Closing the Cancer Divide: Living, Learning and Leading

First Indian Cancer Congress New Delhi, November 21, 2013

Dr. Felicia Marie Knaul
Director, Harvard Global Equity Initiative, Global Task Force on Expanded Access to Cancer Care and Control Assoc Professor, Harvard Medical School Sr. Economist, Fundacin Mexicana para la Salud Founder and President, Tmatelo a Pecho Board Member, Union for International Cancer Control

January, 2008 June, 2007

From anecdote

to evidence

Nobel Amartya Sen,

Cancer survivor diagnosed in India 60 years ago

Harvard, Breast Cancer in Developing Countries, Nov 4, 2009

Global Task Force on Expanded Access to Cancer Care and Control

Closing the Cancer Divide:

An Equity Imperative
Expanding access to cancer care and control in LMICs:
M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate

I: Should be done II: Could be done III: Can be done

1: Innovative Delivery 2: Access: Affordable Meds, Vaccines & Techs 3: Innovative Financing: Domestic and Global 4: Evidence for Decision-Making 5: Stewardship and Leadership

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
More than 85% of pediatric cancer cases and 95% of deaths occur in developing countries.

The Cancer Transition

Double burden for health systems
Mirrors the epidemiological transition LMICs increasingly face both infectionassociated cancers, and all other cancers. Cancers increasingly only of the poor, are not the only cancers affecting the poor
LMICs account for >90% of cervical and 70% of breast cancer deaths. Both are leading killers especially of young - women.

Breast and cervical cancer Incidence & mortality, % change 1980-2010

300
200

BREAST Cases Deaths

CERVICAL Cases Deaths

Lower income

Lower Middle income

Upper Middle income

Developing

High income

Global

The Cancer Divide: An Equity Imperative

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:
1. 2. 3. 4. 5. Preventable cancers (infection) Exposure to risk factors Treatable cancer death and disability Stigma and discrimination Avoidable pain and suffering

Facets

100%

Facet 3: The Opportunity to Survive (M/I) Should Not Be Defined by Income

Children Adults Survival inequality gap

Leukaemia

All cancers LOW INCOME HIGH INCOME LOW INCOME HIGH INCOME

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

In Canada, almost 90% of children with leukemia survive. In the poorest countries only 10%.

Facet 5: The most insidious injustice: the pain divide Non-methadone, Morphine
N. America
Equivalent opioid consumption per death from HIV or cancer in pain: Poorest 10%: 54 mg Richest 10%: 97,400 mg US/Canada: 270,000 mg

Asia

India

Africa
Data: http://www.treatthepain.com/methodology Calculations: HGEI/Funsalud Knaul et al. Eds Closing the Cancer Divide.

Latin America

The 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.

Challenge and disprove the myths about cancer

M1. Unnecessary

M2. Unaffordable M3. Inappropriate

M4: Impossible

Investing In CCC: We Cannot Afford Not To

Total economic cost of cancer, 2010: 2-4% of global GDP Tobacco is a huge economic risk: 3.6% lower GDP Inaction reduces efficacy of health and social investments

1/3-1/2 of cancer deaths are avoidable: 2.4-3.7 million deaths, of which 80% are in LIMCs Prevention and treatment offers potential world savings of $ US 130-940 billion

The Diagonal Approach to Health System Strengthening

Rather than focusing on either disease-specific vertical or horizontal-systemic programs, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps and optimize available resources Diagonal strategies major benefits: X = > parts Bridge disease divides using a life cycle response avoids the false dilemmas between disease silos Generate positive externalities: e.g. womens cancer programs fight gender discrimination; pain control 4all

Women and mothers in LMICs face many risks through the life cycle Women 15-59, annual deaths
- 35% in 30 years
Mortality in childbirth Breast cancer Cervical cancer Diabetes

342,900

166,577

142,744

120,889

= 430, 210 deaths

Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.

Challenge and disprove the myths about cancer

M1. Unnecessary M2. Unaffordable M3. Inappropriate

M4: Impossible

Closing the Cancer Divide:

A BLUEPRINT TO EXPAND ACCESS IN LMICs

Applies a diagonal approach to avoid the false dilemmas between disease silos -CD/NCD- that continue to plague global health

Diagonalizing Cancer Care: Financing & Delivery

1. Financing: Integrate cancer care into national insurance and social security programs
Mexico, Dom. Rep., Colombia, Peru, China, India

2.

Delivery: Harness platforms by integrating breast and cervical cancer prevention, screening and survivorship care into MCH, SRH, HIV/AIDS, social welfare and anti-poverty programs.

Mexicos 2003 Health reform created Seguro Popular

Benefits Package
2004: 6.5 m 2012: 54.6 m Vertical Coverage Diseases and Interventions:

Affiliation:

Benefit package:
2004: 113 2012: 284+57

Horizontal Coverage:

Beneficiaries

Mexico Seguro Popular: diagonal, financial protection for catastrophic illness

Accelerated, universal, vertical coverage by disease with an effective package of interventions 2004/6: HIV/AIDS, cervical cancer, ALL kids 2007: All pediatric cancers; Breast cancer 2011: Testicular and Prostate cancer and NHL 2012: Ovarian (colorectal) cancer

Seguro Popular and cancer: Evidence of impact

Breast cancer adherence to treatment:
2005: 200/600 2010: 10/900

Since the incorporation of childhood cancers into the Seguro Popular

30-month survival: 30% to almost 70% adherence to treatment: 70% to 95%.

The human faces of Seguro Popular: Guillermina Avila & Abish Romero

Responding to the challenge of chronicity: Health system functions by care continuum

Stage of Chronic Disease Life Cycle /components CCC Health System Functions
Primary Prevention Secondary prevention Survivorship/ Rehabilitation Palliation/ End-of-life care

Diagnosis

Treatment

Stewardship

Financing

Delivery

Resource Generation

Effective financial coverage of a chronic disease: breast cancer

Cancer Control-Care continuum
Primary Prevention Early Detection

Diagnosis

Treatment

Survivorship

Palliation

Mexico: Large and exemplary investment in financial protection for breast cancer prevention and treatment, yet..a low survival rate. Strengthen early detection, survivorship and palliation: diagonalize delivery

Responding to Breast Cancer: Delivery failure

# 2 killer of women 30-54 5-10% detected in Stage 0-1 Poor municipalites: 50% Stage 4; 5x the rate for rich
% diagnosed in Stage 4 by state
RIch

Poor

Juanita:
Advanced metastatic breast cancer is the result of a series of missed opportunities

Diagonalizing Delivery 1: Integration of cervical & breast cancer education into anti-poverty programs, Oportunidades
Include information in manuales for community workers 1.5 million promoters > 90% of poor Mexican households: 5.8 million families

Diagonalizing Delivery 2: Training primary care providers in early detection of breast cancer
Promoters (+4000), Nurses & MDs (+1400), medical students (+750)
Nuevo Leon, Jalisco, Morelos, Puebla

Significant increase in knowledge, especially in CBE

Duality: evidence and advocacy

Evidence-based advocacy Advocacy-inspired evidence

Action: projects, programs, policies

Be an optimist optimalist

Expanding access to cancer care and control in LMICs: Should, Could, and Can be done