Health Equity: the Local Flavor; dedicated to the memory of Sujal Sofia D. Merajver, MD, PhD,...
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Transcript of Health Equity: the Local Flavor; dedicated to the memory of Sujal Sofia D. Merajver, MD, PhD,...
Health Equity: the Local Flavor;dedicated to the memory of Sujal
Sofia D. Merajver, MD, PhD, Director Center for Global Health
Scientific Director, Breast Oncology ProgramDirector, Breast and Ovarian Cancer Risk Evaluation
ProgramMarch 26, 2011- Symposium in Honor and memory of Sujal Parikh
http://www.globalhealth.umich.edu/
Of all the forms of inequality, injustice in health care is the most shocking and inhumane. ~ Martin Luther King, Jr.
Humanity’s greatest advances are not in its discoveries, but in how those discoveries are used to reduce inequity. ~ Bill Gates
MISSION Science in service of global health equity.
TOOL Global Translational Research but what is it?
Global Health Translational Research
Use and adaptation of scientific knowledge,
social and humanistic frameworks, and
technologies to sustainably promote health
equity
“Western health discourse introduces core components of Western
culture, including a theory of human nature, a definition of
personhood, a sense of time and memory and of moral authority”
NYT, 1/10/10
Working with partners towards health equity
GH Translational
Research
UM CGH Objectives
Educational Engagement
ProgrammaticWork: Focus
areas
Nursing
Law
Medicine
ISRCHGD
PSC
Pharmacy
Social Work
Public Health
Kinesiology
Dentistry
Architecture Urban Planning
Mathematics
ComputationalBiology
Bioengineering
Natural Resources and Environment
Public Policy
Anthropology
Information
Understanding, preventing, managing,
and curing diseasein global populations
in a sustainable framework
Mission: Science in the service of global health equity
What is equity?
Definition: local variablesRecognition: local data
Evaluation: locally appropriate: in contextSustainability: locally feasible: affordable
Health disparities
Population-specific differences in the presence of disease, health outcomes, or access to health care.
Examples: access to mammography screening breast cancer mortality by stageincidence rates of chronic disease
What is health equity?
Absence of systematic disparities in health or in the major social determinants of health between groups with different social advantage (e.g. wealth, power, prestige). (from Braveman&Gruskin, 2003)
—equal mortality for stage and biology matched cancer
—equal proportion of age-appropriate screening for cancer
Equity goes further: the local flavor
Groups already disadvantaged by their position in a social hierarchy have less access to health resources and thus will experience worse outcomes: an ethical judgment
calls forAddressing the social and medical determinants
of health that put social groups at a disadvantage for good health outcomes
All global health challenges are “local”: lessons from doing
• Define health disparities in a community (assessing)
• Prioritize which ones to address given resources (planning)
• Address the disparities (doing)• Evaluate if the interventions worked (reckoning)• Learn from mistakes and regionalize (growing)
GH Translational Research addresses inequities in non-communicable disease
• Assessing: Cross-disciplinary in-country and US• Planning: Involves in-country socio-political
structures; US agencies; all stakeholders (patients!)
• Doing: Multifaceted plan is implemented• Reckoning: Multicultural evaluation• Growing: Sustainable and dynamic; longitudinal
robustness
13
We envision healthcare that honors
each individual patient and family,
offering voice, control, choice, skills in
self-care, and total transparency, and
that can and does adapt readily to
individual and family circumstances
and differing cultures, languages, and
social backgrounds.
With so many cultures and so much history, is there common ground?Molecular scienceInformation technologies Human dignity Outcomes…
Patient centered care: core elements
• Education and shared knowledge• Involvement of family and social contacts• Collaboration and team management• Sensitivity to and interweaving with non medical
and spiritual dimensions of care• Respect for patient needs and preferences• Free flow of patient access to information
Non-communicable disease: Major GH translational research challenges
• Lack of infrastructure to diagnose complex diseases– Initial treatment depends on accurate diagnosis
• Adaptation of laboratory, clinical assessment, data transmission• Understanding burden of disease: registries, culturally adapted long-term follow-up
– Chronic diseases are highly heterogeneous• Interventions adapted to low resources areas require creativity and innovation, not
watering down of existing high-resource environment approaches
– Outcomes depend on consistent of management• Ability and infrastructure for longitudinal assessment of chronic diseases is a must
in the developing world
• Deficit in delivery and utilization of palliative care– Definition of pain and suffering
• Mental health modulates major chronic disease outcomes: cancer, CVD
Progression of Age Pyramid with Socioeconomic Development in Ethiopia
U.S. Census Bureau, International Database http://www.census.gov/ipc/www/idb/index.php [Accessed 20 Jan 2010].
