The dread disease: cancer in the developing world.
Subject: Developing countries (Health policy)
Public health (Research)
Chronic diseases (Risk factors)
Chronic diseases (Research)
Authors: Parsi, Kayhan
Bhattacharya, Dhrubajyoti
List, Justin
Pub Date: 05/01/2011
Publication: Name: The Hastings Center Report Publisher: Hastings Center Audience: Academic; Professional Format: Magazine/Journal Subject: Biological sciences; Health Copyright: COPYRIGHT 2011 Hastings Center ISSN: 0093-0334
Issue: Date: May-June, 2011 Source Volume: 41 Source Issue: 3
Topic: Event Code: 970 Government domestic functions; 310 Science & research
Product: Product Code: 8000120 Public Health Care; 9005200 Health Programs-Total Govt; 9105200 Health Programs NAICS Code: 62 Health Care and Social Assistance; 923 Administration of Human Resource Programs; 92312 Administration of Public Health Programs
Geographic: Geographic Scope: United States Geographic Code: 0DEVE Developing Countries; 1USA United States
Accession Number: 268403513
Full Text: The triumvirate of HIV/AIDS, tuberculosis, and malaria have dominated our public health focus in the developing world. Having claimed millions of lives, these infectious diseases have prompted a large-scale response. Concomitant with these efforts has been a burgeoning bioethics literature examining global health and distributive justice. A scholarly wasteland only a decade ago, there is now a growing and rich literature that aims to unpack our moral obligations when it comes to diseases that affect the majority of the world (many living in absolute poverty). Now, added to the persistent challenges posed by infectious diseases is the growing burden of diseases such as cancer, which disproportionately affect developing nations.

The rates of noncommunicable chronic diseases, including cancer, continue to increase in low-income countries. (1) Recent estimates suggest that the case fatality from cancer may be as high as 74.5 percent in low-income countries, compared to 46.3 percent in high-income countries. (2) Survival rates for some cancers, such as testicular and breast cancers, have been positively related to country income. (3) Additionally, low education levels, poor health literacy, and advanced presentation of different cancers lead to further difficulties for people in developing countries.

The disparity between cancer resource allocation in lower and higher income countries is stark--about 5 percent of total global funds dedicated to cancer are spent in developing countries. (4) Together with an estimate that 80 percent of disability-adjusted life years lost to cancer worldwide occur in developing countries, (5) a renewed focus on solutions to cancer care in resource-poor settings is past due. Disparities in treatment and survival outcomes are perpetuated by a lack of adequate evidence-based guidelines and treatment algorithms for cost-effective cancer care in developing countries. (6) Most countries have not implemented effective national control strategies that can save lives. (7) Promising models of cancer control in lower- and middle-income country health systems exist, however, and there has already been some discussion of established models in Mexico and Colombia, which both have national insurance plans, and of nascent scale-up efforts ongoing in Rwanda, Malawi, and Haiti. (8)

At the heart of scaling up cancer care in resource-poor settings is the pervading assumption that cancer care cannot be provided efficiently or equitably. There are least two problems with this assumption. First, a more generalized version of this assumption has been disproved; there are examples of successfully scaled-up HIV/AIDS and tuberculosis treatment programs in resource-poor settings. (9) Second, the assumption that meaningful cancer care is not feasible in lower-income countries imparts a particular view of reality that reinforces inequity. As John Seffrin of the American Cancer Society has forcefully pointed out, global cancer disparities illustrate a collective failure to actualize the universal human right to access an adequate standard of health, and these disparities in cancer care and mortality demonstrate some of the most glaring social inequalities in health. (10)

CanTreat International, also known as the Informal Working Group on Cancer Treatment in Developing Countries, recently highlighted three key lessons learned from the HIV/ AIDS movement that may be applicable to cancer care. (11) First, access to cancer treatment should be mandatory. The World Health Organization's current list of essential chemotherapies is a start in this direction. Second, cancer control needs to be mainstreamed into comprehensive health systems along with ways to provide high-quality care in order to detect and address cancer effectively. Third, advocacy and education are essential, including efforts to define public health priorities and treat cancers within the existing health system to continue to improve cancer interventions and the health system as a whole.

The global disease burden of breast cancer provides a helpful illustration. Every year, over one million women are diagnosed with breast cancer worldwide, and an additional four hundred thousand die from the disease. (12) Breast cancer, however, is unique, insofar as it primarily affects women who must bear the additional burden of numerous social inequities. In low- and middle-income countries, these disparities extend beyond stereotypical gender roles and affect fundamental rights and freedoms, including access to education, employment, health care, and political representation. (13) Together, these factors sustain a cultural fatalism that may undermine efforts to reduce risk by promoting behavioral modification and collective action.

Breast cancer, like most cancers, develops over a long period of time, so preventive, diagnostic, and treatment regimens must ideally be implemented at critical junctures across the life span of the disease in order to be effective. Consequently, there are multiple points of intervention, longitudinally and prescriptively, though preventive or therapeutic measures. Organizations such as the Breast Health Global Initiative have spearheaded efforts to address these issues by providing guidelines on resource allocation for prevention, treatment, and programmatic elements (such as human resources and support systems). (14) Health, however, is a social construct, and justice would entail a recognition that the disproportionate impact of illness as experienced by women cannot be fully addressed without securing general access to care and empowering choice in matters affecting one's health and well-being. Women generally lack the opportunity to directly challenge their governments for failure to implement treaty obligations.

