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Human Rights – World Cancer Congress Mary Robinson, Geneva, 30 August 2008

At the beginning of the century, a few short years ago, the world’s leaders made specific commitments, which, if implemented, will improve respect for the right to health across the world. These commitments are set out in the United Nations Millennium Declaration, which was adopted in September 2000.

At Realizing Rights, we believe that the MDG health goals will be achieved only if there is a strong focus on human rights, including the right to health. We have worked closely with Professor Paul Hunt, the first United Nations Special Rapporteur on the right to health, and we strongly endorse his recognition of what the right to health really means. What it means is the fulfillment of a right to health through effective health systems in place. Let me quote what Paul Hunt said in a report to the UN General Assembly:

“The right to health can be understood as a right to an effective and integrated health system, encompassing health care and the underlying determinants of health, which is responsive to national and local priorities, and accessible to all.

In other words, the health systems must encompass both health care and the underlying determinants of health such as adequate sanitation and safe drinking water. It must be accessible to all. Not just the wealthy, but also those living in poverty. Not just those living in urban areas, but also the remote villagers. The health system has to be accessible to all disadvantaged individuals and communities.”

Social and economic progress over the course of the last century has helped people in many countries enjoy longer, healthier lives. Health interventions are now available to prevent or treat most conditions, including cancer. Yet in many countries as life expectancy increases, so does the incidence of chronic diseases, including cancer.

Cancer is a worldwide problem, and disparities in cancer mortality highlight the unconscionable global inequalities in access to public health and medical services. Cancer was responsible for 13% of deaths in the world in 2007 and will become the single leading cause of death by 2010. More than 70% of the world’s cancer deaths occur in low or middle-resources countries, where 80% are detected too late for effective treatment. While the incidence of cancer has been increasing worldwide and deaths due to cancer have been increasing significantly in low- and middle-income countries, mortality has been decreasing in the USA during the past 15 years.

Cancer control is a human rights issue: governments, the private sector, professional associations and others all must work together to improve cancer prevention and mitigate its impact by ensuring that health systems, including cancer prevention and treatment services, are accessible to all. Concerted efforts also must be made to understanding and addressing the social, economic and cultural factors that drive health-related inequities, including gender inequalities.

According to WHO up to a third of cancers can be cured if detected early, and incidence of cancer can be reduced by another third by prevention strategies aimed at reducing exposure to cancer risk. These strategies include changes in tobacco use, excessive alcohol consumption, occupational hazards and chronic viral infections.

Indeed, I would like to place particular emphasis on prevention.  I would hope that this Geneva World Cancer Congress will concentrate not only early diagnosis and therapy, but also on the effects of environmental pollution and degradation in the aetiology of cancer almost all other aspects of modern health improvements have come about through programmes of prevention. For example immunization and clean water provision in the case of infections disease.  Hand washing in obstetrics wards was introduced long before it was understood why it actually worked, that had to wait for the discovery of micro-organisms.

I understand that for some classes of cancer the average onset in the population is decreasing, a fact that belies the commonly used argument that “we are all growing older and therefore cancer is bound to increase”.  Clearly, when living in the present of a large number of relatively newly introduced man made carcinogenic influences, the likelihood of getting cancer will  be some function of age, i.e. the time spent under such influences.  But it is worrying that the broader population also seems to be increasingly affected.

Unequal access to the benefits of medical advances in the treatment of cancer are an example of the inequities in access to health. Cancer receives little attention in Africa partly because of the heavy burden of communicable diseases. Yet the life time risk of cancer for women in Africa is about 10% which is only about 30% lower than the risk in developed countries. The cancers with the highest risk for women are cervical, breast and HIV-associated Kaposi’s sarcoma. The most prevalent cancers in males are Kaposi’s sarcoma, liver, prostate bladder and lymphoma. Due to economic development and the associated lifestyle changes and increasing population age, the cancer burden in African countries is likely to increase. In Africa the lifetime risk of cancer death is almost double the risk in developed countries, and yet few countries have comprehensive cancer control programmes in place.

Inadequate or failing health systems are a key barrier to scaling up health promotion initiatives and life-saving interventions in many countries. In Sub-Saharan Africa there are problems with overwhelmed and under resourced cancer services. Radiation therapy equipment is used in the treatment of 50% of cancers but this equipment is available for less than 20% of patients in Africa. In Europe there are 5 machines per million patients, in Africa there are barely 0.2 per million. In the treatment of colon cancer, stapler guns are used in the developed world which obviates the use of colostomy bags. These stapler guns are generally unavailable in African hospitals – and yet colostomy bags are unaffordable to many patients.

The global shortage of health workers contributes to weakened health systems and is another serious impediment to improved health outcomes, including cancer control. Effective, integrated health systems simply cannot be achieved without healthcare workers in sufficient numbers. ,

And yet health workers in many developing countries often face challenges such as unpredictable funding for salaries and transport, and a shortage of adequate education and training opportunities. Health worker migration is influenced also by the ‘pull’ from industrialized countries, which themselves are suffering a shortfall in health professionals as a result of rapidly ageing populations, the rising demand for health services, and lack of attention to education and professional training to meet domestic health needs.

Global advances in the diagnosis and treatment of cancer will have limited impact in a country such as Ethiopia which has 3 doctors per 100,000 people. Indeed, 13 African nations have fewer than 5 physicians per 100,000 people. Malawi has just 266 doctors in the entire country. The fact is that Africa is short 800,000 doctors and nurses and currently trains only between 10 and 30% of the skilled health workers needed. Then it loses 20,000 trained health professionals per year to migration, with up to 60% of doctors in some countries migrating within 2 years of graduation. The prevalence of HIV/AIDS also contributes to the decimation of the workforce. The crisis in human resources for health is contributing to the growing gap between what is known about cancer and what is being done around the world to control it.

