Closing the cancer divide for women: Part 1

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Guest Lecture, 27 de febrero de 2013

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Closing the cancer divide for women: Part 1

  1. 1. ClosingClosing thethe cancercancer dividedivide ff PP 11fforor womenwomen:: PartPart 11 Guest Lecture February 27th, 2013 Felicia Marie Knaul, PhDFelicia Marie Knaul, PhD Harvard Global Equity Initiative, Global Task Force on Expanded Access toHarvard Global Equity Initiative, Global Task Force on Expanded Access toq y , pq y , p Cancer Care and Control in LMICsCancer Care and Control in LMICs Tómatelo a Pecho A:C. MéxicoTómatelo a Pecho A:C. México Mexican Health FoundationMexican Health Foundation
  2. 2. F d tFrom anecdote … … to evidence
  3. 3. The night of my high school prom visiting myThe 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.
  4. 4. In the children’s cancer ward of the Hospital Pediátrico de Sinaloa promoting Sigamos Aprendiendo en el Hospital. Culiacán, late 2005.
  5. 5. January, 2008June, 2007
  6. 6. Battling sepsis in the Médica Sur Hospital. Mexico City. July 2008
  7. 7. Launching a program h M iat the Mexican Health Foundation the day I got sepsis. July 2008.
  8. 8. Juanita:Jua ta: Advanced metastatic breast i f icancer is the result of a series of missed opportunitieso ssed oppo tu t es
  9. 9. From anecdoteFrom anecdote … t id… to evidence
  10. 10. Closing the Cancer Divide:Closing the Cancer Divide: A BLUEPRINT TO EXPAND ACCESSIN LOWA BLUEPRINT TO EXPAND ACCESSIN LOW AND MIDDLE INCOME COUNTRIESAND MIDDLE INCOME COUNTRIES Report and overview availableReport and overview available in English, Spanish, and Russian at: http://www hgei harvard edu/http://www.hgei.harvard.edu/ Coming soon in: Arabic and Chines Closing the Cancer Divide:Closing the Cancer Divide: An Equity ImperativeAn Equity Imperative Closing the Cancer Divide:Closing the Cancer Divide: An Equity ImperativeAn Equity Imperative Book distributed by Harvard University Press and available at: htt // h h d d / An Equity ImperativeAn Equity ImperativeAn Equity ImperativeAn Equity Imperative http://www.hup.harvard.edu/
  11. 11. Dedicated to: Amanda J. Berger (1987 2012)(1987-2012)
  12. 12. GTF.CCC Members
  13. 13. GlobalGlobal TaskTask ForceForce onon ExpandedExpanded AccessAccess toto CancerCancer Care andCare and Control inControl in DevelopingDeveloping CountriesCountriesControl inControl in DevelopingDeveloping CountriesCountries l b l h lth= global health + cancer care
  14. 14. Closing theClosing the Cancer DivideCancer Divide:: A BLUEPRINT TOA BLUEPRINT TO EXPANDEXPAND ACCESSACCESS IN LMICsIN LMICsA BLUEPRINT TOA BLUEPRINT TO EXPANDEXPAND ACCESSACCESS IN LMICsIN LMICs Applies a diagonalApplies a diagonal approach to avoidapproach to avoidapproach to avoidapproach to avoid the false dilemmasthe false dilemmasthe false dilemmasthe false dilemmas between disease silosbetween disease silos --CD/NCDCD/NCD-- thatthat ti t lti t lcontinue to plaguecontinue to plague global healthglobal healthglobal healthglobal health
  15. 15. Closing the Cancer Divide: A E it I tiAn Equity Imperative I: Much should be doneI: Much should be done II: Much could be done III: Much can be done 1: Innovative Delivery1: Innovative Delivery 2: Access to Affordable Medicines, Vaccines & TechnologiesVaccines & Technologies 3: Innovative Financing: Domestic d Gl b land Global 4: Evidence for Decision-Making 5: Stewardship and Leadership
  16. 16. Challenge and disprove theChallenge and disprove the myths about cancery Expanding access to cancer care and control in l d iddl i i M1 U low and middle income countries: M1. Unnecessary M2. Unaffordable •Should, M2. Unaffordable M3. Impossible •Could, and M4: Inappropriate •Can…..
