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Journal of Cancer Research and Therapeutics, Vol. 7, No. 3, July-September, 2011, pp. 249-250 Editorial Global disparities in cancer care: The ABCD for access and the inverse care law Rajiv Sarin Prof. of Radiation Oncology and I/C Cancer Genetics Unit, ACTREC, Tata Memorial Centre, Navi Mumbai, India PMID: 22044802 DOI: 10.4103/0973-1482.87000 Availability, Burden, Cost effectiveness and Distributive justice are the interwoven ABCD determinants of access. These have to be vocalized timely, persistently and with vigor to influence government policies and their implementations. Lack of access to basic amenities, which includes healthcare, overwhelms billions of poor people in large parts of Africa and Asia; it also hurts millions living in underserved pockets within the affluent countries. Thus the ABCD of access can be examined and acted upon, across the world, although in slightly different measures. Availability of infrastructure, equipment, drugs, devices and human resources commensurate with the burden of disease is the key substrate on which cost-effective cancer care delivery models can be developed in a distributive justice system. In developing countries, the handicap of resource constraints is often made worse by poor planning, archaic local or government policies and little interest among multinational companies to promote low-cost drugs, devices and equipment. Low- and middle-Income countries (LMIC) is a tag on a bag of rags and riches, with the latter concentrated in small number of self serving pockets. In the poorest of the countries, widespread non-availability of vital cancer care resources, including skilled manpower, renders discussions on cost effectiveness and distributive justice almost to an academic exercise. It is hard to imagine that even in 21 st century there are countries in the sub Saharan Africa without a single radiotherapy machine. In the middle-income countries and emerging economies like India where the availability gap is gradually reducing, decentralization and distributive justice assume greater meaning and immediacy. Even in many high-income countries, issues of access and uptake of timely cancer screening and treatment add to the pre-existing disparities for the disadvantaged races, socio-culturally or geographically isolated groups and migrants. Burden of cancer, measured and reported in terms of its population incidence, prevalence, morbidity, mortality and socio-economic impact, gives social and political weight for greater resource allocation and for monitoring of national cancer plans. The high-income industrialized nations invested significant resources for this specific purpose and now have a comprehensive catalog of various facets of the cancer burden with reliable long-term time trends. The situation in LMICs is very heterogeneous with majority of low-income countries having only cancer spectrum data or at best some sketchy population level cancer incidence data. India is one of the very few developing countries where consistent data on cancer burden from a network of urban and rural population based registries has helped greater funding and expansion of the National Cancer Control Program. Burden of sub-optimal cancer care and its outcome should be the impetus to improve the situation by setting pragmatic targets and achieving them in a step-wise manner. [1] Cost effectiveness of cancer care, not always taken into account while making national cancer plans, turns out to be a key determinant of the reach and sustainability of cancer care measures. The spiraling cost of cancer management will increase disparities, become unsustainable even in affluent countries and cripple fledgling cancer control plans in many LMICs. Only few LMICs with expanding technological base and sustained economic growth like India, China and a few others have found some relief in low-cost generic cancer drugs and indigenous devices and equipment. The rise of molecular targeted therapies has undoubtedly revolutionized the outcome for chronic myeloid leukemia and a few other uncommon tumors. Unfortunately, the adjuvant and metastatic indications for which they are now most commonly used provide small clinical benefit and adds a disproportionately huge burden on national cancer spending. The promise of personalized medicine through genomics and targeted therapies is intellectually appealing to scientists, interesting developments for oncologists and ray of hope for cancer victims. However, for providers and funders of cancer care, the yardsticks are different. It is feared that increasing list of hugely expensive and weak weapons against cancer will have a lion′s share of the available financial resources, leaving little for the expansion of more potent and cost-effective cancer care measures. The hyped and hyper-expensive targeted therapies would do larger societal good only if a sharp inflection is seen in their efficacy and cost. While the criteria for cost effectiveness would always be somewhat arbitrary, measures of quality adjusted life years gained against cost measured in terms of nation′s per capita purchase power adjusted GDP is being increasingly accepted. [2] Distributive justice is an old social concept of fair distribution of limited resources. It assumes new meaning for the complex care required for cancer in a setting of growing disparities. Based on discussions of a group of experts convened by the Office of Minority Health, US Department of Health and Human Services at a conference to address healthcare disparities, Putsch and Pololi [3] argue that the "American healthcare system has developed in a fashion that permits and may support ongoing, wide spread inequities based on poverty, race, gender, and ethnicity. Institutional structures also contribute to this problem". Wilmot argues that the National Institute for Health and Clinical Excellence (NICE) is failing to adequately explain and justify its decisions to the British public on which treatments should be provided by the NHS, particularly in terms of distributive justice. [4] He argues that this failure arises from the fact that NICE works within the frameworks of positivist science and liberal ethics, largely to the exclusion of other perspectives. In a recent JCRT editorial, describing the current Indian cancer scenario, Nagraj makes an interesting case for distributive justice through public private participation in India. [5] Irrespective of national wealth and political systems, constraints and commerce act as equal and opposing forces pitted against the real needs. Together they shape the contours, contents and delivery of a health care system. An ideal health care system nurturing all its citizens from cradle to grave is a utopian dream, which may perhaps be fulfilled in small-sized affluent countries with a small and homogenous population. Inequality is inherent in all health care systems. Only its magnitude, form and the victims change with national resources, socio-political systems, governance and biomedical advances. These ABCD determinants play out in the real world to deny access to those who need it the most, resulting in the ′ Inverse Care Law ′. Julian Tudor Hart, a British physician in a Lancet article in 1971 [6] stated this law as "the availability of good medical care tends to vary inversely with the need for it in the population served". He also argued that inverse care law operates more completely where medical care is most exposed to market forces. With availability lacking, burden of disease rising, cost effectiveness loosing and distributive justice begging, the stranglehold of the inverse care law will be hard to unshackle. References
Copyright 2011 - Journal of Cancer Research and Therapeutics |
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