10
Expanding the Role of the Global Community in Cancer Control

This report makes the case—not for the first time—that recognition of the burden that cancer imposes and some level of response are feasible in every country. It also identifies feasible opportunities of particular importance in the countries where resources have constrained the response to cancer. Another critical element is support—both in resources and in expertise—from the “global community.” Until now, international support has been forthcoming almost exclusively from cancer-focused organizations, but not from the broader based health and development sector, such as foreign aid from individual countries (through agencies such as the U.S. Agency for International Development, or USAID), the World Bank, and major nonprofit organizations, which provide substantial support for health infrastructure and for infectious diseases in low- and middle-income countries (LMCs). Another largely untapped resource is the U.S. and international academic community, particularly given a large increase in interest in global health and the establishment and growth of university global health programs. The support of all of these groups strongly influences the health agendas of the recipient countries. A lack of focus on cancer from these external parties easily translates to a lack of focus of LMCs themselves on cancer.

This chapter reviews the programs and activities of major sectors of the international community in relation to cancer control in LMCs and discusses further needs and opportunities. The role of advocacy, including by the global community, is covered separately in Chapter 9.



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Cancer Control Opportunities in Low- and Middle-Income Countries 10 Expanding the Role of the Global Community in Cancer Control This report makes the case—not for the first time—that recognition of the burden that cancer imposes and some level of response are feasible in every country. It also identifies feasible opportunities of particular importance in the countries where resources have constrained the response to cancer. Another critical element is support—both in resources and in expertise—from the “global community.” Until now, international support has been forthcoming almost exclusively from cancer-focused organizations, but not from the broader based health and development sector, such as foreign aid from individual countries (through agencies such as the U.S. Agency for International Development, or USAID), the World Bank, and major nonprofit organizations, which provide substantial support for health infrastructure and for infectious diseases in low- and middle-income countries (LMCs). Another largely untapped resource is the U.S. and international academic community, particularly given a large increase in interest in global health and the establishment and growth of university global health programs. The support of all of these groups strongly influences the health agendas of the recipient countries. A lack of focus on cancer from these external parties easily translates to a lack of focus of LMCs themselves on cancer. This chapter reviews the programs and activities of major sectors of the international community in relation to cancer control in LMCs and discusses further needs and opportunities. The role of advocacy, including by the global community, is covered separately in Chapter 9.

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Cancer Control Opportunities in Low- and Middle-Income Countries THE “GLOBAL COMMUNITY” IN GLOBAL CANCER CONTROL A few major organizations support cancer control internationally: United Nations (U.N.) organizations, mainly the World Health Organization (WHO) and its research affiliate, the International Agency for Research on Cancer (IARC), and the health program of the International Atomic Energy Agency (IAEA); government cancer institutions, such as the National Cancer Institute (NCI) of the U.S. National Institutes of Health (NIH), the International Network for Cancer Treatment and Research; cancer societies and advocacy groups, such as the American Cancer Society and the international umbrella organization for cancer societies and advocacy, the International Union Against Cancer (UICC). All these groups play high-level, visible roles in raising awareness about the magnitude of the cancer problem, and in promoting cancer control. Beneath the layer of major organizations and major programs is a much broader array of organizations and professionals with narrower roles, confined either to a country or area, or to a particular aspect of cancer control research or practice. No global inventory of these efforts exists. Efforts include, for example, the Open Society Institute and the Diana Fund, which are major supporters of expanding hospice and palliative care programs in Eastern and Central Europe, Africa, and elsewhere. Individual cancer centers in Europe and the United States have entered into “twinning” relationships with centers in low-resource settings, providing technical assistance, training, research support, and financial support, over the long term. Professional societies, notably the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (ESMO), provide training, fellowships, and other types of assistance to colleagues and institutions in LMCs. Some multinational pharmaceutical companies have programs to make oncology drugs available to cancer centers in low-resource countries where patients or governments otherwise would not be able to afford them. Foundations also fund research projects and service delivery. The Gates Foundation has been the main supporter of cervical cancer prevention research in low-resource settings. UN AGENCIES: WHO, IARC, AND IAEA The United Nations and its agencies relate directly to national governments. Governments look to WHO for guidance on health priorities, policy, and planning and for technical assistance. IAEA also acts through agreements with governments. It has pursued an active role in establishing and upgrading radiotherapy facilities and providing for their safe and effective operations.

