Putting public health back into the global cancer agenda.
Putting public health back into the global cancer agenda.
复制标题
将公共卫生重新纳入全球癌症议程。
DOI：
10.1093/annonc/mds522
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发表时间：
2012
期刊：
影响因子：
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通讯作者：
R. Sullivan
中科院分区：
文献类型：
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作者：
R. Sullivan
大多数癌症患者将在远离高收入国家公民所享受的医疗保健环境中生活和死亡。严酷的现实是，大多数人会迟到、治疗不足（或根本不治疗），可能因治疗相关费用而破产，对于那些死于癌症的人来说，许多人不会有一个“美好的死亡”[1]。尽管现实如此严酷，但直到最近 2011 年 9 月在纽约召开的联合国非传染性疾病问题高级别会议上，癌症以及实际上所有非传染性疾病 (NCD) 才被排除在全球健康菜单之外[2]。本应是一个对全球癌症采取强有力的公共卫生立场的机会，但却变成了相互竞争的政治议程的大杂烩。所以理查德·洛夫等人。及时而受欢迎的呼吁将公共卫生旗帜重新插回全球癌症领域，这对癌症界和政策制定者来说是一个急需的警钟[3]。这提醒我们，全球癌症控制并不是世界卫生组织（WHO）和其他权威国际机构的专属领域，而是需要个人的帮助以及癌症中心和代表组织等国家机构的长期承诺。事实上，这已经发生并且产生了巨大的影响。印第安纳大学与肯尼亚西部埃尔多雷特在过去十年中建立了友好的癌症服务和双文化理解。还需要做更多这样的事情。然而，除了治疗的培训、教育、人力和基础设施支持的迫切需求之外，新兴、低收入和中等收入国家（LMIC）仍然是长期癌症控制的棘手问题。让我们明确一点。高收入国家的经验对我们几乎没有什么借鉴意义。洛夫正确地指出了中低收入国家正在经历的流行病学转变的巨大差异。全球癌症负担是在一个完全未经检验的背景下发生的，其中所有年龄组和社会经济阶层的多种疾病负担（双重、三重和四重负担）[4]与边际医疗保健系统的发展和全球化交叉[5]。然而，关于如何构建公共卫生癌症系统并考虑到这些复杂而广泛的健康社会决定因素的研究仍然很少[6]。显而易见的是，当前的政策方法过于“一刀切”，对中低收入国家之间的实际差异宽度缺乏敏感性。撒哈拉以南非洲国家的人类发展指数范围为 182 至 62，预期寿命低至 36 岁至 > 60 岁，而且从语言的角度来看，存在 2000 多种不同的文化，这些国家的癌症控制背景说明了情况的复杂性 [7]。正如洛夫指出的那样，我们尚未解决包括腐败在内的国家系统性功能失调这一棘手问题。在许多中低收入国家，很难谈论癌症控制，因为它们无法满足社会正常运转的基本标准。但即使有一个有效的系统可以参与，迄今为止在解决中低收入国家癌症公共卫生问题上所采取的方法往往是不充分和误导的。在前一种情况下，通过高收入伙伴关系分配给癌症控制的资金水平低得可耻。从我们自己对研究成果的研究中我们知道，全球研发知识中只有不到 4% 适用于中低收入国家，而就主要联邦或慈善组织的资助而言，这个数字也同样令人尴尬，不到 2% [8, 9]。任何认为我们正在满足全球癌症患者需求的想法都是不切实际的。正如洛夫指出的那样，我们以高收入技术为中心的癌症控制范式与基于人口的解决方案所需的现实脱节，这是危险的。暂时把缺乏针对癌症的公共卫生方法放在一边，即使是治疗模式也远远落后于曲线。过度关注癌症药物完全没有抓住重点。癌症控制和治愈的方式是手术和放射治疗[10]。尽管药物发挥着重要或显着的附加作用，但 TRIPS 和其他知识产权保护机制的影响正在剥夺大多数中低收入国家获得基本癌症药物的机会；世界卫生组织的名单变成了纸老虎。那么需要做什么呢？首先是真正的政治认识，即公共卫生确实包括癌症和其他非传染性疾病。太多的声音继续反对他们的加入。当然，它需要进行定制；例如，癌症并不是阿富汗最紧迫的公共卫生问题。但这需要阐明。癌症界需要参与全球肿瘤政治，并利用其掌握的大量手段来指导合理、敏感和有效的合作规划。显然还需要更多的实地研发，例如，除了烟草控制之外，还缺乏成本效益研究来指导政策制定者开发负担得起的护理包。预防还需要采取新的方法，采用更多跨学科的方法来应对癌症危险因素复杂的社会文化生态。例如，对于全球化影响癌症负担的途径和机制尚未达成共识。这些领域迫切需要可行的政策研究。虽然爱等人。征集更多编辑内容 Annals of Oncology 23: 2995–2996, 2012 doi:10.1093/annonc/mds522 2012 年 10 月 19 日在线发布
The majority of cancer patients will live and die in health care settings far removed from that enjoyed by citizens in highincome countries. The stark reality is that most will present late, be undertreated (or not at all), possibly be bankrupted by the costs associated with treatment and for those who die with cancer many will not have a ‘good death’ [1]. Despite this harsh reality, cancer and indeed all non-communicable diseases (NCD) have been off the global health menu until relatively recently with the UN high-level meeting on NCD in New York in September 2011 [2]. What should have been a chance to make a strong public health stand against global cancer instead turned into a pot pourri of competing political agendas. So Richard Love’s et al. timely and welcome call to replant the public health flag back deep into global cancer territory is a much needed wake-up call to the cancer community and policymakers [3]. It is a reminder that global cancer control is not the exclusive domain of World Health Organization (WHO) and other august international bodies but needs help from individuals and long-term commitments from national institutions such as cancer centers and representational organizations. Indeed, this is already happening and with great effect. Indiana University’s twinning with Eldoret in West Kenya over the last decade has built impressive cancer services and bicultural understanding. More of this is needed. However, beyond the immediate needs of training, education, manpower and infrastructure support for treatment remains the thorny issue of long-term cancer control in emerging, lowand middle-income countries (LMIC). And let us be clear. The experiences of high-income countries have