At the Intersection of Health, Health Care and Policy Cite this article as: Joanne Silberner A New Priority For Low-Income Countries: Fighting Cancer Health Affairs, 34, no.4 (2015):551-554 doi: 10.1377/hlthaff.2015.0184

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Toward the future: Ugandan Vice President Edward Ssekandi plants a tree in 2011 to mark the future site of the Uganda Cancer Institute–Fred Hutch Cancer Centre, in Kampala. doi:

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A New Focus

A New Priority For Low-Income Countries: Fighting Cancer For decades, infectious diseases were seen as the biggest health threat in the developing world. That’s beginning to change. BY JOANNE SILBERNER

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n October 4, 2011, a twofoot-tall tree was planted at the Uganda Cancer Institute (UCI) in Kampala as part of a big ceremony. The vice president of Uganda was there. So was Harold Varmus, then head of the US National Cancer Institute. There were American and Ugandan physicians as well as nurses, patients, and tradi-

tional singers and dancers. The UCI, started in 1967,1 had for most of its history struggled along without much outside help. In fact, at one point there was only one doctor for the 22,000 patients who came in each year. The little tree was surrounded by the modest tin-roofed buildings and rusting repurposed shipping container that at the time constituted the UCI. The

Photograph by Jacqueline Koch/Fred Hutch News Service

tree represented a promise that a modern three-story research center would be built by the UCI, the Ugandan government, the Seattle-based Fred Hutchinson Cancer Research Center, the US Agency for International Development (USAID), and several other foreign donors. Such an investment in advancing cancer research and prevention is a relatively new phenomenon in most of Africa. In a recent commentary for the Lancet, Felicia Knaul, Rifat Atun, Paul Farmer, and Julio Frenk—all of the Harvard T.H. Chan School of Public Health—describe how for years the prevailing attitude in the global health community was that efforts to prevent or treat cancer in low- and middle-income countries were “unnecessary, unaffordable, unattainable, and inappropriate because they divert resources from other more acute and burdensome health priorities.”2 The young tree in Kampala, a placeholder for a new building, suggested that this old mind-set had begun to fade and that the global health community was undergoing a profound shift in attitude.

Throughout the twentieth century, governments and aid groups trying to improve health in the developing world were primarily interested in infectious diseases. Cancer was not a global issue. The earliest efforts to combat cancer in low- and middle-income countries were small in scale, with little involvement or buy-in from local governments or large international donors. That’s not to say nothing was going on. For example, St. Jude Children’s Research Hospital, in Memphis, Tennessee, started an international outreach program in the early 1990s, with programs in China, Brazil, and El Salvador. In 1996 USAID, at the behest of Congress, funded a breast cancer screening, diagnosis, and treatment program for Ukrainian women to see if there were any long-term effects of the nuclear accident in Chernobyl ten years earlier.3 Susan G. Komen started with local health and outreach programs in 1999

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Entry Point and is now involved in screening, detection, and treatment. And some professional organizations—for example, the American Society for Clinical Oncology and the American Society of Hematology—have had their own projects in developing countries around the world. But until several years into the twentyfirst century, the billion-dollar investments in global health went mostly to the “big three” infectious diseases: HIV, TB, and malaria. There were large global campaigns—including those of the President’s Emergency Plan for AIDS Relief (PEPFAR); the GAVI Alliance; and the Global Fund to Fight AIDS, Tuberculosis, and Malaria—but no global fund for cancer. As Christopher Wild, head of the International Agency for Research on Cancer (IARC), part of the World Health Organization, says, “There’s not always been a very receptive audience.” Change has come for multiple reasons. There are new numbers on cancer incidence showing that the global burden of cancer is higher than many people expected. Advocates for cancer care have become increasingly vocal about not leaving poor people out. And economists have calculated the value of preventing and treating cancer in developing countries. Demographics play a key role in the changing focus on cancer. Two organizations, the IARC and the Institute for Health Metrics and Evaluation (IHME), have been counting cancers, and their numbers highlight a growing irony. The programs that target HIV, TB, and malaria and projects to improve maternal and child health are bringing down the number of premature deaths, so that people in poor countries are living into the older age groups in which cancer is more common. In 1990, says Christopher J.L. Murray, director of the IHME, 3.2 million people in the developing world died from cancer. “Now we have 5.1 million” dying of it each year, he says. Outside of sub-Saharan Africa most of the infectious diseases have dropped out of the ranks of leading causes of death, and cancers are on the increase, Murray has found. Overall, in terms of groups of diseases, cancer comes out as the number-two killer—ahead of infectious diseases and second only to heart dis552

