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

1. 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

2. 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?

3. 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

4. UM CGH Objectives Working with partners towards health equity Educational Engagement Programmatic Work: Focus areas GH Translational Research

5. Natural Resources and Environment Pharmacy Understanding, preventing, managing, and curing disease in global populations in a sustainable framework Public Health Kinesiology ISR CHGD PSC Public Policy Medicine Law Architecture Urban Planning Dentistry Anthropology Nursing Social Work Computational Biology Information Mathematics Bioengineering

6. 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

7. 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

8. 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

9. 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

10. Equity goes further: the local flavor Better outcomes Favorable SES More access

11. 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)

12. 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. 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.

14. 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

15. 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

16. 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].

17. 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

18. Cancer Registries of Africa in Ci5 Vol. IX Five Registries in Five Countries (of 53) Tunisia (Central) Egypt (Gharbiah) Algeria (Setif) Uganda (Kyando Co.) Zimbabwe (Harare) Ci5 Vol. IX covers 11% of the world’s population; >70% of the data are from North America & Europe <1% of African population is covered by the 5 registries of Africa. Source: Ci5 Vol. IX, IARC

19. 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

20. 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.

21. 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

22. Ugandan Population Pyramids & Projections re. Breast Cancer 2000 2025 2050 Projected Population of Uganda: 10.9M (100%) 32.5M (297%) 22.2M (203%) Projected Breast Cancer Cases Per Year: 2264 (239%) 5687 (601%) 947 (100%) Projected Breast Cancer Deaths Per Year: 1014 (240%) 2578 (609%) 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

23. “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

24. Cancer in 0-14 yr olds as % of all cancer Overall childhood cancer rates are more uniform globally than adult rates. % of All Cancers Globocan 2002

25. Survival Trends For Children with Cancer 100 HICs Survival % Inequality Gap LMICs 10 1950 1960 1970 1980 1990 2000

26. Childhood Cancer Frequencies (%) BL 71% KS

27. 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

28. 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

29. 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

31. 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

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

34. 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

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

36. Treatment varies depending where you live

37. 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

38. SES-Adjusted Meta-Analysis, 2006>13K AA & 75K WA Breast CA Pts; 19 Studies AA Mortality Risk: 1.28 (95% CI 1.18-1.38) Newman et al, JCO 2006

39. Map

40. 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

41. 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

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

43. 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

44. 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

45. 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)

46. US:Developing 500:1

47. Median morphine costs for developing and developed countries. Developing Countries Developed 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

48. UM-Ghana Collaboration: Cultural and Academic Exchange