Cancer care in areas of drug conflict

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Published: 26 Nov 2018
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Dr Enrique Soto - National Institute of Medical Sciences, Mexico City, Mexico

Dr Enrique Soto speaks to ecancer at the CCLMIC meeting at the Royal Society of Medicine in London, UK.

He discusses the very serious issue of how to manage cancer care and drug violence in places such as Mexico.

Dr Soto explains some of the difficulties with sending health workers to villages, or getting patients to hospitals far away from where they live, and even the embezzlement of money.

He outlines ways that we can combat this, and also what he thinks the future holds for this problem.

At this meeting I was invited to speak about cancer care related to drug violence in Mexico and the so-called narco wars that have been ravaging the country since 2006. The reason I was invited to talk about this is because this is a neglected part of cancer care. So when we think about conflict we usually think about war, armies moving around territories, refugees, refugee camps, but we also have to notice that violence, even in urban settings of highly developed middle-income countries like Mexico, can have a deep impact in the way people access care. So at this meeting I was able to discuss some of the issues that are related to cancer control and its relationship with violence.

Starting in 2006 the Mexican government launched an offensive on drug cartels; they mobilised the Mexican army and the Mexican navy inside the Mexican territory in order to stop the drug trade in Mexico. This led to what we could call diversification of the activity of the cartels and instead of dedicating themselves only to the drug trade they also resorted to other types of criminal activities like kidnapping, murdering, extortion etc. This, of course, led to a higher rate of violence-related deaths so currently 7% of all deaths among Mexican men are related to violence and about 100,000-250,000 people have been killed by violence over the last decade. But this also led to changes in the way people live their everyday life. So Mexicans, a large proportion of Mexicans, about 25 million Mexicans, have been victims of some form of crime and 70%, or 80% of Mexicans in some regions, feel unsafe at their home or at their workplace. This, of course, leads to changes in their everyday activities. So one out of three Mexicans has stopped driving in the road, one out of five Mexicans has stopped taking taxis or public transportation and, of course, when you are talking about accessing healthcare, going to a clinic, maybe going to a hospital that is in another village or in a larger city far away from where you live, this is a barrier for accessing healthcare and cancer care in particular.

Not only have people changed the way they live but violence has also impacted healthcare structures and the healthcare system in general. So drug violence has actually targeted physicians – physicians, nurses and other healthcare personnel – particularly those working in the more remote and rural regions of the country. Many of the people, or the healthcare personnel, that are working in those regions are actually medical students. So in Mexico last year medical students are sent to villages to work as village doctors for a year, it’s something called a social service. Many universities actually had to pull out their students from those regions because they were facing this unsafe environment. Almost 40% of physicians working in rural Mexico feel unsafe at their workplace, inside the clinic. Of course this leads to a void in primary care. So some regions of the country are facing empty clinics, so even if patients have symptoms or are feeling bad they have nowhere to go to because the clinic is closed and the physician is not there. In some territories up to 20% of clinics have been closed at any given time over the last ten or twelve years and this is certainly a problem when you are trying to access primary prevention measures for cancer care like cancer screening, early detection of symptoms or even other preventative strategies such as smoking cessation, for instance.

Actually, we did a study in which we looked at the reporting of breast cancer cases throughout Mexico and we found out that in a very violent region of Mexico, the northeast, starting in 2009 the reported number of breast cancer cases went down dramatically. We, of course, do not think that this is because breast cancer just stopped happening in this region but since there were no physicians working at those clinics at that moment, the clinics were closed, physicians were not at the point of care, then the cases were not getting reported. We do not know what happened to those women who were affected by the disease now – did they get their treatment elsewhere? Did they just not get treatment? This is something that is under-studied and that we need to look into – how is this actually affecting the outcomes of people who get cancer in those regions?

The final point which is very important is how corruption within the healthcare system and local government has affected the way we provide cancer care. About half of the population of Mexico is covered by the federal government through a system called Seguro Popular which has made great improvements in the health of Mexicans because it provides care to people who were previously uninsured. But there is a lot of embezzlement from Seguro Popular funds so last year a think tank from Mexico City reported that in 2016 alone about £232 million was embezzled from Seguro Popular. This, of course, has direct repercussions on cancer care because it leads to less investment, you can purchase less medication etc.
So, in order to tackle all of this and since the main goal of this meeting is to foster collaboration, there are many things that we can do and that we can align with the general goals of cancer care. Improving the fragmentation of the healthcare system so that people can get care regardless of whether one specific clinic is closed; providing better safety for healthcare personnel working in rural areas – protecting them, increasing their salaries, making working conditions better so that they can stay and provide care for the population. We have to be transparent about the way we finance healthcare and international organisations and the governments of high income nations have a very important role to play in that setting pressuring the Mexican government to be transparent about the way in which healthcare is financed. Finally we need to do research – we need to find out what is happening and how to improve this. Of course this is dangerous because it’s a dangerous situation but this is something that needs to be done because only if we measure it and if we figure out exactly what’s happening we will be able to solve it.

What do you think the future will hold with the violence ongoing?

It’s difficult to know. The current expectations are that things will probably continue to be the same in the near future. Mexico is changing governments this year so it still needs to be seen what the new government will do regarding violence and choosing cancer care. Even with the financing of the healthcare system I think it’s too early to say what’s going to happen in the future but I’m sure that the new Ministry of Health will be very interested in figuring out ways in which to improve the delivery of healthcare and cancer care to people living in areas with high violence.