Wisconsin Public Television University Place presents  Dr. Jim Cleary  A Global Approach to Non-communicable Diseases December 9, 2011 UP666   CC >> Welcome to Global Hot Spots brought to you by the Wisconsin Alumni Association and the UW Madison Division of Continuing Studies. Today's topic is called A Global Approach to Non-communicable Diseases, and we are very pleased to have with us today Dr. James Cleary who is an associate professor of medicine in the medical oncology section of the UW School of Medicine and Public Health. He's director of the palliative medicine at UW Hospital and Clinics and is a special adviser also to the UW Global Health Institute. Dr. Cleary serves as academic medical director for Agrace Hospice Inc. for Dane County. After receiving his medical degree from the University of Adelaide Medical School in South Australia, Dr. Cleary completed his internal medicine residency and oncology fellowship at the Royal Adelaide Hospital. He is an international leader in palliative medicine and is a board member and past president of the American Academy of Hospice and Palliative Medicine. Will you please join me in welcoming Dr. James Cleary. [APPLAUSE] >> Thank you very much, indeed. We came to Madison 18 years ago at the request of Dr. --, an invitation. 

And that was, we came for two years and we're still here 18 years later. And I think that happens to Madison, doesn't it? My wife is from North Queensland. For any of you who know Australia, that's the tropics. It's the equivalent of Fiji. She had never seen snow before we arrived in Madison, and we arrived in February with 18 inches on the ground. She's still here for some reason. What I'd like to do today, and we'll try and do this as much as we can with the cameras, is that just a little too loud for you, folks? It is for me too. I can hear myself. I'm not going to try and do anything here. There's a far volume thing. 

>> Go ahead. >> You've got it. >> See if I can fix you. >> Fix me. It's just reverberating that little bit. The other option I have, we're going to come down just a little bit, is I'll just lower this. Is that better? Okay, that's less now. Good. It was reverberating too much. When I say global health, what do you think of? Cancer? Well, I'm an oncologist, okay, leading question. 

What else do you think of? >> Tuberculosis. >> Tuberculosis. >> Malaria. >> Malaria. >> AIDS. >> AIDS. Interesting you came up with those three, or four now. Already in this world more people die a year from cancer than die from AIDS, malaria and tuberculosis. That may surprise you. It's a startling figure for most because we think of developing countries, and I'll try and use the term low and middle income countries because that's the most politically correct term because mean people claim the United States is still a developing country. 

We got a lot of developing to do. So low and middle income countries is probably the better language to use. But already more people die of HIV, tuberculosis and malaria. Or more people die of cancer than do of those diseases. So I'm just going to put this in a context that we talk about in terms of these situations. What are the definitions? Many people feel public health is what we do. The university, the state, what's our public health strategy? Many would argue that in the United States we don't really have a public health system, as opposed to those countries with universal healthcare. International health, really those folks who live somewhere else. Let me remind you, the United States is in the world. So global health actually encompasses the whole world and not just what happens overseas. 

Or as we say in Australia: OT, over there. And everyone has to go when we go walkabout at the end of university, we tend to go over there which is somewhere outside of Australia. So global health affects us all. So it reflects that we may actually have a lot to learn from other people at the same time. And just focusing in on that global health, issues directly or indirectly that affect health that transcend national boundaries, this is really something that we're working on as a major strategy together. Access to health, looking to health equity amongst nations and for all people is a major objective, and it's highly interdisciplinary as we move forward with this. Also, you heard this term palliative care. I'm a palliative care physician and many people say what is this term palliative care? Who's the best provider of palliative care in the United States? Hospice. What's the problem with hospice? >> Not available to everyone. >> Not available to everyone? What do you mean not available to everyone? Medicare. 

It's actually one of the few forms of universal healthcare in the United States. Medicare will pay for everything. >> End of life care. >> End of life care. And who wants to sign up and say I'm end of life now? [LAUGHTER] Now you can do it. And when you sign on for it you actually have to sign off the rest of your Medicare. So it's actually a problem. You actually say my focus is now on being comfortable. The term palliative came from the French, care des palliatifs. Hospice has connotations in French, poor house, poor farm. 

How many of remember The Game of Life? When you got to the day of reckoning, you spun the wheel at the very end and you put the money on the four, five, six and if you got a one, two, or three, you went to a poor farm. Now it's a nursing home, they've changed the game. But if you got a seven, eight, nine or ten you actually went to millionaire acres. And hospice has that concept within the French language, so they came up with the term care des palliatifs, but this is what it is: patient centered care, pain and symptom management, family involvement, and really it's synonymous with good medical nursing care. The Institute of Medicine in 2001, and unfortunately it was on September the 13th, 2001, so no one paid much attention, but they released this document two days after 9/11, and they actually focused on communication. These are the skills. Most of us think palliative care is just this last bit: care of the immediately dying. But it really is the whole thing of what we're doing. So here's deaths by cause throughout the world just to bring us back to the global concept. And I'll try and not be in people's way. 

I'm aware of that. So here is what we've got, and what we can see is HIV, tuberculosis really only make up, when I do my math quickly, about 7.5% of deaths, globally. Maybe 8.5%. Heart disease, 30% of deaths. Cancer, 15%. Diabetes, other chronic diseases. What are some other chronic diseases? Diabetes we've got up there at 2%, 1.9%. Alzheimer's, CIPD, they haven't even counted the neurological stuff or defined that in this whole issue yet, and that's actually a big issue. I think that we're competing with someone this afternoon who is actually talking about that in terms of, I think they're talking at 3:00, on the whole issue of neurological diseases globally and the impact that it's having. So look at these numbers. 