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Cancer Control Opportunities in Low- and Middle-Income Countries World Health Organization Cancer Control Activities WHO is the most prominent voice in global health. WHO has maintained at best a modest cancer control program for the past 30 years. As part of a reorganization in 2006, the program became part of the Department of Chronic Diseases and Health Promotion. Cancer control is also a part of other WHO programs, including those focused on tobacco control, reproductive health, occupational health, childhood immunizations, and essential medicines. The high-level policy of WHO is carried out largely at the Geneva, Switzerland, headquarters. Work performed in countries is carried out mainly through the six WHO regional offices and the offices maintained in every member country. The WHO cancer control program has concentrated on the following areas: Promoting and strengthening national cancer control programs Building international networks and partnerships for cancer control Promoting organized, evidence-based interventions for early detection of cervical and breast cancers Developing guidelines on disease and program management Advocating for a rational approach to effective treatments for potentially curable cancers Supporting low-cost approaches to pain relief and palliative care The work of the cancer control program contributed strongly to adoption by the 58th World Health Assembly of a resolution on cancer prevention and control in May 2005, a milestone for the field (see Chapter 1). The resolution is designed to reinforce comprehensive cancer policies and strategies among all member states. It urges development and integration of comprehensive cancer control programs into current and future health care initiatives; the sharing of scientific research; and the development of appropriate information systems, including outcome and process indicators that support planning, monitoring, and evaluation of cancer prevention and control programs. WHO’s 2002 report, National Cancer Control Programs: Policy and Managerial Guidelines (World Health Organization, 2002), provides information on planning, implementing, managing, and evaluating cancer programs. It outlines the scientific basis for cancer prevention, early detection, cure, and care; discusses the appropriateness of particular technologies; and describes how to manage national programs tailored to different resource settings. (See Chapter 1 for a more complete discussion.)

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Cancer Control Opportunities in Low- and Middle-Income Countries The Cancer Control Programme has co-established or actively promoted the following programs and initiatives for cancer prevention: The Tobacco Free Initiative (TFI), established in July 1998 to focus international attention, resources, and action on the global tobacco epidemic. TFI provides global policy leadership, encourages mobilization at all levels of society, and promotes the WHO Framework Convention on Tobacco Control. WHO Framework Convention on Tobacco Control (FCTC), ratified in November 2004 and the first public health treaty negotiated under the auspices of WHO. FCTC includes provisions that set international standards on tobacco price and taxes, advertising, labeling, illegal trade, and secondhand smoke. The Treaty became law for the signatories in February 2005. Global Strategy on Diet, Physical Activity and Health, endorsed by the May 2004 World Health Assembly, to improve public health through healthy eating and physical activity. WHO Initiative for Vaccine Research, including vaccines against some of the infections that can cause cancer, such as hepatitis B and C and human papillomavirus, as well as schistosomiasis and other helminths. The INTERSUN Program, established in 1992 by WHO and a number of international partners, to improve protection against ultraviolet radiation and prevent its effects, including skin cancer. Global Strategy on Occupational Health for All: The Way to Health at Work, supporting healthier workplaces, including reduction in exposure to carcinogens. “A Community Health Approach to Palliative Care for HIV and Cancer Patients in Africa,” a joint project including five countries1 to improve the quality of life of HIV/AIDS and cancer patients in sub-Saharan Africa. WHO Regional Offices WHO divides the world into six regions: Africa, the Americas, Southeast Asia, Europe, Eastern Mediterranean, and Eastern Pacific. One country in each region houses the permanent regional office. The staff of regional offices work directly with their designated countries. In addition, each country has its own resident WHO representative and delegation of varying size. Regional staffs include a chronic disease advisor, who may or may not be a cancer specialist (although no current advisors are cancer specialists). 1 Botswana, Ethiopia, Tanzania, Uganda, and Zimbabwe.

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Cancer Control Opportunities in Low- and Middle-Income Countries International Agency for Research on Cancer IARC, established in May 1965 as a WHO agency, is a research organization located in Lyon, France. Its mission is to “coordinate and conduct research on the causes of human cancer, the mechanisms of carcinogenesis, and to develop scientific strategies for cancer control.” IARC’s work focuses on epidemiology, environmental carcinogenesis, and research training. IARC does not conduct clinical trials or conduct research on other aspects of cancer patient care, nor is it directly involved in the implementation of control measures or legislation aimed at controlling carcinogens. Most of IARC’s efforts have been in and about high-income countries, but they have maintained an interest and some specific initiatives directed at LMCs in each major area of emphasis. IARC has four main objectives (International Agency for Research on Cancer, 2006): Monitoring global cancer occurrence: IARC gathers data on incidence, mortality, and survival for hundreds of countries. The data are available electronically and in published reports. Most prominently, the 8th edition of its report, Cancer Incidence in Five Continents, includes information on more than 200 countries. IARC also estimates cancer incidence and mortality for every country in the world in its GLOBOCAN electronic database. Identifying the causes of cancer: Through committees, IARC assesses the carcinogenicity to humans of various agents, mixtures, and exposures. More than 800 agents have been reviewed since 1972 and published through the IARC Monographs Programme on the Evaluation of Carcinogenic Risks to Humans. Exploring the mechanisms of carcinogenesis: IARC laboratory research concentrates on the interaction of carcinogens with DNA, with particular emphasis on identifying carcinogen-induced, endogenous, and inherited mutations. The aim is to identify potential points of intervention to prevent progression to clinical disease. Developing scientific strategies for cancer control: The goals of IARC’s programs are primary prevention and early detection of cancer. A recent example is the evaluation of low-technology screening methods for cervical, breast, and oral cancers in developing countries. IARC maintains a number of databases related to its core functions. These include descriptive epidemiology, carcinogens, and molecular epidemiology. Training Programs IARC coordinates an annual 3-week summer school program of 1-week modules designed to stimulate cancer research by improving scientific

