By 2020, 15 million people worldwide will have cancer and nine million of them will be living in developing countries, according to World Health Organization estimates. Harvard University physician and medical anthropologist Paul Farmer is determined to ensure that prediction doesn’t come true. Farmer, a pioneer in global health, has a history of tackling big problems. His Ph.D. dissertation on HIV in Haiti ran to 1,000 pages, leading Harvard to impose a cap. Since then, as co-founder of the nonprofit Partners In Health, he has brought medical treatments, from basic primary care to antiretroviral therapies for AIDS, to millions of the world’s poor.
Farmer’s work—chronicled in the Tracy Kidder best seller Mountains beyond Mountains and in his own books—has inspired governments and global agencies to do likewise. Recently he has focused his attention on cancer in the developing world, where the disease is increasingly common and costly treatments are often hard to come by. In the medical journal the Lancet last October, he and a team of other leaders from the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries announced an ambitious, multipronged plan to increase these countries’ access to cancer medical resources—by raising money, driving down the cost of drugs, and figuring out new ways to get those drugs to patients in need. Science writer Mary Carmichael spoke with Farmer at his office in Boston. Excerpts follow.
Scientific American: What does it mean to say that cancer is on the rise in developing nations? Is it part of a worldwide pattern?
Farmer: Incidence is hard to measure, and “cancer” epidemiology isn’t the same in, say, Jordan as it is in Burundi because, for one thing, Jordan has more medical resources. But there are some general trends. In 1970, 15 percent of cancer diagnoses were in developing countries. That number was 56 percent by 2008. And the death rates are almost 50 percent greater in low-income countries than in those with high incomes. I don’t like the term “lifestyle,” but some of the risk factors for cancer such as exposure to viruses and pollutants or toxic chemicals are more widely prevalent, and that increases the incidence. Also, in a lot of countries life expectancy is going up. What that means is that if you’re treating drug-resistant tuberculosis or HIV, now you can get people to survive for decades, but that gives them more time to die of a malignancy.
One reason cancer is on the rise is that other causes of death are declining?
Yes. One of the points in our recent Lancet piece is that we really need to integrate cancer prevention and care by marshaling various preventives, diagnostics and therapeutics. Instead of having different programs regarded as radically separate, the more you can bring them together, the more bang you’ll get for the buck. That’s true of all efforts to strengthen health systems. But with cancer, the need to integrate is especially clear, because there’s not just one way to approach the disease. Some types can be prevented with vaccines, such as some liver and cervical cancers, certain head and neck cancers, et cetera. Others are curable with chemotherapy or radiation or surgery. And others, you can palliate for discomfort. So you need to get different institutional players in medicine involved. You also need to make sure cancer care is part of national health insurance programs for the poor, as it already is in Mexico and Colombia.
Do you think cancer has been ignored in the developing world? It seems like infectious diseases—HIV, TB, malaria—get more attention.
If you go back to 2003, there really were not any programs to diagnose and treat AIDS either and very few for tuberculosis and malaria. The U.S. President’s Emergency Plan for AIDS Relief had been proposed, but it hadn’t actually rolled out. And with the Global Fund to Fight AIDS, Tuberculosis and Malaria, one of the first grants went to Haiti, and that didn’t come in until 2003. So that’s very recent history—AIDS, tuberculosis and malaria weren’t on the map either. Poor people’s problems in general just were not on the map.
Why not? And what put them there?
The 1990s was in my view a decade of terribly low expectations in global health. I think people had started thinking that the number of public health interventions possible in a given nation-state was related directly to the GDP of that nation-state. What that meant is that you’d hear things like, “Haiti’s so poor that we really can’t afford to waste resources on anything that isn’t cheap.”
But then AIDS shows up, and it’s a transnational phenomenon. So to have strategies that are only focused on what’s available in one country when the diseases go back and forth—it’s crazy, right? And by the turn of the millennium, AIDS, tuberculosis and malaria were killing six million people a year, almost entirely in places where there weren’t enough resources. Then new media really made everybody feel like they were on the same planet, so suddenly you would have people Skyping from Haiti to Harvard. That’s when the Bill & Melinda Gates Foundation and the Global Fund and the President’s Emergency Plan, the largest financial commitment any country had ever made to fighting a single disease, came into play, and that changed the landscape radically, but again, that was only in the past few years.
Cancer was a problem then, too. Why wasn’t it part of the global health agenda in the early 2000s?
It should have been. But I do think it was good to focus on some of the other burdens of disease and gaps in treatment because, after all, AIDS, tuberculosis and malaria were all neglected. If you said, “Let’s have a global fund to fight diseases and poverty”—well, we’ve tried that before, and it didn’t work so well. I think there was something really compelling about the U.S. President’s Emergency Plan for AIDS Relief focused on one disease. Still, when there’s perceived scarcity of resources, you do get people saying, “All the attention’s focused on AIDS. None of it’s focused on ‘fill in the blank.’” But that kind of competitiveness over resources is not great. Let’s not make the same mistake again and again and again. We shouldn’t assume that in a resource-poor setting you’re only going to have enough money to do a good job on a few things.
Can you harness the competition among diseases for the good?
I think you can. That’s what this global cancer task force is trying to do, in a sense to say, “Okay, we’ll focus on cancer,” knowing that we also have to work on strengthening health systems overall and on vaccines, diagnostics, chemotherapy and palliative care. The complexity of cancer means that people are working together, and we’re trying to use this integrative approach of revamping the whole health system.