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ease, according to Murray. The cancer death statistics are getting attention at high levels. “If you’re the government of Brazil or Mexico or India or China, these are really diseases you have to deal with,” says Murray. “They see their expenditures on cancer, and they see the number, and they see the demand.” Another reason for the increased interest in cancer is that some of the researchers who are documenting the new burden of cancer are also highlighting prevention and treatment as human rights issues. In 2010 the Lancet published a seminal article authored by twenty-three people, including such medical luminaries as Paul Farmer of Partners in Health and Julio Frenk, dean of the Harvard T.H. Chan School of Public Health.4 Among the other authors were cyclist Lance Armstrong, economist Jeffrey Sachs, and Her Royal Highness Princess Dina Mired of Jordan. Together they called for “an immediate and large-scale global response,”4(p1186) pointing to the shifting burden of cancer. In 1970, 15 percent of new cancers occurred in developing countries. That share had risen to 56 percent in 2008 and was projected to be 70 percent by 2030.4(p1186) The authors cited a 2009 estimate claiming a cancer mortality rate of 75 percent in low-income countries, compared to 46 percent in high-income countries. Of the total disability-adjusted life-years lost worldwide to cancer, 80 percent were in developing countries. Yet developing countries accounted for only 5 percent of the spending on cancer. In 2011 the United Nations held a high-level meeting on noncommunicable diseases and stated its intentions to focus on four groups of diseases: cancer, cardiovascular disease, chronic lung diseases, and diabetes.5 In the same year, Varmus created the Center for Global Health at the National Cancer Institute. And in 2013 Varmus and Harpal Kumar, CEO of Cancer Research UK, published a commentary in Science Translational Medicine that summarized the conclusions of cancer experts from fifteen high-, middle-, and low-income countries who had attended a conference held at the National Institutes of Health.6 Diseases that used to be 34:4

considered rich people’s problems were now firmly entrenched around the world. With the recognition of cancer’s increase and with global health advocates insisting that all people have the right to cancer treatment, economics has come into play. Health economists have started making an economic case for investing in cancer prevention and treatment in poor countries. “The benefits of investment accrue beyond the individual,” says Harvard economist Rifat Atun, one of the authors of the 2010 Lancet paper. “Addressing cancer and chronic illness will help countries in reducing their burden of illness and help their economies,” he says. “Their economic growth will help not just them but other countries as well. Everyone benefits.” He and others have calculated that the lost productivity due to cancer around the world outweighs the cost of prevention and treatment.7 But a disproportionately small amount of money is going into cancer. Says Wild of the IARC, “There’s a mismatch between the burden of disease and the investment in health aid.” Joseph Dieleman and colleagues at the IHME reported last year in Health Affairs that while half the world’s burden of disease is due to noncommunicable illnesses, including cancer, only 1.5 percent of the money spent on health aid goes to these diseases.8 “Let’s not make the mistakes we made with HIV,” says Atun. “We waited many years. We thought it was too expensive, not feasible.” But the believers showed the world that a strong global response was possible and necessary. “This is what we’re arguing with cancer,” Atun says. “It can be done.”