And what they're saying is what is really astounding with these non-communicable diseases, so we've named some communicable diseases, 60% of all deaths in the world now come from non-communicable diseases. And what is astounding is 80% of these are in low and middle income countries. Most of us think it's a disease for us obese, sedentary United States folks, Australians I'll included in there, the drinking Australians, they're the people who have the heart attacks and stuff. But you only have to do your math. What percentage of the world's population is India? A sixth. China? Quarter. So you start doing your math and saying with those massive people and as they move into middle income country status and are now moving into high income country status with the BRIC countries, as we affectionately call them, and I think I get them right, Brazil, Russia, India and China are the BRIC countries. So if we start thinking about those major populations, they're beginning to move into this area. So what are the factors that contribute primarily to these non-communicable diseases? What causes them? Hmm? Livestock. Get more specific. 

Diet. What else? >> Lack of exercise. >> Lack of exercise. Susie always been a great exerciser. >> Heredity. >> So heredity is actually one of those big factors in there. We can't choose our parents in most cases. You can't choose your parents, they choose you.  But heredity is one of the things we don't have control over. But lifestyle issues. 

Tobacco. Tobacco, tobacco, tobacco. You may be surprised to know that two months ago the Australian government approved legislation that has moved to plain paper packaging of cigarettes. They will now come with brown paper packaging with the horrible pictures on them, and the only identifying thing about the brand will be at the bottom so when they're on the shelf you know that they're a Marlboro or they're Benson & Hedges. I'm even forgetting names of these cigarettes now. But they are doing such that the tobacco companies are furious. You can imagine that this is freedom. They're impacting their freedom of information and the ability of free speech. We should be able to put our cigarette logos anywhere, and the Australian government has said screw you, this is a public health issue, we're doing this. And they're being very provocative and doing it, and the health minister is really being very strong about this. 

Exercise. Does lack of exercise cause cancer?  We know that being overweight now actually might contribute to some cancers. We know that exercise can help people from actually being overweight. Jonathan Patz, the director of the Global Health Institute, has actually recently, and you may have seen this in the paper, if we road to Trader Joe's we're actually going to save billions of dollars in terms of improving health. Don't ride your car but if you ride your bicycle to Trader Joe's or walk to Trader Joe's, those simple little things, we're actually going to have a huge impact on the health care for everyone. So this is stuff that they're encouraging us to do now is to get out and exercise. Diet, how does diet impact these diseases?  Particularly, heart disease. Some evidence coming in with cancer. There's evidence now for some of the cancer stuff. Colon cancer, if you exercise and have a good diet, the benefit of this is as good as some of the chemotherapy that was standard therapy five years ago in terms of recurrence. 

So diet and exercise has a big impact on many of these situations. Clearly cholesterol is one of the other big issues where it comes in. If we can keep our cholesterol down. So we can keep our cholesterol down, the bad cholesterol down by diet, how do we get the good cholesterol up? Your HDL? Exercise. So this is the ripple effect of all of this. The lung stuff, primarily from smoking. Diabetes, what's the most common cause of diabetes in this country at the moment? Obesity. And I think in the last survey, Wisconsin actually went down in percentage of people who were obese. And there's some wonderful maps, I didn't bring them, but they actually can show year by year the different states. Where's the largest propensity of obesity in the United States? South, southeast. 

Hugely, we can see the percentage, huge percentage of people who are actually obese in those situations. So when we look at this and where is what's going to happen in the next few years, they've slightly slipped, but where is the growth of these non-communicable diseases? Africa. Infectious diseases will increase, this is deaths, will increase by 6%. They'll increase by 25%, 27%, in Africa. And you can see these other numbers. Eastern Mediterranean, these are WHO regions, so eastern Mediterranean actually includes the whole way from Morocco through to Pakistan. And you say, well, Pakistan is nowhere near the eastern Mediterranean, but that's how the WHO defines them. Even within the southeast Asian, western Pacific, they have countries who don't talk to each other but they're next to each other, they divide them up into different regions. Israel, which I actually think is right on the very east of the Mediterranean, is in Europe for this purpose because they can't talk with anyone else. So these are significant issues. 

But here's the things that we can prevent. One, in particular is important in Wisconsin, is it's the harmful use of alcohol. And it's interesting how that keeps coming up. Everyone is happy to ban tobacco but we still quibble about whether we should ban or come down on alcohol. So we don't like the harmful use of alcohol. The good use of alcohol is okay. So in men, those four drinks a day. Women, two drinks a day, particularly wine. And there's some evidence now coming out that spirits may actually increase breast cancer and some of the cancers that we're seeing. Alcohol and tobacco together clearly contribute to esophageal cancer, head and neck cancer, some bladder cancers, so the harmful use of alcohol, particularly if you're a smoker. 

And for many years the tradition was for men to go to the bar, drink their beer, and have a cigarette away from their wife, and they were the people who were getting these cancers. So there are the four major risk factors. This year, in September, the United Nations had its first meeting on non-communicable diseases. What was the other health meeting, UN summit, on in terms of health? AIDS. That started the whole Global Fund. What do you know about the Global Fund at the moment? Global Fund was set up to fund all sorts of projects with HIV. Three weeks ago they announced that they're not giving any gifts or making any donations because they don't have any money. So they've done huge, huge work around the world in terms of HIV, malaria and tuberculosis, but they're now actually saying they don't have enough money, countries are not contributing because of the economic problems. That's a problem. But based on the work of the former prime minister of Ghana, British Ghana in South America, they came forward and said too many people are dying in the Caribbean because of non-communicable diseases. 

Non-communicable diseases are responsible for about 80% of the deaths in Jamaica, 80%. Now you put back and say, well, what are they here? They're living like us. Jamaica is quite wonderful. They have Kentucky Fried Chicken, but they kicked out McDonald's. You may go, gee, I can't get the ice cream anymore, why go to Jamaica. But an actual fact, they said, and they actually worked on this, they do not have Kentucky Fried Chicken. Sorry, they don't have McDonald's. They do have Burger King. So it's not to say that they're blameless in terms of these problems, but it's many of these fast food industries that are coming in, the sugar industries, the soda, where are we moving in terms of industry in terms of health? Many of the large food companies are doing exactly what the tobacco companies did. As we become more stringent in the United States, they're moving their marketing offshore and, of course, what do you need to drink if you're alive living in Jamaica or Namibia? You got to have Coca-Cola or Pepsi-Cola. 

