Fk Final to Pfizer 17 mayo 2012

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Closing the Cancer Divide:

Strategies for ActionMay 17, 2012

Pfizer Medical, New Yorkd

Felicia Marie Knaul, PhDHarvard Global Equity Initiative,

Global Task Force on Expanded Access to

Cancer Care and Control in LMICs

Mexican Health FoundationTmatelo a Pecho


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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 and

is being done


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From anecdote

to evidence


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January, 2008

June, 2007


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Global Task Force on Expanded

Access to Cancer Care and

Control in Developing Countries

= global health + cancer care


10/50GTF.CCCMembers


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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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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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Mirrors the overall epidemiologicaltransition

LMICs increasingly face both cancersassociated with infection, and all other

cancers.

Cancers that are increasingly only of thepoor, are not the only cancers of the poor.

The Cancer Transition

* Frenk et al


14/50Source: 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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#2 cause of death in wealthy countries

#3 in upper middle-income#4 in lower middle-income

and # 8 in low-income countriesMore than 85% of pediatric cancer cases and 95% of

deaths occur in developing countries.

For children & adolescents

5-14 cancer is


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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 factors

2. Preventable cancers (infection)

3. Treatable cancer death and disability4. Stigma and discrimination

5. Avoidable pain and suffering

The Cancer Divide:

An Equity Imperative

Face

ts

E i k f


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Age-standardized prevalence of risk factor in adults aged 15+ years

Men

Women

Both sexes

%o

fpopulation

0

20

40

60

Low

income

Lower

middle

Upper

middle

High

Exposure to risk factors:

Daily Tobacco Smoking

Source: WHO. The Global Status Re ort on Noncommunicable Diseases 2010.

I id d li f


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MortalityIncidence

Incidence and mortality of

cervical cancer(adjusted rate per 100,000 women)


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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

lity

gap

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:

Cancerespecially in

women and children - adds a

layer of discrimination ontoethnicity, poverty, and

gender.

Survivorship

care is non-existent.

Th t i idi i j ti


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The most insidious injustice:

lack of access to pain controlNon-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

E di t


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A) Should be done:

B) Could be done:

C) Can be done

Myth 1. Unnecessary

Myth 2. Inappropriate


Myth 4: Impossible



W d h i LMIC


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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 delivery?

Shared risk factors

Co-morbidity

Life cycle approach

Efficiency: Common need for strong healthsystem platforms

Knowledge sharing and inter-institutional

collaborationEconomic development

Social justice


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Delivery: Harness platforms byintegrating breast and cervical

cancer prevention, screening andsurvivorship care into MCH,

SRH, HIV/AIDS, social welfareand anti-poverty programs.

A Diagonal Strategy:

Di l St t i


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Diagonal Strategies:

Positive ExternalitiesPromoting prevention and healthy lifestyles:

Reduce risk for cancer and many other diseases

Reducing stigma around womens cancers:

Contributes to reducing gender discriminationPromoting access to education for children w/ cancer

Reduces poverty, contributes to social development

Introducing cancer treatment for childrenImproves hygiene and reduces intra-hospital infections

Pain control and palliation

Reducing barriers to access is essential for cancer as

well as for for other diseases and for sur er .

E di t


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A) Should be done: necessary

and appropriate

B) Could be done:

C) Can be done


Myth 4: Impossible



` /80 i i i i


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`5/80 cancer disequilibrium(Frenk/Lancet 2010)

Almost 80% of the DALYs lost

worldwide to cancer are in LMICs,yet these countries have only a very

small share of global resources for

cancer ~ 5% or less.

I i I CCC


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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

- 80% in LIMCs

Th t t l th di id


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The costs to close the cancer divide

may be less than many fear:

All but 3 of 29 LMIC priority cancer chemo and hormonalagents are off-patent: many < $100 / course

Cost of drug treatment: cervical cancer + HL + ALL(kids)

in LMICs / year of incident cases: $US 280 mPain medication is cheap

Prices drop: HPV 2011 from $US 100 /dose to:

