- The Dread Disease:Cancer in the Developing World
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 waste-land 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...