2000
2025
When Do People Die?Per Cent Distribution of Age at Death, 2004
>80% of deaths in AFR occur prior to age 60yr
In HICs, >80% occur after age 60yr
Age distribution of deaths in EMR is intermediate between AFR & HICs
Cancer Registries of Africa in Ci5 Vol. IXFive Registries in Five Countries (of 53)
Egypt(Gharbiah)
Tunisia(Central)
Source: Ci5 Vol. IX, IARC
<1% of African population is covered by the 5 registries of Africa.
N. America
Europe
Asia
Oceania
S+C. America
AfricaUganda
(Kyando Co.)
Zimbabwe(Harare)
Algeria(Setif)
Ci5 Vol. IX covers 11% of the world’s population; >70% of the data are from
North America & Europe
Kernel Density Estimate of the Distribution of Life Expectancy
Bloom D E, Canning D PNAS 2007;104:16044-16049
Many African countries “left behind”
Currently, ~60 Million die each year
The Overall Rate of Cancer in Africa Is Lower Than In High-Income Regions
Crude Rates per 100,000
Note that African regions have higher Mortality/Incidence ratios reflecting poorer outcomes for cancer patients.
Cancer Cases Are Rising Globally Especially in Lo-/ Middle- Income Settings: Most cancer
deaths already occur in lo/mid income areas
Data Source: Globocan 2002
Cancer DeathsMillionsper year
Cancer currently accounts for ~12.5% of ~60 Million global deaths
~11 Million deathsby 2030
Ugandan Population Pyramids & Projections re. Breast Cancer
Source: IARC’s Globocan 2000
947 (100%) 2264 (239%) 5687 (601%)Projected Breast Cancer Cases Per Year:
Projected Population of Uganda:10.9M (100%) 22.2M (203%) 32.5M (297%)
423 (100%) 1014 (240%) 2578 (609%)Projected Breast Cancer Deaths Per Year:
The trouble with the future is that it usually arrives before we are ready for it. A.H. Glasgow
2000 2025 2050
Human Resources for Health and Development: A Joint Learning InitiativeThe Rockefeller Foundation, 2003
“The harvest is plentiful, but the workers are few.” Mt. 9:37
MD’s/100K Population
Healthcare workers:
Cancer in 0-14 yr olds as % of all cancer
Globocan 2002
% o
f All
Canc
ers
Overall childhood cancer rates are more uniform globally than adult rates.
Survival Trends For Children with Cancer
HICs
LMICs
100
10
Surv
ival
%
1950 1960 1970 1980 1990 2000
Inequality Gap
Childhood Cancer Frequencies (%)
Cancer Type USA-W Brazil Uganda
Leukemias 31 28 6
Lymphomas 10 21 29
CNS 21 13 1
Sympathetic 9 2 1
Retinoblastoma
3 8 6
Renal 7 9 4
Hepatic 2 0 1
Bone 4 6 3
Soft Tissue 7 4 41
BL
KS
71%
Down-staging breast and cervical cancer in low- and medium-resource countries
• Neglect of early detection: low resources, in-country age pyramid
• > 60-80% of cancers present at advanced stage• Adoption of early-detection technologies from high-
resource areas not feasible or indicated• Treatment of advanced cancer more difficult and
costly• Lack of palliative care: unrelieved cancer pain is a
significant burden in life quality
Specific challenges for demonstration projects in cancer in Africa
• Resource appropriate settings– Stratification by need, exposures: urban vs rural– More dense vs less dense, tailored by access
• Transition between detection and therapy– Adaptation of clinical research infrastructure– Adaptation of technologies
• Global health grid: expand early diagnosis, optimize care, measure outcomes
Central Question
Disease appropriate strategies and technologies needed to downstage
diagnosis and medical care infrastructure needed to transition from detection to
treatmentFocus: breast cancer
Downstaging
• Yearly mammographic screening in women >50 decreases mortality from breast cancer– Enables detection of earlier cancers that can be
cured– Treatments for early-stage disease have a better risk-
benefit ratio
Zambia
Chad
Cote d'Ivoire
Malawi
Mali
IndiaNepal
Viet Nam
Philippines
Senegal
South Afri
ca
Bosnia and H
erzegovin
a
Dominican Republic
Russian Fe
deration
Mexic
o
Ukraine
Greece
Brazil
Czech
RepublicSp
ain
Germany
Portugal
Italy
United Kingdom
France
Norway
0
10
20
30
40
50
60
70
80
90
100
Percentage of women (50-69) who have ever had a mammogram, 2003.
