Beauty without the Breast

By Felicia Marie Knaul

Forewords by Julie R. Gralow and Paul Farmer
Epilogue by Julio Frenk
"Through each others eyes: sharing what weve learned from living with cancer" Massachusetts General Hospital April 12, 2014

The night of my high school prom visiting my father, Sigmund Knaul, at Mount Sinai Hospital, Toronto a few weeks before his death from cancer. May 1984.

In the childrens cancer ward of the Hospital Peditrico de Sinaloa promoting Sigamos Aprendiendo en el Hospital. Culiacn, late 2005.

At Hannahs art show with Maha in front of her painting of me. Summer, 2007.

With Maha and Hannah after painting our faces in Disneyland in San Francisco just after the initial mammogram, October/November 2007.

Battling sepsis in the Mdica Sur Hospital. Mexico City. July 2008

Just before going into surgery to remove the suspicious lymph node. Mdica Sur Hospital. April, 2011.

Photograph taken by Julio of my strange hair growth pattern. Paris. Spring 2009.

Waking up early to the celebration of my 42nd birthday at home in Mexico City. April 24th, 2008 with Hannah and Maha.

On a walk in Chapultepec Park, Cuernavaca with Maha and Hannah. Photo taken by Julio. Spring, 2008.

With my brother Jonathan now I know we look alike. Cuernavaca, May, 2008.

With Julio in Acapulco using an A-shaped tent dress. Spring, 2008.

At Tres Vidas swimming bald and enjoying the water. March, 2008.

Maha and the Princess of Baldness created in January of 2008. Mexico City.

With Maha on her 8th birthday at Red Acre Farm, Stow, Massachussetts, September 1, 2012.

Photograph I took of myself during the first dose of FEC. Seattle Cancer Care Alliance, January 2008.

Launch of Tmatelo a Pecho program. CARSO Health Institute, Mexico City. March 11th, 2008.

Launching a program at the Mexican Health Foundation the day I got sepsis. July 2008.

Julio joined me and kept me company in almost every chemotherapy session. He talks about this in his letters. Mdica Sur Hospital, Mexico City. Spring 2009.

The human faces of Seguro Popular: Guillermina Avila

International seminar celebrating the Seguro Popular and universal coverage of breast cancer treatment. October, 2011. With a patient who traveled from Guadalajara to share her story. Mexico City.

The human faces of Seguro Popular: Abish Romeo

With Abish Romero, Mercedes Juan, and Secretary of Health Salomn Chertorivski at the International Seminar Breast Cancer and Seguro Popular: Inclusion and Innovation. Mexico City. October 2011.

Breast Cancer: Delivery failure

# 2 killer of women 30-54 5-10% detected in Stage 0-1 Poor municipalites: 50% Stage 4; 5x the rate for rich
% diagnosed in Stage 4 by state

RIch

Poor

Effective financial coverage of a chronic disease: breast cancer

Cancer Control-Care continuum
Primary Prevention Early Detection

Diagnosis

Treatment

Survivorship

Palliation

Mexico: Large and exemplary investment in financial protection for cancer prevention and treatment for women, yet a low survival rate. Opportunities to improve delivery and meet need.

Juanita:
Advanced metastatic breast cancer is the result of a series of missed opportunities

With Julie Gralow visiting a terminal patient in the Hospital Regional de Ciudad Guzmn. Jalisco, Mxico. August 2011.

Diagonalizing Delivery:
Training primary care providers in early detection and mangement of breast cancer
Promoters (+4000), Nurses & MDs (+1400), medical students (+750) Nuevo Leon, Jalisco, Morelos, Puebla Significant increase in knowledge, especially in CBE

With Sonia Ortega and Hctor Arreola after the launch of the Spanish language version of the Global Task Force (GTF.CCC) report commemerating World Cancer Day. Mexico City. February 2012.

GTF.CCC = global health cancer care

Closing the Cancer Divide: Challenge the myths about cancer in Low and Middle Income Countries
Expanding access to cancer care and control in LMICs:
M1. Unnecessary M2. Unaffordable M3. Impossible M4: Inappropriate
I: Should be done II: Could be done III: Can be done

The Cancer Divide: An Equity Imperative

Cancer is a disease of both rich and poor; yet it is increasingly the poor who suffer:
1. 2. 3. 4. 5. Exposure to risk factors Preventable cancers (infection) Treatable cancer death and disability Stigma and discrimination Avoidable pain and suffering

Facets

The Opportunity to Survive Should Not Be Defined by Income

100%

Children

Adults Survival inequality gap

Leukaemia

All cancers LOW INCOME HIGH INCOME LOW INCOME HIGH INCOME

Source: Knaul, Arreola, Mendez. estimates based on IARC, Globocan, 2010.

In Canada, almost 90% of children with leukemia survive. In the poorest countries only 10%.

The most insidious injustice: the pain divide

Non-methadone, Morphine Equivalent opioid consumption per death from HIV or cancer in pain: Poorest 10%: 54 mg Richest 10%: 97,400 mg US/Canada: 270,000 mg
267,000 mg 37,000 mg

Asia
272,000 mg

2,300 mg
Data: http://www.treatthepain.com/methodology Calculations: HGEI/Funsalud Knaul et al. Eds Closing the Cancer Divide.

India

Africa
Latin America

Living and learning

Drew G. Faust
President of Harvard University 22+ year BC survivor

Nobel Amartya Sen,

Cancer survivor diagnosed in India 60 years ago

Harvard, Breast Cancer in Developing Countries, Nov 4, `09

Living & Learning

Allan Brandt Medical Historian
now undergoing second stem cell transplant

Be an optimist optimalist