To some extent, many of these companies have become the new pharma. And I'll put out pharma, pharmacological, pharmaceutical industry, has actually got some criticism as of late in the paper. You all have seen it. The conflict of interest issues. Are they only in the business of making money. Are they truly reporting the study data. If we take some of the antidepressants and the suicide risk in children, those sorts of things. This pharma in the hole business of making money. That's the way our retirement is paid in most cases. When it's our retirement, we don't tend to object, but then we understand that there's health issues. 

This is becoming very, very significant. Countries are going offshore in order to make sure they keep their income up. And they're taking all the bad things that we are saying are bad now and are starting to do this. We can learn a lot from them. As we look at chain supply or supply chain issues in low and middle income countries, who has some of the most efficient supply chain issues? Industry. I've heard you can find a Coke bottle in most places of the world or a plastic thing lying in the middle of the Sahara Desert. And you sit there and say how did this Coke bottle get there? The Coke folks have worked out how to do it. There is even an advertisement on television, I can never remember who it is which is probably good, about the vending machine that's suddenly empty. The kid goes up and suddenly it's telephoning off to the distributor in the United States who's then got a truck delivering the drinks just because it was suddenly empty in the machine. And this is where technology is going even in low and middle income countries. 

So as much as we may think it's a problem in Madison schools, this is actually a bigger problem around the world as we move forward. But the UN met on this. They met in September. They actually had a number of processes. Health ministers met in April in Moscow, and they had the Moscow summit where they actually said, okay, we're going to address this seriously. They had a civil society meeting in May in New York where a number of us representatives of 600 organizations actually went and sat down in the main chamber of the United Nations and didn't get to say anything. But a number of the representatives of non-government organizations did get to speak, and it was opportunity for people from delegations to actually listen. Let me pose a problem: where is the United Nations health services based?  Geneva. So the World Health Organization is the arm of the United Nations that deals with health. And suddenly they said we're having a summit in New York and our New York offices are now responsible for all of this. 

No one in New York at the United Nations knows anything about health. So they suddenly had all these people in the New York delegations, the US embassy to the United Nations, Australian, all the sudden you have all these staff people who know nothing about health writing a declaration about health. So that created some problems because they were starting from the word go. Luxembourg and Jamaica were the two countries that were chosen to chair this session. And then they met for two and a half days. It was meant to be two days to start with. They tried to force it into one. But in actual fact, 190 of 198 countries, their leaderships spoke at this summit on the health care issues. They dragged on. This was actually, they kept saying we're going to give you two days, but there were so many people waiting. 

It's interesting to go for the United Nations. I hope we can put this on TV. I am told that the chair can never interrupt a president. But they can interrupt health ministers. So when Barack Obama gets up to speak, he can talk for as long as he likes because no one will stop him. And this happens when we see the president of Iran gets up to talk or Robert Mugabe gets up to talk, they get to talk as long as they like because they're presidents. But health ministers get five minutes and sit down, and they're interrupted and told their time is off. So, while there were 38 heads of government talked, the heads of government actually dragged the whole thing out too long. So they were saying it's nice to have heads of government but sometimes they talk too long. Very, very significant issues. 

What was the end result of that meeting?  We got a declaration.  Fifty-four items in the declaration actually came out and it was meant to be everyone was quite excited. No one promised a thing. Not a single government stood up and said we are committing dollars. When the first meeting came with HIV, countries stood up and said we will commit millions and millions of dollars. PEPFAR, the presidents emergency relieve fund for AIDS relief actually came out of the first global summit with George Bush saying we'll do this, and many people say it's one of the great legacies of the Bush Administration was what he did for HIV/AIDS throughout the world, coming out to over 20 countries eventually supporting him through the PEPFAR efforts. But no one contributed anything in this situation. I am a palliative care physician and I'm just putting up there, so we got mentioned, we didn't get mentioned until item 34 in the declaration. But we got mentioned. And they actually say we're going to focus on palliative care. 

But according to national priorities, they gave them an out. This was the language, it was much softer and people were saying they chickened out. Particularly, Princess Dina of Jordan actually came out in her opening speech at the assembly and said this declaration is too soft. You're actually not holding governments' feet to the fire, you're giving them too many outs because you've said according to national priorities in taking into account domestic circumstances. It's estimated by 2020, deaths of non-communicable diseases will have cost the world $34 trillion. $34 trillion. We're talking about a few trillion, I think, with the US deficit at the present time. It's estimated that the net result of NCDs by 2020 will have cost the world $34 trillion. This is lost income, people have done this math, lost productivity, the impact on healthcare. This is the cost that is going to be to the world. 

Yet no one stood up and contributed any money whatsoever. One of the critical players in this whole group was the Union for International Cancer Control, UICC. They're base in Geneva. The Carbone Cancer Center is a member, but in 2008 they had a world cancer declaration, and these are the things they actually came up with. They said we're going to be able to measure tumors, measure the cancers, who's got cancer. We have very good cancer registries in this state, around the United States so you know what's going on. Two percent of the African population people are covered by tumor registries, 2%. The country that used to have the best tumor registry, Zimbabwe, which you can imagine doesn't have the best tumor registry at the present time. So we don't have a very good record of what's going on with cancers and other diseases around the world. Particularly, I'm interested in effective pain control and how important that has been overall. 