The issue of health worker migration poignantly illustrates our global inter-connectedness and points to the importance of a constructive dialogue between sending and receiving countries around health worker migration issues including immigration, education and training, workers’ rights, and recruitment ethics. The Health Worker Migration Policy Initiative, a partnership including the WHO, the Global Health Workforce Alliance and Realizing Rights, is assessing policy innovations to date to address the challenge of health worker migration. The Initiative is working on the development of a code of practice which will address the rights of migrating workers as well as address the tension between the maximization of the economic returns of migration against societal effects of medical migration in sending countries. In this context, other policy action to be considered include retention strategies in sending nations, health workforce strategies in destination countries, bilateral and multilateral agreements and codes, use of the diaspora to support the strengthening of health systems in resource poor countries, and internal migration policies.

The recent commitment by the G8 nations in Hokkaido, Japan to actively address the critical shortages of health workers across the world is very welcome. The recognition by Japan and the other G8 countries that a competent supported health workforce is fundamental to developing robust health systems and to reaching health and development goals gives us reason to be optimistic that this critical situation will receive the attention which it deserves.

I referred earlier to the importance of addressing gender and other social, economic and cultural factors that drive health-related inequities. Gender inequalities can shape the distribution of disease, access to and use of health services, and the course of health outcomes. Without serious attention to gender inequalities related to access to health education, immunization and screening, cancer control initiatives will be compromised.

The GAVI Alliance, of which I am a board member, recently adopted a policy to promote increased coverage, effectiveness and efficacy of immunization and related health services by ensuring that all girls and boys, women and men, receive equal access to these services. We also adopted a new vaccine investment strategy, which will prioritize future support of new and underused vaccines to fight deadly disease in the developing world, including cervical cancer.
Globally, this disease affects an estimated 500,000 women each year and leads to more than 250,000 deaths, the vast majority in developing countries. This is, clearly, a disease of poverty and inequity. The most commonly occurring cancer in Africa is cancer of the cervix with an estimated 79,000 new cases each year. The incidence of cervical cancer in most of Europe, North America, Australia and New Zealand was similar but now is low due to effective screening and prevention.

While HPV vaccines now exist to prevent cervical cancer and are being rolled out in developed countries, access remains limited in developing countries where they are most needed. Most women affected do not have access to local health systems or routine gynecological care, including regular HPV screening which has played a critical role to date in preventing cancer in industrialized countries. If current trends continue, there will be over one million new cases annually by the year 2050.

Expanding early prevention and control programmes to include vaccination, while improving existing screening and treatment services, will dramatically reduce the high rates of cervical cancer in developing countries, as has been achieved in developed countries. One of the most effective tools to prevent the development of cervical cancer, the Pap Smear, is rarely used in Africa, due to lack of availability. The availability of highly effective HPV vaccines has been a major step in the prevention of this deadly cancer in industrialized countries. While there are obstacles to implementing the delivery of these vaccines, such as the necessity to administer it to adolescents who do not routinely have health visits and cultural barriers, there has been widespread acceptance among the healthcare community, women’s groups and the general public in the developed and developing world. Much more needs to be done to ensure that every woman has access to this vaccine.

Childhood cancer is rare but, today, very treatable. Overall, 75% of children with cancer live for 5 or more years in Europe and North America. In Central America 3 year survival ranges from 48% to 62%. Improved survival rates are largely due to improved diagnosis and better treatment. 80% of children with cancer are in developing countries and more than half of them will die prematurely. They are often diagnosed too late or not diagnosed at all. Treating childhood cancer does not have to be expensive. By developing treatment regimes that take into account a country’s medical facilities and providing proper training and advice to doctors, great progress can be made with relatively limited funds.

A coordinated strategy by the global cancer control community-one that combines innovative science and sound public health policies can save a huge proportion of the 90,000 young lives lost every year.

Another factor in cancer care is use of analgesia. Cancer patients experience severe pain-often excruciating-without the use of opioid analgesics. These drugs are not expensive nor are they in short supply. Global consumption of opioids has almost doubled during the past decade but most of this occurred in Europe and North America In 2006, these two regions, containing less than 20% of the world’s population accounted for 89% of the consumption of morphine. Under-treatment of pain, particularly among poor populations, is due to several factors. Obstacles to effective pain management can be attitudes, accessibility and the regulatory environment. Inadequate knowledge and skills in pain management are also to blame as are irrational fears of addiction. There is also gender disparity in the experience of pain and evidence is increasing that there are physiological reasons for this. This has been designated the Global Year Against Pain and October 11th 2008 is Palliative Care Day whose theme is “Palliative care is a Human Right”. Bringing increased attention to this facet of disease is essential to dealing with obstacles to giving relief to the millions of terminally ill patients who suffer unnecessarily.

The World Cancer Declaration highlights the many challenges to be faced in overcoming the global burden of cancer and outlines the critical steps needed to build the basis for sustainable delivery of effective cancer prevention, early detection, treatment and palliative care worldwide. There have also been many advances and we now realize that cancer is preventable and treatable but not without concerted action and attention to screening programmes, prevention campaigns and palliative care services especially in low income countries.

Much more must be done to encourage the international support necessary to make life-saving tools available to those who need them most and to ensure that robust health systems are in place to support their delivery. These and other steps to advance global health are not just matters of moral concern: they are issues of fundamental human rights. We all have a role to play in moving the cancer control agenda forward.

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