by Julio Frenk, MD, MPH, PhD
Dean, Harvard School of Public Health
While it’s well known that cancer is a leading cause of death and disability worldwide, what is less recognized and understood is the significant growth of cancer in the developing world. Only two decades ago, the percentage of new cases was similar for developed and developing regions. Today, 55 percent of new cases arise in developing nations—a figure that could reach 60 percent by 2020 and 70 percent by 2050.
Unless a shift in mindset occurs—with those committed to global health investing more in cancer information, prevention, screening, and treatment—the number of new cancer cases worldwide will grow from around 12 million today to 15 million in 2020, with much of that growth occurring in developing nations.
According to the most recent World Health Organization (WHO) estimates, in 2004 there were 7.4 million cancer deaths worldwide, representing around 13 percent of total deaths. More than 70 percent of those deaths occurred in low- and middle-income countries.
PUBLIC HEALTH SUCCESSES SET STAGE
Why is cancer increasing in the developing world?
Ironically, successes in other realms of public health are partly behind this shift. Gains made against infectious diseases and increases in child survival beyond age 5 now make it possible for people in developing countries to live long enough to suffer the noncommunicable diseases associated with age. Yet infectious diseases remain serious threats, creating a double burden of ill health.
In low- and middle-income countries, the high incidence of malignant tumors related to communicable diseases, such as the human papilloma virus (HPV), reflects a dearth of reliable systems for disease control and screening services. By contrast, the increasing incidence of lung, breast, and colorectal cancer is largely the result of demographic and lifestyle changes, including longer life expectancy and accelerated urbanization, which in turn leads to reproductive patterns (pregnancy at older ages, low prevalence of breastfeeding) and lifestyles (tobacco consumption, high calorie intake, alcohol abuse) associated with several forms of cancer.
A COMPREHENSIVE VIEW OF GLOBAL HEALTH
The global health agenda remains focused primarily on communicable diseases and the traditional identification of international health with infectious disease control. We need, however, to adopt a more comprehensive view. First, the separation between communicable and noncommunicable diseases is not as clear-cut as it was once thought. According to WHO, one-fifth of all cancers worldwide are caused by chronic infections produced by agents such as HIV, HPV, hepatitis B virus, and Helicobacter pylori.
In addition, noncommunicable diseases and injuries are increasingly prevalent in the developing world. Problems only of the poor—such as common infections, undernutrition, and maternal deaths-are no longer the only problems of the poor. Impoverished groups also suffer the highest rates of many chronic ailments, such as cardiovascular diseases, cancer, and mental disorders. “Healthwise, the Northern Hemisphere and the Southern Hemisphere outside of sub-Saharan Africa are more alike than different,” says Barry R. Bloom, former Harvard School of Public Health dean.
FALSE DILEMMA CREATES BARRIERS
Today’s alarming cancer statistics stand in stark contrast to an equally alarming lack of awareness, both locally and globally. Sadly, a false dilemma has created barriers to action. Screening procedures for cancer are considered too difficult and costly to implement. Some experts argue that it is unethical to screen, because treatment is unaffordable for the vast majority of the population. Finally, observers ask: Why tackle cancer when so many are ill and dying from communicable diseases and the backlog associated with underdevelopment?
In middle-income countries, access to screening and treatment for cancer tends to be limited to affluent populations and to the minority of insured persons. Even in upper-middle-income countries, where noncommunicable diseases now account for the largest proportion of the burden of disease, cancer rarely appears at the top of the health agenda.
Why is cancer absent from the global public health agenda?
To address the health needs of the developing world, we need health reforms that take into account the reality of the disease burden these nations face. In the case of the recent Mexican health reform, for example, two separate financial funds were created-one to address catastrophic health problems, including cancer in children and cervical and breast cancer in adults, and another for community health encompassing prevention and screening procedures for noncommunicable diseases, including several forms of cancer.
SPREADING INFORMATION, CHANGING ATTITUDES
Information will play a key role—in risk assessment, provision of services, training, academic research, and policy implementation. Information will also be critical to confront the cultural resistance that stymies the fight against cancer. In many developing countries, it is not uncommon for women with breast cancer to be considered diminished in their femininity. Concerned about the possibility of being abandoned by their spouses when discovered ill, many decide not to look for care—or, if they do, to reject proper treatment.
Fortunately, governments in developing nations are becoming more aware of the cancer threat. In 2005, the 58th World Health Assembly passed a resolution calling on member states to intensify action against the disease by developing and reinforcing cancer control programs. Efforts to support research on cancer in developing countries, though still meager, are also increasing. A major breakthrough was the approval of a $50 million grant from the Bill & Melinda Gates Foundation to create the Alliance for Cervical Cancer Prevention.
Breast cancer is also being recognized as a major public health challenge. Recent efforts include the creation, by the Fred Hutchinson Cancer Research Center with support from Susan G. Komen for the Cure, of the Breast Health Global Initiative in 2002. Working with Dana-Farber and Brigham and Women’s Hospital, HSPH is also highlighting breast cancer in developing countries as a challenge to women’s health and global equity.
CANCER BELONGS IN THE GLOBAL HEALTH AGENDA
To place cancer on the global health agenda, we must expand the United Nations’ Millennium Development Goals to include health targets related to noncommunicable diseases common in low- and middle-income countries, such as hypertension, diabetes, and the most prevalent malignancies. We also have unprecedented opportunities in today’s five revolutions in health: life sciences, telecommunications, systems thinking, knowledge management, and human rights.
In this spirit, it would be useful to invoke the words of the Nobel laureate Amartya Sen at the International Symposium on Human Security, held in Tokyo in 2000:
“We live in a world that is not only full of dangers and threats, but also one where the nature of the adversities is better understood, the scientific advances are more firm, and economic and social assets that can counter these menaces are more extensive. Not only do we have more problems to face, we also have more opportunities to deal with them.”
Let this keen awareness of the challenges, tempered by the realistic optimism offered by current opportunities, inspire the crucial work needed to face the global epidemic of cancer.
This article is based on remarks made by Dean Frenk at the Dana-Farber/Harvard Cancer Center on April 7, 2009. Octavio Gómez-Dantés provided valuable input.