But UICC, when they talk cancer control, they talk about putting a third of a country's resources into prevention, they talk about a third for early detection and treatment, there's not much point in setting up a mammogram service if you don't have surgeons to do operations on breast cancer. You can do all the pap smears you like for cervix cancer, but if you don't have gynecologists who can do something with it, there's little point in doing this early screening. And then they're saying a third should be focused on palliative care. This is a great favorite publication of mine, many of you probably read it, The Onion. [LAUGHTER] The world death rate is holding steady at 100%. [LAUGHTER] And they quoted from the WHO saying that despite everything, I and think there's a wonderful thing, if I can read it, they actually put in here a quote and I'll come to it. Maybe it's not in this slide. But they actually attribute, I think it's to Ross Perot, that we just wasted all our money on healthcare and not being able to find a cure of death. What a waste it's been. But I think it's important to remember. 

Palliative care in some countries is really a very important national strategy. So this is an example from Australia, supporting Australians to live well at the end of life. And this is put out for public discussion, it's publicly talked about and it's really gained some prominence. And here they go through another strategy. We need to make people aware. We need to build a capacity for quality palliative care. So Australia is doing a very good job. What is one of the advantages Australia may have with this, or you may say disadvantages, but what's one of the advantages? Universal health coverage. I won't say socialized medicine, but we do have universal health coverage. I have made the point to a number of people that I only hear comparisons of the US and Canada. 

I think the comparison with the US and Australia may be useful. We only spend 7% to 8% of our GDP on healthcare. Everyone is covered under the national system and you pay an extra 1.5% tax for that, and if you want to take out extra insurance you can. Canada doesn't allow that privilege. But if you want to take out extra insurance, you can pay the extra, and you go to non-teaching hospitals for that healthcare. So it's actually, to me, a nice mix, and I always had private insurance because I didn't want my colleagues delivering our children because I knew too much about them. [LAUGHTER] And when you start thinking that yourself, you have to say what do I want for other people as well. Let me give you a case. Eighty-year-old woman. She has endometrial cancer with bone metastases. 

She has a small stroke. She has a fall and breaks her hip. So here she's got advanced cancer of the uterus. She's broken her hip, what should we do?  Tough, isn't it? I know what I want to do if it's me. Fix the hip. Who's going to pay for it? Medicare but she may end up having to pay a percentage of that. So she's got some important family events coming up that she wants to be around for so she elected to have her hip replaced, but this becomes an important issue. Could we just keep someone like this comfortable, in bed, lying down and actually saying let's just keep you comfortable. We'll put you on pain medicines. She won't be mobile. 

She'll probably die of pneumonia in a couple of weeks. So what is the goal of care? And I just mentioned this with hospice a bit earlier that when we sign on to hospice in the United States you actually have to sign off the rest of your Medicare. And I think one of the challenges we face in the United States at the moment is it is a single payer system with rationing. And everyone saying they don't really like it. You may say it's not rationing on hospice but most hospices limit the services you can get. Can I get more chemotherapy on hospice? You'll see advertisements saying yes, but when the rubber hits the road, hospice has to pay for the chemotherapy from the money the federal government gives them so it's much less. So what are we doing in healthcare? We often hear this language of palliative versus curative. What diseases do we cure?  I know you're not physicians, but what diseases, some of you might be, what diseases do we cure? Polio? So if I get polio, you're going to cure me? We've eradicated polio supposedly from the world. TB, really? Particularly in Africa at the moment, we've got multi-drug resistance TB cropping up. Infections I'll give, some infections. 

What do we mean by cure?  You will have seen, I have a, I blog. I've joined the social media thing. And we just recently had a series of films out on a group called Life Before Death and they put out one called Cure. And we put up some of the definitions that people have for cure. Painpolicy.wordpress.com is our blog site where we address a lot of these issues. Here is a survival curve. So we've worked out 100% of people die, and here's the number of years. Red is the normal population. The disease. A disease is curable if the people who get that disease don't die of the disease. 

So that's a population definition. Remember I said a disease is curable, not people. I tend, I don't use the word cure in my clinical practice as a cancer specialist. We don't have evidence of disease, we may have controlled things at the moment, I don't even use the word remission, that has connotations in terms of definitions with hematological. So there's no clinical evidence of disease at the moment. People say give us the magic of the cure. But let's be real. A disease is curable if people with that disease don't die of the disease. We can do this. Someone who presents with a very early breast cancer, less than one centimeter, no lymph nodes involved with the current therapies, they're not going to die of that breast cancer. 

The population, they're going to die of something else. New breasts cancer. Early colon cancer. What about a man with testicular cancer who has brain metastases, lung metastases, is that curable?  What do you say to Lance? This is the challenge we face as we talk cure when we got Lance Armstrong who had brain metastases, lung metastases and went on to win seven Tour de Frances and a third. Let's remind you he got a third at the age of 38 or whatever. How can we talk, this is strange language. It's interesting, I was just on a conference call with the LiveStrong folks yesterday, his foundation, and they don't use the word cure when you're waiting on their answering machine. It's actually we're fighting to help people deal with cancer. They're covering the whole spectrum. In fact, they support some of our palliative care efforts because of the whole need for cancer pain relief which we're coming to talk to. 

Most of the diseases, what we do in cancer medicine, I would say all medicine, is actually focused on prolonging survival. In some cases, it may be a matter of days to weeks, pancreatic cancer. In other cases it may be months, it may be years. But we're aiming to prolong survival, and we ought to define that a lot more. Equally, a lot of what we do has no impact on survival whatsoever. And that's where palliative care is particularly important. But while I say that there's actually no impact on survival, what are we going to do with Mrs. MB?  We could send her off to hospice. She could go to hospice. There's cost economics associated with this. Medicare, if she has a surgery, can she go to hospice? Can she really get palliative care? What we're trying to do with palliative care is actually trying to break down this barrier. 

We're actually trying to move things from this throwing people over the wall. And what we actually say is there's nothing else we can do. There's actually been a report on the quality of dying. This was put out by the Lien Foundation and published in The Economist. Reputable, non-medical journal but very reputable. And here they there, they ranked the different countries, and just because that's very small, I'll blow it up for you. You can see the United States and Canada came in at number nine. Most people who actually see this, Americans, say, well, they obviously asked the wrong questions if we came in number nine. The World Health Organization, do you know where they rank the US in terms of healthcare? Thirtieth. It's around, depending on the year, 28 to 32. 