  17. 17. The Cancer Transition i h id i l i l i i The Cancer Transition Mirrors the epidemiological transition LMICs increasingly face both infectionLMICs increasingly face both infection- associated cancers, and all other cancers. Cancers increasingly only of the poor, are not the only cancers affecting the poor.not the only cancers affecting the poor.
  18. 18. For children & adolescentsFor children & adolescents 5-14 cancer is #2 cause of death in wealthy countries 5 14 cancer is #2 cause of death in wealthy countries #3 in upper middle-income#3 in upper middle income #4 in lower middle-income and # 8 in low-income countries More than 85% of pediatric cancer cases and 95% of d th i d l i t ideaths occur in developing countries.
  19. 19. The cancer transition in LMICs: breast and cervical cancer % Change in # of deaths LMIC t f 53% % Change in # of deaths 1980-2010LMICs account for >90% of cervical cancer deaths and >60% of breast 20%19%>60% of breast cancer deaths. 0% LMIC’s High Both diseases are leading killers -31% LMIC s High income leading killers – especially of young Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011. 31% women.
  20. 20. Mortality from breast and cervical cancer in  México 1955‐2010México 1955 2010 Tasa por 100,000 mujeres ajustado por edad 12 16 8 4 Mama Cervix 0 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2010 2006: CS>CC. Por primera vez en más de 5 décadas. Fuente: Lozano, Knaul, Gómez‐Dantés, Arreola‐Ornelas y Méndez, 2008, Tendencias en la mortalidad por cáncer de mama en México, 1979‐2007. FUNSALUD, Documento  de trabajo. Observatorio de la Salud, con base en datos de la OMS y la Secretaría de Salud de México.
  21. 21. Mortalidad de cáncer de mama y cervical en México 1979-2010cervical en México 1979-2010 Nuevo León30 oredad Nuevo León 20 25 30 Cáncer de mama Cáncer de cérvix ajustadopo 5 10 15 30 Oaxaca 00mujeresa 0 5 1979 1980 1985 1990 1995 2000 2005 2010 980 990 000 010 980 980 980 15 20 25 apor100,00 1 1 2 2 1 1 1 0 5 10 Tasa 0 1979 1980 1985 1990 1995 2000 2005 2010 1980 1990 2000 2010 1980 1980 1980 Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola‐Ornelas and Méndez.
  22. 22. Evolution of difference between mortality rate from cervical and breast cancer in Mexico  by level of municipal marginality  10 15                                Breast cancer) (1979 ‐2010) 5 ence                       ‐Mortality rate B 0 Differe e Cervical cancer‐ Very High High ‐10 ‐5 79 80 85 90 95 00 05 10 (Mortality rate Average Low Very Low 197 198 198 199 199 200 200 201 Year
  23. 23. TheThe CancerCancer Divide:Divide: disparities inp outcomes between poor and rich directly related to inequities in access and differences into inequities in access and differences in underlying socio- economic and health conditions • The divide is the result of concentrating risk conditions. factors, preventable disease, suffering, impoverishment from ill health and death l tiamong poor populations. • fueled by progress in cutting-edge science and medicine in high-income countries.
  24. 24. The Cancer Divide: C i di f b h i h d An Equity Imperative Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:yet it is increasingly the poor who suffer: 1 Exposure to risk factors1. Exposure to risk factors 2. Preventable cancers (infection)( ) 3. Treatable cancer death and disability acets 4. Stigma and discrimination 5 A id bl i d ff i Fa 5. Avoidable pain and suffering
  25. 25. Facet 1: Exposure to risk factors: Daily Tobacco Smoking Men Women on 60 Women Both sexes ulati 40 fpopu 20 %of 20 % 0 Low Lower iddl Upper iddl High Age-standardized prevalence of risk factor in adults aged 15+ years income middle middle Source: WHO. The Global Status Report on Noncommunicable Diseases 2010.
