closing the cancer divide: an equity imperative for women and health 071211
TRANSCRIPT
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Felicia Marie Knaul
Harvard Global Equity Initiative,
Mexican Health Foundation
Tmatelo a pecho
World Health Organization
December 6th, 2011
Closing the cancer divide:
an equity imperative
for women and health
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Closing the Cancer Divide:A Blueprint to Expand Access in LMICs
I: Much should be doneII: Much could be done
III: Much can be done
1: Innovative Delivery
2: Access to Affordable Medicines,
Vaccines & Technologies
3: Innovative Financing: Domesticand Global
4: Evidence for Decision-Making
5: Stewardship and Leadership
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Applies a diagonal
approach to avoid
the false dilemmasbetween disease silos
-CD/NCD- thatcontinue to plague
global health
Closing the Cancer Divide:A BLUEPRINT TO EXPAND ACCESS IN LMICs
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Global Task Force on Expanded
Access to Cancer Care and
Control in Developing Countries
= global health + cancer care
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A) Should be done:
B) Could be done:
C) Can be done
Myth 1. Unnecessary
Myth 2. Inappropriate
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
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Cancer is a disease of both rich and poor;
yet it is increasingly the poor who suffer:
1. Exposure to risk factors2. Preventable cancers (infection)
3. Death and disability fromtreatable cancer
4. Stigma and discrimination
5. Avoidable pain and suffering
The Cancer Divide:
An Equity Imperative
Fac
ets
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Risk factor concentration: Obesity
Epidemic in countries such as Mexico
10
60
8
32
57
25
10
2
37
25
36 37
29
2
Malnutrition Adequate
Overweight
Obesity
1988
1999
% women 20-49 years
2006
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Cancer is becoming a leading cause
of childhood death: Epi transition
M. tumorsInf + parasiticRespiratory infs
Source: Estimates based on data from the Ministry of Health, Mexico.
1979
1990
2000
2008
0
10%
20%
30%
40%
1979
1990
2000
2008
1-4 5-14
% of total mortality, Mexico, 1979-2008
Cancer, 5-14: 3rd in upper middle income,
4th in lower middle, 8th in low income countries.
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Mirrors the overall epidemiological
transitionprotracted and polarized*:
LMICs increasingly face both cancersassociated with infection, and all other
cancers.
Cancers that were once considered only ofthe poor, now cease to be the only cancers
of the poor. (e.g. cervical & breast cancer)
The Cancer Transition
* Frenk et al
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MortalityIncidence
Incidence and mortality of cervical cancer(adjusted rate per 100,000 women)
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Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.
The cancer transition in LMICs:
breastand cervicalcancer
53%
20%19%
-31%
0%
LMICs High
income
% Change in # of deaths1980-2010LMICs account for
>90% of cervical
cancer deaths and
>60% of breast
cancer deaths.
Both diseases are
leading killers
especially of young
women.
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The cancer transition within countries:breastand cervicalcancer mortality
Oaxaca
1979-200825
0
8
16 Mexico1955 - 2008
Costa Rica1995 - 2005
0
0
Nuevo Leon1979-200825
0
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Adults
Leukaemia
All cancers
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW
INCOME
HIGH
INCOME
Sur
vival
inequa
litygap
LOW
INCOME
HIGH
INCOME
100%
The Opportunity to Survive (M/I)
Should Not Be Defined by Income
In Canada, almost 90% of children with
leukemia survive.
In the poorest countries only 10%.
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Stigma:
Juanita
Cancer, and
especially
reproductive
cancers, adds
a layer ofdiscrimination
onto gender,
ethnicity, andpoverty.
Th t i idi f t
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The most insidious facet:
access to pain control
Non-meth, Morphine-e opioid consumption per death from HIV or cancerUSACanada
Austria
Germany
Denmark
UAE
Norway
KuwaitJapan
050,000
280,000
$0 $40,000 $80,0000
1,000
$0$3,500
Low
Income0
10,000
$0 $14,000
Low
middle
Qatar
Gap in access to pain control: 54 mg per HIV/cancer death in pain in the
poorest decile to >97,000 in the richest decile of the worlds countries.
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A) Should be done:
B) Could be done:
C) Can be done
Myth 1. Unnecessary
Myth 2. Inappropriate
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
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Women and mothers in LMICs
face many risks through the life cycle
Women 15-59, annual deaths
Diabetes
120,889
Breast
cancer
166,577
Source: Estimates based on data from WHO: Global Health Observatory, 2008 and Murray et al Lancet 2011.
Cervical
cancer
142,744
Mortality
in
childbirth
342,900
- 35%in 30
years
= 430, 210 deaths
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The Diagonal Approach to
Health System Strengthening
Rather than focusing on disease-specific vertical
programs or only on horizontal system
constraints, harness synergies that provideopportunities to tackle disease-specific priorities
while addressing systemic gaps.
Optimize available resources so that the whole ismore than the sum of the parts.
Bridge the divide as patients suffer diseases over a
lifetime, most of it chronic.
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Why diagonal?
