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Felicia M. Knaul


Closing the Cancer Divide: The Opportunity of Lifetimes

Posted: 02/04/2013 7:30 pm

For the poor, cancer remains a silent killer. Breaking this silence could save hundreds of thousands and likely even millions of lives each year -- most of them in developing, low- and middle-income countries (LMICs).

Though I am not a fan of the military metaphor, would this not truly be a win in what has been termed a "war against cancer"? Even more so, would it not be an opportunity to act to address a moral and equity imperative and to show that all lives are equally important, be they rich or poor?

Today, Monday, February 4, is World Cancer Day. Led by the Union for International Cancer Control, this year's event is focused on Target 5 of the World Cancer Declaration [which you should sign if you have not already done so]: dispelling the myths and misconceptions that shroud the topic of cancer and prevent effective action. Many of the most heinous of those myths are related to how cancers affect the poor.

In fact, many of the cancer myths are fuelled by misconceptions and bias about the interactions between poverty and health. They are then driven and fired by gender discrimination, abuse of the rights of children, and racism. Add a layer of stigma to this brew, and we achieve the lethal concoction that threatens most people in LMICs, and indeed many of the poor who live in high-income countries, who are unfortunate enough to be diagnosed with cancer.

I am an economist who has dedicated the past two decades to trying to improve the equity and financing of health systems, primarily in Latin America. I am also a woman diagnosed and treated for breast cancer in a country that I am proud to call my home -- Mexico -- where a large proportion of the population lives in poverty. My diagnosis in 2007, in a small clinic in Cuernavaca, Morelos, at age 41, with no prior history of the disease, provided me with a new and much deeper understanding of the horror of what it means to face a potentially fatal, chronic disease and lack the means to access care. Though I was fortunate enough to have all manner of support -- financial and personal -- living a disease is very different than studying it. And feeling the desperation of being diagnosed with a disease that can result in death is to experience what we hope others do not. I have written two books about my own experience Tómatelo a Pecho and more recently Beauty without the Breast.

Since my own diagnosis, I have dedicated my personal and my professional experience -- my life and my work -- to confronting the myths that perpetuate an unacceptable inequity, the gaping 'cancer divide.' the disparities in incidence and mortality from preventable and treatable cancers between rich and poor countries and populations. The divide is also excruciatingly [I choose and use this word deliberately] evident in disparities in access to pain control and protection from stigma. And, the cancer divide is starkly revealed by appalling statistics -- behind which lurk human faces -- that allow those of us who do have access to treatment to begin to comprehend this injustice. To cite just one example, almost 90 percent of Canadian children diagnosed with leukemia can expect to be cured, while 90 percent of their counterparts in the world's poorest countries are doomed to die.

Closing the cancer divide is indeed a moral and equity imperative -- a point that has been put forward by a group of global health and cancer leaders who are both colleagues and friends and who generously participate in the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTF.CCC).

Cancer no longer discriminates against the rich in favor of the poor; rather, it is the poor who bear an increasingly disproportionate share of cancer suffering. Further, the concentration of cancer death and suffering among the poor is part of a vicious circle. The poor are also those with the least access to effective health care and financial protection, and tend to live in countries with weak health systems that are particularly ill-prepared to meet the challenge of cancer. Yet -- and this is simultaneously shocking and uplifting -- much of the cancer burden borne by the poor is highly ameliorable to prevention and cure using interventions that often do not depend on costly drugs or technologies.

Dispelling Deadly Cancer Myths

The four overarching myths that have shrouded and undermined global efforts to address the cancer divide are lodged in the reductionist claim that addressing cancer in developing countries is (1) unnecessary, (2) unaffordable, (3) unattainable, and (4) inappropriate because it would divert resources from other, supposedly competing, health priorities. These falsehoods have plagued efforts to develop an effective prevention and treatment approach and strengthen health systems in LMICs not only to meet the challenge of cancer, but also for non-communicable and chronic diseases more generally.