And again most people say they must ask the wrong questions. Where do we come number one in that WHO survey? [INAUDIBLE] >> Not just dollars spent, we have the best protection of patient information in the world. [LAUGHTER] We have the best protection of information. We have 60 million people who don't get appropriate care or have access to care, but we have the best confidentiality in the world. And we get number one for that which we may be thankful but maybe we need to have tradeoffs at times. What they did, here's the UK, here's Uganda, they looked at a number of issues across the board and gave different scores based on basic end of life care, basic quality of life and they looked at these parameters and gave them the score. And the put in the US here, consistently eight or nine across the board, but in terms of access, the cost, if you don't have hospice, Medicare benefit, it can actually be very expensive to get end of life care. And that's why they drop down. So for people over the age of 65 who have Medicare it's quite reasonable. Many health insurance companies did not provide money in this situation. 

And they even went and looked at different things. Public awareness. Is this a taboo subject in the United States, death and dying? Yeah. I challenge medical students, I say go home for Thanksgiving and as mom pulls out the pumpkin pie, ask her about their advanced directives. [LAUGHTER] And one kid came back and said mom put the pie back in the oven and it stayed there. [LAUGHTER] And you sit there going oh, dear, that was bad. Whereas someone else said oh, yeah we've been meaning to talk to you about that; here's our advanced directives and, by the way, you're the agent. There's a series or a movie out at the moment you may have seen on public television, Consider the Conversation, made by a school teacher here in Oconomowoc and a hospice social worker from Rainbow Hospice at Jefferson. And that's actually getting a lot of air play at the moment. You can get it at Amazon online, Consider the Conversation. 

And it's got some beautiful footage in it from different people talking about this. Terry, the producer, the filmmaker who is the school teacher, he actually won Wisconsin teacher of the year. Went off the White House, met with George W Bush, was talking to his brother on the walk out as he and his wife walked back to the hotel enjoying the day, and his brother told him he had pancreatic cancer. But he had actually held off telling him until after he got the award because he knew that his brother probably wouldn't have even gone to the White House if he had known. And he goes on to tell the story of his brother with metastatic pancreatic cancer. The stories of the people with Lou Gehrig's disease, a physician from California, who talks very powerfully about, we talk about the hundred things I do every day, getting a cup of coffee, getting the paper, getting the mail, what happens when I start losing the ability to do those things? And what number will I get down to in those hundred things? When will life not have value for me as a person? Will it be when I can't kiss my wife? Will it be when I can't answer the telephone? Will it be when I can't go to the bathroom by myself? So it asks all these important questions and the importance of talking to each other about this. It's fascinating that we talk to each other about the finances. How many in the room have a will? You see. Everyone's got that finance thing sorted out, who's going to get the money. I won't but it's an important question. 

Power of attorney for healthcare? Good showing. Very good. I congratulate you. That, to me, is the most important document is to actually have someone designated to make decisions for you. I have a naked power of attorney for healthcare. What do you mean naked? No I didn't sign it in the nude. What it is, is I've left it totally open for my wife, who is my agent, to make up her mind what she wants to do. Because I could start putting in stipulations and writing things in, once I start writing things in, we, as doctors, start interpreting them. He doesn't have a terminal illness under mine. He says he doesn't have a terminal illness. 

So we can start debating this stuff which is why I've left mine basically, my wife can do what she wants to. She does anyway. [LAUGHTER] Oh, dear, I'm in trouble now, aren't I? What we need to do in this system is actually disrupt healthcare. Many of you may be aware of disruptive innovations, talked about at Harvard extensively. We need to disrupt healthcare and integrate palliative care throughout. And there's even studies now that show by getting palliative care involved early, we're actually improving survival. This is a lung cancer population, and what they did was they got standard cancer therapy for their lung cancer or they got standard therapy plus palliative care. And the red line, the upper line, is the people who got palliative care. They actually lived longer. They lived the similar, we prolong survival the same as most lung cancer drugs do. 

That's approximately a billion dollars a year if it was a drug. But because it's palliative care, a service, it really hasn't taken off like we would normally see it. And just so you know, Mrs. MB was Barack Obama's grandmother.  So this has really become a reality, and the president has said this is a significant issue. Many of you recall 2008, he took time off from electioneering, he's making up for it now. He took time off for electioneering to go and visit his grandmother when she had the fall, and she had her surgery and she died some two weeks later after the surgery. In a New York Times article, he's saying healthcare is a tough issue. Toughest part of healthcare: end of life care. We need to be addressing this. $20,000 a week, how much do you pay? He's a wealthy man. 

She elected and then things went bad, and he said we need to address this. And this is somewhat where the whole death panel conversation came about and really created some problems for us overall. We can't have a meaningful discussion about this in Washington now. I'll skip, but this is the global health initiative that he has now brought in, and what he's saying is drawing on the president's emergency relief plan and saying let's focus on rebuilding healthcare systems as we go forward. It's not just about HIV; it's about non-communicable diseases. If we rebuild healthcare systems, we can actually have a big impact. So this is healthcare systems for palliative care. The green countries are the countries that have been identified as having good palliative care. The yellow countries are the countries that have been identified as having no activity identified for palliative care. And this was back in 2004. 

We're going to have a look at this a little bit in terms of how it's changed. This is a recent one, 2008. You can think Australia went backwards. They've since gone to full green. We're equal with the United States. I got upset and said you can't actually be light green, you have to be dark green. Uganda is now classified as being having almost full integration. And you may sit there and say that's a little surprising, South Africa, but we can see whole parts of the world that are not doing any of this sort of care. We can also look at this in terms of number of services. I think they put 43 in, so China gets good because it's got 43 services. 