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Cancer Control Opportunities in Low- and Middle-Income Countries knowledge and developing skills. Course selection preference is given to professionals from resource-poor countries to strengthen their research institutions and build local capacity. Researchers and support staff from groups or institutions involved in cancer monitoring, evaluation of care practices, prevention activities, or etiological research are eligible to attend IARC training programs. Subjects of the modules may include cancer registration, epidemiologic methods and research, and interpretation of cancer statistics. Fellowships More than 500 cancer research fellowships have been awarded to junior scientists since 1966. Recently, the program was broadened to award postdoctoral fellowships to junior scientists from LMCs to work directly with one of the research groups at IARC headquarters. Visiting Scientist Awards are also offered for experienced investigators from universities or research institutions to spend up to one year at IARC working with one of the research groups on a topic related to the Agency’s objectives. International Atomic Energy Agency (UN) IAEA may seem an unlikely home for a cancer control program for resource-poor countries, but it takes its mandate directly from the 1956 statute creating the “Atoms for Peace” agency: “The Agency shall seek to accelerate and enlarge the contribution of atomic energy to peace, health and prosperity throughout the world” (IAEA, 1956). IAEA began in 1980 to provide radiotherapy equipment and train staff in its use in LMCs. IAEA has provided more than $145 million in cancer-related assistance to developing countries (IAEA, 2006). In 2004, the Programme of Action for Cancer Therapy (PACT) was established as a comprehensive cancer control assistance program, with IAEA leading collaborations with a wide range of partners (IAEA, 2004) (see Chapter 8 for a discussion of PACT’s potential role in supporting cancer centers in LMCs). This perspective represents a significant evolution of strategic thinking and investment on the part of IAEA, beyond radiotherapy. In the past IAEA has established a number of radiotherapy-only centers. In some places, these have formed a nucleus for developing more comprehensive treatment, but in other places they have remained solely radiotherapy centers. Historically, IAEA Member States asked for assistance with radiotherapy through “technical cooperation” projects, which ranged from setting up a country’s first radiotherapy center to upgrading facilities. All projects included providing equipment as well as training in clinical use of

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Cancer Control Opportunities in Low- and Middle-Income Countries the machinery, dosimetry, safety, and maintenance, following internationally accepted guidelines for safety (Levin et al., 2001). Where the request from a Member State was for a first radiotherapy center, a comprehensive feasibility study was carried out by IAEA and involving the relevant Ministry of Health and the medical community. Staff training, equipment, and expertise needs were estimated and a layout of the buildings was produced. The framework for feasibility studies is laid out in IAEA technical documents that cover various aspects of the use and safe operation of radiotherapy units. Since 1995, radiotherapy has been initiated in several resource-poor countries, such as Ethiopia, Ghana, Namibia, Uganda, Mongolia, Zambia, and Yemen, and expanded or upgraded in numerous others. Projects in Eastern Europe, for example, have focused on upgrading technology and improving the skills of radiotherapy professionals, both of which had deteriorated during the period of regional economic decline following the collapse of the Soviet Union. Two regional projects, with cost sharing by recipient governments, upgraded facilities in Albania, Armenia, Bosnia and Herzegovina, Croatia, Macedonia, Georgia, and Moldova. Several hundred radiotherapy professionals from these countries were supported for participation in basic and continuing professional development courses. These projects continue and others have been initiated to address the still-serious inadequacies in low- and middle-income countries in Africa, Latin America, Asia, and Eastern Europe (Levin et al., 2001). Radiotherapy Resource Inventories In 1959 IAEA began compiling a registry of radiation therapy facilities in clinical settings, with a final update published in 1976. The inventory was restarted in 1995 as the Directory of Radiotherapy Centres (DIRAC) and is now available on the Internet (http://www-naweb.iaea.org/nahu/dirac/default.shtm). DIRAC is updated as IAEA receives information from the various countries. OTHER SOURCES OF GLOBAL SUPPORT FOR CANCER CONTROL National Research Agencies: The Example of the U.S. National Cancer Institute NCI is the main source of U.S. government support for international cancer research and training. Most of the international interaction is with other high-income countries, but NCI has a substantial portfolio of work in

