The WHO defines urban, rural and remote areas by the characteristics of the settlements, such as population density and accessibility to urban areas. (1)WHO. Increasing access to health workers in remote and rural areas through improved retention. Http://www.who.int/hrh/retention/guidelines/en/index.html (accessed Sept 22, 2012).
Latin America is characterized by the concentration of its population in large cities, where resources, such as wealth, income, government interest, and health care, accumulate. (2)UN HABITAT. State of the cities of Latin America and the Caribbean 2012: towards a new urban transition.http://www. Unhabitat.org/pmss/listItemDetails.aspx?publicationID=3380 (accessed Aug 22, 2012). The reported percentages of people living in urban areas compared to those living in rural areas vary depending on the reference source and measurement methods. Urban and rural populations are defined as the populations settled in areas classified as urban or rural according to the criteria used by each area or country. (3)WHO. Global health observatory data repository. Demographic and socioeconomic statistics: population. Http://apps.who.int/gho/data/ (accessed Feb 13, 2013). (4)United Nations, Department of Economic and Social Affairs. On-line data: urban and rural population. Http://esa.un.org/unpd/wup/unup/index_panel1.html (accessed Oct 15, 2012) The popular perception that approximately 75– 80% of the population of Latin America is settled in urban areas is questioned by several researchers; therefore we present data collected from WHO and the United Nations Department of Economic and Social Affairs (79% urban), and data collected by NASA based on population density measurements indicating that the 55% of the population is urban (figure 3 and table 2). (5)Chomitz KM, Buys P, Thomas TS. Quantifying the rural-urban gradient in Latin America and the Caribbean. World Bank Policy Research working paper 3634, June 2005. http://elibrary.worldbank.Org/docserver/download/3634.pdf?expires=1360771624&id=id&accname=guest&checksum=7C7573A181EDDBC9DCFB3474A620A4D9 (accessed Feb 13, 2013).
NASA data shows that Guyana and French Guiana have the highest percentage of people living in remote areas and none in urban areas; while in the Bahamas, Puerto Rico and El Salvador, the majority of the population resides in urban areas with a population density of at least 1,000 people per square mile. Compared to the distribution of the population in Canada, Great Britain and the USA, Latin America has around 10% more people settled in rural areas (Table 2). (6)Chomitz KM, Buys P, Thomas TS. Quantifying the rural-urban gradient in Latin America and the Caribbean. World Bank Policy Research working paper 3634, June 2005. http://elibrary.worldbank.Org/docserver/download/3634.pdf?expires=1360771624&id=id&accname=guest&checksum=7C7573A181EDDBC9DCFB3474A620A4D9 (accessed Feb 13, 2013).
There is a consensus, however, that the majority of the Latin American population (> 50%) resides in urban areas, and that this percentage is increasing.49 Rural and remote populations are especially vulnerable to adverse cancer outcomes. . They often live in areas where oncologists and cancer treatment specialists are unavailable, and where local health centers cannot provide specialized cancer prevention services, screening services, treatment, or care for people who survive cancer. Cancer. There are significant disparities between urban, rural and remote populations with respect to poverty and access to health care. According to 2011 Latin American data, 24% of the urban population lives in poverty, while poverty affects 50% of the rural population. (7)ECLAC. Statistical Yearbook for Latin America and the Caribbean, 2012. http://www.eclac.cl/cgi-bin/getProd.asp?xml=/publicaciones/xml/4/48864/P48864.xml&xsl=/publications/tab-i.xsl&base=/publications/top_publicaciones-i.xs # (accessed Feb 14, 2013). In our case, we talk about inequalities in cancer detection, diagnosis and treatment in Latin America due to differences in access to care between urban and rural populations, and we describe cancer treatment in remote populations.
