CGI, Day 3 – Addressing Cancer in the Developing World: Health Equity and an Overlooked Public Health Crisis

The panel is preceded by this video.

Dr. Sanjay Gupta (Chief Medical Correspondent, CNN) leads the panel, featuring:

Lant Pritchett’s old point notwithstanding, the reality has become that the “developing world” now originates 56% of the cases of cancer in the world, up from ca. 14% a decade ago.  (Actually, this somewhat presents evidence for Mr. Pritchett’s point about trade-offs; the developing world is now able to live long enough and well enough that death from cancer has become important.)

Dr. Gupta starts by celebrating that some cancers that were not able to be treated anywhere in the world are now treatable everywhere in the world.  But the developing world cannot afford treatments for some types of cancer to the level needed. Dr. Gupta is a Board member of Livestrong, and speaks about the way the organization—especially through the discipleship of Lance Armstrong—has changed the way many people think about cancer.

HRH Princess Mired notes that much of the progress in Jordan occurred after King Hussein himself went very public with his battle with cancer, putting a public face on the disease.  HRH Mired notes that since then, the major cancer treatment center—the King Hussein Cancer Center—now includes the word “cancer” in its name and provides access to consultations, information, and treatment for people who live near the center and those who can communicate with it through a regional center.

She notes that there are areas in which they would like to make progress in Jordan, such as establishing Cord Blood Banks, and other things that people in the developed world “take for granted.”

Dr. Gupta asks Dr. Paul Farmer to speak specifically about Haiti.  Dr. Farmer notes that there is one (1) oncologist in Haiti, and none in Rwanda or Burundi.  It is difficult to use preventive measures once one already has leukemia—but need to make that much more of an effort in prevention and early detection.  Dr. Farmer notes that cervical cancer is a communicable disease;  there is a “cervical cancer belt” in the developing world.  There is a vaccine, there are preventive care activities, and there are many other possibilities for reducing the rate of death from cervical cancer—it is delivery mechanisms and education that need to be provided. (Dr. Farmer notes, for instance, that Partners in Health teamed with Gardasil to provide vaccinations for young girls and women in Haiti.)

Next up is Dr. Charles-Patrick Almazor, who reaffirms that there is significant progress that has been made, and notes some of the “on the ground” successes in post-earthquake Haiti.

Felicia Knaul and Lance Armstrong join the group.

Dr.Gupta notes that Lance Armstrong came to CGI and announced that he would be racing again, primarily to extend the reach and successes of Livestrong.  Armstrong notes that he wasn’t worried so much about the idea of winning another Tour de France or any “knock on [his] legacy” as he was in extending the work of the Livestrong Foundation.  And he believes that the effort has paid off well in those terms.

Ms. Knaul (who has a Ph.D., and therefore might be more properly referred to as Dr. Knaul), whose original commitment was “enhancing and empowering women health care workers,” notes that breast cancer is now the #2 killer of young (ca. 30-54) women in Mexico and the developing world. Ms. Knaul is a breast cancer survivor herself, and notes that what is worse than “having to take it in the vein is not being able to because you don’t have enough money to be able to pay for it.”  (Note: Ms. Knaul’s last round of treatment was last Wednesday; technically, she is not yet “a cancer survivor.”) She moves on to speak of “other kinds of failures,” such as the women who do not get mammograms because they expect that their husband will leave them if they are diagnosed with breast cancer. In that context, the Commitment made yesterday to teaching men is most encouraging for her.

Ms. Knaul also notes that she was in the audience when Lance Armstrong announced his Commitment in 2008, and that she herself was inspired by his actions to expand her own efforts.

Dr. Gupta highlights a few people in the audience who are also working to reduce cancer, including John Noseworthy of the Mayo Clinic, who “established the Healthcare Alliance for Tobacco Dependence Treatment” to work to support realization of the WHO Framework Convention on Tobacco Control; Dr. Lawrence Shulman of Dana-Farber and Harvard, which is working in several of the developing areas; HRH Princess Ghida Talal, who is leading an effort to establish a “personalized medical center” at the King Hussein Medical Center; and Letha Sanderson of Uganda, the founder of Wrap Up Africa.

