XXXVIII. Health Care Reform and Cancer Prevention and Control

Two years ago the American Cancer Society (ACS) made the bold decision to address severe deficiencies in the United States’ health care delivery “system” as its major concern. This was both startling and perfectly understandable. Startling because those of us in the cancer research community were (and to a large extent still are) committed to primary prevention of cancer as our primary goal. Understandable, because the debacle that healthcare has become in this country impedes everything else that we do promote health.


While the Cancer Prevention and Control Program remains strongly committed to scientific discovery that will lead to improvements in primary prevention of cancer, we also recognize that many severe deficiencies in our health care delivery “system” lead to a variety of poor outcomes for people who receive a cancer diagnosis. In general, and more starkly evident here in South Carolina than just about anywhere else, poor outcomes are most disparate for the poorest and most socially deprived among us. Unfortunately, like metastatic cancer, these social and economic problems are spreading in our population. Along with other major problems facing us at this critical time in human history, such as global warming, the denial must stop before we can mobilize the will, energy, intelligence, and creativity of the scientific community and its allies and supporters before we can make effective change.


In the preceding paragraphs I was very deliberate in using quotes around the word “system” because it really is fanciful to call the haphazard and profoundly unfair way health care is delivered in the US a “system.” For a very long time now individuals and groups have called upon government to create a fair, efficient, and accountable system of health care. Such voices were first raised in the Roosevelt and Truman administrations. This dallying over true health care reform has gone on for far too long. Besides denying care for easily treatable conditions it has allowed Americans to become profoundly unhealthy by implicitly promising to provide treatment that has little or no chance of improving quantity or quality of life; a promise on which it often delivers at great expense to all of us who pay ever-increasing taxes and insurance premiums.


Congress has an opportunity to include a strong public health insurance option this year, thus providing that option to anyone who chooses to participate. Such a broad-based plan would have real bargaining clout – especially important in keeping both the insurance and pharmaceutical companies honest. In order to control costs, a strong public health insurance option must be available nationwide and be accountable to us, the taxpayers. It also needs to stress personal responsibility to improve and maintain good preventive health practices. Unlike the current corrupt and profoundly unfair system of health care financing, it should be sufficiently transparent so that it can be monitored by our representatives in Congress.


There is no precedent, anywhere in the world, for anything but government to do this. What’s much scarier than the silly rhetoric about “socialized medicine” that began nearly ¾ of a century ago is the reality that we are spending an obscene amount of money making insurance companies and their chief executives fabulously wealthy while:
1. We experience some of the worst health indicators, including those associated with many cancers, in the civilized world
2. Our doctors spend more and more time dealing with insurance industry-induced red tape and regulatory requirements rather than the important issue of patient care for which they were called to their profession in the first place and spent many years being trained
3. Those of us who are insured experience red tape in the form of improperly denied claims that take many hours of our precious time to battle (and for which the insurance companies gladly pay their employees as a devious, but reliable, way to maximize profits)
4. Those of us who are uninsured or underinsured (who, together, now constitute the majority of Americans) are forced to use grossly inefficient methods for receiving health care and, when we do get seriously ill, are often left paupers by a “system” gone badly awry


For those of us who have experienced government-supervised health care in other parts of the developed world we know that:
1. These systems are much more efficient and easily accessible than the monstrosity that exists here
2. Health outcomes are much better than they are here, virtually across the board
3. These systems are humane and have shorter waiting times for most routine procedures than those experienced here
4. Doctors and other health professionals have higher morale and better measures of job satisfaction than their counterparts here – largely because they are allowed to actually practice evidence-based medicine most of the time that they are at work
5. Health professionals make reasonable salaries that are comparable to, and often exceed their counterparts here – except for some subspecialties


Having just experienced how well the greed-based financial services industry regulated itself while looking out for our interests, we should seize our rightful power to make the system of delivering health care accountable to the people. While we are at it, we actually might start paying better attention to the issue of health.

XXXVII. Poverty, Gender and Health

Many people in the world are too entrapped in the throes poverty to realize that combining a sense of intellectual curiosity with social activism is even a possibility. When we Westerners (even the poorest amongst us) talk about “stress” it is at an altogether different level than that experienced by the poorest half of humanity – people forced to live on fewer than a couple of dollars a day, for whom a day of missing work may literally mean the difference between life or death, and where medical care for even serious ailments is pretty much impossible.