Barriers to Health Care for Urban and Rural Populations
Of the 590 million inhabitants of Latin America, (8)The World Bank. Latin America’s population growth slows but region’s services still insufficient. Http://web.worldbank.org/ WBSITE/EXTERNAL/COUNTRIES/LACEXT/0,,contentMDK:23037599~pagePK: 146736~piPK:146830~theSitePK: 258554.00.html (accessed Jan 3, 2013) An estimated 54%, or nearly 320 million, have no health care coverage. (9)PAHO. Exclusion in health in Latin America and the Caribbean. Http://www2.paho.org/hq/dmdocuments/2010/ExtensionExclusion_Health_Latin_America_Caribbean.pdf (accessed Jan 3, 2013). Language barriers, unemployment , underemployment, geographic isolation, low levels of education, and illiteracy in health issues are all factors that explain the exclusion of medical care. For the poorest populations in urban and rural areas, even in the context of free health care, access may be limited by the inability to pay for medication. (10)WHO. Why urban health matters, 2010. http://www.who.int/worldhealth-day/2010/media/whd2010background.pdf (accessed Aug 30, 2012). 3 The lack of accessible transportation, the inconvenient hours of clinical activities, and long waiting times are other factors that pose obstacles to medical care. (11)Montgomery M. Urban poverty and health in developing countries. Http://www.prb.org/pdf09/64.2urbanization.pdf (accessed Feb 13, 2013).
En América Latina, los campesinos pobres son generalmente más desfavorecidos que los pobres en las ciudades. (12) Economic Commission for Latin America and the Caribbean. Shaping the future of social protection: access, financing and solidarity. http://www.eclac.org/publicaciones/xml/0/24080/ lcg2294i.pdf (accedido Feb 13, 2013). A menudo no tienen seguro y presentan un alto riesgo de tener gastos desmesurados de salud. (13) OECD reviews of health systems: México. Paris: OECD Publishing, 2005. (14) Wyszewianski L. Financially catastrophic and high-cost cases: definitions, distinctions, and their implications for policy formulation. Inquiry 1986; 23: 382–94. La escasa disponibilidad y baja calidad de los servicios de atención del cáncer, incluyendo el personal de salud, equipos, laboratorios y equipos de diagnóstico, agravan la desigualdad en el acceso al tratamiento del cáncer en las zonas rurales frente a las urbanas. (15) Velasquez-De Charry LC, Carrasquilla G, Roca-Garavito S. Equity in access to treatment for breast cancer in Colombia. Salud Publica Mex 2009; 51 (suppl 2): 246–53 (en Español). (16) Unger-Saldana K, Pelaez-Ballestas I, Infante-Castaneda C. Development and validation of a questionnaire to assess delay in treatment for breast cancer. BMC Cancer 2012; 12: 626. 9 Un análisis de 12 países de América Latina mostró que los individuos en el quintil más bajo de los ingresos y los que viven en las zonas rurales son los que tienen un riesgo más alto de gastos inesperados de salud. (17) Knaul F, Wong R, Arreola-Ornelas H, et al. Household catastrophic health expenditures: a comparative analysis of twelve Latin American and Caribbean Countries. Salud Publica Mex 2011; 53 (suppl 2): 85–95.
Unfair Distribution of Cancer Centers and Specialists
According to the WHO database of medical devices, the number of physical and technological resources, such as doctors, nurses and machines, normally used to diagnose and offer cancer treatment are insufficient in Latin America. (18)Unger-Saldana K, Pelaez-Ballestas I, Infante-Castaneda C. Development and validation of a questionnaire to assess delay in treatment for breast cancer. BMC Cancer 2012; 12: 626. The availability of doctors in Latin America varies from 48 per 100,000 inhabitants in Guyana to 374 per 100,000 in Uruguay (the world average is 101 per 100,000 inhabitants in lower middle income countries and 224 in upper middle income countries). (19)WHO. World health statistics 2011. http://www.who.int/whosis/whostat/2011/en/index.html (accessed Jan 3, 2013). The density of hospital beds, an indicator of the availability of hospitalization services and an important aspect of cancer care ranges from 80 per 100,000 in Honduras to 290 per 100,000 in Uruguay (range 60–760 per 100,000 in low-income countries), compared to an average of 220 in lower middle income countries and 360 in upper middle income countries. (20)WHO. World health statistics 2011. http://www.who.int/whosis/whostat/2011/en/index.html (accessed Jan 3, 2013). Radiotherapy units vary from six per 100,000 people in Bolivia and Paraguay to 57 per 100,000 in Uruguay. Data from Brazil, Colombia, Mexico, and Peru indicate that oncology services are concentrated in large cities, and this pattern is similar in other Latin American countries. These institutions house most of the medical specialists and specialized teams necessary to provide cancer diagnosis and treatment services. (21)WHO. World health statistics 2011. http://www.who.int/whosis/whostat/2011/en/index.html (accessed Jan 3, 2013). This uneven distribution of services, aggravated by the Acceleration of migration to cities has put pressure on urban resources, further limiting health care services. (22)WHO. Why urban health matters, 2010. http://www.who.int/worldhealth-day/2010/media/whd2010background.pdf (accessed Aug 30, 2012). The result is that poor farmers have been disproportionately affected.