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Cancer Control Opportunities in Low- and Middle-Income Countries LMCs. NCI works cooperatively with the Fogarty International Center of NIH and with extramural institutions through bilateral agreements, grants, and contracts. NCI international expenditures are primarily devoted to foreign grants and contracts, bilateral scientist exchanges and training under the NIH Visiting Program, workshops, and international dissemination of cancer information. Most recently, in 2006, NCI has made a major commitment to partner with IAEA and the PACT Alliance (see above and Chapter 8) to improve cancer control in LMCs. NCI will support a pilot of the expanded PACT, which will involve providing a team of cancer control experts from the United States (Clanton, 2006). Two of the most prominent activities supported by NCI in LMCs are the Middle East Cancer Consortium (MECC; see below) and the International Network for Cancer Treatment and Research (INCTR; see below). The other area of emphasis in multiple countries is cancer registration. Training is carried out through the scientist exchange programs and other educational opportunities, and research through a large number of individual research projects involving LMCs. NCI also contributes support to many large and small workshops and meetings around the world. Scientist Exchange and Other Training Programs In FY 2005, more than 1,000 foreign scientists spent time at NCI, about one-third of them from LMCs. NCI also supports scientists from developing countries for training in U.S. laboratories outside of NCI, and in overseas laboratories in developed countries. The Oncology Research Faculty Development Program helps young but established scientists from developing countries prepare for careers as investigators and for leadership positions in cancer research in their home country. The cost is shared by NCI and the sponsoring laboratory. Participants from LMCs are also given support to attend an annual NCI course on cancer prevention and control offered by the NCI Division of Cancer Prevention. NCI Research NCI supports a wide range of research in all aspects of cancer control and in many LMCs. A few examples include: A community-based, randomized-control evaluation of low-cost methods for early detection of breast and cervical cancers in women at the Tata Memorial Hospital, in Mumbai, India, including clinical breast examination without mammography, self-examination, and visual inspection of the cervix by trained female health workers

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Cancer Control Opportunities in Low- and Middle-Income Countries Research on esophageal cancer in China, where incidence of the disease is highest in the world, including two nutritional intervention trials, in collaboration with the Chinese Academy of Medical Sciences A collaborative study between NCI and investigators in Ukraine and Belarus to study the long-term health consequences of the Chernobyl nuclear accident A binational study with Brazil on Epstein-Barr virus-associated lymphoma, particularly Burkitt’s lymphoma, in Brazil Cancer Registration in Developing Countries NCI assists with training and sponsors participation of personnel from developing countries at courses on cancer registration conducted by IARC in Lyon, France, and the School of Public Health at Emory University in Atlanta, Georgia. In cooperation with the Middle East Cancer Consortium, cancer registry training programs have been held around the Middle East. In recent years, training programs also have been held regionally around the world, drawing participants from many countries. The Middle East Cancer Consortium MECC was founded in 1996 as a partnership between the United States and the Ministries of Health of Cyprus, Egypt, Israel, Jordan, the Palestinian Authority, and most recently, Turkey. The MECC objective is to reduce the incidence and impact of cancer in the Middle East through collaborative research. Since its inception, MECC’s major activities have been the Cancer Registry Project and the Small Grants Programme. Cancer communication is another priority. The Cancer Registry Project supports population-based cancer registries within member countries, and develops linkages among them. The first monograph about cancer incidence in the region, based on the new registries, was published in 2006 (Freedman et al., 2006). The consortium also supports training, basic research, enhancement of public health and patient care, quality control, and international communications. The Small Grants Programme is for clinicians and scientists to conduct research. All research projects, which are funded based on a merit review, require collaboration between more than one MECC country. International Network for Cancer Treatment and Research INCTR is a not-for-profit, nongovernmental organization dedicated to cancer control in the developing countries of Asia, Africa, and Latin America. It was founded in 1998 by UICC and the Institut Pasteur in Belgium, and

