Closing the cancer divide: an equity imperative for women and health

Felicia Marie Knaul Harvard Global Equity Initiative, Mexican Health Foundation Tmatelo a pecho World Health Organization December 6th, 2011

Closing the Cancer Divide:

A Blueprint to Expand Access in LMICs
I: Much should be done II: Much could be done III: Much can be done
1: Innovative Delivery 2: Access to Affordable Medicines, Vaccines & Technologies 3: Innovative Financing: Domestic and Global 4: Evidence for Decision-Making 5: Stewardship and Leadership

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

Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries

= global health + cancer care

Expanding access to cancer care and control in LMICs:

A) Should be done:
Myth 1. Unnecessary Myth 2. Inappropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

The Cancer Divide: An Equity Imperative

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

Facets

Risk factor concentration: Obesity Epidemic in countries such as Mexico

% women 20-49 years
60 57

2006 1999 1988

8 2 2
Adequate Malnutrition

Overweight
37 29

36 37 25

Obesity

32 25 10

10

Cancer is becoming a leading cause of childhood death: Epi transition

40%

% of total mortality, Mexico, 1979-2008

30%

1-4

5-14
M. tumors Inf + parasitic Respiratory infs

20%

10%

1979

1990

2000

Source: Estimates based on data from the Ministry of Health, Mexico.

Cancer, 5-14: 3rd in upper middle income, 4th in lower middle, 8th in low income countries.

2008

1979

1990

2000

2008

The Cancer Transition

Mirrors the overall epidemiological transition protracted and polarized*:
LMICs increasingly face both cancers associated with infection, and all other cancers. Cancers that were once considered only of the poor, now cease to be the only cancers of the poor. (e.g. cervical & breast cancer)
* Frenk et al

Incidence and mortality of cervical cancer

(adjusted rate per 100,000 women)
Incidence Mortality

The cancer transition in LMICs: breast and cervical cancer

LMICs account for >90% of cervical cancer deaths and >60% of breast cancer deaths. Both diseases are leading killers especially of young women.
% Change in # of deaths 1980-2010
53%

19%

20%

0%

LMICs

High income
-31%

Source: Knaul, Arreola, Mendez. estimates based on IHME, 2011.

The cancer transition within countries:

breast and cervical cancer mortality
16

Mexico
1955 - 2008

Costa Rica
1995 - 2005

0
0

25

Oaxaca
1979-2008

25

Nuevo Leon
1979-2008

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

100%

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%.

Stigma: Juanita

Cancer, and especially reproductive cancers, adds a layer of discrimination onto gender, ethnicity, and poverty.

The most insidious facet: access to pain control

Non-meth, Morphine-e opioid consumption per death from HIV or cancer
10,000

Low middle

USA Canada

280,000

Austria
0 $0

$14,000

Germany
Denmark

1,000

Low Income

Norway
0 $0

$3,500

Japan

50,000 UAE Kuwait Qatar

$80,000

$0

$40,000

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.

Expanding access to cancer care and control in LMICs:

A) Should be done:
Myth 1. Unnecessary Myth 2. Inappropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

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.

The Diagonal Approach to Health System Strengthening

Rather than focusing on disease-specific vertical programs or only on horizontal system constraints, harness synergies that provide opportunities to tackle disease-specific priorities while addressing systemic gaps.
Optimize available resources so that the whole is more than the sum of the parts. Bridge the divide as patients suffer diseases over a lifetime, most of it chronic.

Why diagonal?
Shared risk factors Success and life cycle Common need for strong health systems platforms Economic development Social justice

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 for cancer, for other diseases, and for surgery.

A Diagonal Strategy:
Delivery: Harness platforms by integrating cancer prevention, screening and survivorship support into MCH, SRH, HIV/AIDS, social welfare and anti-poverty programs.

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate B) Could be done:
Myth 3. Unaffordable

C) Can be done
Myth 4: Impossible

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 GDP Prevention 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

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

Expanding access to cancer care and control in LMICs:

A) Should be done: necessary and appropriate B) Could be done: affordable C) Can be done
Myth 4: Impossible

Champions
Drew G. Faust
President of Harvard University 22+ year BC survivor

Nobel Amartya Sen,

Cancer survivor diagnosed in India 50 years ago

Harvard, Breast Cancer in Developing Countries, Nov 4, `09

Successes treating other diseases:

MDR-TB treatment
WHO 1997, Multidrug-resistant tuberculosis is too expensive to treat in poor countries; it detracts attention and resources from treating drug-susceptible disease.

Reduced prices of second-line TB drugs

Drug % Decline in price 1997-9

Outcomes in MDR-TB patients in Lima, Peru receiving at least 4 months of therapy

failed therapy died 8% 8%

Amikacin
abandon therapy 2%

90% 84% 97% 98%

Source: Paul Farmer., 2009

Ethionamide
cured 83%

Capreomycin Ofloxacin

Mitnick et al, Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. NEJM 2003; 348(2): 119-28.

Success in treating several cancers. Mexico: cervical cancer.

16

12

0 1965 1975 1985

1955

1995

2005

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)

Financing innovations: Domestic

Integrate 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

Seguro Popular and cancer: Evidence of impact

Since the incorporation of childhood cancers into the Seguro Popular
30-month survival: 30% to almost 70% adherence to treatment: 70% to 95%.

Access to medicines an anecdote Breast cancer adherence to treatment:

2005: 200/600 2010: 10/900

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 strategies:

Seguro Popular for Breast Cancer, Mexico Benefits: covered interventions
Catastrophic Illness ACCELERATED VERTICAL COVERAGE: Ex: breast cancer,

Package of essential personal services

Community Health Services - NUTRITION

Poor

Rich

Beneficiaries: Population covered

Innovations in Financing: Global

Integrated, innovative financing mechanisms that have gone to scale Global Fund and GAVI - can be leveraged RMNCH platforms provide models for broad-based international partnership and commitment-building for cancer and NCD. Recent, diagonal partnership initiatives are promising - pink ribbon red ribbon

Addressing women, health +and+ NCDs in LMICs:

Shared advocacy to achieve stronger health systems Common implementation platforms Multi-stakeholder alliances in-country Commitment-based funding models Common, attainable goals Measurement of progress: evidence and metrics

Be an optimist optimalist.