Optional protocols are treaties that fill this gap by empowering women to file a complaint with an international treaty-monitoring body and determine whether a violation has occurred. Of 182 parties to the Convention on the Elimination of All Forms of Discrimination Against Women, only 102 (or 56 percent) have ratified its optional protocol. This is troubling since the CEDAW Committee has received ten claims over the past decade, half of which involved health-related issues, including forced sterilization, informed consent, and domestic violence. (15) These forums allow women to hold governments accountable on an international stage, matching governments' general treaty obligations to concrete measures that positively affect population health.

Different ethical frameworks, both utilitarian and rights-based, reinforce the call to expand cancer care in developing countries. (16) Increasingly, more justice-based arguments and health disparities research are likely needed to continue pushing policy-makers toward prioritizing cancer control in developing countries, as well as to improve upon the estimated meager 5 percent of global cancer monies dedicated to addressing cancer in developing countries. Such global health disparities are a growing concern of bioethicists. Tom Beauchamp and James Childress have argued in their most recent edition of Principles of Biomedical Ethics for a vigorous cosmopolitan theory of global justice. (17) Bioethics scholars such as Madison Powers and Ruth Faden have argued for reducing the inequities that are the most unjust. (18) The health disparities we see with cancer are inextricably linked to poor resources, inadequate education, and weak infrastructures.

The increasing cancer burden in the developing world poses significant ethical, social, cultural, and public health challenges. As a field, public health has taken the lead on addressing many issues related to global health and justice. Although bioethics has historically been concerned with the micro issues of clinical and research ethics, many more bioethicists are grappling with the ever-growing cadre of global health challenges and the justice implications they raise. The growing burden of cancer in the developing world should occupy a central role in this challenge.

This column appears by arrangement with the American Society for Bioethics and Humanities

(1.) K.M. Narayan et al., "Global Noncommunicable Diseases--Where Worlds Meet," New England Journal of Medicine 363 (2010): 1196-98.

(2.) N. Beaulieu et al., Breakaway: The Global Burden of Cancer--Challenges and Opportunities. A Report of the Economist Intelligence Unit (August 2009), at htt p:// marketing/pdf/EIU_LIVESTRONG_Global_Cancer_Burden.pdf.

(3.) P. Farmer et al., "Expansion of Cancer Care and Control in Countries of Low and Middle Income: A Call to Action," Lancet 376 (2010): 1186-93.

(4.) T. Ngoma, "World Health Organization Cancer Priorities in Developing Countries," Annals of Oncology 17, suppl. 8 (2006): viii9-viii14.

(5.) Committee on Cancer Control in Low- and Middle-Income Countries, Board on Global Health, Institute of Medicine of the National Academies, Cancer Control Opportunities in Low- and Middle-Income Countries, ed. F.A. Sloan and H. Gelband (Washington, D.C.: National Academies Press, 2007).

(6.) D.J. Kerr and R. Midgley, "Can We Treat Cancer for a Dollar a Day? Guidelines for Low-Income Countries," New England Journal of Medicine 363 (2010): 801-3.

(7.) J.R. Seffrin, "Cancer Control as a Human Right," Lancet Oncology 9, no. 5 (2008): 409-411.

(8.) Farmer et al., "Expansion of Cancer Care and Control in Countries of Low and Middle Income."

(9.) Ibid.

(10.) Seffrin, "Cancer Control as a Human Right."

(11.) CanTreat International, "Scaling Up Cancer Diagnosis and Treatment in Developing Countries: What Can We Learn from the HIV/AIDS Epidemic?" Annals of Oncology 21, no. 4 (2010): 680-82.

(12.) B.O. Anderson, "Guideline Implementation for Breast Healthcare in Low-Income and Middle-Income Countries," Cancer 113, suppl. 8 (2008): 2221-43.

(13.) A. Srinivasan, "Breast Cancer in Women: A Public Health Perspective," chapter 19, Women's Global Health and Human Rights (Sudbury, Mass.: Jones and Bartlett, 2010).

(14.) A. McTiernan et al., "Breast Cancer Prevention in Countries with Diverse Resources," Cancer 113, suppl. 8 (2008): 2325-30; A. Eniu et al., "Guideline Implementation for Breast Healthcare in Low- and Middle-Income Countries: Treatment Resource Allocation," Cancer 113, suppl. 8 (2008): 2269-81; J. Harford et al., "Guideline Implementation for Breast Healthcare in Low- and Middle-Income Countries: Breast Healthcare Program Resource Allocation," Cancer 113, suppl. 8 (2008): 2282-95.

(15.) D. Bhattacharya, "The Perils of Simultaneous Adjudication and Consultation: Using the Optional Protocol to CEDAW to Secure Women's Health," Women's Rights Law Reporter 31 (2009): 42-103.

(16.) F. Kerr and D. Kerr, "Do We Bear Any Moral Responsibility for Improving Cancer Care in Africa?" Annals of Oncology 17, no. 12 (2006): 1730-31.

(17.) T. Beauchamp and J. Childress, Principles of Biomedical Ethics, 6th ed. (New York: Oxford University Press, 2009), 264-67.

(18.) M. Powers and R. Faden, Social Justice: The Moral Foundations of Public Health and Health Policy (New York: Oxford University Press, 2006).
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