Global Health Ethics, Politics, and Economics. Yale University, Guest Lecture, 5 de marzo de 2013

1. Global
Health
Ethics,
Poli1cs,
and
Economics
Yale
University
Guest
Lecture,
March
5,
2013

2. From anecdote …
… to evidence

3. January,
2008
June,
2007

4. Battling sepsis in the
Médica Sur Hospital.
Mexico City. July 2008

9. Juanita:
Advanced metastatic breast
cancer is the result of a series
of missed opportunities

10. Launching a program
at the Mexican
Health Foundation
the day I got sepsis.
July 2008.

12. From anecdote …
… to evidence

13. GTF.CCC
Members

14. = global health + cancer care

16. Challenge and disprove the
myths about cancer
M1. Unnecessary
M2. Unaffordable
M3. Impossible
M4: Inappropriate
• Should,
• Could, and
• Can…..
….be
Expanding access to cancer care and control in
low and middle income countries:

17. " Mirrors the epidemiological transition
" LMICs increasingly face both infection-
associated cancers, and all other cancers.
The Cancer Transition
" Cancers increasingly only of the poor, are
not the only cancers affecting the poor.

18. #2 cause of death in wealthy countries
#3 in upper middle-income
#4 in lower middle-income
and # 8 in low-income countries
More than 85% of pediatric cancer cases and 95% of
deaths occur in developing countries.
For children & adolescents
5-14 cancer is

19. 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.
Mortality
from
breast
and
cervical
cancer
in
México
1955-­‐2010
0
4
8
12
16
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
Mama
Cervix

20. Mortalidad de cáncer de mama y
cervical en México 1979-2010
0
5
10
15
20
25
30
1979
1980
1985
1990
1995
2000
2005
2010
Oaxaca
Tasapor100,000mujeresajustadoporedad
Nuevo León
0
5
10
15
20
25
30
1979
1980
1985
1990
1995
2000
2005
2010
1980
1990
2000
2010
1980
1980
1980
1980
1990
2000
2010
1980
1980
1980
Source:
Knaul
et
al.,
2008.
Reproduc=ve
Health
MaBers,
and
updated
by
Knaul,
Arreola-­‐Ornelas
and
Méndez.
Cáncer de mama
Cáncer de cérvix

21. • The divide is the result of concentrating risk
factors, preventable disease, suffering,
impoverishment from ill health and death
among poor populations.
• fueled by progress in cutting-edge science and
medicine in high-income countries.

22. 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 disability
4. Stigma and discrimination
5. Avoidable pain and suffering
The Cancer Divide:
An Equity Imperative
Facets

23. Adults
Leukaemia
All cancers
Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.
Children
LOW
INCOME
HIGH
INCOME
Survival
inequalitygap
LOW
INCOME
HIGH
INCOME
100%
Facet 3: The Opportunity to Survive
Should Not, but Is Defined by Income
In Canada, almost 90% of children with
leukemia survive.
In the poorest countries only 10%.

24. Cancer – especially in
women and children - adds a
layer of discrimination onto
ethnicity, poverty, and
gender.

25. Facet 5: The most insidious injustice
is lack of access to pain control
Non-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

26. Challenge and disprove the
myths about cancer

27. Investing In CCC:
We Cannot Afford Not To
" Inaction reduces efficacy of health and social investments
" Total economic cost of cancer, 2010: 2-4% of global GDP
" Tobacco is a huge economic risk: 3.6% lower GDP
Prevention and treatment offers potential
world savings of $ US 130-940 billion
1/3-1/2 of cancer deaths are “avoidable”:
2.4-3.7 million deaths,
of which 80% are in LIMCs
✓

28. The costs to close the cancer divide
may be less than many fear:
" All but 3 of 29 LMIC priority cancer chemo and
hormonal agents are off-patent
" Cost of drug treatment: cervical cancer + HL +
ALL(kids) in LMICs / year of incident cases: $US
280 m
" Pain medication is cheap
" Prices drop: HepB and HPV vaccines
" Delivery & financing innovations are
underutilized & undeveloped: purchasing
fragmented, procurement unstable

29. Challenge and disprove the
myths about cancer

30. 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

31. The Diagonal Approach to
Health System Strengthening
" Rather than focusing on either disease-specific
vertical or horizontal-systemic programs, harness
synergies that provide opportunities to tackle disease-
specific priorities while addressing systemic gaps and
optimize available resources
" Diagonal strategies:  X = > Σ parts
" Bridge disease divides: patients suffer over a lifetime, most
of it chronic.
" Generate positive externalities

32. Diagonal Strategies:
Positive Externalities
" Promoting prevention and healthy lifestyles:
" Reduce risk for cancer and many other diseases
" Reducing stigma around women’s cancers:
" Contributes to reducing gender discrimination
" Promoting access to education for children w/ cancer
" Reduces poverty, contributes to social development
" Pain control and palliation
" Reducing barriers to access is essential for cancer as
well as for for other diseases and for surgery.

