WHO Director-General addresses staff at cancer research agency
Dr Margaret Chan
Director-General of the World Health Organization
Dr Wild, distinguished scientists, staff, ladies and gentlemen,
It is a great pleasure for me to address the staff of the International Agency for Research on Cancer, especially on World Cancer Day.
I know that I am speaking to distinguished senior scientists, but also to scientists at an earlier stage in their careers. This is a deliberate mix and a good one. Outstanding senior scientists provide leadership and rigour, while younger scientists bring the vigour of fresh ideas and enthusiasm.
IARC is the cancer research arm of WHO. You set the international cancer research agenda, with an increasingly strong bias towards problems and needs in the developing world.
You identify exposures, in the general environment, at the workplace, or in homes, that are clearly, probably, or possibly carcinogenic to humans. This work supports regulatory decisions that confer protection across entire populations. This is one of the most beloved approaches in public health.
You look for risks and clues of causation by coordinating large international epidemiological studies, and you follow up these clues through fundamental research at the molecular and genetic levels.
Through GLOBOCAN, you keep the world alert to changing trends in cancer incidence, mortality, and prevalence. You are the definitive source of such data. You help set research and public health priorities by identifying the leading types and causes of cancer for countries at different levels of economic development.
Over the years, you have contributed to significant progress for some types of cancer. But, as we know, the precise cause of the majority of cancers is still not fully understood. On balance, current trends and projections for the future are not at all encouraging, especially for the developing world.
I cannot pretend to understand all the lines of investigation that you are pursuing as you probe the causes and mechanisms of cancer. Areas like cancer genomics and epigenomics, and concepts like the significance of polymorphism at a specific gene locus or cellular signalling pathways, are outside my vocabulary and beyond my expertise. I look forward to your presentations this afternoon, which will likely improve my vocabulary and broaden my understanding.
To borrow a phrase from your Director, I share the esteem, actually the affection, expressed worldwide towards IARC. Your reputation for scientific excellence is so strong that I can take it for granted that you are moving on the right track to unlock the secrets of cancer aetiology and pathogenesis.
I can think of no other disease that has kept its secrets for so long and despite such attention from the world’s best research institutions.
But I can understand some aspects of your work immediately and readily appreciate its significance. I will put some of these activities into a broader public health perspective and describe some specific areas where your investigations converge with top priorities for WHO, its Member States, and the international public health community.
I can do so with confidence. The 132nd session of the Executive Board closed just last week. NCDs occupied a prominent place on the agenda. The Board approved a draft global action plan for NCDs for the coming years and endorsed a monitoring framework with 25 indicators and 9 voluntary targets.
IARC scientists will recognize many of these indicators as they draw heavily on your work. I am referring to indicators that pertain to smoking, alcohol use, diet, and physical activity, but also to screening for the early detection of cancer and the use of vaccines to prevent some cancers.
Ladies and gentlemen,
The September 2011 high-level meeting of the UN General Assembly on the prevention and control of noncommunicable diseases was a watershed event. I thank IARC staff for contributing to preparations for the event, including publication of the first global status report on NCDs. This work has certainly had an impact.
The Political Declaration adopted at the meeting gave WHO a clear leadership role along with some heavy, time-bound responsibilities, including negotiation of the monitoring framework and indicators.
Negotiation and agreement on the monitoring framework take us a big step forward. The framework gives efforts to combat NCDs a solid foundation for charting progress and adapting strategies in line with results.
It promotes internationally comparable assessments of trends and helps benchmark the situation in individual countries. In addition, the framework’s 25 indicators give countries a wide range of policy options for addressing pressing problems and achieving their objectives.
The UN high-level event changed the place of cardiovascular disease, cancer, diabetes, and chronic respiratory diseases on the international health and development agendas. The eyes of governments are now wide open to the multiple threats posed by these diseases. Countries are deeply alarmed by current trends on several fronts, and by projections for the future.
These are the diseases that break the bank. In some Asian countries, the costs of caring for diabetes alone already consume nearly 15% of the national health budget, and the burden is growing.
The situation with cancer is particularly alarming. In 2011, the Lancet Oncology Commission concluded that the costs of treating cancer are becoming unaffordable for even the wealthiest countries in the world.
As noted, clinical oncology operates in a culture of excess: excessive diagnostic tests, excessive interventions, and excessive promises that create unrealistic hope and unrealistic expectations for patients and their families.
These expectations, in turn, lead to agreement to undergo end-of-life interventions that are toxic, painful, disconcerting, and extremely expensive yet of no proven benefit.
This is another problem that research needs to address, though doing so will be hard. The culture of excess has another dimension. Many doctors and surgeons are oblivious to the costs of the technologies they use and the investigations they order.
Given these and many other challenges, countries are fully aware of the primary importance of prevention. This awareness was acknowledged in the Political Declaration, which described prevention as the cornerstone of the global response. Given the costs of cancer care, prevention is likely to be the only viable policy option for many low-income countries.
For prevention, countries also understand that the broad social, environmental, and economic determinants of NCDs must be addressed. The cooperation of multiple sectors of government is indispensable.
Prevention requires population-wide interventions that are beyond the power of ministries of health to introduce. The health and medical professions can plead for lifestyle changes and tough tobacco regulations, treat patients, and issue the medical bills, but they cannot reengineer social environments in ways that encourage people to make healthy lifestyle choices.
None of this is easy. Let me sketch the nature of the challenge by quoting four strong statements set out in your handbooks on cancer prevention.
After tobacco control, maintaining a healthy body weight and regular physical activity is the second most important way to prevent cancer.
Approximately one in ten cancers in western populations is due to an insufficient intake of fruit and vegetables.
