Oslo, Norway,
31 July 2000

11^th International Conference on Cancer Nursing
"Building Bridges for the Future"
Global strategies for cancer control and care

It’s my pleasure to address you all today, and also to welcome you to my home country Norway.

Two weeks ago, I was at the International AIDS Conference in Durban. The memory that will last from that trip was a visit to a ward for HIV-infected children, some of them with multidrug-resistant TB. Afterwards, I addressed a meeting of nurses who were working with AIDS patients.

Watching these dying children and talking with some of those brave women who cared for them and for millions of other AIDS patients reinforced the tremendous respect and deep-felt sympathy I have with those who care for the chronically and terminally ill. The stamina, the courage and the ability to give are truly impressive among these women and men who day after day fight to keep despair at bay in the midst of this dreadful epidemic.

Fortunately, in the field of cancer, there is steady and encouraging progress to assist us in persevering and keeping our morale high. One-third of the cancer burden is curable using today's technology, and this proportion is expected to rise over the coming years. Much can be done to reduce the future load of cancer cases.

Yet, I don’t have to spell out to any of you the burden placed on nurses in cancer care. When the doctors leave after their visit, it is the nurses who are left to fill the other 23 hours of the day; making complicated issues comprehensible for patients and their families, assisting them with coming to terms with uncertainty and despair, and carrying out the myriad of tasks that make up high-quality care.

Before turning to the theme of my address, I would like to pay a heartfelt tribute to the courage and commitment of those millions of nurses who are providing cancer care all over the world.

Colleagues,

Cancer is the cause of 12% of all deaths world-wide. Unless a concerted prevention effort is undertaken now, the number of new cancer cases globally is projected to double from today’s level to 20 million each year in 20 years.

For WHO – and for all who are involved in cancer care, control and prevention – this poses a series of great challenges.

• We must reduce the gap between rich and poor – both between and within countries – in the access to services, drugs, technology and care, in order to save lives and make treatment as good and effective as it possibly can be.
• We must reduce the future burden of disease attributed to cancer through health promotion and effective prevention.
• We must continue to improve health systems to provide cost-effective cancer control and care.

Let me start with equity.

Developing countries must deal with the double burden of increasing communicable and noncommunicable diseases such as cancer.

Moreover, in both industrialized and less-developed countries, cancer incidence and cancer survival are related to socio-economic status. Lower classes tend to have higher cancer incidence and poorer cancer survival than higher social classes. Social class differences in cancer incidence can, in part, be explained by known risk factors, particularly tobacco smoking, occupational exposure, reproductive behaviour, diet and chronic infections. But it is also significant that cancer is diagnosed at an advanced stage more often in lower than in higher social classes

We have to be forceful advocates for the large proportion of the world's population who still do not have access to the basic services and commodities they need.

As health professionals, we must shape events in line with the values of health for all - equity, fairness and social justice. We need to eliminate disparities between people who have and people who do not have access to health systems in which care is delivered by competent providers and the systems are responsive to the needs of people in the communities they serve.

Big words. What do they mean in practice?

They mean that health is put more centrally on the development agenda – by governments in both rich and poor nations. They mean that non-communicable diseases – where cancer takes a central place – are recognized as a crippling burden for countries whose health systems have been designed and equipped to deal with infectious diseases and primary health care and, therefore, are not able to respond to the added burden of cancer control and care.

This raises challenging questions about how to achieve the highest attainable levels of health without the highly expensive interventions we have been relying on until now.

For cancer, this means finding ways to use existing technology in ways that make them affordable for larger parts of the population. How do you spread screening technologies and skills out to areas and staff outside the specialized cancer units? How do we use cutting-edge knowledge to find treatment and care strategies that work where resources are scarce? How can the best health professionals be retained and sustained? How can others be helped to perform to their full potential? Such questions must be given priority in research centres – as well as in health ministries the world over.

Nurses together are a powerful voice that can bring about significant change within their local organizations and communities in their national policy-making institutions, and in the support of international efforts to reduce health-related inequities.

Technological and policy changes as well as the overriding need to find health solutions that reach all in an equitable manner, means that the line separating clinical medicine and public health has become increasingly blurred. In short: clinical medicine is also public health.

This leads me to the second challenge.

When the World Health Organization set out to improve health 50 years ago, there were hopes that drugs, vaccines and medical technology would provide the tools to achieve health for all.

Decades of health development have clearly shown that technologies are not enough to guarantee people's health. A range of civil, cultural, economic, political and social conditions have to be addressed as well.

Many of the major determinants of better health lie outside the health system. Knowledge - made available to people. Clean environments. Access to basic services. Fair societies. Fulfilled human rights. Good government. Enabling people to make decisions relevant to their lives, and to act on them.

Let us agree on the key points: for people to have the power to be healthy, they first need knowledge. Accurate, reliable knowledge about how to achieve good health, and about the risks to health that they face in their daily lives. As we see from the recent trends of reduction in heart diseases and cancers in several industrialized countries, up-to-date, applicable knowledge is a pre-requisite for better health.

Knowledge is necessary, but it is not sufficient. For people to have the power to be healthy, they must be in a position to choose better health. That is why health promotion has focussed extensively on the issues of healthy cities, healthy schools, healthy workplaces and healthy homes. Environments within which people can choose to be healthy, and implement their choices in their daily lives.

