariat, Global Task Force on Expanded Access to Cancer Care and Control inDeveloping Countries

Associate Professor, Harvard Medical SchoolFounder: Tmatelo a Pecho

Global Health and Cancer:a Seattle Perspective

Seattle

Global Health and Cancer: Evidence based Advocacy 140311

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