I got into this work for a variety of reasons that I have discussed over these entries. Early on in my career I realized that poverty is the strongest predictor of poor health and female literacy is wealth’s most important modifier. When women have financial resources they generally tend to buy clothes, food, and school supplies for their children. When men have financial resources they generally tend to buy weapons; alcohol, tobacco and other drugs; and things powered by internal combustion engines. The typically male way of using resources digs families (indeed whole societies) deeper into the depths of poverty. The female way of using resources provides a ladder out – a means of escape. There are lots of exceptions, but this is useful generalization. Really, what percentage of people who go on homicidal rampages with semi-automatic weapons are women?

Kerala, a state in South India dominated by a matrilineal system of passing resources on to the next generation, has an overall adult literacy rate of about 90% (which is considerably higher than that of South Carolina), has health indicators better than that of South Carolina, has had a freely elected communist government for all but about 5 years of the 62 years since independence (quite unlike South Carolina’s regressive political system), and average wealth (expressed as State Domestic Product) less than 10% than that of South Carolina! Now there’s common sense and efficiency for you.


In an article we published 15 years ago [Hertz E, Hebert JR, Landon J. The influence of economic factors on life expectancy, infant mortality and maternal mortality rates. Soc Sci Med 1994;39:105-114.] we showed that overall wealth predicted health outcomes, but the most interesting lesson could be learned from four “outliers” (i.e., countries whose statistics were not fully explained by the economic-epidemiologic models). Egypt and the U.S. were much worse off than expectation – and both had military budgets far higher than the world average (at that time they each spent 43% of total government expenditures on the military). Costa Rica and Sri Lanka were much better off than expectation – the former did not have (and still continues not to have) an army and Sri Lanka (at that time at least) expended very little on its military. Twenty-five years of civil war, I am sure, has taken its toll on Sri Lankan health indicators.


Also as I have mentioned before, the trends I have seen emerge over the time that I have been in this line of work are not encouraging. Oppressive regimes, especially with respect to women’s rights, have emerged in a wide belt from North Africa, through the Middle East, Western Asia, and Southeast Asia and into the Malay Peninsula and the Indonesian Archipelago. India stands as one of the few bright lights in this darkening landscape.


What does this have to do with health and cancer in particular? Plenty. Without an engaged, well-educated female population no country will be able to throw off the shackles of poverty and poor health. This applies not only to whole countries, but to any political unit – just look at the states within India: from the male-dominated, generally regressive, unhealthy North to the more egalitarian, progressive, not all that much wealthier, but much healthier South. Cancer prevention and control requires careful use of scarce resources; eating good food; avoiding tobacco; and sensible screening for many of the common cancers that are becoming a bigger problem all over the world. Societies that value women so that their voices can be heard will make decisions that can reduce overall cancer rates and lead to downstaging disease at the time of diagnosis.

XXXVI. Reflecting on the Grand Opening

It has been 4 days since we finished welcoming people to the new home of the South Carolina Statewide Cancer Prevention and Control Program. I wanted to share some of what I said in my introductory remarks. Here goes.

This is a great and auspicious day. Many thanks to friends within the University of South Carolina, community members, faculty from other institutions of higher education and clinical partners from around the state, representatives from the National Institutes of Health and sister organizations around the country for being here to celebrate with us today.

What began as a promise and a dream those many years ago has moved decisively from the abstract to the concrete (and steel, glass, granite, and bamboo). I feel blessed to be able to celebrate the opening of the Cancer Prevention and Control Program in this new and beautiful place on this day in early June of 2009. It is a wonderful thing to contemplate the future dreams that will come to pass in our new home; the discoveries that will be made, and the promises that will be kept.


Many of us call ourselves “educators” and even more of us are parents and mentors of one sort or another. We all know that to live meaningfully means to learn and to teach. Though reflection is a necessary part of living life well, much of what we do does not happen in isolation – and some of it can, should be, and is very public.


In academia we are judged primarily by the papers we publish and the grant funding we garner. But we are called to this work for even more important reasons: to change the world for the better; to touch lives in meaning ways. So, as the director of the CPCP I need to reconcile the need to be productive academically as well as socially and ethically. My own heroes are people who understand that life has little worth without social, economic, environmental and healthcare justice. It was the driving force for Mahatma Gandhi and his disciple, Martin Luther King Jr. Their legacy lives on in the form of the two smartest, most enlightened leaders in the world today, Manmohan Singh and Barack Obama. So, the promise that we have for a better, healthier tomorrow is shared by people who understand the fundamental meaning of life and support us in the work we do here in the South Carolina, elsewhere in the US, in India, and in other parts of the world.