  26. 26. Facet 1: Risk factor concentration: Ob it E id i l M iObesity Epidemic, example Mexico % 20 49 60 57 % women 20‐49 years 37 37 Overweight Obesity 2006 32 25 37 25 36 37 29 y 1988 1999 25 251988 10 8 10 2 22 2 Malnutrition Adequate
  27. 27. Facet 2: Incidence and i imortality, cervical cancer (adjusted rate per 100,000 women) MortalityIncidence ( j p , )
  28. 28. Facet 3: The Opportunity to Survive Sh ld N b I D fi d b I 100% Should Not, but Is Defined by Income AdultsChildren ine Leukaemia Surviv equality All cancers val ygap LOW INCOME HIGH INCOME LOW INCOME HIGH INCOME In Canada, almost 90% of children with leukemia survive Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010. leukemia survive. In the poorest countries only 10%.
  29. 29. Cancer – especially in Facet 4:Facet 4: women and children - adds a layer of discrimination onto Stigma:Stigma: layer of discrimination onto ethnicity, poverty, andethnicity, poverty, and gender. S i hiSurvivorship care is non-care is non existent.
  30. 30. Facet 5: The most insidious injustice is lack of access to pain controlis lack of access to pain control Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain: Poorest 10%: 54 mg per death Richest 10%: 97,400 mg per death
  31. 31. Challenge and disprove theChallenge and disprove the myths about cancer M1 Unnecessary NECESSARYNECESSARYM1. Unnecessary NECESSARYNECESSARY M2. Unaffordable: ….for the poorUnaffordable: ….for the poorpp M3. Inappropriate: either/or Ch ll i i li kiChallenging cancer implies taking resources away from other ‘diseases of the poor’ M4: Impossible
  32. 32. Investing In CCC: We Cannot Afford Not To Inaction reduces efficacy of health and social investments Total economic cost of cancer, 2010: 2-4% of global GDPg Tobacco is a huge economic risk: 3.6% lower GDP 1/3-1/2 of cancer deaths are “avoidable”: 2 4 3 7 million deaths✓ 2.4-3.7 million deaths, of which 80% are in LIMCs ✓ Prevention and treatment offers potentialeve o d e e o e s po e world savings of $ US 130-940 billion
  33. 33. The costs to close the cancer divide b l th fmay be less than many fear: All b t 3 f 29 LMIC i it h d h lAll but 3 of 29 LMIC priority cancer chemo and hormonal agents are off-patent Cost of drug treatment: cervical cancer + HL + ALL(kids) in LMICs / year of incident cases: $US 280 m Pain medication is cheap Prices drop: HepB and HPV vaccinesPrices drop: HepB and HPV vaccines Delivery & financing innovations are underutilized & undeveloped: purchasing fragmented procurement unstableundeveloped: purchasing fragmented, procurement unstable
  34. 34. Prices drop: drugs and vaccines Second-line TB Drugs (Farmer, 2009) % Decline in price 1997-9 p g Amikacin 90% Ethionamide 84% C i 97%Capreomycin 97% Ofloxacin 98% Hep B vaccine: decline from a 1982 launch price of over $100 to $0.20 a dose has enabled developing countries to dramatically increase vaccination rates with support from GAVI HPV vaccine in LMICs: B f 2011 f $US 30 $US 100 d vaccination rates with support from GAVI • Before 2011: from $US 30 to $US 100 per dose • PAHO Revolving Fund: decreased from US$ 32 per dose in January 2010 to US$ 14 per dose in April 2011. • GAVI: June 2011 Merck offers vaccine at US$ 5 per dose for low income countries.