But when you consider it's only got a few services for a quarter of the world's population, it probably shouldn't be green in this definition. We can also look at this thing of morphine consumption. How many of you have had morphine? Like Bill Clinton, you didn't inhale, is that right? No. Oxycodone? Hydrocodon? Vicodin? These are all opioids. Fentanyl? These are all opioids that we actually use and have now. What we have is the United States consumes approximately 100 milligrams of morphine per person per year. A hundred milligrams per person per year. Let me find one, Sudan, 0.004 milligrams per person per year. No pain control. That is effectively what is happening. 

And we can look at this in other ways. We've actually converted all the opioids, we've taken out the methadone, which is largely used for treatment of addiction, and we can actually, the United States comes in there as the top country at 482 milligrams opioids per person per year. 482 milligrams. Did you have your 482 milligrams this year? [LAUGHTER] But when we need it, it's there. As opposed to a person who gets run over by a car in South Africa, no pain relief. A person who gets shot in the civil war in Sierra Leone, no pain relief. A woman in child birth in southeast Asia, no pain relief during child birth. So most of the world's people actually lack access to opioids. And this is a new report that was just released, a very important global health report, released at Harvard by the Global Task Force for Expanded Access to Cancer Care and Control in low and middle income countries. That's a mouth full. 

GTF.CCC is what it comes down to. But very important report and we worked with them on this. What this shows is for cervical cancer, pediatric cancers and breast cancers, it shows in those top two lines the variation between the mortality rate, so the top wealthiest countries, it's three per 100,000 for cervical cancer, 36 for the poorest 10% of countries, so you can say, if I do my math right, ten-fold difference. Pediatric cancers, five-fold difference. Breast cancer mortality versus incidence, it's a two-and-a-half-fold difference. For pain relief, 580-fold difference between the top countries and the bottom countries. This is now being declared the greatest inequity in global health, the fact that people don't have access to pain medicines. You'll hear the language that people should actually have access to pain relief or it's a human right. Freedom from pain is a human right is actually being promoted. It's not the freedom from pain itself, it's the access to pain relief should actually be the human right. 

We cannot guarantee that people will be pain free, but we can do a lot to make sure that they have access. This is what really it works down to. High income countries, 48 consume 90% of the world's opioids. Nine percent is consumed by the low and middle income countries even though they represent 83% of the world's population. It's like many of the other inequities. And in just the closing few minutes, I'm going to try and share with you a story, and if I flip to this desk PC, it is going to happen, and let's see if we can make this happen now. And I'm going to fast forward it as much as I can to the bit we really want. This was a program that was actually shown.  I'm cranking up volume here. I may need some help to get more volume. 

 If not,  I can do that.  Here we go. We actually were in India, these people went to India, and they we worked with folks with Cipla Pharmaceuticals, and this is where they currently are. >> ...Various institutions is absolutely massive. >> In the US, Canada and much of Europe, simpler drug laws and the marketing power of pharmaceutical companies make access to expensive brand name prescription pain killers much easier, but even some wealthier countries suffer from lack of access to opiates. As this map shows, people in more than half the countries around the globe have a limited access to medical morphine, and of that number, more than half face severe shortages of pain medication. [traffic noise]  Here, in Ukraine, some of the same bureaucratic hurdles that plague India mean that even a former decorated KGB colonel is left to die in pain. §§  Artur Shumanov has stage four prostate cancer and is living out the end of his life alone and suffering. [SPEAKING FOREIGN LANGUAGE] It got so bad, he says, he's left his family in Kiev and moved to this cottage in a remote village hours from the capital. [SPEAKING FOREIGN LANGUAGE] The under treatment of pain is a huge, huge issue. 

In Ukraine, pain is part of life.  >> We invited Dr. James Cleary, a leading authority on global palliative care, to -- the scope of the problem here. >> Because of his pain, he's cut himself off from his family. What greater time is there for a man to need his family than when he's facing advanced disease? But what did he say? He didn't want them to see him cry. >> Artur has found his own way to numb his agony. [SPEAKING FOREIGN LANGUAGE] And if it gets bad enough, Artur showed us his other plan to stop the pain. [SPEAKING FOREIGN LANGUAGE] >> To watch Artur reach under his pillow as he's talking about potentially ending his own life and then just pulling out this gun. It's not a gun in a cupboard, this is a gun that he sleeps on. So clearly the impact of this severe pain is great if he's that close most of the time. >> Critics of Ukraine's system say it's a throw back to the old Soviet days of red tape with cumbersome paperwork and arbitrary limits on doses. 

>> What you see in Ukraine is that four doctors have to sign off on every prescription of morphine. In Ukraine, 50 milligrams is the maximum per day. In the US, there are people who will get thousands of milligrams every four hours. So it's a night and day difference. >> Drug availability is so strict in Ukraine that the little morphine that is available is hand delivered to patients at home by nurses. [SPEAKING FOREIGN LANGUAGE] And there are no pill forms of the drug, only antiquated so-called IM or intramuscular doses that must be injected with a needle. We were there when a nurse arrived Artur's house with a small dose of injectable pain killer. >> Really? That's how you're doing care? Oh, boy. >> The injection gave Artur a little relief but he said the pain soon returned. >> I haven't order an IM injection for a patient in 20 years. 

The medicine only lasts for approximately two hours, so patients are spending a lot of time in pain. An ambulance comes to your home, you say what am I going to do if it doesn't come? You want me just to suffer in this situation? >> There is one place in Ukraine where patients in pain can have ready access to pain killers: in the hospital. At the Cherkassy Oncology Hospital in Kiev, cancer patients like these were clearly comfortable, certainly a contrast to what we saw in the countryside. That's because in hospital, physicians like Dr. Arana Shlaga don't have to abide by the strict dose limits, and hospital staff are readily available to administer the drugs to patients in pain. >> He's looking very comfortable at the moment. [SPEAKING FOREIGN LANGUAGE] >> But the policy in Ukraine is that patients who have completed their treatment or who are deemed terminal are sent home. And physicians like Dr. Shlaga know they're sentencing them to suffering. >> Will he go home on morphine? [SPEAKING FOREIGN LANGUAGE] >> He cannot get morphine. >> That must be tough for you when you send people home? [SPEAKING FOREIGN LANGUAGE] >> Thanks for understanding. Yes it's hard. 