In the way that the National Cancer Institute, and the NIH more generally, classifies people I am a basic scientist. Really, that is the way I think. Still, I am a realistic and a keen student of the history of public health. That impressive, and very public record, shows clearly that those changes in the environment that lead to more equitable sharing of resources have had much more to do with increases in longevity and improvements in the quality of life over the past 150 years than all of the remarkable achievements in biomedicine over that time. An important part of our job is to ensure that findings in the basic sciences are not exquisitely irrelevant with respect to the cancer-related and other disparities we are charged with reducing and ultimately eliminating.


We are often led to profoundly incorrect conclusions when we choose the expedient over the correct way to do our work. Many of you have heard me give examples of how we can get things wrong when we think narrowly and in isolation. As the plan for this building evolved, it was clear that the new home of the Cancer Prevention and Control Program had to be a very public place. It needed to be on a very busy corner in our beautiful city. It needed to convey openness and a sense of optimism and striving toward excellence that captures the essence of our program. An area called Innovista and a building named Discovery seemed perfect. Here we are.


On days like today, I am called to reflect on the many connections that have brought me, indeed all of us, to a place like this. There are accidents in life, but much of what happens can be predicted in advance and even more can be explained in retrospect. We are here because of the excellent things that we do: the many papers that we publish in high-impact journals; the many grants that are funded. Not only are we productive in an absolute sense, but we are extraordinarily efficient in the use of scarce and precious resources.


Although statisticians warn about extrapolating beyond the range of the data, university administrators know that they can only project based on past performance and that we are very likely to continue to be highly productive by any standard. So, we were a logical choice to be the first tenants in this new campus so filled with the promise of a better tomorrow. It is my hope, desire, and plan to expand the program. We have tens of millions of dollars in outstanding grants that could lead to exponential growth in the near future. Expansion is a good thing. However, we need to understand where we have come from and the promises that we have made along the way. We are driven by a commitment to social, economic, environmental and healthcare justice.


The philosophy of what we do and our commitment to the community are not sideshows. They are fundamental to our purpose. As president Obama reminded us recently, it takes a special kind of courage to criticize your friends. You are the people who will hold us accountable. Consider this an open invitation to do so.

I have spent most of the last six months living and working in India. Although I worked hard and much was accomplished, including fulfilling my commitments to people back home, this time away has given me a special opportunity to reflect on life. Of all the words that I could pick to describe my feelings over this time, I would have to choose gratitude.


I am blessed to have a wonderful family, amazing colleagues, and daily contact with people who are dedicated to the mission of the program, and understand that they are only as great as the commitments they make and the promises they keep.

Three people will be speaking to you over the next hour and a half. Not only will this be entertaining but it will give you great insight into the future of public health and how three amazing and very different people see, experience, and wish to help in delivering on the promise.


I first met Patricia Pastides about 20 years ago, when I was a faculty member at the University of Massachusetts Medical School in Worcester Massachusetts and her husband, Harris, was a faculty member at the School of Public Health in Amherst. Over the years we have become good friends. I wouldn't say that our relationship is limited to food, but eating and cooking together has been a source of comfort, joy, and learning over these decades. I would not be in South Carolina if it weren't for Harris and Patricia. More than any academic leaders I have met in my life, they understand what the CPCP is fundamentally all about.


Dr. Claudia Baquet is my counterpart as an NCI (CRCHD) Community Networks principal investigator. She directs the Maryland Regional Community Network (MRCN) Program to Eliminate Cancer Health Disparities, which is a model nationally, and very much specifically for South Carolina, for how to work to effectively educate legislators and others to change health policy in larger systems to reduce cancer-related and other disparities. Claudia, a pathologist by training and public health educator and activist by avocation, has been a great mentor to me and other members of the South Carolina Cancer disparities community network.


Dr. Leslie Cooper is the Program Officer from the National Cancer Institute, Center to Reduce Cancer Health Disparities and team member of the South Carolina Cancer Disparities Community Network. The SCCDCN is the main vehicle through which we conduct community-based participatory. Over the four years that our network has existed, Dr. Cooper has evinced a deep interest in what we do and support for our philosophy, perspective, and work style. At the same time, we have come to understand just how very good she is at doing her job. Not only does she make truly amazing observations on the scientific and programmatic side of things, she is a great connector. She is one of those rare individuals who can see connections between things that may appear superficially to have no relation to one another, but when connected amazing things happen.
(NB: Many more pictures from the Grand Opening are available on the CPCP website)

XXXV. Grand Opening

I loved being in India. In the time that I knew I would be there, much was accomplished. When the time came to leave, I left with an overwhelming feeling of gratitude and just about no regret. As I had suspected, I also got some new perspectives on how we work here. I am gratified that after a week of being back home, this place still feels “new.” The depressing things I heard about American’s reactions to the economy news while I was a way are not hanging like a dark cloud over life here. There is great promise in the air. As life was in India, and just about everywhere I suppose, perception is formed by the close-up and personal relationships we have with the people with whom we have contact on the playing fields of life. We have wonderful people here and I am lucky to have helped to create the playing fields on which all play.