Yet, the combination of knowledge and a healthy environment may not be enough. Many people will still not feel that the power to be healthy is in their hands. The third element is their being empowered to make the healthy choices for themselves - and stick to them. This means local, national - and even international - policies that give them the freedom to do what they want, and need, to do.

Nurses can contribute significantly on all three counts.

Smoking is now recognized as being the most important preventable cause of human cancer and responsible for more than 230 000 new cases in North America and more than 420 000 cases annually in Europe.

Paradoxically, in many countries, healthcare providers, including nurses, smoke as much or even more than the general population. What kind of message are we sending to the members of our communities? While regulations against smoking in public hospitals and health clinics exist, in many areas these are ignored. Again, what lifestyle choices are we, as health providers, promoting through our daily actions?

But we must of course go well beyond that.

In 1996, the International Union Against Cancer (UICC) issued a Tobacco Control Fact Sheet, "Enhancing the Nurses' Role in Tobacco Control". In this document they noted that nurses are the world's largest group of health professionals and that nurses can make an important contribution to global efforts to control the tobacco epidemic. Nursing organizations such as the International Council of Nurses (ICN) are working in partnership with WHO to contribute to the global effort.

To be effective, public health professionals must learn to work at the heart of the political process with their elected political leaders.

We must help policy-makers, regulatory authorities and trade bodies make the best decisions possible. The tougher the issue for society, the greater the need for health professionals to help decision-makers reach informed judgements.

We in WHO have learnt that programmes and policies are most likely to be sustained and successful if the people they are meant to serve are engaged in their design and implementation. Initiatives that rely on one sector alone are less likely to be effective than multi-sectoral efforts. Local initiatives are more likely to be effective when supported through global efforts.

The issue of tobacco illustrates this. The current annual toll of 4 million tobacco deaths world-wide will rise to 10 million by 2030. Seventy per cent of the increase will damage developing countries. The WHO Framework Convention on Tobacco Control will become one of the most powerful tools to promote health.

Full negotiation on this item will begin in October, and already we see emerging unprecedented global support for strong action. Adoption of the Convention, and its implementation, will be a crucial move by nations of the world to adopt healthy public policies.

Colleagues,

The third challenge is to strike the right balance between controlling health costs and ensuring that adequate resources are available for health. It is a delicate political and economic exercise. Economic realism, linked to science-based knowledge and the basic principle of the right to health care for all, must be the foundation for any health systems development in this new century.

The success of health policies, of improvements in health care, and of efforts to control disease depends on the people who provide it. This applies whatever the nature and type of health system, and the resources available. When all is said and done by the political leadership, the fact remains that it is mainly medical practitioners and other health professionals who will determine how health systems address illnesses that cause poverty, undermine well-being, or promote inequities.

Responding to the challenges and improving performance will require changes in the way we practise and the way we provide health care. Enhancing the health of populations requires strong awareness of the centrality of health, and political commitment, as well as strong involvement and personal commitment from health professionals.

You - as members of one of the principal professions within health – have a major role in shaping change, in improving and expanding the response of health systems – focussing always on what people want and need.

You have valuable advice to offer on where scarce resources should be invested. You can help to establish the right balance between treatment and prevention, in providing improvements in population health status.

An integrated approach to primary prevention, through the promotion of early detection activities, and strengthening curative treatment and palliative care, represent the core of WHO's strategy for cancer control.

Research indicates that nursing interventions can be cost-effective in screening for women's health - in particular for breast cancer and cervical cancer. Effectiveness is also demonstrated in assisting individuals and families in health promotion activities and the management of pain.

Nurses, and especially oncology nurses, are seen to be active at country level in the development of cancer control programmes and reinforcing WHO's palliative care strategy. The International Society of Nurses in Cancer Care is a partner in the global network that strives to improve the accessibility to basic care and pain relief to the millions of patients with cancers.

There are increasing demands and expectations for cancer research to strengthen the evidence base of preventive interventions. Oncology nurses are invited to continuously contribute to the knowledge base. We are embarking on new approaches for translating evidence into action - moving from norms and standards, into public health legislation through legally- binding conventions.

I am delighted by the partnership that exists between nursing and other nongovernmental organizations. Today we heard about the International Coalition of Nurses for Tobacco Control from your President, Ms. Connie Yanbor, that involves several organizations. This Coalition will ensure pooling resources and facilitate North and South partnership in reforming and developing the capacity of health systems at the global, regional, national and local levels.

What I am outlining amounts to a large challenge for nurses – as well as the rest of us. To achieve results, nursing education should integrate management of cancer into curricula in order to prepare practitioners to advocate structural changes in health care systems to insure equitable access to the highest possible level of safe and effective health care.

We must ensure training of competent nurses who can function in multidisciplinary teams. More and more there is an increase in interdisciplinary care of all types of patients, but most notably cancer patients. Intervention research studies are promoted that may lead to better compliance with cancer programmes and the implementation of appropriate technologies for low resource settings. WHO is endorsing the palliative core curriculum for nursing that has been developed by the International Society of Nurses in Cancer Care.

In your deliberations in the coming few days, you will be addressing various issues related to the health of individuals, families and communities, and how nurses and nursing can make a difference. In partnership with you and other agencies, together we can contribute to effective cancer care by advocating relevant health system reforms at regional, national and local levels.

The challenge for us is to know how we can best build on each other’s expertise to establish effective networks for cancer prevention and treatment strategies. We need to address the health needs of all people, but must make greater efforts on behalf of the poor and vulnerable members of our communities.

At WHO we welcome your valuable partnership and expertise.

Thank you.