Health Equity: the Local Flavor;dedicated to the memory of Sujal

Sofia D. Merajver, MD, PhD, Director Center for Global Health

Scientific Director, Breast Oncology ProgramDirector, Breast and Ovarian Cancer Risk Evaluation

ProgramMarch 26, 2011- Symposium in Honor and memory of Sujal Parikh

http://www.globalhealth.umich.edu/

Of all the forms of inequality, injustice in health care is the most shocking and inhumane. ~ Martin Luther King, Jr.

Humanity’s greatest advances are not in its discoveries, but in how those discoveries are used to reduce inequity. ~ Bill Gates

MISSION Science in service of global health equity.

TOOL Global Translational Research but what is it?

Global Health Translational Research

Use and adaptation of scientific knowledge,

social and humanistic frameworks, and

technologies to sustainably promote health

equity

“Western health discourse introduces core components of Western

culture, including a theory of human nature, a definition of

personhood, a sense of time and memory and of moral authority”

NYT, 1/10/10

Working with partners towards health equity

GH Translational

Research

UM CGH Objectives

Educational Engagement

ProgrammaticWork: Focus

areas

Nursing

Law

Medicine

ISRCHGD

PSC

Pharmacy

Social Work

Public Health

Kinesiology

Dentistry

Architecture Urban Planning

Mathematics

ComputationalBiology

Bioengineering

Natural Resources and Environment

Public Policy

Anthropology

Information

Understanding, preventing, managing,

and curing diseasein global populations

in a sustainable framework

Mission: Science in the service of global health equity

What is equity?

Definition: local variablesRecognition: local data

Evaluation: locally appropriate: in contextSustainability: locally feasible: affordable

Health disparities

Population-specific differences in the presence of disease, health outcomes, or access to health care.

Examples: access to mammography screening breast cancer mortality by stageincidence rates of chronic disease

What is health equity?

Absence of systematic disparities in health or in the major social determinants of health between groups with different social advantage (e.g. wealth, power, prestige). (from Braveman&Gruskin, 2003)

—equal mortality for stage and biology matched cancer

—equal proportion of age-appropriate screening for cancer

Equity goes further: the local flavor

Groups already disadvantaged by their position in a social hierarchy have less access to health resources and thus will experience worse outcomes: an ethical judgment

calls forAddressing the social and medical determinants

of health that put social groups at a disadvantage for good health outcomes

Equity goes further: the local flavor

More access

Better outcomes

Favorable SES

All global health challenges are “local”: lessons from doing

• Define health disparities in a community (assessing)

• Prioritize which ones to address given resources (planning)

• Address the disparities (doing)• Evaluate if the interventions worked (reckoning)• Learn from mistakes and regionalize (growing)

GH Translational Research addresses inequities in non-communicable disease

• Assessing: Cross-disciplinary in-country and US• Planning: Involves in-country socio-political

structures; US agencies; all stakeholders (patients!)

• Doing: Multifaceted plan is implemented• Reckoning: Multicultural evaluation• Growing: Sustainable and dynamic; longitudinal

robustness

13

We envision healthcare that honors

each individual patient and family,

offering voice, control, choice, skills in

self-care, and total transparency, and

that can and does adapt readily to

individual and family circumstances

and differing cultures, languages, and

social backgrounds.

With so many cultures and so much history, is there common ground?Molecular scienceInformation technologies Human dignity Outcomes…

Patient centered care: core elements

• Education and shared knowledge• Involvement of family and social contacts• Collaboration and team management• Sensitivity to and interweaving with non medical

and spiritual dimensions of care• Respect for patient needs and preferences• Free flow of patient access to information

Non-communicable disease: Major GH translational research challenges

• Lack of infrastructure to diagnose complex diseases– Initial treatment depends on accurate diagnosis

• Adaptation of laboratory, clinical assessment, data transmission• Understanding burden of disease: registries, culturally adapted long-term follow-up

– Chronic diseases are highly heterogeneous• Interventions adapted to low resources areas require creativity and innovation, not

watering down of existing high-resource environment approaches

– Outcomes depend on consistent of management• Ability and infrastructure for longitudinal assessment of chronic diseases is a must

in the developing world

• Deficit in delivery and utilization of palliative care– Definition of pain and suffering

• Mental health modulates major chronic disease outcomes: cancer, CVD

Progression of Age Pyramid with Socioeconomic Development in Ethiopia

U.S. Census Bureau, International Database http://www.census.gov/ipc/www/idb/index.php [Accessed 20 Jan 2010].