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Cancer Control Opportunities in Low- and Middle-Income Countries is supported by NCI as well as by membership fees, project-related grants and contracts, and corporate sponsorships. INCTR headquarters are at the Institut Pasteur, with branches and offices in the United States, France, England, Brazil, Egypt, Tanzania, India, and Nepal. Mission and Strategy INCTR’s mission is to build capacity for cancer treatment and research in countries with limited resources through long-term collaborative projects focused on local or regional problems. Projects are designed to bring immediate benefits to patients or to prevent cancer in the population while providing professional education and training as well as opportunities for cancer research. INCTR promotes collaborations between wealthy countries and countries with limited resources, and encourages the formation of cooperative groups, consortia, networks, and partnerships with corporate, professional, academic, and governmental and nongovernmental organizations. Partners include IARC (for cervical cancer screening), NCI (for education and training), King Faisal Research Center in Saudi Arabia (for translational research), and Eli Lilly and Novartis (for clinical trials workshops and data management). Projects are developed with the advice and participation of various INCTR committees and strategy groups as well as independent scientific advisors and the Special Panel of the INCTR Advisory Board, which is made up of distinguished oncologists and pathologists from developing countries. INCTR Collaborating Units, Associate Members, Branches, and Offices Projects are conducted in participating institutions or their departments, referred to as INCTR collaborating units, which are involved with cancer research, treatment, and education in the developing world. Projects, whether related primarily to research or to training and education, are conducted jointly, often in concert with other organizations or INCTR member institutions. They may entail the preparation of protocols, guidebooks, or training manuals; the transfer of technology; or the development of policy. INCTR Associate Members include individuals, corporations, institutions, and organizations (e.g., professional societies and associations) from developed and developing nations. Branches are legally independent nonprofit entities at the national or regional level, working to raise and disburse funds in support of the INCTR mission. Branches interact with cancer centers or units, professional organizations, or elements of national or regional governments, and coordinate ongoing INCTR programs and projects within the country or region. Each branch has an administrative

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Cancer Control Opportunities in Low- and Middle-Income Countries structure and may employ medical, scientific, and support staff. Current INCTR branches include: Alliance Mondiale Contre le Cancer (France) INCTR Egypt INCTR USA INCTR Brazil Nepalese Network for Cancer Treatment and Research INCTR offices, which are extensions of INCTR, Brussels, conduct activities similar to branches and may evolve into branches. Offices currently exist in Tanzania, United Kingdom, and India. Education Program INCTR runs workshops, training courses, and symposia, as well as a Visiting Expert Program in which cancer specialists in a variety of disciplines spend days to weeks in institutions in developing countries. Training is conducted in-country where possible by Visiting Experts, or in INCTR-accredited centers in nearby countries of similar socioeconomic status. An attempt is made to focus training activities on specific countries, which currently include Iraq, Jordan, Afghanistan, and several African countries. The Education Program has a strong focus on clinical trials and data management, oncology nursing, pediatric oncology, and hematological neoplasms. Past meetings have included: Workshop on Chemotherapy Administration and Palliative Care for Oncology Nurses (Yaoundé, Cameroon, March 2003) Pediatric Oncology Update (with Shaukat Khanum Memorial Cancer Hospital & Research Centre, Dubai, October 4–6, 2003) Lymphoma Workshop (Cairo, Egypt, October 16–18, 2003) Cancer Nursing Training (Cairo, Egypt, October 16–18, 2003) Pediatric Oncology Update (with the Chinese Pediatric Oncology Society, Chongqing, November 20–23, 2003) Clinical Trials Workshop (São Paolo, Brazil, September 2004) Multidisciplinary Workshop (for social workers, psychologists, and others involved in the support of patients with cancer, São Paolo, Brazil, September 2004) Palliative Care Program INCTR has begun work in palliative care in Nepal. INCTR has sent medical and nursing palliative care experts to Nepal and identified four

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Cancer Control Opportunities in Low- and Middle-Income Countries institutions where patients can receive palliative care. Training has been organized for local staff members, and patients are now being cared for in these units. A home hospice program is also being established. INCTR plans to use this as a demonstration program and to train personnel. Similar work is planned for other countries in Asia and Africa. Translational Research The Translational Research Program is based at the King Fahad National Children’s Cancer Centre within the King Faisal Specialist Hospital and Research Centre in Riyadh, Saudi Arabia. This program is focused on improving understanding of pathogenesis, improving diagnosis, and defining prognostic factors, particularly in acute lymphoblastic leukemia (ALL). Other Activities INCTR has helped to establish three cooperative groups to carry out epidemiological research and clinical trials in developing countries. They are described below. The Leukemia Study Group of India This group is focusing initially on ALL, conducting clinical trials with the aim of improving survival rates through a better understanding of epidemiology, clinical features, and biological characteristics. The major cancer centers organizing the effort will serve as regional centers for education and training for peripheral centers and hospitals. The Middle East Children’s Cancer Association MECCA has members from 13 Middle Eastern countries who have agreed to work together in improving the prevention, early detection, and treatment of children with cancer. The group will focus initially on ALL. The Retinoblastoma Group of Mexico This group has representatives from most regions in Mexico and is in the process of establishing a registry for retinoblastoma and common treatment protocols. DEVELOPMENT ASSISTANCE FOR NONCOMMUNICABLE DISEASES, 1995–2002 In the only analysis of its type, Michaud (2004) examined the share of development assistance going toward noncommunicable diseases (referred to in this report as chronic diseases), including cancer. The chronic disease portion of the global burden of disease by region in 2001 was a point of

