Guest Lecture, 27 de febrero de 2013

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. F d tFrom anecdote …
… to evidence

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. In the children’s cancer ward of the Hospital Pediátrico de Sinaloa
promoting Sigamos Aprendiendo en el Hospital. Culiacán, late 2005.

5. January, 2008June, 2007

6. Battling sepsis in the
Médica Sur Hospital.
Mexico City. July 2008

13. Launching a program
h M iat the Mexican
Health Foundation
the day I got sepsis.
July 2008.

15. Juanita:Jua ta:
Advanced metastatic breast
i f icancer is the result of a series
of missed opportunitieso ssed oppo tu t es

16. From anecdoteFrom anecdote …
t id… to evidence

17. 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/

18. Dedicated to:
Amanda J. Berger
(1987 2012)(1987-2012)

19. GTF.CCC
Members

20. 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

21. 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

22. 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

23. 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…..

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. 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

30. 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.

31. 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

32. 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.

33. 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

34. Facet 2: Incidence and
i imortality, cervical cancer
(adjusted rate per 100,000 women)
MortalityIncidence
( j p , )

35. 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%.

36. 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.

37. 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

38. 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

39. 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

40. 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

41. 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.

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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.

49. 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

50. Challenge and disprove theChallenge and disprove the
myths about cancer
M1 UnnecessaryM1. Unnecessary
M2. UnaffordableM2. Unaffordable
M3. Inappropriate
M4: Impossible

51. 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

52. 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

53. Rural Rwanda: 0 oncologist
Burkitt´s
lymphoma
Embryonal
RhabdomyosarcomaRhabdomyosarcoma
Source: Paul Farmer., 2009

54. 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

55. México: IT IS POSSIBLE

56. ‘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

57. 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

58. 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 ”

59. 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

60. 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

61. 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.

62. 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

63. 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

64. 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

66. 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

67. 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

68. 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

69. 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

70. 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

71. Thank youThank you