2000

2025

When Do People Die?Per Cent Distribution of Age at Death, 2004

>80% of deaths in AFR occur prior to age 60yr

In HICs, >80% occur after age 60yr

Age distribution of deaths in EMR is intermediate between AFR & HICs

Cancer Registries of Africa in Ci5 Vol. IXFive Registries in Five Countries (of 53)

Egypt(Gharbiah)

Tunisia(Central)

Source: Ci5 Vol. IX, IARC

<1% of African population is covered by the 5 registries of Africa.

N. America

Europe

Asia

Oceania

S+C. America

AfricaUganda

(Kyando Co.)

Zimbabwe(Harare)

Algeria(Setif)

Ci5 Vol. IX covers 11% of the world’s population; >70% of the data are from

North America & Europe

Kernel Density Estimate of the Distribution of Life Expectancy

Bloom D E, Canning D PNAS 2007;104:16044-16049

Many African countries “left behind”

Currently, ~60 Million die each year

The Overall Rate of Cancer in Africa Is Lower Than In High-Income Regions

Crude Rates per 100,000

Note that African regions have higher Mortality/Incidence ratios reflecting poorer outcomes for cancer patients.

Cancer Cases Are Rising Globally Especially in Lo-/ Middle- Income Settings: Most cancer

deaths already occur in lo/mid income areas

Data Source: Globocan 2002

Cancer DeathsMillionsper year

Cancer currently accounts for ~12.5% of ~60 Million global deaths

~11 Million deathsby 2030

Ugandan Population Pyramids & Projections re. Breast Cancer

Source: IARC’s Globocan 2000

947 (100%) 2264 (239%) 5687 (601%)Projected Breast Cancer Cases Per Year:

Projected Population of Uganda:10.9M (100%) 22.2M (203%) 32.5M (297%)

423 (100%) 1014 (240%) 2578 (609%)Projected Breast Cancer Deaths Per Year:

The trouble with the future is that it usually arrives before we are ready for it. A.H. Glasgow

2000 2025 2050

Human Resources for Health and Development: A Joint Learning InitiativeThe Rockefeller Foundation, 2003

“The harvest is plentiful, but the workers are few.” Mt. 9:37

MD’s/100K Population

Healthcare workers:

Cancer in 0-14 yr olds as % of all cancer

Globocan 2002

% o

f All

Canc

ers

Overall childhood cancer rates are more uniform globally than adult rates.

Survival Trends For Children with Cancer

HICs

LMICs

100

10

Surv

ival

%

1950 1960 1970 1980 1990 2000

Inequality Gap

Childhood Cancer Frequencies (%)

Cancer Type USA-W Brazil Uganda

Leukemias 31 28 6

Lymphomas 10 21 29

CNS 21 13 1

Sympathetic 9 2 1

Retinoblastoma

3 8 6

Renal 7 9 4

Hepatic 2 0 1

Bone 4 6 3

Soft Tissue 7 4 41

BL

KS

71%

Down-staging breast and cervical cancer in low- and medium-resource countries

• Neglect of early detection: low resources, in-country age pyramid

• > 60-80% of cancers present at advanced stage• Adoption of early-detection technologies from high-

resource areas not feasible or indicated• Treatment of advanced cancer more difficult and

costly• Lack of palliative care: unrelieved cancer pain is a

significant burden in life quality

Specific challenges for demonstration projects in cancer in Africa

• Resource appropriate settings– Stratification by need, exposures: urban vs rural– More dense vs less dense, tailored by access

• Transition between detection and therapy– Adaptation of clinical research infrastructure– Adaptation of technologies

• Global health grid: expand early diagnosis, optimize care, measure outcomes

Central Question

Disease appropriate strategies and technologies needed to downstage

diagnosis and medical care infrastructure needed to transition from detection to

treatmentFocus: breast cancer

Downstaging

• Yearly mammographic screening in women >50 decreases mortality from breast cancer– Enables detection of earlier cancers that can be

cured– Treatments for early-stage disease have a better risk-

benefit ratio

Zambia

Chad

Cote d'Ivoire

Malawi

Mali

IndiaNepal

Viet Nam

Philippines

Senegal

South Afri

ca

Bosnia and H

erzegovin

a

Dominican Republic

Russian Fe

deration

Mexic

o

Ukraine

Greece

Brazil

Czech

RepublicSp

ain

Germany

Portugal

Italy

United Kingdom

France

Norway

0

10

20

30

40

50

60

70

80

90

100

Percentage of women (50-69) who have ever had a mammogram, 2003.