The South Carolina Statewide Cancer Prevention and Control Program was founded in 2003 to address some of the largest cancer disparities in the country; and, in some instances, in the world. For example, African Americans in South Carolina have the highest rate of one of the most deadly forms of cancer of the esophagus (squamous cell) in the nation. It is about 7 times higher than what is seen in European Americans, despite the fact that the rate of cigarette smoking (this cancer’s major risk factor) in African Americans is much lower. The prostate cancer incidence rate among African Americans is the highest in the nation (and about 80% higher than that of European Americans), and mortality is the highest in the world. Similarly, the death rate among African-American women diagnosed breast cancer is the highest in the nation. Indeed, it would be hard to find an example that does not disfavor African Americans.

In its short history the Cancer Prevention and Control Program has made good progress in describing the “cancer problem” in terms of both the scale and diversity of the kinds of cancers we see and where they are located within our beautiful, if somewhat beleaguered, state. This has entailed working with many other partners, including those in state government, such as the best-in-the-country South Carolina Central Cancer Registry. The August 2006 special issue of the Journal of South Carolina Medical Association was unprecedented in providing a graphical description of cancer in a state within the U.S., for and allowing the voices of the community to be heard in a peer-reviewed medical journal. On the front cover of the current (1 June 2009) issue of Cancer, is featured our article (1) on mapping cancer mortality rates within our state (and the first of its kind for anyplace in the world). It can be accessed through a link from the CPCP website. These careful descriptions are things about which South Carolinians can be justifiably proud. Indeed, they have become models nationally. This map (printed with permission from the copyright owner, American Cancer Society and the publisher, John Wiley & Sons, Inc.) illustrates the dire situation with respect to breast cancer.

It is not enough, though, just to describe the problem. We are not “ivory-tower” academicians. So, these careful descriptions also should point the way to solutions. So, we also have begun to address some of the underlying causes related to the larger environment in which we all live, and the various lifestyle choices we all make. Our goal in this is to identify things that individuals, or many of us working collectively, can do to reduce the rates of many different types of cancer and the destruction and suffering of individuals, families, and communities they cause. Many of the things that we have found to reduce rates of cancer also will help individuals, families, and entire communities to help control other major killers and causes of disability, such as diabetes, heart disease, and stroke. The wonderful Cancer Prevention and Control Program members that constitute our program are a smart, fun-loving and inviting group of people. It will take them, working in concert with members of the community (see XXXII. Interdisciplinarity and Community-Based Participatory Research), to really change things for the better.

Much of our work focuses on diet and physical activity. Fundamental changes are needed if we are going to make a real, durable difference in terms of lowering the rates of cancer and other deadly diseases. We also believe that these changes expand how people see, taste, smell, and otherwise experience the world. Indeed, the universe to which people are introduced is bigger than what they had known before. All of us believe that we cannot do this with a heavy heart; so, we really try to make it fun. This does not mean that it is not hard work. When one is confronted with a life-threatening illness, or whole communities whose very existence is threatened, it is absolutely essential to take it seriously. Most major changes that have occurred in the world have been made by people who understand the gravity of the problem they are confronting, while at the same time greeting the challenges with both resolve and great senses of humor.

This next weekend, the 5th and 6th of June, the Cancer Prevention and Control Program will celebrate the grand opening of our new location at 915 Greene Street (across from the Colonial Center) in USC's new Innovista campus. As careful stewards of public funding (though none of these events are paid from public coffers), we feel a special obligation to open the doors to experiencing the world in a new way to the public we are here to serve. On Saturday, the 6th, events including cooking demonstrations and many different forms of entertainment (including music and a visit by Cocky!) will be open to the public (see http://cpcp.sph.sc.edu/ for more information).

Reference:
Hebert JR, Daguise VG, Hurley DM, Wilkerson RC, Mosley C, Adams SA, Puett R, Burch JB, Steck SE, Bolick-Aldrich S. Mapping cancer mortality-to-incidence ratios to illustrate racial and gender disparities in a high-risk population. Cancer 2009;115(11):2539-52.