http://www.globalhealth.umich.edu/
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 Program
Director, Breast and Ovarian Cancer Risk Evaluation
Program
March 26, 2011- Symposium in Honor and memory of Sujal Parikh
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
UM CGH Objectives
Working with partners towards health equity
Law
Public
Health
ISR
Natural Resources
Architecture
CHGD and Environment
Urban Planning
Dentistry
PSC
Understanding, preventing,
managing,
Anthropology
Medicine
and curing disease
in global populations
Pharmacy
in a sustainable framework
Nursing
Social Work
Public Policy Kinesiology
Computational
Biology
Mathematics Information
Bioengineering
Mission: Science in the service of
global health equity
What is equity?
Definition: local variables
Recognition: local data
Evaluation: locally appropriate: in context
Sustainability: 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 stage
incidence 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 for
Addressing the social and medical determinants
of health that put social groups at a
disadvantage for good health outcomes
Equity goes further: the local flavor
Better
outcomes
More
access
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
With so many cultures and so much history, is there
common ground?
Molecular science
Information technologies
Human dignity
Outcomes…
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.
13
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
2000
2025
U.S. Census Bureau, International Database http://www.census.gov/ipc/www/idb/index.php [Accessed 20 Jan 2010].
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. IX
Five Registries in Five Countries (of 53)
Algeria
(Setif)
Tunisia
(Central)
Egypt
(Gharbiah)
N. America
Europe
Asia
Oceania
Uganda
(Kyando Co.)
Zimbabwe
(Harare)
<1% of African population is covered by
the 5 registries of Africa.
Source: Ci5 Vol. IX, IARC
S+C. America
Africa
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
Currently, ~60 Million die each year
Many African countries “left behind”
Bloom D E, Canning D PNAS 2007;104:16044-16049
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
Cancer currently accounts for ~12.5% of ~60 Million global deaths
~11 Million deaths
by 2030
Cancer Deaths
Millions
per year
Data Source: Globocan 2002
Ugandan Population Pyramids &
Projections re. Breast Cancer
2000
2025
2050
Projected Population of Uganda:
10.9M (100%)
22.2M (203%)
32.5M (297%)
2264 (239%)
5687 (601%)
1014 (240%)
2578 (609%)
Projected Breast Cancer Cases Per Year:
947 (100%)
Projected Breast Cancer Deaths Per Year:
423 (100%)
The trouble with the future is that it usually arrives before
we are ready for it. A.H. Glasgow
Source: IARC’s Globocan 2000
“The harvest is plentiful, but the workers are few.”
Mt. 9:37
MD’s/100K Population
Healthcare workers:
Human Resources for Health and Development: A Joint Learning Initiative
The Rockefeller Foundation, 2003
Cancer in 0-14 yr olds as % of all cancer
% of All Cancers
Overall childhood
cancer rates are
more uniform
globally than
adult rates.
Globocan 2002
Survival Trends For Children with Cancer
100
Survival %
HICs
Inequality Gap
LMICs
10
1950
1960
1970
1980
1990
2000
Childhood Cancer Frequencies (%)
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
Cancer Type
BL
71%
KS
Down-staging breast and cervical cancer in lowand medium-resource countries
• Neglect of early detection: low resources, incountry 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
treatment
Focus: 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
Percentage of women (50-69) who have ever had a mammogram, 2003.
100
90
80
USA
70
60
50
40
30
20
10
0
World Health Organization Statistical Information System
(WHOSIS). http://www.who.int/whosis/en/ [1/20/2010]
Distribution of Breast Cancer Cases Stage
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
IV
III
II
I
40.00%
30.00%
20.00%
10.00%
0.00%
Bahrain
Saudi Arabia Palestinians
US White
US Black
South African South Korea
Black
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
Bassett
Coates
Gordon
Ansell
Neale
Eley
Perkins
Simon (>49 yo)
Simon (<50 yo)
Franzini
Howard
Wojcik
Yood
El Tamer
Roetzheim
Albain Premen
Albain Postmen
Polednak
Bradley
Jatoi 1995-99
Crowe
Combined
.1
.5
1
mortality hazard
5
AA Mortality Risk: 1.28 (95% CI 1.18-1.38)
Newman et al, JCO 2006
10
Map
Building capacity for global health in
breast cancer
Improve diagnosis
Adapt multidisciplinary case conference to GH
Establish easy communication technologies: example: gmail,
mobile phones, remote sensing
Consult and follow-up
Promote 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
Sofia
On 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
updated
thanks, Omar
On Sat, Aug 16, 2008 at 11:30 PM, Sofia Merajver <sofia.merajver@gmail.com> wrote:
Good Luck!!'
my best wishes for your patient
On 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, Omar
On Fri, Aug….
Hi Dr Omar
I 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,
Salaam
Sofia
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
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
Year
stage I
Stage II
Stage III
Stage IV
Urban
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
+100%
+58%
+95%
-8%
-13%
-73%
-60%
Change +60%
Palliative Care
Most immediately devastating GH inequity
GHTR 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:Developing
500:1
Median morphine costs for developing and developed countries.
$120
40%
38%
$108
35%
$100
30%
$80
$60
25%
$52
Developing Countries
Developed Countries
20%
15%
$40
10%
$20
5%
$0
3%
0%
Cost for 30 days (USD)
Cost as % of monthly per capita GNP
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