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Cancer Control Opportunities in Low- and Middle-Income Countries reference. Worldwide, chronic diseases accounted for 46 percent of the global burden of disease and communicable diseases, 42 percent (the balance of disease burden is due to injuries). In developing regions chronic diseases accounted for about 40 percent of the total burden of disease, in contrast to developed countries, where the corresponding figure was nearly 80 percent. Heterogeneity is also significant among developing regions: Communicable diseases still predominate in sub-Saharan Africa and part of the Eastern Mediterranean region. Everywhere else—Latin America and the Caribbean, parts of the Eastern Mediterranean, Southeast Asia, and the Western Pacific, representing 3.8 billion people—chronic diseases have surpassed noncommunicable diseases. Data Sources The review included the major sources of data on funding provided by bilateral and multilateral agencies to developing country health sectors. For bilateral development agencies, the Organization for Economic Cooperation and Development (OECD) creditor reporting system (CRS) is the most comprehensive source of comparable data. The database lists all projects funded by donor and recipient country, with a short description of the project and the total funding. Chronic disease projects were identified through the project descriptions. The only multilateral agencies for which projects related to chronic diseases could be identified were WHO and the World Bank. To improve comparability and minimize year-to-year fluctuations, the funding levels (commitments in the case of WHO and disbursements for all others) are reported as 3-year rolling averages. The overall result is likely an underestimate of the actual amount. For some projects, the descriptions were not specific enough, and other projects (e.g., infrastructure projects) could have a wide range of effects, including improved chronic disease control. Finally, other sources of funding, such as IAEA, are not included. Results Bilateral Agencies In 2002, the latest year in the analysis, official development assistance from bilateral agencies totaled $2.9 billion. A total of $3.2 million—0.1 percent—was allocated to the prevention and control of chronic diseases. The 8-year total from 1995 to 2002 was $35.5 million. The 3-year rolling averages increased from $3.4 million in the early period (1995 to 1997) to $5.5 million for 1998 to 2000, and decreased to $4.4 million for 2000 to 2002. Of the total allocated to chronic diseases from1995 through 2002, 6

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Cancer Control Opportunities in Low- and Middle-Income Countries percent was allocated to cancer, 35 percent to mental disorders, 8 percent to tobacco control, and the remaining 50 percent for other NCDs. The specific projects identifiable as cancer related (including tobacco control) are listed in Table 10-1. On the donor side, the United Kingdom and Sweden contributed 43 percent of the 8-year total ($8.7 million and $6.7 million, respectively). Trends over the period for individual donor countries were mixed. Australia and Sweden increased funding the most. Finland and the Netherlands substantially decreased their commitments. For all other countries, there was little change (Table 10-2). The Eastern Mediterranean region and Europe received the most bilateral funding for chronic diseases ($6.4 million and $5.7 million, respectively, 1995–2002). Southeast Asia received the least ($1.4 million) (Table 10-3). Multilateral Agencies In 2002, WHO allocated 3.6 percent of its total budget ($44 million) to chronic diseases (Table 10-4). About one-third went to mental health, 30 percent to tobacco control, and 37 percent to unspecified chronic disease projects. The chronic disease share of total regional expenditures was lowest in sub-Saharan Africa (1.6 percent) and highest in Southeast Asia (6.6 percent). The specifics of global and interregional activities (apart from tobacco control and mental health) were available for about half the total $7.6 million. Approximately $1.1 million went for risk factor prevention and risk factor surveillance for diet, nutrition and physical activity, and cardiovascular risk management. A total of $2.4 million was allocated to cardiovascular diseases, diabetes, cancer, chronic respiratory conditions, and aging. WHO expenditures for noncommunicable diseases (NCDs) nearly tripled between 1998–1999 and 2002, increasing from $16 million to $43.6 million per year, with most of the increase in funding for tobacco control and mental health. For all other chronic diseases, the increase was from $9.4 million to $14.3 million per year. World Bank loans for chronic diseases between 1997 and 2002 totaled $109.5 million, with the 3-year average increasing from $7 million (1997–1999) to $20–21 million between 1998 and 2002. Nearly all of these loans went to Eastern Europe (the Russian Federation, Albania, Armenia, Latvia, Croatia, Lithuania, Romania, and Azerbaijan) as part of larger health-sector loans, mostly for cardiovascular disease prevention and the control of smoking and alcohol abuse. In late 2005, the World Bank began to reexamine its investments in chronic diseases. A new work program will examine the economic and health burden of the major chronic diseases in the Bank’s client countries,

