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Connecting Cancer Control and Culture

Sarah is an intern at GCI and a junior at Tufts University studying International Relations and Community Health. At GCI, Sarah helps manage Global Tumor Board videos and finds fascinating and informative material to share on GCI’s social media platforms (be sure to follow us on Twitter, Facebook, and LinkedIn!)


 

If you were looking for a make-it-yourself cure for a headache, then my neighbor’s mom was sure to have the answer. She often used certain fruits, powders, or herbs from her home country, Pakistan, for fatigue and a variety of other common ailments. Growing up in a small, diverse suburb in Maryland, I encountered an array of traditional medicines, including some from my own household, and I still enjoy learning about them. Naturally then, I was pleased to read Oswaldo Salaverry’s article, “Back to the roots: traditional medicine for cancer control in Latin America and the Caribbean.”

The article, which precedes GCI’s Lancet Oncology commission, “Planning Cancer Control in Latin America and the Caribbean,” calls on medical and public health professionals to recognize and incorporate traditional medicine into Latin American cancer control. This might be done, for example, by engaging traditional healers in cancer prevention or diagnosis.

Traditional medicines are more popular than you may think. Salaverry notes that about 65% of the globe uses traditional medicine in some capacity according to WHO. When traditional medicine is so ubiquitous, ignoring it risks alienating many people. It’s time to bridge the gaps between “modern” cancer care and traditional medicine through culturally tailored health interventions and plans.

Leave a comment below on a health-related cultural practice you’ve grown up with or encountered over the years!

How Fragmented Health Systems Hurt Patients

Health system fragmentation is common in low- and middle-income countries. Most countries in Latin America have fragmented health systems with many different health coverage schemes – none of which are universal, and most of which exclude the poorest and most vulnerable patients. The result? A large proportion of patients who need care the most cannot access it, especially for complex chronic diseases like cancer.

 

What is health system fragmentation?

Health system fragmentation happens when there are many different health “subsystems” that coexist, providing care for different parts of a country’s population. Each of these subsystems has their own way of financing and delivering healthcare, and each provides healthcare to different types of people.  For example, one subsystem will provide coverage for government workers, another will cover formally employed persons, and yet another will attempt to provide basic health benefits for the unemployed, etc.

 

What is the problem?

The problem is that when these subsystems operate independently from one another, they create major gaps in the provision of health services, often leaving out the poorest patients. Overall, fragmented health systems are less efficient, and provide fewer resources to those who need care the most, leading to great health inequities throughout a country. The issues arising from health system fragmentation are compounded by the fact that many health systems are not well funded by government spending in the first place, especially for chronic diseases like cancer. In fact, while Latin America spends an average of 7.7% of its GDP on cancer care, the U.S. spent nearly 18% of its GDP. Now imagine this small amount of money being used inefficiently and spread over a much larger population. Low- and middle-income countries represent 85% of the world’s population and 61% of new cancer cases globally, but they account for only 6% of global expenditures on cancer care.

 

A major barrier to accessing care

Fragmented health systems are very difficult for patients to navigate. Trying to move from a primary care center to a more specialized cancer center can be confusing, difficult, or even impossible if a patient doesn’t have proper insurance coverage. Because of this, fragmentation causes delays in diagnosis and initiating treatment, leading to late-stage disease and high mortality rates. Patients throughout Latin America have low screening rates, delayed referrals, and sometimes won’t even seek medical help because of these barriers.

 

“Catastrophic out-of-pocket expenses”

When health systems are fragmented (and not well-funded to begin with), they require high out-of-pocket expenses from patients at the hospital when they seek health care. Now imagine a family without health insurance, or even an inadequate public health insurance. If a member of that family is diagnosed with cancer, they would face health payments that would drive them into poverty – what we call “catastrophic out-of-pocket expenses.” In 2008, it was estimated that ⅓ of the people in Latin America were considered at high risk for such impoverishment due to catastrophic health expenditures.

 

Moving toward Universal Health Coverage

The WHO, in partnership with the World Bank, developed an agenda in 2015 to move towards universal health coverage (UHC) worldwide. It is clear that there are major gaps in the provisions of healthcare around the world: over 400 million people do not have access to one or more essential health services. Universal health coverage, in the form of national insurance schemes provided by governments, would not only ensure that basic health care is provided to everyone in that country, but would make the provision of health services more efficient and more equitable.