  35. 35. What is innovative about innovative financing? • establishment of integrated financing• establishment of integrated financing mechanisms that mobilise, pool, allocate, and channel financial resources to LMICs • provide platforms that can expand to addressprovide platforms that can expand to address health needs in LMICs Th L t O t 25 2012• The Lancet, Oct 25 2012 • What is innovative about innovative financing? The Lancet, Oct 25 2012 Atun, Knaul, Akachi, Frenk PAHO Strategic Fund includes NCDs, 2012 
  36. 36. Opportunity: I ti Gl b l Fi iInnovative Global Financing • Integrated financing mechanisms mobilise poolIntegrated financing mechanisms mobilise, pool, allocate, and channel financial resources to LMICs e g Global Fund GAVI PAHO SFLMICs – e.g. Global Fund, GAVI, PAHO SF • provide platforms & concepts that can be d t d t dd th h lth d i LMICadapted to address other health needs in LMICs • What is innovative about innovative financing? Lancet,  Oct 25 2012 Atun, Knaul, Akachi, Frenk PAHO Strategic Fund includes NCDs, 2012  Pink Ribbon Red Ribbon‐ a diagonal initiative g Global Paediatric Financing Entity
  37. 37. Global Paediatric Oncology Financing Entity O t it• Opportunity: – 90% in 25 poorest countries die; 90% in richest live – Could save >60 000 livesCould save >60,000 lives – Move PedOnc off the GLOBAL list of top killers • Problem: small, geographically fragmented demand; no, g g p y g ; market for drugs; complex delivery (?); many countries without financing; other countries have $ and yet face drug shortagesdrug shortages • Delivery solution: innovative global delivery mechanisms (St. Judes/My Child Matters; Sick Kids;( y ; ; DFCI etc) • Financing solution: global opportunity
  38. 38. Challenge and disprove theChallenge and disprove the myths about cancer M1 Unnecessary NECESSARYNECESSARYM1. Unnecessary NECESSARYNECESSARY M2. Unaffordable:Unaffordable: ….for the poor….for the poorpp M3. Inappropriate: either/or Ch ll i i li kiChallenging cancer implies taking resources away from other ‘diseases of the poor’ M4: Impossible
  39. 39. The Diagonal Approach to Health System Strengthening R th th f i ith di ifiRather than focusing on either disease-specific vertical or horizontal-systemic programs, harness i th t id t iti t t kl disynergies that provide opportunities to tackle disease- specific priorities while addressing systemic gaps and ti i il bloptimize available resources Diagonal strategies: X = > Σ parts Bridge disease divides: patients suffer over a lifetime, most of it chronic. Generate positive externalities: e.g. women’s cancer programs also combat gender discrimination; access to pain control supports surgery platformscontrol supports surgery platforms
  40. 40. Why diagonal delivery?Why diagonal delivery? Sh d i k f tShared risk factors Co-morbidityy Life cycle approach Efficiency: Common need for strong healthEfficiency: Common need for strong health system platforms Knowledge sharing and inter institutionalKnowledge sharing and inter-institutional collaboration E i d l tEconomic development Social justicej
  41. 41. Diagonal Strategies: P iti E t litiPositive Externalities Promoting prevention and healthy lifestyles:g p y y Reduce risk for cancer and many other diseases Reducing stigma around women’s cancers:Reducing stigma around women’s cancers: Contributes to reducing gender discrimination Introducing cancer treatment for children Improves hygiene and reduces intra-hospital infectionsImproves hygiene and reduces intra hospital infections Promoting access to education for children w/ cancer R d t t ib t t i l d l tReduces poverty, contributes to social development Pain control and palliation Reducing barriers to access is essential for cancer as well as for for other diseases and for surgery.
