The Harvard Global Equity Initiative: From Research to Policy

A Conversation With Felicia Knaul, PhD

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Felicia Knaul, PhD

Frankly, denial of pain medication is a form of torture. Living pain free is a human right that can be met, even in our poorest areas.

Felicia Knaul, PhD

The Harvard Global Equity Initiative is a research program at Harvard University that is dedicated to promoting equitable global development, with a strong emphasis on health-care issues. This initiative brings together scholars, policymakers, advocates, and practitioners from around the world to address global-equity challenges by contributing evidence and research.

The ASCO Post recently spoke with the Harvard Global Equity Initiative Director, Felicia Knaul, PhD, about her research in breast cancer in low- and middle-income countries and her work in enhancing access to pain control in resource-challenged areas of the world. Dr. Knaul is a breast cancer survivor.

Cancer Survivor’s Perspective

Does being a breast cancer survivor affect the way you approach the work you’re currently engaged in?

Yes, profoundly. In 2007, I was diagnosed with breast cancer in a small clinic in Cuernavaca, the capital and largest city of the state of Morelos in Mexico, which is my home. At the time, I was 41-years-old, with no history of the disease; the diagnosis gave me a deeper understanding of the shock and sense of helplessness one has after a cancer diagnosis. But in my case, I was fortunate enough to have great medical, personal, and financial support during my treatment and survivorship, which is not the case in much of Mexico, where large portions of the population live in poverty.

After my diagnosis, I dedicated my personal and professional life to confronting the inequity and cancer divide of preventable and treatable cancers that exists between rich and poor countries. In 2008, I founded the Mexican nonprofit organization, Cáncer de Mama: Tómatelo a Pecho, which promotes research, advocacy, awareness, and early-detection initiatives.

Goals of the Global Task Force

Another collaborative enterprise that the Harvard Global Equity Initiative is part of is the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries. There are some shocking figures that put the inequity problem into perspective. For instance, of the 7 million cancer deaths per year worldwide, more than 70% occur in the developing world. And despite this enormous burden, only 5% of global cancer resources are spent in the developing world.

In October 2011, the Harvard Global Equity Initiative released the report Closing the Cancer Divide: A Blueprint to Expand Access in Low and Middle Income Countries. The report has been disseminated worldwide, describing innovative models for achieving expanded access and supplying a well-drawn plan for future action in resource-constrained areas.

Moreover, the Global Task Force will focus on areas that have largely been neglected. Working from the standpoint of health-system strengthening, we will specifically target ways to implement cancer care pathways and expand medical coverage of existing vaccines; detect and treat cancers early, where cure and significant life expectant are likely; and increase services for palliation of cancer symptoms to reduce unnecessary human suffering.

Enhancing Cancer Services

Can you discuss a specific strategy that you feel will make a meaningful impact on cancer care services in a poor region?

To promote and increase the level of cancer care in the poorer areas of the world, you first must assess the primary needs of the population to develop a strategy. For example, my colleagues and I recently completed a report in Mexico looking at breast cancer knowledge among health-care promoters before and after focused training.

It’s important to note that breast cancer is the leading cause of death in adult women, and the mortality rates are rising, now exceeding the mortality rates of cervical cancer. Like in most poor countries, in Mexico, breast cancers are typically diagnosed at an advanced stage, making the outlook for positive outcomes dismal. On the positive side, as part of Mexico’s health reform, in 2003 the Popular Health Insurance program was established, covering about 50 million Mexicans who were otherwise uninsured. And since 2007, breast cancer care is included in Popular Health Insurance coverage. However, access to screening services for early detection remains limited in the poor sections of the country.

In our report, we assessed the effectiveness of a train-the-trainer program in two states in Mexico, where community health workers are a vital part of the health-care force. Realizing the opportunity to expand care, Mexico is committed to increasing the number of these workers to promote early detection of breast cancer and improve outcomes. We worked with local organizations to develop and implement the train-the-trainer program to improve breast cancer knowledge among community health-care workers. We then surveyed the workers before and after the 3-month training period, which included one-on-one classes and online classes.

We found that the trained workers had significantly increased their knowledge of breast cancer in areas including early detection screening, risk factors, treatments, and insurance coverage. So in low-income areas of the world, easy-to-implement training programs can enhance cancer services markedly and cost-effectively.

Closing the Pain Divide

Can you discuss your role as Director of the Harvard Global Equity Initiative in addressing untreated cancer pain in low- and middle-income countries.

Similar to my approach to breast cancer, I approach the issue of cancer pain through the lens of personal experience. In 1984, my father Sigmund Knaul, who was a Holocaust survivor, died of stomach cancer at the age of 60. My father’s cancer was swift and deadly; he died within 4 months of his diagnosis. I was 18 at the time, and his suffering from inadequately treated cancer pain left a lasting impression on me.

During his final days in the hospital, when he desperately needed better pain control, I had to struggle with the medical staff, who were reluctant to prescribe more morphine. In the end, I was the one who gave him the extra medication. When I administered the final dose of morphine, I did it with peace of mind, because he was in such severe, uncontrolled pain.

It was largely the memory of my father’s struggle with horrible cancer pain that later fueled my passion to help close the pain divide that exists between the rich and poor sections of the world. To that end, as Director of the Harvard Global Equity Initiative, I’m pleased that we’ve created the Harvard Global Equity Initiative–Lancet Commission on Global Access to Pain Control and Palliative Care.

The raw data on this issue are nothing short of startling. The difference in opioid consumption per cancer death is close to 600-fold between the poorest 20% and the richest 20% of countries. For example, the United States and Canada consume about 300,000 mg per pain-related cancer death, compared with 450 mg in Uganda and 47 mg in Haiti. The World Health Organization estimates that about 5.5 million terminal cancer patients are suffering in severe pain because they do not have access to opioid medications.

Ironically, global and national health systems have the ability to close this divide of needless suffering. A huge part of the problem is caused by archaic drug regulations, which need to be addressed through lobbying and education.

For instance, in Mexico not only does a doctor have to have a special prescription pad for pain meds, but also those prescription pads are only available in major cities. Making matters worse, they only produce a limited amount of these special pads. This makes it almost impossible for young physicians working in rural areas to prescribe adequate pain medications for their cancer patients. And Mexico is a middle-income country with a solvent economy. Lack of access to opioids in other parts of the world, such as sub-Saharan Africa, is catastrophic.

Frankly, denial of pain medication is a form of torture. Unfortunately, far too few are willing to acknowledge this human crisis. Living pain free is a human right that can be met, even in our poorest areas. This terrible pain divide can be closed, and it’s a cause that the health-care community needs to rally around. ■

Disclosure: Dr. Knaul reported no potential conflicts of interest.