GAVI $5 and PAHO $14Market potential is underutilized and undeveloped

Purchasing is fragmented and procurement is unstable

Delivery innovations are unexploited

E di t


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A) Should be done: necessary

and appropriateB) Could be done: affordable

C) Can be doneMyth 4: Impossible



Initial views on MDR TB


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In developing countries,people with multidrug-

resistant tuberculosis usually

die, because effective treatment

is often impossible in poor

countries. WHO 1996

Initial views on MDR-TB

treatment, c. 1996-97

Source: Paul Farmer., 2009

MDR-TB is too expensive to

treat in poor countries; it

detracts attention and resources

from treating drug-susceptible

disease. WHO 1997


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Outcomes in MDR-TB

patients in Lima, Peru

receiving at least fourmonths of therapy

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

All patients initiated therapy

between Aug 96 and Feb 99

Source: Paul Farmer, 2009

Drug % Decline inprice 1997-9

Amikacin 90%

Ethionamide 84%

Capreomycin 97%

Ofloxacin 98%

Making common

cause with WHO:

Reduced prices ofsecond-line TB drugs

Cured

83%

Abandontherapy

2%

Failed

therapy

8%

Died

8%

Ch i


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Harvard 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

Ch i f LMIC M i


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Champions from LMICs: Mxico

R l R d 0 l i


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Rural Rwanda: 0 oncologist

Source: Paul Farmer., 2009

Burkitts

lymphoma

Embryonal

Rhabdomyosarcoma

St J d I t ti l


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St. Judes International

Outreach Program

Twinning in 20+ countries

El Salvador: 5-year survival for children

with ALL increased from 10% to 60% in

five years

Cure4Kids/OncopediaOver 31,000 users in more than 183

countres

Success in treating several


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Mexico: cervical cancer.

Source: Knaul et al. 2008. Re roductive Health Matters and u dated b Knaul Arreola-Ornelas and Mndez based on WHO data WHOSIS 1955-1978 and Ministr o Health in Mexico 1979-2006

0

4

8

12

16

19551965

1975

1985

1995

2008

Success in treating several

cancers.

Fi i i ti


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Financing innovations:

DomesticIntegrate CCC into national insurance and

social security programs to

express previously suppressed demandbeginning with cancers of women and children:

Mexico, Colombia, Dominican

Republic, PeruChina, India, Taiwan

Rwanda, Kenya

A diagonal approach to social


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Horizontal Coverage: Beneficiaries

A diagonal approach to socialinsurance and financing

I i l ti


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# of covered services

Source: Comisin Nacional de Proteccin Social en Salud, 2012

Increase in population coverage +

expansion of package of services

Households affiliated

to Seguro Popular

2006

2004

~100%

2012

2005

~17.2

millonesdefamilias

9%

30%

20%

42%

1.5 3

.5millones

5.1millones

7.3millo

nes

53%

9.1m

illones

2007

2008

61%

10.5

millones

2009

85%

14.7

millones

2010

+113

146

249262

266

2006

2004

2

012

2005

2007

2008

2009

2010

275

2011

89%

2011

15.4millones

Mexico Seguro Popular:


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Mexico Seguro Popular:financial protection for catastrophic

illnessAccelerated, universal, vertical coverage by disease

with a package of interventions

2004/5: ALL in children, cervical, HIV/AIDS

2006: All pediatric cancers then all children and

newborns for almost everything

2007: Breast cancer

2011: Testicular cancer, prostate and NHL

Seguro Popular and cancer:


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Seguro Popular and cancer:

Evidence of impact

Since the incorporation of childhood

cancers into the Seguro Popular

30-month survival ALL: 30% to almost 70%

Breast cancer adherence to treatment:

2005: 200/6002010: 10/900

Access to medicinesan anecdote

Horizontal and vertical


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Horizontal and vertical

financial protection strategies:

Seguro Popular, Mexico

Beneficiaries: Population covered

Benefits:

coveredinte

rventions

Catastrophic Illness

ACCELERATED VERTICAL COVERAGE:

Ex: childrens cancer, breast cancer

Package of essential

personal services

Community Health Services eg nutrition and vaccinations

Poor Rich

Insurance for a new generation

J it


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Juanita:Advanced metastatic breast

cancer is the result of a series

of missed opportunities

Program to reduce


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Program to reducebarriers:

Breast cancer, Mexico

Results: promoters nurses doctors


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Results: promoters, nurses, doctors

Challenge: from survival to survivorship


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Be anoptimist

optimalist

Expanding access to cancer care and control in

LMICs: Should, Could, and Can be done


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@amazonFALL: @Harvard U Press

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Fk Final to Pfizer 17 mayo 2012