[Ip-health] Richard Horton in The Lancet - Offline: Why has global health forgotten cancer?

Thiru Balasubramaniam thiru at keionline.org
Mon Sep 10 12:09:10 PDT 2018


Offline: Why has global health forgotten cancer?
Richard Horton

Later this month (at the UN General Assembly) the global health community
will likely witness an inflection point in the history of non-communicable
disease (NCD) prevention and control. But one fact is certain. Whatever
countries do to show they are taking NCDs more seriously, cancer treatment
will be missing from their commitments. Cancer's undeserved neglect makes
it the Cinderella of the emerging NCD movement. As health diplomats
celebrate their political success, millions of people living with cancer
will be consigned to early and painful deaths. Nothing illustrates the
embedded irrationality of global health more than our attitudes to cancer.
In 2016, according to the Global Burden of Disease, 8·9 million people died
from cancer (23% of total worldwide deaths from NCDs, and 16% of deaths
from all causes). The leading causes of cancer death are tumours of the
trachea, bronchus, and lung (1·7 million deaths); gynaecological cancers
(breast, cervix, ovary, and uterus: 1 million deaths); gastric cancer (834
000 deaths); colorectal cancer (829 600 deaths); and liver cancer (828 000
deaths). So why the indifference?

The NCD community has become trapped in an ideology that privileges
prevention over treatment. A similar mistake disfigured the early response
to AIDS. I can recall senior WHO leaders two decades ago agreeing that a
generation of people living with HIV would have to die before the pandemic
could be controlled by prevention. Only anger and activism overturned the
complacency of traditional public health practice. But the NCD community
has no time for anger or activism. It prefers repeating and re-emphasising
the old nostrums. We can all agree that tobacco control and vaccination
against hepatitis B and human papillomavirus are indispensable
interventions to curb cancer. But what about the treatment of breast
cancer? Or surgery for resectable tumours? Or specialist services for
cervical cancer? Or chemotherapy and radiotherapy facilities? Or treatment
for childhood cancers? Or palliative care services? Silence.

Two arguments will be mounted against the charge that global health has
forgotten cancer treatment. First, if global health is about remedying
inequity, and if those remedies are mainly concerned with resource-poor
communities, then cancer treatment cannot be a priority. If, for example,
one examines the top 20 causes of age-standardised disability-adjusted
life-years (DALYs) in sub-Saharan Africa, you will see that cancer is
absent. The global health community is therefore surely right to focus on
AIDS, tuberculosis, malaria, and other infectious diseases. It should
definitely accommodate ischaemic heart disease, stroke, diabetes, major
depression, and chronic obstructive pulmonary disease. But cancer? No. A
second argument is that even if we concede that cancer should be taken more
seriously, the treatment gap will best be filled by focusing not on
specific diseases but on strengthening health systems and achieving
universal health coverage (UHC). Both claims are flawed. Take
gynaecological cancers. The majority of women who die from breast and
cervical cancer live in low-income and middle-income settings. Cancer
should be a major health priority in the poorest countries. That is true
today. It is even more true if one looks only a short distance into the
future. As The Lancet's 2016 Series on Health, Equity, and Women's Cancers
described, 1·7 million women are diagnosed with breast cancer annually. By
2030, the number of women diagnosed with breast cancer is projected to rise
to 3·2 million. It is entirely wrong to suggest that cancer should only be
a concern for richer nations. As to UHC filling the gap in cancer care, one
mistake made by UHC advocates is that repeating the mantra of universal
coverage is empty rhetoric without specifying the services that UHC should
include. Too often, cancer treatment is absent from the debate about UHC.
Some progress is being made. In its 2017 updated “Appendix 3”—a WHO-branded
list of approved policy options to prevent and control NCDs—the agency does
include treatment services for early cervical, breast, and colorectal
cancers, together with palliative care, although none receive the coveted
“bolding”. The Disease Control Priorities Project does not let countries
off the hook so easily and goes further, including services to treat
selected childhood cancers. The global health community has long let down
those living with cancer. It is inexplicable that it continues to do so.

Thiru Balasubramaniam
Geneva Representative
Knowledge Ecology International
41 22 791 6727
thiru at keionline.org

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