33. Challenge and disprove the
myths about cancer

34. Initial views on MDR-TB
treatment, c. 1996-97
“MDR-TB is too
expensive to treat in
poor countries; it
detracts attention and
resources from treating
drug-susceptible
disease.” WHO 1997
Outcomes in MDR-TB
patients in Lima, Peru
receiving at least four
months of therapy
All patients initiated therapy
between Aug 96 and Feb 99
Abandon
therapy
2%
Failed
therapy
8%
Died
8%

35. Champions
Nobel Amartya Sen,
Cancer survivor diagnosed in India
50 years ago
Drew G. Faust
President of Harvard University
22+ year BC survivor

36. Rural Rwanda: 0 oncologist
Source: Paul Farmer., 2009
Burkitt´s
lymphoma
Embryonal
Rhabdomyosarcoma

37. St. Jude’s 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/Oncopedia
– Over 31,000 users in more than 183
countries

38. México: IT IS POSSIBLE

39. ‘Diagonalizing’ Financing:
Integrate cancer care and control into
national insurance and social security
programs to express previously suppressed
demand beginning with cancers of women
and children:
" Mexico, Colombia, Dom Rep, Peru
" China, India, Thailand
" Rwanda, Ghana, South Africa

40. Universal Health Coverage in Mexico
through Seguro Popular
Horizontal
Coverage:
>
54.6
million
Beneficiaries
Ver=cal
Coverage
Diseases
and
Interven=ons:
Expanded
Benefit
Package

41. Evolution of vertical coverage: cumulative #
of covered interventions, 2004-2012
Notes:
SP
=
Seguro
Popular
MING
=
Medical
Insurance
for
a
New
Genera=on
(Children
born
aWer
December
1,
2006
and
un=l
they
are
5
years
of
age)
FPCHE
=
Fung
for
Protec=on
against
Catastrophic
Health
Expenditure
EPHS
=Essen=al
Personal
Health
Services
EPI
=
Expanded
Programme
of
Immunisa=ons
CBP=
Community-­‐based
package
”
0
50
100
150
200
250
300
350
400
450
500
2004 2005 2006 2007 2008 2009 2010 2011 2012
63 65 65 65 65 65 65 65 65
6 6 8 6 12 12 12 12 1322
83
176 184
189 189 198 198 206
6
6
17 20
49 49
49 57
57
110
108 116
128
128
131
MING
EPHS
EPI
CBP
FPCHE
Numberofinterventions
Seguro Popular
284 interventions
MING + SP
FPCHE
57
interventions
CAUSES
91
FPCHE
6
CAUSES
284
FPCHE
57

42. Seguro Popular:
Cancer and the Fund for Protection from
Catastrophic Illness
" Accelerated, universal, vertical coverage by disease
with an effective package of interventions
" 2004: HIV/AIDS
" 2005: cervical cancer
" 2006: ALL in children
" 2007: All pediatric cancers; Breast cancer
" 2011: Testicular and Prostate cancer and NHL
" 2012: Ovarian (colorectal) cancer

43. Seguro Popular and cancer:
Evidence of impact
" Access to medicines – an anecdote
" Since the incorporation of childhood cancers
into the Seguro Popular
" Adherence to treatment: 70% to 95%
" Breast cancer adherence to treatment:
" 2005: 200/600
" 2010: 10/900

44. % diagnosed in Stage 4 by state
• # 2 killer of women 30-54
• Only 5-10% of cases in Mexico are
detected in Stage 1 or in situ
• Poor municipalites: 50% Stage 4; 5x rich
Delivery failure: Breast Cancer
Juanita
Poor/Marginalized

45. Effective financial coverage:
breast cancer in Mexico
– Primary prevention
– Secondary prevention (early detection)
– Diagnosis
– Treatment
– Survivorship care
– Palliative care
Large and exemplary investment in treatment for women
and the health system, yet a low survival rate.
By applying a diagonal approach,
this can and is being remedied.

46. Health System
Functions
Stage of Chronic Disease Life Cycle /components CCC
Primary
Prevention
Secondary
prevention
Diagnosis Treatment
Survivorship/
Rehabilitation
Palliation/
End-of-life care
Stewardship
Financing
Delivery
Resource
Generation
Responding to the challenge of chronicity:
Health system functions by care continuum

47. Benefits:coveredinterventions
Horizontal and vertical financial protection strategies:
Seguro Popular in Mexico
ACCELERATED
VERTICAL
COVERAGE
for
Catastrophic
Illnesses
included
in
the
Fund:
breast
cancer,
AIDS
Community
and
Public
Health
Services
Poor
Rich
CHILDREN:
Health
insurance
for
a
New
Genera1on
Survivorship
Package
of
essen1al
personal
services
Preven=on,
Early
detec=on
Beneficiaries

48. Harness platforms by integrating breast and
cervical cancer prevention, screening and
survivorship care into MCH, SRH, HIV/AIDS,
social welfare and anti-poverty programs.
Solution:
‘Diagonalizing’ Delivery

49. Including breast cancer awareness for
early detection in Oportunidades
• “Guía de orientación y
capacitación a titulares
beneficiarios del programa
Oportunidades” includes
information on breast cancer
as of 2009/10
• 1.5 million copies to
promoters
• Reaches 5.8 million families =
more than 90% of poor
households

50. Solution:
‘Diagonalizing’ Delivery
Results: 000´s promoters, nurses, doctors
Harnessing the primary level of care

51. Survivorship care…
incipient

52. Pain
and
Pallia=on

53. Where are the opportunities?
• LMICs – not months but whole lifetimes to be gained
• Focus on prevention but do not stop there!
– No prevent/treat dichotomization
• Do not take prices as fixed or given – price permeability
• Harness global and national health system platforms
• Innovate in implementation, delivery and financing
– Evaluate, replicate and scale up
– Leapfrog and give forward
• Redefine and reformulate health systems to manage chronicity
• Harness cancer to strengthen health and social systems
• Recognize LMICs as part of a global solution:
 investment in learning, research and human beings

54. Expanding access to cancer care and control in
LMICs: Should, Could, and Can be done