World Health Organization Statistical Information System (WHOSIS). http://www.who.int/whosis/en/ [1/20/2010]

USA

Bahrain Saudi Arabia Palestinians US White US Black South African Black

South Korea0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%Distribution of Breast Cancer Cases Stage

IV III II

I

Breast Cancer Outcome Disparities:Higher Mortality Rates for African Americans

• Socioeconomic Disparities

• Socioeconomic Disparities

• Socioeconomic Disparities

• Delivery of Care

• Tumor biology

• Genetics

• Lifestyle & Reproductive Experiences

• Environmental exposures

• Diet/Nutrition

E. Ward, A. Jemal, et al; Cancer Disparities by Race/Ethnicity and Socioeconomic Status. CA Cancer J Clin 2004; 54:78

Treatment varies depending where you live

SES and Barriers to Optimal Breast Cancer Care in the US

• Screening

• Access to Treatment Advances

• Access to Clinical Trials

• Co-Morbidities

• Delivery of Care/Treatment Recommendations

• Healthcare Workforce Disparities

SES-Adjusted Meta-Analysis, 2006>13K AA & 75K WA Breast CA Pts; 19 Studies

mortality hazard.1 .5 1 5 10

Combined

Crowe

Jatoi 1995-99

Bradley

Polednak

Albain Postmen

Albain Premen

Roetzheim

El Tamer

Yood

Wojcik

Howard

Franzini

Simon (<50 yo)

Simon (>49 yo)

Perkins

Eley

Neale

Ansell

Gordon

Coates

Bassett

AA Mortality Risk: 1.28 (95% CI 1.18-1.38)Newman et al, JCO 2006

Map

Building capacity for global health in breast cancer

Improve diagnosisAdapt multidisciplinary case conference to GH

Establish easy communication technologies: example: gmail, mobile phones, remote sensing

Consult and follow-upPromote measurable outcomes of quality

– Down-staging– Compliance

– Survival– Palliative care

Supplies the infrastructure for future translational work

On Fri, Aug 15, 2008 at 2:09 AM, Sofia Merajver <sofia.merajver@gmail.com> wrote: Dear Omar, I think it is cancer. I have attached a power point slide and the same file in PDF. Please let me know if you have any trouble opening them. You are doing a fabulous job. Keep me posted what happens. I hope there is a diagnosis soon and she can be treated. Best regards, salaam

SofiaOn Sat, Aug 16, 2008 at 3:08 PM, omarsherifomar<omaromar2002@gmail.com> wrote: thanks a lot for the quick response , i opened the attachment , iwill operate her next monday and will keep you updatedthanks, OmarOn Sat, Aug 16, 2008 at 11:30 PM, Sofia Merajver <sofia.merajver@gmail.com> wrote: Good Luck!!' my best wishes for your patientOn Tue, Aug 19, 2008…. Hello How are you .. The biopsy revealed to be granulomatousmastitis. What is the proper line of treatment and does it have a tendency to recur. best wishes, OmarOn Fri, Aug…. Hi Dr OmarI am still investigating what would be best for this patient. I favor a short course of steroids. Yes about 1/4 of them recur and need re-excision or more steroids. I will get back to you with the exact regimen I recommend. How much does the patient weigh approximately?Hope you are very well,SalaamSofia

Hi, Dr. Omar: I would do an incisional biopsy right here, taking skin also. Good luck. I think it is cancer

Translational global health research helps everyone

• Multidisciplinary teams– Epidemiologist: registries, burden of disease– Physician: create new paradigms for early detection– Nurse: help implement breast exam– Educator, health care worker: disseminate

information, patient support services– Engineers, economists: invent and implement new

technologies– Anthropologist/Sociologist: frames in culture

Translational global health research helps everyone

Year stage I Stage II Stage III Stage IVUrban Rural Urban Rural Urban Rural Urban Rural

1999 3.4 1.6 25.4 20.8 50 52 21 25

2004 3.5 4.1 31.3 39.2 41 43 8.5 14.4

2006 5.7 3.3 40.1 40.6 46 45 5.7 9.9

Change +60% +100% +58% +95% -8% -13% -73% -60%

Over only 7 years, breast cancer has been down-staged in Egypt, a mid-resource country, by the most objective measure known: population registry with active registration & integrated program

Palliative Care

Most immediately devastating GH inequityGHTR in PC capable of greatest impact in shortest time at lowest cost: low cost technologies effective (morphine)

Promotes new paradigms of global health– Couples PC (dying patient) to attending relatives

(early detection in high risk individuals, modulation of lifestyle modifiers)

US:Developing500:1

Cost for 30 days (USD)$0

$20

$40

$60

$80

$100

$120$108

$52

Cost as % of monthly per capita GNP0%

5%

10%

15%

20%

25%

30%

35%

40% 38%

3%

Median morphine costs for developing and developed countries.

Developing CountriesDeveloped Countries

De Lima L., Sweeney C., Palmer J.L., Bruera E. Potent analgesics are more expensive for patients in developing countries: A comparative study. Journal of Pain & Palliative Care Pharmacotherapy, Vol. 18(1) 2004

UM-Ghana Collaboration: Cultural and Academic Exchange