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Cancer Control Opportunities in Low- and Middle-Income Countries TABLE 10-1 Bilateral Development Assistance Projects for Cancer 1995–2002 Year Donor Recipient Short Description US$ (000) 1995 Canada Americas unspecified Cervical cancer research 2     Unspecified Tobacco policy research initiative 809     Vietnam Tobacco control political mapping 20   Sweden Africa unspecified Workshop on tobacco control 1 1996 Canada Unspecified Tobacco control research initiative 306 1997 Belgium Kenya Cervical cancer and sexually-transmitted diseases (STDs) 136   Sweden South Africa Tobacco control 10 1998 Australia Unspecified WHO Tobacco or Health program 75   Canada Unspecified Tobacco policy research 492     Turkey Tobacco control strategies 151     Vietnam Tobacco control political mapping 5 1999 Belgium Kenya Cervical cancer and STDs 65   Canada India International initiative for tobacco policy research 24     Unspecified International initiative for tobacco policy research 134     Unspecified Tobacco and ecohealth workshop 1   Italy India Epidemiologic study of hepatic neoplasia risk 22     Tunisia Technical assistance to Habib Hospital and Cancer Institute of Tunisia 624   United Kingdom Unspecified Cervical cancer prevention 337 2000 Australia Unspecified Health education for tobacco control 86   Italy Tunisia Technical assistance to Habib Hospital and Cancer Institute of Tunisia 554 2001 Australia Unspecified Tobacco control capacity-building workshop 51   Belgium Kenya Cervical cancer and STDs 30   Canada Unspecified International initiative for tobacco policy research 171     South Africa International initiative for tobacco policy research 6   Finland Nepal Health education: diseases and disability due to tobacco 24   Sweden Unspecified Tobacco policy cooperation 96 2002 Sweden Vietnam Tobacco control 325   United Kingdom Unspecified Cervical cancer prevention 173 1995–2002 Total Cancer-Related Projects 4,730 1995–2002 Total All Chronic Disease Projects 35,452 SOURCE: Reprinted, with permission, from Michaud (2004). Copyright 2004 by Catherine M. Michaud, Harvard Initiative for Global Health.

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Cancer Control Opportunities in Low- and Middle-Income Countries TABLE 10-2 Bilateral Commitments 1995–2002 for Noncommunicable Diseases by Country, US$ 000s Donor Country 1995–2002 Commitment United Kingdom 8,663 Sweden 6,748 Finland 3,746 Australia 3,519 Netherlands 3,361 Canada 3,272 Italy 2,808 Spain 1,056 Belgium 722 Norway 630 United States 302 Austria 212 Denmark 173 Ireland 92 New Zealand 65 Switzerland 48 France 35 Total 35,452 SOURCE: Reprinted, with permission, from Michaud (2004). Copyright 2004 by Catherine M. Michaud, Harvard Initiative for Global Health. TABLE 10-3 Bilateral Commitments 1995–2002 for Noncommunicable Diseases by Recipient Region, US$ 000s WHO Region 1995–2002 Commitment Africa 2,904 Americas 2,088 Eastern Mediterranean 6,416 Europe 5,662 Southeast Asia 1,403 Western Pacific 3,104 Unallocated to region 3,832 Total 25,409 SOURCE: Reprinted, with permission, from Michaud (2004). Copyright 2004 by Catherine M. Michaud, Harvard Initiative for Global Health. the rationale for public interventions and the roles of government in the control of chronic disease, and the Bank’s comparative advantage in assisting clients in chronic disease control. It will define a strategy to address the priorities across multiple sectors to lay the basis for improved policy advice to clients, as well as more efficient allocation and use of existing resources

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Cancer Control Opportunities in Low- and Middle-Income Countries TABLE 10-4 WHO Budget by Region and Major Chronic Disease Component, 2002, US$ 000       NCD Subcategories WHO Region Total Budget Total for NCDs (% total) Unspecified NCDsa (% NCD total) Mental Health (% NCD total) Tobacco (% NCD total) Africa 309,539 4,927 (1.6) 2,131 (43) 1,306 (27) 1,490 (30) Eastern Mediterranean 104,415 2,234 (2.1) 1,257 (56) 416 (19) 562 (25) Western Pacific 63,037 2,784 (3.3) 919 (33) 1,327 (48) 537 (19) Southeast Asia 110,679 7,313 (6.6) 3,118 (43) 2,339 (32) 1,856 (25) Americas 46,590 2,242 (4.8) 1,148 (51) 508 (23) 587 (26) Europe 68,198 3,194 (4.7) 656 (21) 865 (27) 1,673 (52) Regional total 702,459 22,694 (3.2) 9,229 (41) 6,760 (30) 6,705 (29) Global and interregional total 534,964 21,542 (4.0) 7,612 (35) 7,491 (35) 6,439 (30) Overall total 1,237,423 44,236 (3.6) 16,841 (38) 14,251 (32) 13,144 (30) aCancer is included in this category. SOURCE: Reprinted, with permission, from Michaud (2004). Copyright 2004 by Catherine M. Michaud, Harvard Initiative for Global Health. for impact on chronic diseases (Personal communication, O. Adeyi, Coordinator, Public Health Programs, Human Development Network, World Bank, October 13, 2005). Conclusion The allocation of funds for chronic diseases in recent years bears little relation to the importance of these diseases in terms of burden of disease. The traditional communicable disease targets still dominate health-sector funding. THE UNTAPPED POTENTIAL OF THE ACADEMIC COMMUNITY Major universities across the United States and elsewhere have become increasingly interested and involved in global concerns, especially in health in developing countries. Many have established formal global health programs, the primary goal of which is teaching students. However, some portion of their effort is also directed at carrying out research or other activities in developing countries. Both faculty and students may participate in the overseas portion of these programs.