Yet, these arguments are demonstrably false. Through the GTF.CCC we have compiled and published compelling evidence that demonstrates that many aspects of prevention, treatment, and palliation for the poor are: absolutely necessary to spare millions of people from preventable suffering and death; highly affordable -- especially compared to the enormous and neglected costs of inaction; attainable and implementable in resources-constrained settings using innovation and insight; and appropriate as steps not only to reduce the cancer burden but to strengthen health systems and reduce illness-related poverty across the board.

Necessary: Expanded access to cancer care and control is necessary because it is a health priority for the poor. The necessity is as evident statistically as it is urgent morally. LMICs bear a majority share of the global burden of cancer -- 58 percent of new cases reported in 2008 and an expected increase to 70 percent by 2030 -- making cancer a leading cause of death and disability. For children between the ages of five and 14, cancer is among the top five leading causes of death in middle-income countries, and in the top ten even in the lowest-income countries. Over 90 percent of both cases and deaths from cervical cancer occur in LMICs making this disease now a cancer of the poor. Breast cancer is also a leading cause of death -- especially for young women -- in the vast majority of LMICs. Lethality is measurably higher in LMICs compared to high-income countries for each and every cancer for which an effective treatment exists.

Affordable: Investment in expanded cancer care and control is an opportunity the world cannot afford to continue to miss. Cancer costs the world between 2 and 4 percent of global GDP per year, much of which could be saved by investing in prevention and treatment. Averting the impact of cancer in LMICs would also mean preventing many families from falling into poverty. The cost of expanding cancer care and control is dwarfed in comparison. The total estimated cost of covering drug treatments for unmet needs for cervical cancer, Hodgkins lymphoma, and acute lymphoblastic leukemia, the leading cause of cancer death in children in LMICs, is only U.S. $115 million. That's million with a little "m," not a big "b."

Attainable: Where there is a will there is a way. Examples of successes in resource-limited countries from each region of the world prove what is possible and provide replicable lessons. In countries as different as Rwanda, Jordan and Mexico, lifesaving expansions in cancer care and control have been achieved and documented. Rwanda has implemented a successful national HPV vaccination program to prevent cervical cancer and has opened the first comprehensive cancer referral facility in rural East Africa. Jordan's King Hussein Cancer Center is the first specialty cancer facility in an LMIC accredited by the Joint Commission International. By eliminating financial barriers to treatment for childhood cancers through the Seguro Popular national insurance program for the poor, Mexico has significantly increased adherence to treatment and hence survival rates.

Appropriate: "Either/or" is a mistaken approach -- to cancer care in LMICs and indeed to most of the challenges of global health. Rather than diverting resources from other health needs, many interventions to improve cancer care and control in LMIC can be effectively integrated in ways that will benefit entire health systems. For example, eliminating regulatory barriers, strengthening health systems, and training healthcare workers could improve access to pain control not only for cancer patients but for all of the estimated 2.9 million people per year who needlessly die in moderate or severe pain. Imagine also how much improved management of pain control would do to improve a core area of health care -- surgical platforms? This diagonal approach -- using "vertical" disease-specific interventions to drive improvements horizontally across the health system -- has proven highly effective in other programs.

An Opportunity to Act

World Cancer Day is an opportunity to act on an urgent moral imperative, to challenge the assumption that cancers must remain untreated in poor countries, just as was successfully done for HIV treatment more than a decade ago. Concerted action is needed to follow up on the UN High Level Meeting on the Prevention and Control of Non-Communicable Diseases held in 2011 and for the development of the successor activities to the Millenium Development Goals (MDG).

The cup of antidotes to the challenge of cancer is indeed half full rather than half empty. Yet, to implode global misperceptions, we must include the lives of the poor in the metric of what we value as success in meeting the challenge of cancer.

Felicia M. Knaul is associate professor at Harvard Medical School and director of the Harvard Global Equity Initiative, where she serves as secretariat co-chair of the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. This is the first installment of a regular, monthly blog she is writing for the Huffington Post about the challenges of inequity in global health and about innovative approaches to improving quality and access to health care for poor countries and populations.


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