>> And once they go home, it's not just the patients who suffer, it's also their family members. >> I'm going to stop that there.  The University of Wisconsin Pain & Policy Studies Group, based at the Carbone Cancer, is actually the leading organization in the world for improving access to pain relief. We have an international pain policy fellowship where we're working with people around the world to actually improve access to opioids. We have fellows in some 12 countries at the moment. I had the opportunity to meet with Her Majesty, the Queen, two and a half years ago at the 20th anniversary of Help the Hospices. And there, she and I talked about the fact that the United Kingdom had paid for the first oral morphine that was given in Sierra Leone. And -- was actually trained here in ministership at hospice in Sierra Leone, and now you say this is the first morphine that's been given in this country. So highly significant. Kenya, Nepal, south American countries, Columbia, Vietnam is now making progress in terms of its access to opioids. 

We have a very good collaborative partnership with India, and we're also working around eastern Europe where many countries are actually still struggling from the implications of the Soviet regime as it did Ukraine, but the first tipping block in this was actually Romania where we saw significant improvement in the laws that happen in Romania. There's three primary issues that we need to address. There's often many laws and policies that stop this. There's actually the need to educate physicians. And we also need to make drugs available. If you do any one of these things, just one, the other two don't get done. You need all three together. You can have drugs available. We visited a cancer center in Calcutta. A hundred tablets of immediate release morphine, but the laws didn't allow the physicians to prescribe them. 

They went past their use by date. They're still sitting in the cupboard in the cancer center. They expired. So these are the challenges we face, but, again, I'll come back. This was a Wisconsin idea, you've mentioned Wisconsin idea earlier. This came from the Wisconsin cancer plan initiative of the late '70s, early '80s that June Dahl and David Joranson started, and it's now this Wisconsin idea going global. So thank you very much for your attention today. I'm happy to take any questions that you might have at the moment. [APPLAUSE]  >> Thank you so much, Dr. Cleary. We have a microphone here so you can be heard. 

If you have any questions, I'd be happy to bring it to you.  >> Hi, I'm just wondering if there are any programs anywhere in these countries for stopping smoking? There clearly are for AIDS transmission. >> So tobacco secession, in low and middle income countries there's very little focus on that at the moment. And again, where is most of the programmatic resources? A lot of what we do in this country is actually the psychological type interventions which are resource intense. Already we're seeing, one of the things I mentioned in the world cancer declaration is the brain drain. People come to the United States, I heard a figure recently, there are more Ethiopian trained doctors in the Washington, DC, area than there are in Ethiopia. Says something about the problems that we have. Many, I've also heard that we have the best healthcare system in the world for doctors which may be a reason we actually attract doctors here. So no, they don't. And particularly as many interventions are also patches, lozenges which have an expense and cost to them at the moment, they're not going through. 

They may be an advantage to us because some countries have actually very little smoking. India has a big smoking problem, they also have the beetle nut problem which they chew. China, huge smoking problem. But some African countries, it's not that prevalent yet and they may actually be able to get in there and stop it. Equally, they have the ability as they go forward to actually tax, and it's been estimated that we can fund all the efforts that we wanted to do with non-communicable diseases by putting, I think it's a penny packet on low and middle income countries, 10 cents a packet on high income countries, and we can actually fund the whole global health effort for non-communicable diseases very quickly. California has shown already a dramatic drop in death rate from cancer, lung cancer, and they were the first state in this country to actually really jump up tobacco tax, and it really shows the effectiveness that cancer death, lung cancer death rate has dropped faster than most people predicted in California. So it does show the advantage of taxing tobacco out of the system. As long as they don't tax my wine. [LAUGHTER] Because that's non-harmful. [LAUGHTER] Other comments, questions? Sir. 

>> What is the impact of environmental pollutants on medical conditions, water, air, and is that diminishing or increasing across the globe? >> So the question relates to what is the impact of environmental pollutants. There's actually, and you may have seen it, there's a story in the last two days from the San Antonio breast meeting, there's no clear identification of chemical agents in the United States as the cause of breast cancer. We know, and if we go into some of the, we know that radiation is actually a risk factor for cancers, and people are so worried about Japan now. Indoor smoke is probably the biggest cause of chronic airways disease in the world at the moment. And you start thinking about this, what do you mean by indoor smoke? You go into a round house in Ethiopia which doesn't have an outlet for the fireplace that's in there. So you particularly have women spending a lot of their time in these enclosed spaces with no chimney in the room, and so the indoor smoke is actually a huge risk factor. We look and we're working with a project now in the Punjab which is an Indian Punjab as opposed to Pakistan Punjab. The Punjab is called the breadbasket of India. Very, very fertile area in the foothills of the Himalayas. Absolutely beautiful but as they've moved into sort of more western technology with pesticides and insecticides, while we have tractors and stuff that go through and collect this, they still have people hand-spraying, hand-picking and we're actually seeing a dramatic rise in cancers there. 

So I think we have a lot to learn, and, equally, people are pushing other ways in low and middle income countries where we can be greener in terms of protecting the whole situation. Equally, I've shared with people from India, maybe Gandhi had it right and maybe we should all be sitting around with our spinning wheels and just staying in the village concept rather than industrializing. So there are all these issues that are coming up as we move to the factories and things of China, India, the outsourcing, all the risk factors there. Just one final thing, we were in Gwangju for a UICC meeting last year, and I was talking to the US consul general, and he said there was one factory there that had 400,000 people in the factory. This was under one roof. 400,000. You can imagine Dane County, the population of Dane County worked in this one factory, 400,000 people. That gives you some example of the size of these sorts of things that we're talking about as we talk about industrial situations and things. Does that help? Sir. >> What percentage of the population is served by underground market in opiates. 