Dr. Gupta asks Dr. John Seffrin of the ACS to talk about the American Cancer Society’s efforts to reduce tobacco use in developing countries. Dr. Seffrin notes that cancer is becoming the #1 cause of death in the world “for the first time in all of history.”  Livestrong and the ACS published a study about a month ago, noting that the cost to the world is about $895 Billion per year, “not including health-care costs associated with the treatment of cancer.”  The economic burden of the top fifteen diseases shows clearly that cancer is far and away the worst.  And the spread of smoking tobacco has clearly exacerbated this in the developing world.  Killed 100 million people in the last century; will kill 1,000,000,000 in this century if there is no intervention.

The first question from the floor is about possibility of using of local herbs and natural

Fran Drescher, a CGI regular whose own commitment in this area can be found at the link,  follows, asking how we educate and motivate women to go from “My husband will leave me if I have cancer” to “What will happen to my family if I die of cancer?”  Princess Mired notes that taboos don’t come from nowhere; they come from ignorance. People start from the expectation that cancer is contagious, that prevention and early detection are not possible.  Need to have the information disseminated, and especially to work on the men to change both the social behavior.  In four years, they have reduced the rate of people in Stage 3 and Stage 4 cancer from 70% to 35% through an”early detection” program that was started after people started to see survivors. Need to show survivors.

Ms. Knaul notes that the mortality rate in Mexico from cervical cancer has gone from 16% to 8% in the past ten years—primarily because of earlier detection and treatment, but also because of improvements in the treatment itself.  She notes that this especially can be applied in the Developed World, where opportunities for research and

Jonathan Quick of Management Sciences for Health noted the parallel between treating cancer and treating AIDS in the developing world. In the case of AIDS, they got through the four “barriers”: (1) the mental barrier (“it can’t be done”), (2) the cost barrier (treatment costs reduced from $12,000 to $3,200), (3) the money barrier (addressed by a global fund), and (4) the “practicality barrier.”  Where are we with cancer?  Dr. Farmer notes that those four barriers have been overcome in many cities, but that rural areas still need all four barriers to be overcome.  “People who say “there is no market” are trying to stop a conversation, not start one.”  When you don’t know any survivors in your neighborhood, it’s more difficult to accept that one can survive.  (The examples of King Hussein and, especially, Lance Armstrong seem especially relevant.)

Dr. Gupta asks Lance Armstrong about Livestrong’s decision to “go global.”  Armstrong notes that they were responding to demand: discovered that the idea of Livestrong resonated in places such as Mexico and India.  It is left to Mr. Armstrong to note that cancer is such a diverse disease—“we talk about cancer—boom, six letters—but it’s different than that.”  It’s correct to be honest about it:we’re going to have to knock of this disease on type at a time.  We know the diseases we can cure today (testicular cancer, some lymphomas, cervical cancer and breast cancer with early detection).  “It’s not a simple three-page document, but it is doable.”

With straightforward chemotherapy approaches, have been able to cure kids with various sarcomas.  We do have to scale up the program.

Former HHS Secretary Donna Shalala asks about geography: having to travel reduces ability to treat rural cancer patients..  She notes that more than fifteen years ago, Egypt set up regional cancer centers and flew oncologists to those areas once a month—a great political and popular success. (There were also pay incentives for the oncologists, to cover the travel requirement.)

Ms. Knaul notes that. when you add the technologies available, you don’t necessarily have to move the patient or the doctors so much; St. Jude’s is able to offer pediatric cancer care in Jordan while the oncologist remains in Memphis.  Princess Mired re-emphasizes this, nothing that the Jordanian doctors have weekly “training sessions” with the doctors in Memphis.

Have to understand that cancer has potentially become the most curable of all diseases; could be saving 10,000 lives a day if could apply the advances in the United States alone to the rest of the world.

Lance Armstrong again takes it down to a human level:  if we teach a kid never to pick up a cigarette, we just “cured” cancer.  Need to re-emphasize sharing: information, resources, programs.

Ms. Knaul notes that there are some countries, such as Mexico, that are considering financing reform so that people have access to cancer treatment—a move that will strengthen the health care system itself.

Dr. Farmer talks about competition, competing for scarce resources.  Only a partnership will work.  Resources are less limited than at any other time in human history.  Cannot make the same mistake—contrasting prevention with care—that was made in the past.  One of the main causes of death is that people become destitute providing care.  Need for that not to happen.

Dr. Almazor presents optimism; Princess Mired notes that we cannot change our future without change.  “Cancer does not even appear as a line item on any Global Health Agenda.” All of the successes and survivors—AIDS, TB, etc.—have the specter of having to face cancer and heart disease.  She closes by noting that we need to measure the cost of cancer not in human deaths, but prefer to see hospitals and treatment centers that remedy the problem.

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