The Special Case Of Cancer Addressing cancer in low- and middleincome countries will take both new and old tools. Treating cancer is much more complicated than treating infectious diseases. “There are so many kinds of cancer, and so many drugs, that it’s almost overwhelming for a country with very limited resources to think about,” says Julie Gralow, a professor of medical oncology at the University of Washington who’s been working to bring attention to cancer in poor countries since 1997. “And some of those drugs are ridiculously

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overpriced.” So much more than medication is needed, says Ted Trimble, head of the National Cancer Institute’s Center for Global Health. “For cancer you need pathology, imaging, surgery, medical oncology, radiation oncology, nursing oncology—a whole host of disciplines are critical.” And there’s one more challenge, he notes: stigma. In many parts of the world, people with cancer won’t admit that they have the disease because they’re afraid that they and their families will be shunned. Cancer is not completely different or separate from infectious diseases. In fact, 15–20 percent of the world’s cancers are the result of infection.9 There’s hepatitis B, which is a major cause of liver cancer. Human papillomavirus (HPV) causes cervical cancer. Helicobacter pylori, a bacterium, can cause stomach cancer. Untreated HIV infection can lead to Kaposi’s sarcoma and other cancers. The list goes on. Fortunately, many infectious diseases can be fought with vaccines. Multiple nongovernmental organizations (NGOs) around the world, with funding from the Bill & Melinda Gates Foundation and other philanthropies, have been working to introduce the HPV vaccine into low- and middle-income countries. And China has a program to vaccinate all of its people against hepatitis B.10

Looking Ahead Today the little tree at the Uganda Cancer Institute has been replaced by the UCI Fred Hutch Cancer Research Centre—a gleaming three-story, 25,000 square foot building with an outpatient clinic, chemotherapy rooms, research labs partly funded by USAID, and more.11 It’s now scheduled to open in May. Up the hill is a modern six-story hospital built by the government that is also

Cancer is not completely different or separate from infectious diseases. In fact, 15–20 percent of the world’s cancers are the result of infection. due to open soon. And in neighboring Rwanda, as in Haiti, Partners in Health patches American consultants in by phone to help with cancer diagnosis and treatment plans that can be carried out in a primary care environment. Recently, more NGOs have taken on cancer prevention and treatment. Former President George W. Bush’s “Pink Ribbon Red Ribbon” initiative has focused on breast cancer and cervical cancer in sub-Saharan Africa. And local politicians in low- and middle-income countries are speaking out about the need to fight cancer. Some of them— such as Beth Mugo, Kenya’s former minister of public health and sanitation— have been spurred by their own battles with cancer.12 Meanwhile, clinical and policy researchers hope that a landmark study on the overall impact of noncommunicable diseases, released in December by the Council on Foreign Relations, will focus more attention on the field.13 The World Bank has been supporting local projects on cancer care and control. And at the World Economic Forum in Davos, Switzerland, in January 2015, Franco Cavalli, chair of the World Oncology Forum, called on the world leaders and major funders in attendance to create a global fund for cancer. To guide policy makers’ next steps, careful research is needed, says Harvard’s Atun. “What can ensure these cost-effective interventions are taken up?” he asks. Take HPV vaccination,

which has proved to be a tough sell in some countries. “Is the barrier local political will, is it the way the budgets are allocated, is it that we don’t have the human resources? We need to understand country by country what those barriers are.” “It’s time to put research into practice,” says Trimble, of the Center for Global Health. Tobacco control is high on the list. “There’s a number of low-cost interventions that we know now that just need to get out the door. We need to convey that they work, they work well, and we need them to become routine.” The Millennium Development Goals (MDGs)—specific targets and timelines developed with the aim of eliminating poverty in its many dimensions around the globe—expire at the end of this year. When the goals were established following a United Nations Summit in 2000, not one focused on cancer or any of the other noncommunicable diseases. As a result, governments and NGOs, intent on meeting the MDGs, didn’t devote much money or effort to fighting cancer. Advocates are lobbying hard for the incorporation of cancer prevention and treatment in the Sustainable Development Goals, the replacements to the MDGs due to be announced later this year. The IARC’s Wild is optimistic that the coming years will see cancer included on the global health agenda. “There’s a growing political awareness of cancer as a major public health problem,” he says. What remains is for the statistics to show whether this increased awareness will translate into longer, healthier lives. Many experts are sure that it will. ▪

Joanne Silberner ([email protected]) is a freelance reporter and teaches journalism at the University of Washington, in Seattle.