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Cancer Control Opportunities in Low- and Middle-Income Countries University global health programs are an untapped resource for cancer control. The point is already made that progress in cancer control involving collaborations between low- and high-resource countries will require services and research at ground level. The example of institutional “twinning” has involved cancer centers per se, not global health programs, and the expertise required is largely clinical, including clinical research. However, many major universities house cancer centers as well as global health programs. One could envision a collaboration with a core clinical component that also takes on other projects. Examples might be helping to develop cancer registries along with IARC, working on community education and outreach about cancer, and exploring the legal and policy aspects of opioid drug availability (e.g., in collaboration with the WHO Coordinating Center for Policy and Communications in Cancer Care). This type of commitment could contribute in a meaningful way to improving cancer control in the partner country and provide opportunities for faculty and students in a variety of disciplines. The challenge is, at least in part, letting those in decision-making roles in global health programs know what opportunities exist or could be created in cancer control. The formation of a university consortium on global health could aid this process (see next section). University Consortium on Global Health Representatives of 17 major North American universities with active commitments to global health, and several academic associations, met in April 2005 at Boston University to explore the potential value of coming together in a consortium to support and expand global health programs and promote “global health literacy.” A main purpose of the consortium—should it be developed formally—would be to create the means for a collective voice for global health that could communicate with greater strength than individual members. It would also be a place for exchange of ideas among members and for input from outside the academic community. We propose that an explicit goal be to explore the range of opportunities that could be open to university global health programs, with the aim of broadening the areas in which work is taking place. The consortium idea appears to have a good chance of taking hold, with next steps being planned (Keusch, 2006). SUMMARY AND RECOMMENDATIONS Global health and development organizations and institutions are highly influential in helping LMCs develop, funding, and carry out their health agendas. Historically, the priorities have been overwhelmingly the infectious diseases that kill children and increasingly adults (mainly AIDS

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Cancer Control Opportunities in Low- and Middle-Income Countries and tuberculosis). Cancer, although not the leading health problem in these countries, imposes a significant and growing burden, but has been overlooked by most of the global development and academic communities. The exceptions are those that are exclusively cancer focused, which do concern themselves to varying degrees with cancer in LMCs. Still, only a tiny share of global health resources has been devoted to cancer. There are signs that the balance has begun to change, with recognition by WHO and others that chronic, noncommunicable diseases must be addressed at the same time as infectious diseases. However, the danger is that the common risk factors for other chronic diseases will continue to dominate activities, leaving cancer (which shares fewer risk factors) behind. Cancer must have its own identity and recognition if the compelling opportunities across the spectrum of cancer control, highlighted in this report, are going to be acted upon. RECOMMENDATION 10-1. International Organizations WHO should maintain a strong capacity for cancer control analysis and guidance to assist the many countries that rely on them for health-related information and policy advice. Capacity is needed both at WHO headquarters and in the regional offices. RECOMMENDATION 10-2. Development Assistance The bilateral aid agencies, including the U.S. Agency for International Development, should consider adding aspects of cancer control to their discussion agendas with LMCs, and adding funding for specific projects that fit into national cancer control plans and programs. RECOMMENDATION 10-3. National Institutions The U.S. National Cancer Institute and other established cancer research and funding organizations both in the United States (e.g., the Centers for Disease Control and Prevention) and in other countries should help to establish and facilitate relationships between U.S. cancer centers and centers in LMCs and encourage U.S. researchers, through grant programs, to undertake collaborative research of relevance to LMCs. RECOMMENDATION 10-4. The Academic Community Universities with active global health programs should consider opportunities in cancer control, as well as the more traditional areas of focus. If a university consortium is developed, one function should be to encourage and facilitate a broader agenda of topics, cancer control among them.

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