World Health Organization Statistical Information System (WHOSIS). http://www.who.int/whosis/en/ [1/20/2010]
USA
Bahrain Saudi Arabia Palestinians US White US Black South African Black
South Korea0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%Distribution of Breast Cancer Cases Stage
IV III II
I
Breast Cancer Outcome Disparities:Higher Mortality Rates for African Americans
• Socioeconomic Disparities
• Socioeconomic Disparities
• Socioeconomic Disparities
• Delivery of Care
• Tumor biology
• Genetics
• Lifestyle & Reproductive Experiences
• Environmental exposures
• Diet/Nutrition
E. Ward, A. Jemal, et al; Cancer Disparities by Race/Ethnicity and Socioeconomic Status. CA Cancer J Clin 2004; 54:78
SES and Barriers to Optimal Breast Cancer Care in the US
• Screening
• Access to Treatment Advances
• Access to Clinical Trials
• Co-Morbidities
• Delivery of Care/Treatment Recommendations
• Healthcare Workforce Disparities
SES-Adjusted Meta-Analysis, 2006>13K AA & 75K WA Breast CA Pts; 19 Studies
mortality hazard.1 .5 1 5 10
Combined
Crowe
Jatoi 1995-99
Bradley
Polednak
Albain Postmen
Albain Premen
Roetzheim
El Tamer
Yood
Wojcik
Howard
Franzini
Simon (<50 yo)
Simon (>49 yo)
Perkins
Eley
Neale
Ansell
Gordon
Coates
Bassett
AA Mortality Risk: 1.28 (95% CI 1.18-1.38)Newman et al, JCO 2006
Building capacity for global health in breast cancer
Improve diagnosisAdapt multidisciplinary case conference to GH
Establish easy communication technologies: example: gmail, mobile phones, remote sensing
Consult and follow-upPromote measurable outcomes of quality
– Down-staging– Compliance
– Survival– Palliative care
Supplies the infrastructure for future translational work
On Fri, Aug 15, 2008 at 2:09 AM, Sofia Merajver <[email protected]> wrote: Dear Omar, I think it is cancer. I have attached a power point slide and the same file in PDF. Please let me know if you have any trouble opening them. You are doing a fabulous job. Keep me posted what happens. I hope there is a diagnosis soon and she can be treated. Best regards, salaam
SofiaOn Sat, Aug 16, 2008 at 3:08 PM, omarsherifomar<[email protected]> wrote: thanks a lot for the quick response , i opened the attachment , iwill operate her next monday and will keep you updatedthanks, OmarOn Sat, Aug 16, 2008 at 11:30 PM, Sofia Merajver <[email protected]> wrote: Good Luck!!' my best wishes for your patientOn Tue, Aug 19, 2008…. Hello How are you .. The biopsy revealed to be granulomatousmastitis. What is the proper line of treatment and does it have a tendency to recur. best wishes, OmarOn Fri, Aug…. Hi Dr OmarI am still investigating what would be best for this patient. I favor a short course of steroids. Yes about 1/4 of them recur and need re-excision or more steroids. I will get back to you with the exact regimen I recommend. How much does the patient weigh approximately?Hope you are very well,SalaamSofia
Hi, Dr. Omar: I would do an incisional biopsy right here, taking skin also. Good luck. I think it is cancer
Translational global health research helps everyone
• Multidisciplinary teams– Epidemiologist: registries, burden of disease– Physician: create new paradigms for early detection– Nurse: help implement breast exam– Educator, health care worker: disseminate
information, patient support services– Engineers, economists: invent and implement new
technologies– Anthropologist/Sociologist: frames in culture
Translational global health research helps everyone
Year stage I Stage II Stage III Stage IVUrban Rural Urban Rural Urban Rural Urban Rural
1999 3.4 1.6 25.4 20.8 50 52 21 25
2004 3.5 4.1 31.3 39.2 41 43 8.5 14.4
2006 5.7 3.3 40.1 40.6 46 45 5.7 9.9
Change +60% +100% +58% +95% -8% -13% -73% -60%
Over only 7 years, breast cancer has been down-staged in Egypt, a mid-resource country, by the most objective measure known: population registry with active registration & integrated program
Palliative Care
Most immediately devastating GH inequityGHTR in PC capable of greatest impact in shortest time at lowest cost: low cost technologies effective (morphine)
Promotes new paradigms of global health– Couples PC (dying patient) to attending relatives
(early detection in high risk individuals, modulation of lifestyle modifiers)
Cost for 30 days (USD)$0
$20
$40
$60
$80
$100
$120$108
$52
Cost as % of monthly per capita GNP0%
5%
10%
15%
20%
25%
30%
35%
40% 38%
3%
Median morphine costs for developing and developed countries.
Developing CountriesDeveloped Countries
De Lima L., Sweeney C., Palmer J.L., Bruera E. Potent analgesics are more expensive for patients in developing countries: A comparative study. Journal of Pain & Palliative Care Pharmacotherapy, Vol. 18(1) 2004