  42. 42. Women and mothers in LMICs f i k th h th lif lface many risks through the life cycle Women 15-59, annual deathsWomen 15 59, annual deaths Diabetes Breast cancer Cervical cancer Mortality in childbirth- 35% in 30 years 120,889166,577 142,744342,900 430 210 d h Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011. = 430, 210 deaths
  43. 43. Challenge and disprove theChallenge and disprove the myths about cancer M1 UnnecessaryM1. Unnecessary M2. UnaffordableM2. Unaffordable M3. Inappropriate M4: Impossible
  44. 44. Initial views on MDR-TB 1996 9treatment, c. 1996-97 “MDR-TB is too expensive to treat in Outcomes in MDR-TB patients in Lima, Peru poor countries; it detracts attention and p , receiving at least four months of therapy resources from treating drug-susceptible months of therapy Abandon Failed therapy 8% Died 8% disease.” WHO 1997 CuredCured 83%83% therapy 2% 8% All patients initiated therapy between Aug 96 and Feb 99
  45. 45. Championsp Nobel Amartya Sen, Cancer survivor diagnosed in India Drew G. Faust President of Harvard University Cancer survivor diagnosed in India 50 years ago President of Harvard University 22+ year BC survivor Harvard, Breast Cancer in DevelopingHarvard, Breast Cancer in Developing Countries, Nov 4, `09Countries, Nov 4, `09
  46. 46. Rural Rwanda: 0 oncologist Burkitt´s lymphoma Embryonal RhabdomyosarcomaRhabdomyosarcoma Source: Paul Farmer., 2009
  47. 47. St. Jude’s International Outreach Program • Twinning in 20+ countries –El Salvador: 5-year survival for children with ALL increased from 10% to 60% inwith ALL increased from 10% to 60% in five years • Cure4Kids/Oncopedia –Over 31,000 users in more than 183 countriescountries
  48. 48. México: IT IS POSSIBLE
  49. 49. ‘Diagonalizing’ Financing:Diagonalizing Financing: I t t d t l i tIntegrate cancer care and control into national insurance and social securityy programs to express previously suppressed demand beginning with cancers of womendemand beginning with cancers of women and children: Mexico, Colombia, Dom Rep, Peru China, India, Thailand R d Gh S h Af iRwanda, Ghana, South Africa
  50. 50. Universal Health Coverage in Mexico through Seguro Popular ge   e ntions:  Packag Coverag nterven nefit P ertical C es and I ed Ben Horizontal Coverage: Ve Disease xpande g > 54.6 million Beneficiaries D Ex
  51. 51. Evolution of vertical coverage: cumulative # f d i i 2004 2012of covered interventions, 2004-2012 500 CAUSES  284 FPCHE    57 400 450 108 116 128 128 131 MING FPCHE s MING + SP 57 300 350 49 49 49 57 57 110 108 116 EPHS EPI CBP erventions FPCHE 57 interventions 200 250 184 189 189 198 198 206 17 20 mberofinte S P l interventions CAUSES 91  FPCHE       6 100 150 6 6 8 6 12 12 12 12 1322 83 176 184 189 189 6 6 Num Seguro Popular 284 interventions Notes: 0 50 2004 2005 2006 2007 2008 2009 2010 2011 2012 63 65 65 65 65 65 65 65 65 6 6 SP = Seguro Popular  MING = Medical Insurance for a New Generation (Children born after December 1, 2006 and until they are 5 years of age) FPCHE = Fung for Protection against Catastrophic Health Expenditure EPHS =Essential Personal Health Services EPI = Expanded Programme of Immunisations CBP= Community‐based package ”
  52. 52. Seguro Popular: Cancer and the Fund for Protection fromCancer and the Fund for Protection from Catastrophic Illness Accelerated, universal, vertical coverage by disease with an effective package of interventionsp g 2004: HIV/AIDS i l2005: cervical cancer 2006: ALL in children2006: ALL in children 2007: All pediatric cancers; Breast cancer 2011: Testicular and Prostate cancer and NHL 2012 C l t l2012: Colorectal cancer
  53. 53. Seguro Popular and cancer: Evidence of impact Since the incorporation of childhood cancers i t th S P linto the Seguro Popular Adherence to treatment: 70% to 95% Breast cancer adherence to treatment: 2005: 200/600 2010: 10/900 Access to medicines – an anecdote
  54. 54. Effective financial coverage: b t i M ibreast cancer in Mexico – Primary prevention – Secondary prevention (early detection) – DiagnosisDiagnosis – Treatment S i hi– Survivorship care – Palliative care Large and exemplary investment in treatment for women and the health system, yet a low survival rate. By applying a diagonal approach, this can and is being remedied.