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NOTES 1 Uganda Cancer Institute. Background [Internet]. Kampala: UCI; c 2015 [cited 2015 Feb 23]. Available from: http://www.uci .or.ug/history-and-background 2 Knaul FM, Atun R, Farmer P, Frenk J. Seizing the opportunity to close the cancer divide. Lancet. 2013;381(9885):2238–9. 3 Pillsbury B, Green EC, Harper GR, Galayda V. Ukraine breast cancer support: participatory evaluation of USAID technical assistance [Internet]. Washington (DC): USAID; 2000 Jun [cited 2015 Feb 23]. Available from: http:// pdf.usaid.gov/pdf_docs/ PDABS760.pdf 4 Farmer P, Frenk J, Knaul FM, Shulman LN, Alleyne G, Armstrong L, et al. Expansion of cancer care and control in countries of low and middle income: a call to action. Lancet. 2010; 376(9747):1186–93. 5 United Nations. Political declara-

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tion of the high-level meeting of the General Assembly on the prevention and control of noncommunicable diseases [Internet]. New York (NY): UN; 2011 Sep [cited 2015 Mar 1]. Available from: http://www.un.org/ga/ search/view_doc.asp?symbol=A/ 66/L.1 6 Varmus H, Kumar HS. Addressing the growing international challenge of cancer: a multinational perspective. Sci Transl Med. 2013; 5(175):175cm2. 7 Knaul FM, Gralow JR, Atun R, Bhadelia A, Frenk J, Quick J, et al. Closing the cancer divide: overview and summary. In: Knaul FM, Gralow JR, Atun R, Bhadelia A, editors. Closing the cancer divide: an equity imperative. Cambridge (MA): Harvard University Press; 2012. p. 3–26. 8 Dieleman JL, Graves CM, Templin T, Johnson E, Baral R, LeachKemon K, et al. Global health de-

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velopment assistance remained steady in 2013 but did not align with recipients’ disease burden. Health Aff (Millwood). 2014; 33(5):878–86. 9 American Cancer Society. Infections that can lead to cancer [Internet]. Atlanta (GA): ACS; [last revised 2014 Sep 24; cited 2015 Mar 2]. Available from: http:// www.cancer.org/acs/groups/cid/ documents/webcontent/002782pdf.pdf 10 Hepatitis B Foundation. Hepatitis B and primary liver cancer [Internet]. Doylestown (PA): The Foundation; [last updated 2014 Mar 7; cited 2015 Feb 23]. Available from: http://www.hepb.org/ professionals/hepb_and_liver_ cancer.htm 11 Fred Hutchinson Cancer Research Center. UCI-Fred Hutch Cancer Centre [Internet]. Seattle (WA): The Center; c 2015 [cited 2015 Feb 23]. Available from http://

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www.fredhutch.org/en/labs/ vaccine-and-infectious-disease/ international-programs/globaloncology/uganda/uci-buildingprogress.html 12 Lornah K. Government seeks support of diaspora medics in fighting cancer. Star [serial on the Internet]. 2012 Mar 1 [cited 2015 Mar 2]. Available from: http:// www.the-star.co.ke/news/article28125/government-seekssupport-diaspora-medicsfighting-cancer 13 Daniels ME Jr, Donilon TK, Bollyky TJ. The emerging global health crisis: noncommunicable diseases in low- and middleincome countries [Internet]. New York (NY): Council on Foreign Relations; 2014 Dec [cited 2015 Mar 3]. (Independent Task Force Report No. 72). Available from: http://www.cfr.org/diseasesnoncommunicable/emergingglobal-health-crisis/p33883

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