Source: The Economist
04 March 2014
The burden of cancer is falling increasingly heavily on the poor
SARA STULAC is a paediatrician, but doctors in Rwanda must be adaptable. One of her first patients after arriving from America in 2005 was a young girl with a tumour the size of a cauliflower on her face. The girl’s father, a subsistence farmer, had tried traditional healers and local doctors, but the tumour had grown, along with his expenses. An oncologist was needed. If only the country had one. Eventually Dr Stulac called one in America who talked her through the treatment that would save the girl’s life.
What makes this story unusual is its happy ending. According to the International Agency for Research on Cancer (IARC), part of the World Health Organisation (WHO), low- and middle-income countries accounted for 57% of the 14m people diagnosed with cancer worldwide in 2012—but 65% of the deaths. Cancer kills more people in poor countries than AIDS, malaria and tuberculosis combined.
Residents of poor countries have long suffered from cancers, such as those of the liver and cervix, that are associated with infections. But as they have grown richer, drinking, smoking and fatty foods have led to more breast, colorectal and lung cancer. Women who used to die in childbirth now live long enough to develop breast cancer. HIV patients on antiretroviral drugs are dying of other causes.
Glass-half-full types view this as a success. But resources have not shifted with the burden of disease. Many developing countries have no trained oncologists, let alone a treatment centre. Even where care is available, the sick often delay because they are poor or do not know that treatment is urgent. Some languages have no word for cancer.
Poor cancer sufferers are not only more likely to die, but more likely to suffer pain and financial distress. When researchers asked Kenyan and Scottish patients with terminal cancer about their experiences, the Scots spoke of emotional angst while the Kenyans reported severe physical pain and financial worries. Though morphine is cheap, it is scarce in many poor countries, whose governments fear it will cause addiction or be used to make heroin.
Although cancer claims more victims, it receives a tiny fraction of the aid that goes to fighting HIV, malaria and tuberculosis. Three of the Millennium Development Goals dealt with health, but none mentioned cancer. Few of the most modern cancer drugs are considered “essential” by the WHO. Julio Frenk, the dean of the Harvard School of Public Health, says attitudes are similar to those towards AIDS in the 1980s, when treatment for the poor was deemed impractical or unaffordable.
Anti-cancer efforts are in fact very good value for money, says Christopher Wild, the director of IARC. The world spends some $320 billion on cancer treatment and prevention each year, but his group estimates that up to half of cancer deaths could be avoided if the money were spent more wisely. Four-fifths of these avoidable deaths are in low- and middle-income countries.
Lung cancer, which killed 1.6m people around the world in 2012, offers the biggest opportunity. Anti-smoking campaigns already account for most of the aid directed to cancer. But many developing countries have resisted tighter regulation and higher tobacco taxes. Over half of the men in China, Indonesia and Russia smoke. Chinese officials are finally waking up to the staggering public-health costs (see article).
Smaller gains could come from tackling cancers that mostly afflict the poor. Doctors reckon that roughly 80% of liver cancers and 70% of cervical cancers could be prevented by immunising against hepatitis B and human papillomavirus (HPV), which predispose sufferers to the two diseases. Costs are low: just 54 cents for a full course of Hepatitis B vaccine, and $13.50 for HPV. There is no vaccine for Burkitt’s lymphoma, the most common cancer of children in equatorial Africa. But the drugs used to treat it are cheap, effective and relatively easy to administer.
Spotting cancer cases earlier would help, too. About 90% of the patients at the Uganda Cancer Institute were first seen with illnesses so advanced that they would have been hard to treat anywhere, says Corey Casper, an American oncologist who works with the clinic. Earlier treatment could cut mortality by half, he thinks. Low-tech approaches to screening can help. Some countries, including India and Thailand, are testing for cervical cancer using vinegar instead of doing Pap smears, and removing precancerous lesions with liquid nitrogen instead of pricier options. Such successes have an unexpected benefit, too: the more that cancer is seen as survivable, the more readily sufferers will seek timely treatment.
A big worry is whether health-care systems designed to treat acute illnesses would be able to handle the increased caseload. Rwanda provides a model. It now treats several chronic illnesses, including cancer, based on the system it used for HIV, now itself a chronic disease. Community health workers offer decentralised care, which keeps costs down. Young girls receive the HPV vaccine, data on cancer cases are stored and doctors can consult oncologists in America as needed. In 2012 the country opened its first modern cancer centre. More young girls with tumours are surviving as a result.