Harvard health economist Felicia Knaul had long fought for the interests of poor people in Latin America when a breast cancer diagnosis brought her attention to tremendous global disparities in health care. Knaul, an associate professor at Harvard Medical School and director of the Harvard Global Equity Initiative, spoke about that disparity earlier this month at a Harvard School of Public Health World Cancer Day event, and wrote about it in a recently published book, “Beauty Without the Breast.”
Q. You describe a cancer divide between wealthy countries like the United States and poorer countries. What do you mean by that?
A. Cancer is not only a disease increasingly of the poor, it’s a disease in which the poor are suffering even more.
Q. You describe many of these cancer
cases as preventable. What do you mean by that?
A. Tobacco, of course, obesity, indoor cooking. It’s almost always poor women who die of cervical cancer, which we know how to prevent and also diagnose in precancerous [stages].
Q. Even treatment for pain is different?
A. Among patients with HIV or cancer, in the 10 percent of poorest countries in the world you see about 54 mg [of morphine or morphine equivalents used] per person; in the 10 percent richest countries in the world, it’s 100,000 mg per person; it’s 200,000 in the US and Canada.
Q. And the outcomes of cancer care are markedly different in poor countries than they are in places like the United States?
A. If you take a disease like retinoblastoma [a type of eye cancer], most children in high-income countries will hope for a cure and also live through the disease retaining their sight. In developing countries, the majority will not live through the disease and the few that do will lose their sight. These are the divides that truly concern us.
Q. Is this divide primarily a financial issue?
A. There’s an incredible amount that can be done in terms of avoidable and preventable cancers that is really quite low-cost. [Morphine] itself costs pennies. It’s an access issue and an issue of developing appropriate regulatory environments. For other interventions like the HPV vaccine [to prevent cervical cancer], there are some cost issues, but there are also many countries, quite poor, who have found solutions to this. Investing in prevention in developing countries is much less costly than what we’re losing in terms of productivity and suffering.
Q. Your own illness made you more aware of how different your care would have been if you were not an American?
A. Absolutely. This is something I knew before as an economist, but it’s very different to study a health system than to live a health system. I’ve always had a passion and a need to do something about poverty. The understanding [I have] about cancer as a disease and the voice that gives me to advocate for better access, not only to cancer care but more generally, came with my disease.
Q. How is your health now, five years after your diagnosis?
A. I’m doing very well as far as I know. I talk about surviving with the disease, rather than talking about being a survivor. I think that cancer is a disease that once you have it, you always live with it, either because of the effects of treatment, the fear of recurrence, or the bodily scars that you wear as a result of the disease.
Q. You wrote the book in part to talk about this. What was your main message?
A. Cancer, and breast cancer in particular, is a huge challenge to the health of women in developing countries. Through this disease, we can see how to truly empower women. One of the greatest barriers we face for women’s cancer particularly in low- and middle-income countries is discrimination and stigma and what we would call in Latin America “machismo.” It’s all about how one could become empowered through a disease, and how important it is to use that to improve access to health globally.
Q. In this country, routine breast cancer screening before age 50 has become controversial. What is your position?
A. I adhere to the American Cancer Society recommendations, which are mammography beginning at age 40 for women who have no family history. If there’s a family history, usually you include mammography, MRI, ultrasound, and very close vigilance. I believe very strongly in knowing your own body, trying to look for changes, and feeling comfortable in your own body.
Q. How was your own breast cancer discovered?
A. I was discovered at 41, in my baseline mammogram. That mammogram really worked for me. But I’m not saying that’s the rule in all cases. I think the breast clinical exam and knowing your own body is extremely important.