>> So what percentage of the population is served by the underground market. It's interesting I didn't show it, but I can recommend, again, our blog. It's there. You can search freedom of pain to find this movie. But an actual fact, the next scenes go on to a man who is actually collecting opioids from other people who had been legally prescribed and he was delivering this to Artur. And so we're sitting in the back of a van and I thought he just wanted to have a talk and he opened up this thing and there he's got vials of morphine that's he's transporting illegally, and if we get stopped by the police, three years in jail. And I didn't really like the concept of spending three years in a Ukrainian jail. [LAUGHTER] This is a very small part of it. If we go to countries like Kazakhstan, Kurdistan, they actually have a lot more use of, and isn't even illegal there, this is heroin grown in Afghanistan making its way there, and they're using that for both pain control and recreational use. There is actually very little illegal transfer between countries of opioids. 

This is highly controlled. The International Narcotic Control Board in Vienna controls this. There's a huge movement in terms of illegal for recreational use, but we think very little of that enters the pain market. Having said that, we know from experience there's a decent percentage of people in the United States who got on to methadone maintenance programs for drug addiction because they had poorly treated pain. They couldn't get appropriate pain care, and the one place they could get opioids was to turn up at a methadone clinic once a day and get methadone. You may have seen reports on the opioid epidemic, the deaths in the United States at the present time, we actually don't think that's been well analyzed, and there needs to be a much better analysis of it. Most of it seems to be blamed on the prescription of oxycodone, but methadone is the major drug involved. It's not just opioids, it's also drugs like Xanax, the anti-anxiolytic, anti-anxiety drugs. It's a combination. So it seems to be a general drug abuse issue rather than just blaming physicians. 

Having said that, Florida, in terms of oxycodone and some of you may have seen it in Forbes magazine recently, Florida was actually prescribing more oxycodone than the rest of the United States. And no one in the higher authorities had picked this up as being significant that one state was prescribing. And what they had there was pill mills. And what's a pill mill? A pill mill is where I can actually, as a physician, write a script and dispense it in the one visit. We don't have that in Wisconsin. You've got to go to a pharmacist. But if you handed me 40 bucks in Florida, 40 bucks, I write a script, give you the tablets and off you go. And I can see about a hundred of those people an hour. Florida has just passed legislation that's actually stopped that, and that's actually been identified as a major source of illegal drugs in the United States. Any other comments? >> Any other questions? >> Sir. 

>> I'm fairly ignorant about your area of specialty, but one thought that came through my mind as you were going through this is that much of the cancer related to us living longer and that we all know we're going to die and sometimes I see some of it as more tied to longer life expectancy. And my other question is related to what's your position on medical marijuana? >> I don't inhale. [LAUGHTER] Let me start with, I can say this, I got a call from the Steven Point paper or something the other day, I hit the big time in media. [LAUGHTER] So I can address the marijuana one first. The state medical society, Wisconsin Medical Society came out with a statement which I tend to support, that if, in fact, it's a drug it should go through the appropriate processes, a pharmaceutical agent, marijuana, go through the appropriate processes for approval which is the FDA. Just having a free for all saying here's a smoked product you can take, I actually believe that there are probably very, very good properties within marijuana that have analgesic effect. There is a drug that's now approved in Canada, not approved here. It was developed by an English company. It's a cannabinoid. It's a spray that you give, so I think that the US will be really worried about now having a spray. 

I equally have problems with the fact that we're, while we move to get away from a smoked tobacco that we would still allow another smoked product with all the impurities. My son tells me that water filtered is then the way to deliver because then you remove some of the impurities. I don't know if he's telling me from experience or not. But these are the things. I think morphine is a natural product. It's grown as a natural product. Just as a little aside, I mentioned heroin before, the most common drug used for patients at the end of life in the United Kingdom is, in fact, heroin. They use heroin and physicians prescribe heroin in the United Kingdom. And you can just imagine me writing a script for heroin here, and suddenly the DEA and the SWAT teams would be down, could they get it? But it's the most common drug. It's actually a pro drug for morphine. 

It's diacetylene morphine, so it's just a derivative. It gets broken down to morphine. So when we talk about the magic of heroin, it's nothing magical whatsoever. It's another opioid. In terms of people living longer? Yes. The cardiovascular people have had a major impact in mortality over the last 25 years. We have not seen that drop in mortality with cancer. And this is per hundred thousand people. So we have not had, all this money that we've spent at the NCI and things has had little impact in terms of the overall mortality from cancer. It's becoming small increments. 

The biggest change has actually been from the public health issues. If we can correct indoor smoke, if we can correct tobacco, correct the industrial things that cause, there was a cancer of the scrotum was associated with chimney sweeps years ago because the young boys as they went up and down chimneys got the soot and ashes on their scrotum and they got cancer from it. That no longer happens. We no longer actually seem, or rarely see, cancer of the scrotum. That's an example of industrial things. Asbestos, the Australian prime minister the other day, sorry foreign minister, suggested maybe the world should ban asbestos. We've still got countries, Canada mining it, Australia mining it, but this is a drug that we ought to actually be banning because of its industrial problems. We've not had the impact with cancer. Yes, people are living longer, and we're increasingly seeing this in the low and middle income countries as we treat the infectious diseases. I think there are some countries now that are actually reporting very, very effective mosquito net. 

They're dropping malaria rates dramatically, and we're actually seeing the impact now as people live longer and get cancers. So yes it is. >> I think we'll stop there. I appreciate your attention, and I appreciate you being here. If you have additional questions, I bet Dr. Cleary would stick around for a minute or two, so feel free. And I just want to thank you again for coming. Best wishes for wonderful holidays, and we'll look forward to seeing you after the new year. Thanks. [APPLAUSE] >> Thank you very much, indeed.