  55. 55. Responding to the challenge of chronicity: Health system functions by care continuumHealth system functions by care continuum Health System F ti Stage of Chronic Disease Life Cycle /components CCC Functions Primary Prevention Secondary prevention Diagnosis Treatment Survivorship/ Rehabilitation Palliation/ End-of-life care Stewardship FinancingFinancing Delivery Resource Generation
  56. 56. Horizontal and vertical financial protection strategies: S P l i M iSeguro Popular in Mexico entions ACCELERATED VERTICAL COVERAGE for Catastrophic Illnesses included  in the Fund: breast cancer,  AIDS interve Survivorship Prevention,  Early detection overed Package of essential personal services nefits:co CHILDREN: Health insurance for a New Generation Ben Community and Public Health Services CHILDREN: Health insurance for a New Generation Poor Rich Beneficiaries
  57. 57. Delivery failure: Breast Cancer •# 2 killer of women 30-54 y # 2 killer of women 30 54 •Only 5-10% of cases in Mexico are detected in Stage 1 or in situdetected in Stage 1 or in situ •Poor municipalites: 50% Stage 4; 5x rich % diagnosed in Stage 4 by state Juanita Poor/Marginalized
  58. 58. Solution: ‘Diagonalizing’ Delivery Harness platforms by integrating breast and cervical cancer prevention, screening andp , g survivorship care into MCH, SRH, HIV/AIDS, social welfare and anti-poverty programssocial welfare and anti poverty programs. E ample:Example: • Mexico: integration of breast and cervical cancer awareness and screening into the national anti-poverty programinto the national anti-poverty program Oportunidades
  59. 59. Including breast cancer awareness for l d i i O id dearly detection in Oportunidades • “Guía de orientación y capacitación a titularescapacitación a titulares beneficiarios del programa Oportunidades” includesp information on breast cancer as of 2009/10 • 1 5 million copies to• 1.5 million copies to promoters • Reaches 5 8 million families =Reaches 5.8 million families more than 90% of poor households
  60. 60. Where are the opportunities?Where are the opportunities? • LMICs not months but whole lifetimes to be gained• LMICs – not months but whole lifetimes to be gained • Focus on prevention but do not stop there! – No prevent/treat dichotomizationp • Do not take prices as fixed or given – price permeability • Harness global and national health system platforms • Redefine and reformulate health systems to manage chronicity • Innovate in implementation, delivery and financing Evaluate replicate and scale up– Evaluate, replicate and scale up – Leapfrog and give forward • Harness cancer to strengthen health and social systemsg y • Recognize LMICs as part of a global solution: investment in learning, research and human beings
  61. 61. BeBe ananBeBe anan optimistoptimistoptimistoptimist optimalistoptimalistoptimalistoptimalist Expanding access to cancer care and control inExpanding access to cancer care and control in LMICs: Should, Could, and Can be done
  62. 62. CC i ?i ?CancerCancer-- Did you Know?Did you Know? Disproving the MythsDisproving the MythsDisproving the MythsDisproving the Myths About Cancer inAbout Cancer in WORLDWORLD CANCERCANCER ResourceResource--constrained Settingsconstrained Settings CANCERCANCER DAYDAY SeminarSeminar HarvardHarvard SchoolSchool ofof PublicPublic HealthHealth FebruaryFebruary 1st, 20131st, 2013 SeminarSeminar Felicia Marie Knaul, PhDFelicia Marie Knaul, PhD Harvard Global Equity Initiative, Global Task Force on Expanded Access toHarvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control in LMICsCancer Care and Control in LMICsCancer Care and Control in LMICsCancer Care and Control in LMICs Tómatelo a Pecho A:C. MéxicoTómatelo a Pecho A:C. México Mexican Health FoundationMexican Health Foundation Union for International Cancer ControlUnion for International Cancer Control
  63. 63. Thank youThank you

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