Diet, nutrition, excess energy consumption and inadequate physical activity are considered important contributors to increasing cancer incidence rates worldwide.
And finally: The increasing prevalence of overweight and obesity is presumably due to the increasing availability of highly palatable, high energy foods and an increasingly sedentary lifestyle.
Implicit in all these statements is a need to influence lifestyle choices. On the surface, this sounds like an easy, low-tech route to reducing a large part of the cancer burden.
From my 35 years of experience in public health, I know that changing human behaviours is one of the hardest things to do. This is all the more difficult when doing so pits public health against the interests of powerful multinational corporations.
This is what we are up against: the globalization of unhealthy lifestyles, including the ready availability, nearly everywhere, of cheap, convenient, tasty, unhealthy, heavily marketed, and highly profitable junk food.
And this is why we need an absolutely impeccable evidence base, as you have been building for some years. Evidence should always be the starting point for formulating sound public health policies. In the case of policies for NCD control, evidence is critically important, even decisive, for three main reasons.
First, scientific evidence is a persuasive way to compel political commitment. As we know in public health, without high-level political commitment, you get nowhere. At a time of nearly universal austerity, evidence needs to include some strong economic arguments about the costs of disease and the benefits of prevention.
Second, rock-solid evidence can capture the attention of other sectors of government, appeal to their mandates, and get them to collaborate in the name of health. We see this most obviously with broad support for the WHO Framework Convention on Tobacco Control and its first protocol, adopted in November.
That protocol, aimed at eliminating illicit trade in tobacco, is a carefully crafted legal instrument put together during more than four years of negotiations. Its elements reflect input from multiple sectors, including trade, finance, the environment, customs, law enforcement, and the judicial system.
The importance of multisectoral collaboration as a key approach to disease prevention has been recognized since at least 1978, when the Declaration of Alma-Ata launched the health for all movement. At that time, collaboration was sought with friendly sister sectors, like nutrition, education, housing, and water supply and sanitation.
Today, to tackle the root cause of many cancers and other NCDs, we need to seek cooperation from extremely powerful and profitable multinational corporations whose business objectives are often in direct conflict with public health objectives.
This brings me to my third point. We need support from scientific evidence, ideally mountains and mountains of evidence, to stand up to pressure from industry. This is sometimes direct pressure on our agencies, sometimes backed by governments, to bend or soften conclusions and recommendations that threaten industry interests.
Opposition from industry can have more subtle and arguably even more dangerous consequences for health. This happens when clear lines of evidence, that can be translated into clear preventive advice for the public, get blurred and confused by clever marketing on the part of industry.
There are many differences between the tobacco industry and the food and beverage industries. But some recent studies reveal the use of broadly similar tactics, like: making self-regulatory pledges, lobbying with massive resources to stifle government action, introducing so-called “safer” products, and paying scientists to instill doubts about the conclusiveness of evidence.
No wonder the public is confused. People no longer sit down to enjoy a meal. They sit down to confront a plate full of competing health claims and risks.
It is the job of public health, backed by impeccable scientific evidence, to reduce this confusion. Prevention depends on a well-informed public. But, as I said, this is not an easy job, especially when we compare the meager resources available for health promotion with the money industry can invest in advertising and PR campaigns.
Ladies and gentlemen,
Let me conclude by highlighting areas where IARC research converges with priority approaches being followed by WHO, its Member States, and the international public health community.
The first concerns the shift of the cancer burden to the developing world. IARC has given special attention to cancer control in the developing world since its inception in 1965. This attention is all the more important now, as the growing cancer burden threatens to overwhelm health systems and budgets in the developing world.
Second, when addressing needs in the developing world, you deliberately aim to improve capacity. Your work to support the establishment and operation of good-quality cancer registries is absolutely fundamental.
IARC research is contributing to improvements in service delivery, especially through the design of screening programmes, for cervical, breast, colorectal, and oral cancers, that can function well in resource-constrained settings.
I especially appreciate IARC’s practical guidance on visual screening for the early detection of cervical cancer and the visual detection of oral cancer. Such work can help reduce the huge gaps in survival rates, especially for cancers that are comparatively easy to treat and, in some cases, to cure.
But what I really need to stress is IARC’s huge contribution to prevention. Your studies and reports have established the scientific foundation for some of the strongest preventive policies in public health.
A turning point for tobacco control occurred when IARC classified exposure to second-hand or environmental smoke as carcinogenic to humans. With that conclusion, industry arguments that tobacco use is a personal choice, an exercise of personal freedom, lost all credibility.
As we know, the tobacco industry did its utmost to sabotage that report. The stakes were just that high. I thank you for continuing your efforts in the area of tobacco control, especially by gathering evidence of the effectiveness of specific demand-reduction articles in the Framework Convention.
Equally game-changing is IARC evidence demonstrating an association between cancers that are especially common in the developing world, and persistent infections with viruses, bacteria, and parasites, including schistosomiasis. That work helped open a whole new world for cancer prevention through the use of vaccines.
According to IARC estimates, persistent infections with certain agents account for nearly 20% of the cancer burden worldwide, with developing countries the hardest hit. Just think of the impact of using vaccines to prevent such a large proportion of the cancer burden.
Countries planning to introduce vaccines for hepatitis B and human papilloma viruses get good support from IARC studies. Your research project on hepatitis B in the Gambia required the courage of a multi-decade commitment, but I am convinced it will yield definitive guidance for ministries of health and their development partners.
Ladies and gentlemen,
I have a final comment. Your Director has described efforts to understand the causes of cancer and strategies for its prevention as the “orphans” of cancer research. These areas receive far fewer resources than research in the basic and clinical sciences.
I believe that IARC has given these orphans a good home. Treat them well. On current trends, WHO and the international public health community need research in these areas now more than ever before.