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.
>> Malaria.
>> 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.
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.