 

Importantly, the move toward basic universalism is targeted towards the poorest sectors – the most vulnerable patients with the most barriers to care. Latin American countries have begun to move in this direction by creating special agencies to provide basic care for those who were previously uninsured. Due to this expansion of basic coverage, the proportion of people covered by insurance systems in Latin America grew from 46% to 60% between 2008 and 2013.

 

How to improve patient care now

The move toward universal health coverage will take time and will be more difficult for some countries than others. However, there are ways we can work within the broken systems that currently exist to help patients access the care they desperately need now. For example, through our Patient Navigation Programs, navigators facilitate patients’ passage through fragmented and complex health systems. They help underserved patients access health resources and overcome barriers they may encounter while trying to get cancer care, like making referral appointments and coordinating insurance paperwork. By providing patients with a knowledgeable resource and support system, navigators can help alleviate some of those systematic barriers to care that would usually stop patients in their tracks when trying to access the care they need.

 


The information and data in this post are summarized from our Lancet Oncology commissions: Planning Cancer Control in Latin America and the Caribbean and Progress and Remaining Challenges for Cancer Control in Latin America and the Caribbean

 

Cervical Cancer Control in Latin America

GCI collaborators recently published an extensive review article “Cervical Cancer Control in Latin America: A Call to Action,” led by Dr. Brittany Bychkovsky. The paper outlined the current state of HPV vaccination and cervical cancer screening in Latin America, and noted the challenges of a successful campaign against cervical cancer throughout the region.

 

Here are some key facts from the paper:

  • Human papillomavirus (HPV) is the most common sexually transmitted infection worldwide
  • HPV is associated with the majority of cervical cancers
  • 88% of cervical cancer deaths occur in low- and middle-income countries (LMICs)
  • Cervical cancer is the second most common cause of cancer-related deaths among women in Latin America
  • Deaths from cervical cancer are 100% preventable by vaccination and screening
  • <55% of eligible women in Latin America received a recent Pap test
  • Although 80% of young girls in Latin America live in countries with an HPV immunization program, the majority of girls lack access to receive and complete the vaccine series

 

The paper concluded with a call to action to improve cervical cancer control throughout Latin America. Dr. Bychkovsky and her team put forth some possible strategies for controlling cervical cancer in Latin America moving forward:

  1. Primary prevention (HPV vaccination): The Pan American Health Organization (PAHO) recommends that HPV vaccination be introduced only if the immunization program is public, targets the whole country, and gradually increases its rates to achieve high coverage. The most important factors to consider include:
    • Coverage: The incidence of cervical cancer will be reduced if vaccination coverage is high (>70%).
    • Cost: The HPV vaccine should be procured at reduced rates so the program may be cost-effective for the LMICs of Latin America.
    • Target population: All vaccination plans in Latin America recommend vaccinating preadolescent girls between 9 and 12 years of age.
    • Dose: PAHO and WHO recommend introducing the vaccine on a 3-dose or 2-dose schedule (studies have shown that the 2-dose will likely become the new standard in Latin America.)
    • Administration: Vaccination programs will be most successful if integrated into schools.
    • Monitoring: Programs must be monitored to ensure efficacy, efficiency, and cost-effectiveness.

 

  1. Secondary prevention (screening): In addition to HPV vaccination, screening will remain essential because it can take decades for HPV vaccination to have substantial effects on cervical cancer incidence. The team put forth some strategies for optimal screening practices:
    • Novel approaches: Mobile HPV screening programs, like one implemented in Panama, are effective in reducing cervical cancer incidence and are able to reach the most underserved  communities.
    • HPV-DNA testing: This has proven to be effective as a stand-alone test for screening, and allows self-sampling, which increases participation rates among women in Latin America.
    • Visual inspection with acetic acid (VIA): This has been proven to be an effective screening tool in low-resource areas and can reduce cervical cancer mortality by over 30%.

 

  1. Further management:
    • Patient education: Educational initiatives are essential for increasing awareness, especially among disenfranchised and rural populations. This can be done through media campaigns, or through the use of patient navigation programs (PNPs).
    • Patient navigators: PNPs not only help increase awareness and education on cervical cancer prevention, but they also help assist positively screened women with accessing timely follow-up care and health resources.