Shared risk factors
Success and life cycle
Common need for strong healthsystems platforms
Economic developmentSocial justice
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Diagonal Strategies:
Positive Externalities
Promoting prevention and healthy lifestyles:
Reduce risk for cancer and other diseases
Reducing stigma for womens cancers:Contributes to reducing gender discrimination.
Pain control and palliation
Reducing barriers to access is essential forcancer, for other diseases, and for surgery.
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Delivery: Harness platforms byintegrating cancer prevention,
screening and survivorshipsupport into MCH, SRH,
HIV/AIDS, social welfare andanti-poverty programs.
A Diagonal Strategy:
i
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A) Should be done: necessary
and appropriate
B) Could be done:
C) Can be done
Myth 3. Unaffordable
Myth 4: Impossible
Expanding access to cancer
care and control in LMICs:
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Investing In CCC:
We Cannot Afford Not To
Health is an investment, not a cost
Tobacco is a huge economic risk: 3.6% lower GDP
Total economic cost of cancer, 2010: 2-4% of global GDPPrevention and treatment offers potential world savings of
$ US 131-850 billion mostly due to productivity gains and
reducing suffering
1/3-1/2 of cancer deaths are avoidable:
2.4-3.7 million deaths
Of which 80% are in LIMCs
I i I CCC
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Investing In CCC:
The costs to close the cancer divide
may be less than many fear:All but 3 of 29 LMIC priority, candidate cancer chemo
and hormonal agents are off-patent: many < $100 / course
Cost of drug treatment, cervical cancer + HL + ALL(k)in LMICs / year of incident cases: $US 280 m
Pain medication is cheap
Prices drop:HPV 2011 from $US 100 /dose to
GAVI $5
PAHO $14
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A) Should be done: necessary
and appropriateB) Could be done: affordable
C) Can be doneMyth 4: Impossible
Expanding access to cancer
care and control in LMICs:
Ch i
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26/35Harvard Breast Cancer in Develo in Countries Nov 4 `09
ChampionsNobel Amartya Sen,
Cancer survivor diagnosed in India50 years ago
Drew G. Faust
President of Harvard University22+ year BC survivor
S t ti th di
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Successes treating other diseases:MDR-TB treatment
Source: Paul Farmer., 2009
cured
83%
abandon
therapy
2%
failed
therapy
8%
died
8%
Mitnick et al, Community-based therapy for multidrug-resistant
tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.
Outcomes in MDR-TB patients in Lima,
Peru receiving at least 4 months of therapy
WHO 1997, Multidrug-resistant
tuberculosis is too expensive to treat in
poor countries; it detracts attention and
resources from treating drug-susceptible
disease.
Drug % Decline inprice 1997-9
Amikacin 90%
Ethionamide 84%
Capreomycin 97%
Ofloxacin 98%
Reduced prices of
second-line TB drugs
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Mexico: cervical cancer.
Source: Knaul et al., 2008. Reproductive Health Matters, and updated by Knaul, Arreola-Ornelas and Mndez based on WHO data, WHOSIS (1955-1978), and Ministry of Health in Mexico (1979-2006)
0
4
8
12
16
19551965
1975
1985
1995
2005
Success in treating several cancers.
i i i i
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Financing innovations:
DomesticIntegrate CCC into national insurance programs to
express previously suppressed demand, beginning
with cancers of women and children:Mexico
Colombia
Dominican Republic
Peru
China
India
Rwanda
Taiwan
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Seguro Popular and cancer:
Evidence of impact
Since the incorporation of childhoodcancers into the Seguro Popular
30-month survival: 30% to almost 70%adherence to treatment: 70% to 95%.
Access to medicinesan anecdote
Breast cancer adherence to treatment:2005: 200/600
2010: 10/900
Me ico Seg ro Pop lar:
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Mexico Seguro Popular:
diagonal, financial protection for
catastrophic illness
Accelerated, universal, vertical coverage by disease
with a package of interventions
2004/5: ALL in children, cervical, HIV/AIDS
2006: All pediatric cancers
2007: Breast cancer
2011: Testicular cancer and NHL
Horizontal and vertical financial protection
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Beneficiaries: Population covered
Benefits:coveredi
n
terventions
Horizontal and vertical financial protectionstrategies:
Seguro Popular for Breast Cancer, Mexico
Catastrophic Illness
ACCELERATED VERTICAL COVERAGE: Ex: breast cancer,
Package of essential
personal services
Community Health Services - NUTRITION
Poor Rich
I ti i Fi i
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Innovations in Financing:
Global
Integrated, innovative financingmechanisms that have gone to scale -
Global Fund and GAVI - can be leveragedRMNCH platforms provide models forbroad-based international partnership and
commitment-building for cancer and NCD.Recent, diagonal partnership initiatives arepromising -pink ribbon red ribbon
A i
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Addressing women, health
+and+ NCDs in LMICs:
Shared advocacy to achieve stronger health
systems
Common implementation platformsMulti-stakeholder alliances in-country
Commitment-based funding models
Common, attainable goals
Measurement of progress: evidence and
metrics
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Be an
optimistoptimalist.