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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Challenge and disprove themyths about cancer/NCD
M1. Unnecessary: NECESSARY
M2. Impossible:
Nothing we can do about itM3. Unaffordable: .for the poor
M4: Inappropriate: either/or
Challenging cancer implies taking resourcesaway from other diseases of the poor`
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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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Challenge and disprove themyths about cancer/NCD
M1. Unnecessary: NECESSARY
M2. Impossible:POSSIBLE
M3. Unaffordable: .for the poorM4: Inappropriate: either/or
Challenging cancer implies taking resourcesaway from other diseases of the poor`
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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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Challenge and disprove themyths about cancer/NCD
M1. Unnecessary: NECESSARY
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