What public health interventions will be the most effective in preventing cancer?
Cervical cancer is one malignancy that we could probably almost wipe out because of new preventives, better early detection and treatments, and I wouldn’t have said that 10 years ago.
Because we didn’t have the Gardasil vaccine 10 years ago?
We didn’t. Of course, HPV [human papillomavirus] is sexually transmitted, so you can imagine all of these other primary preventions: so-called safe sex or delayed onset of sexual activity. But humans being humans means that the vaccine is better. Now, maybe the variants of the virus that are not covered by the vaccine could become dominant: we don’t know. And of course, the vaccine doesn’t protect against other sexually transmitted diseases. But it’s something. We start with that. This is a malignancy that really affects poor women, and now we’ve got something that’s going to prevent a big fraction of the cases.
What comes next?
Screening. You can use acetic acid to look at the cervix, and if you see lesions in situ, they can be removed with cryotherapy. They can be burnt out. That’s curative. And after that, of course, you have patients who could have more radical surgery that would be curative, and finally you have patients who couldn’t be cured and need other kinds of therapies, like radiation to palliate their symptoms.
How available are those treatments in the developing world?
Not widely. I had a patient 12 years ago who had metastatic cervical cancer, and she had to go to get radiation therapy in the Dominican Republic because there was none in Haiti. But she did get it, and I just saw her a couple of weeks ago. The question is, if the treatments aren’t available, are we going to use that as the beginning of a discussion or the end of one?
So what’s available right now in the kind of places I work? You start with nothing. If you go to a capital city anywhere in Africa, even the poorest one, you’re always going to find an oncologist or hematologist. But we go to rural areas. What tends to happen is that if you put together decent health care infrastructure in these rural areas, people actually come there from the cities looking for care, because they’re poor. They get referred by the private hematologists and oncologists, who say, “I can’t help you, but I hear these people out in the boondocks are providing cancer diagnosis and care.” When we started working in rural Africa, we knew this would happen, because we had gone through it in Haiti. We became the provider of last resort. In northern Rwanda, there were 500,000 people without a district hospital. So, with the Ministry of Health, we built a hospital. We’ve also tried to get diagnoses made with the help of a Harvard teaching hospital, the Brigham and Women’s Hospital. They’re doing all the pathology for us for free.
You send samples back and forth?
Yes, so with a solid tumor, you just do a biopsy—which we can easily do at any of these sites—send it back, get the diagnosis at the Brigham, and then the Dana-Farber Cancer Institute gets us the chemo, which we deliver in Rwanda with the help of pediatricians and general practitioners and nurses who are there. We’ve been using this model in Malawi, Haiti and Rwanda.
That’s extraordinary, to think that someone in a rural area in Rwanda is getting treated by one of the best cancer centers in the world.
I think it is. We hope that other providers in the field see this and stop saying, “Oh, we can’t do this. It’s Africa. You can’t treat cancer there.”
Could other hospitals develop this kind of partnership?
Every hospital in America has a pathology department and a chemo program. You don’t need them all to do it, but the academic medical centers should be doing this.
You also need to train people on the ground, right?
One of the lessons we learned in Haiti, trying to treat tuberculosis, is that if you want to get people to adhere to treatment, you have to work with community health workers. I remember originally we thought, “We’ve got the doctors, we’ve got the nurses, we’ve got the lab, we’ve got the microscope,” and patients were still dying. And so we had to figure out, what is the delivery problem here? What we discovered is even if you can afford doctors and nurses, you still need community health workers, because they’re in the villages with their neighbors. And of course, the problem was it was a chronic illness and the patients have to stay on the meds. Community health workers could encourage them to take the medications and also help with daily tasks that patients needed.
You also need community health workers for palliative care at the end of life, which is a focus of your cancer work. Obviously, there’s no reason that someone in Africa shouldn’t have it if someone here has it. Do you get resistance to the idea?
In a sense, given the sad fact that all humans are mortal, all care is palliative. But what’s interesting to me as a medical anthropologist is the way some of these terms get perverted. In a place where you have no effective therapy, the “palliative care” term was abused a bit, because the idea was: we can’t treat the cancer or the AIDS, so we’ll just give palliative care. And I think that was a mistake. People should’ve said, we should be doing our best job of treatment and doing palliative care.
But people with painful malignancies, oh, yeah, they need palliation in Haiti just as much as they do at Harvard. And pain management is not a really expensive proposition. It’s very difficult to manage narcotics, that’s true. You have to make sure the drugs are working without too many side effects, and you also have to make sure they aren’t being stolen and sold on the street.
It’s not always that the drugs themselves are so expensive. And again, yes, cancer care is expensive, but is that the end of the conversation or the beginning? Because if it’s the beginning, we can then say, “How do we drive down costs?” And that’s one of the focuses of the task force.
You spend so much time working on policy. Do you still see patients, too?
I’m actually going down tomorrow to Haiti to see a patient, a 25-year-old kid. He had these pulmonary lesions that everybody assumed—correctly—were tuberculosis, but then it turned out he also had lymphoma. I started seeing him about half a year ago, and we got the diagnosis made at the Brigham and then the chemo from the Dana-Farber, and he actually just left the hospital. Believe it or not, his name is Victory.
Is he cured?
I think so. He did six cycles of chemo, and he’s certainly cured of his TB. I’m hoping to see him tomorrow. He went home, but not too far from the hospital. So I can probably dig him up. Not out of the ground, thank God.