little if nothing to teach us. Love rightly points out to the huge differences in the epidemiological transition being experienced by LMIC. Global cancer burden is taking place against a wholly untested background in which multiple disease burdens (double, triple and quadruple burden) [4] across all age cohorts and socio-economic classes intersect with marginal health care systems development and globalization [5]. Yet there remains precious little research into how to construct a public health cancer system taking into account these complex and broad social determinants of health [6]. What is clear is that the current policy approaches are far too ‘one size fits all’ with little sensitivity for the real breadth of differences between LMIC. The context for cancer control in Sub-Saharan Africa with the range of countries’ human development index from 182 to 62, where the life expectancy is as low as 36 to >60 and where, from a linguistic standpoint, there are over 2000 different cultures gives some idea of the complexity of the situation [7]. And as Love points out we have yet to grasp the thorny issue of the systemic national dysfunction, including corruption. It is difficult to talk of cancer control in many LMIC because they fail to meet the basic set of criteria for a functioning society. But even when there is a functioning system with which to engage, the approach taken to date in addressing cancer public health in LMIC has too often been inadequate and misdirected. In the former case, the levels of funds assigned to cancer control through high-income partnerships have been disgracefully low. We know from our own studies into research outputs that <4% of global R&D knowledge is applicable to LMIC settings and in terms of funding from major federal or philanthropic organizations, the figure is also equally embarrassing, <2% [8, 9]. Any notion that we are addressing the needs of global cancer patients is quixotic. Our high-income techno-centric cancer control paradigm is, as Love points out dangerously out of touch with the reality of what is needed for population-based solutions. Putting the lack of a public health approach to cancer aside for a moment even the paradigms for treatment lag far behind the curve. Over-focus on cancer medicines completely misses the point. The modalities of cancer control and cure are surgery and radiotherapy [10]. Even though where medicines play an essential or significant additive role the impact of TRIPS and other intellectual property protection mechanisms is depriving most LMIC of essential cancer medicines; the WHO list becoming nothing more than a paper tiger. So what needs to be done? The first is a genuine political recognition that public health does include cancer and other NCDs. Too many voices continue to whisper against their inclusion. Granted it will need to be tailored; cancer is not Afghanistan’s most pressing public health issue, for example. But this needs to be spelled out. The cancer community needs to engage with global onco-politics and use the considerable means at their disposal to direct a rational, sensitive and effective partnering programming. There is also a clear need for more in field R&D, for example apart from tobacco control there is a dearth of cost-effectiveness studies to guide policymakers in developing affordable care packages. Prevention also needs a fresh approach with more transdisciplinary approaches to the complex socio-cultural ecology of cancer risk factors. There is, for example, no consensus on the pathways and mechanisms through which globalization affects cancer burden. These areas are crying out for actionable policy research. Whilst Love et al. call for more ed ito ria l editorial Annals of Oncology 23: 2995–2996, 2012 doi:10.1093/annonc/mds522 Published online 19 October 2012