Felicia Marie KnaulHarvard Global Equity InitiativeHarvard Medical SchoolGlobal Task Force on Expanded Access to Cancer Care and ControlMexican Health Foundation Tómatelo a PechoUnion for International Cancer Control
Long Wharf Theatre, New Haven; April 5, 2014
Closing the Pain DivideGlobal Health Perspectives,
Global Health and the Arts Conference
From anecdote …
… to evidence
January, 2008June, 2007
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.
… to evidence
From anecdote…
GTF.CCC= global health +
cancer care
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 from treatable
cancers4. Stigma and discrimination
5. Avoidable pain and suffering
The Cancer Divide: An Equity ImperativeFa
cets
Pain Control and Palliative Care: the global scenario
• 8 out of 10 leading causes of death are associated with the need for treatment of severe pain and palliative care.
• Only 8% of the over 100 million people who require palliative care annually have access.
• Only 20 countries in the world have effectively integrated palliative care into their health system.
Access to Palliative Care at End-of-Life
Source: Based on WPCA-OMS, 2014, Global Atlas of Palliative Care at the end of life .
Level 1: UnknownLevel 2: Building CapacityLevel 3a: Isolated provisionLevel 3.b: Widespread provisionLevel 4a: Preliminary integrationLevel 4b: Advanced integrationNot applicable
Pain: a Global Injustice• Every year, tens of millions of people suffer
needlessly in moderate to severe pain, including 5.5 million from cancer
• 83% of people in the world live in countries with little or no access to medications for pain control
• High-income countries account for less than 15% of the world's population but over 94% of consumption of morphine
Latin America
Africa
China:1,276
The Global Pain divide
Mexico: 2,300
272,000 mg
267,000 mg37,000 mg
Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain:
Poorest 10%: 54 mg Richest 10%: 97,400 mgUS/Canada: 270,000 mg
India:717
Opioid Consumption (medical) in The Americas, 1965-2010, Log Scale M
orph
ine
Equ
ival
ence
(mg/
capi
tal)
1000
0 1970 1980 1990 2000 2010Fuente: Pain & Policy Studies Group. Opioid Consumption Motion Chart. University of Wisconsin. (http://ppsg-production.heroku.com/chart )for 2007 (accessed April 22 2011).
CanadaUSA
ArgentinaBrazilChileCosta RicaMexicoColombia
Pain and Palliative Care:a missing agenda
• Not associated with any particular disease• A cause without advocates: The majority
die leaving victims without a voice• Fear of death and pain• The “survivorship dilemma”: those who
live avoid thinking of death or pain
The costs to close the pain divide are less than many fear:
The majority of pain control meds are off patent and cheapYET:
The poor overpay because prices are higher in low income countries
1 month morphine: $1.80-$5.40 versus $60-180
BUT: WE CAN GET THE PRICE RIGHT AND INCREASE ACCESS THROUGH COLLECTIVE ACTION:
Global regulation focuses on control of illicit useDelivery & financing platforms are underutilizedInnovation is undevelopedPurchasing is fragmented, procurement is unstable ,
Recent Global and Regional Advances
• 2013: PAHO opens regional financing and purchasing platform to chronic and non-communicable diseases meds including pain control
• 2014: The WHO Executive Board pre-approved an innovative resolution urging countries to ensure access to palliative care and pain medicine urging– Countries: integrate palliative care into health systems – WHO: increase technical assistance to member countries
to develop palliative care services.
Mexico….• Universal health care through reform that
created Seguro Popular• Innovative legal framework: 2009 Palliative
Care Law: 2013 in General Health Law
…Yet….• Almost 80% - 65,500 - of the 83,771
registered deaths from cancer or HIV/AIDS in 2010, died in pain
Barriers to Access Palliative Care by Health System Function: Mexico
Source: Adapted from Knaul, F. M., Gralow, J. R., Atun, R., & Bhadelia, A. (Eds.). Closing the Cancer Divide. Harvard University Press, 2012.
Health System
Function
Components of the Health Care Continuum
Prevention…Survival Palliative Care, Pain Control and End of Life Care
RegulationMissig: National Plan / ProgramWeak, poorly defined and restrictive regulatory frameworks Absence evaluation and monitoring
Financing
NO explicit coverage of interventions in either the Comprehensive Package for Essential Services or the Fund for Protection Against Catastrophic Expenditure-Social Security there is “an everything” and nothing
DeliveryLacking units and levels for delivery Supply chain and distribution is sporadic and spotty
Resource Generation and
Research
Lack of trained personnelFear of prescriptionTopic not available in medical school curriculumNo published research related to health system
0
1
2345
>5
# pain control clinics in each state; public system Public hospitals with
access to morphine
01
234
5>5
NA
Fuente: Dr. Alfonso Petersen Farah, Presentación: “Clínicas del Dolor”, Foro Internacional Promoviendo las Oportunidades de los Cuidados Paliativos en México. Octubre 11, 2013
N = 30 of 32 states
Delivery: Access to Services at state level in Mexico
Comprehensive and Systematic Solutions are required:
LEGISLATIVE AND
NORMATIVE FRAMEWORK
REGULATORY
FRAMEWORK
SUPPLY CHAIN AND
DISTRIBUTION OF
MEDICATIONS
PATIENT AWARENESS
PREVENTION AND CONTROL
OF ILLEGAL USE AND MEDICAL SUPPORT FOR ADDICTIONS
EVIDENCE ON REAL DEMAND
AND BARRIERS
All-Society Solution is Required:
• Supreme Court• The National Congress• Ministry of Health• COFEPRIS (food and drug regulation) • Insurance system: Seguro Popular, IMSS, ISSSTE and others• Tertiary care hospitals• Associations of Physicians and Health Professionals• Private business sector• Civil society• Academic and teaching institutions• Appropriate regulatory frameworks at the international level
Big Steps Forward:• International seminar, October 2013 • Working group in the Supreme Court, 2013 • Launched the public-private-civil society-
academia joint committee coordinated withCOFEPRIS, 2014
• Development of training materials• Support for international WHO resolution and
INCB • Participation in international workshops and
application of knowledge in Mexico • Establishment of working group to develop a
National Program
Be an optimist
optimalist