In Brazil, cancer treatment services are concentrated in large centers along the Atlantic coast and in the southern and southeastern regions. Mexico City, Guadalajara and Monterrey concentrate the majority of cancer care in Mexico. In Peru, services are concentrated in Lima, Arequipa, Trujillo and Cusco. Often there are no oncology centers in the rural regions of these countries, or if they are available, the centers lack basic services such as radiotherapy or chemotherapy. Radiotherapy units are also concentrated in large cities. For example, in Peru, ten of the country’s 18 radiotherapy units are located in Lima, three in Arequipa, and three in Trujillo, while 20 of the country’s 25 regions lack radiotherapy services. In Mexico, there are 20 linear accelerators for 32 states and seven of them are located in Mexico City.
There is a shortage of all kinds of doctors and specialists in Latin American countries. The number of doctors varies between 48 per 100,000 inhabitants in Guyana and 374 per 100,000 in Uruguay, and the number of nursing personnel between 41 per 100,000 in El Salvador and 650 per 100,000 in Brazil. (23)PAHO. Health Systems Financing. Http://new.paho.org/hq/index.Php?Option=com_content&view=category&layout=blog&id=524&Itemid=932 (accessed Feb 13, 2013). (24)WHO. World health statistics 2011. http://www.who.int/whosis/whostat/2011/en/index.html (accessed Jan 3, 2013). Doctors are unevenly distributed within countries in the areas rural and urban. For example, in Brazil, where the national average is 144 doctors for every 100,000 people, there are 60 doctors for every 100,000 in the northern, more underdeveloped region, compared to 210 per 100,000 inhabitants in the southeast, where the large cities. (25)PAHO. Health Systems Financing. Http://new.paho.org/hq/index.Php?Option=com_content&view=category&layout=blog&id=524&Ite mid=932 (accessed Feb 13, 2013). Similar disproportions are observed in Colombia, Guatemala and Argentina; on the other hand, in rural areas, many doctors are young graduates who serve for a mandatory period there. (26)OECD reviews of health systems: Mexico. Paris: OECD Publishing, 2005. Despite their inexperience, in the absence of specialized oncologists, these graduates are often the first line in diagnosing cancer and referring patients to more specialized centers. (27)Villarreal-Garza C, Garcia-Aceituno L, Villa AR, Perfecto-Arroyo M, Rojas-Flores M, Leon-Rodriguez E. Knowledge about cancer screening among medical students and internal medicine residents in Mexico City. J Cancer Educ 2010; 25: 624–31.
In Latin America, cancer specialists are concentrated in large cities. (28)Bingham A, Bishop A, Coffey P, et al. Factors affecting utilization of cervical cancer prevention services in low-resource settings. Salud Publica Mex 2003; 45 (suppl 3): 408–16. For example, according With the National Cancer Plans of Mexico and Peru, there are a total of 269 oncologists in Mexico, of which 44% work in Mexico City, 8% in Monterrey and 8% in Guadalajara. In Peru, 85% of the 130 medical oncologists reside in Lima. In both Peru and Mexico, several states do not have an oncologist. (29)Mexican Council of Oncology. Training of human resources. Http://www.cmo.org.mx (accessed Jul 15, 2012). (30)General Directorate for Human Resources Development Management. Needs of specialized doctors to establishments in the health sector National Observatory of Human Resources in Health-Lima: Ministry of Health, 2011. In Colombia, 35% of cancer specialists are in Bogotá, and together, Barranquilla, Medellín, Cali and Bogotá they have more than 60%. With this concentration of specialists in urban areas, access to oncology services is difficult in rural regions with less than 100,000 inhabitants, where the average time for an initial evaluation can exceed 200 days. (31)Rosselli D, Otero A, Heller D, Calderón C, Moreno S, Pérez A. Estimation of the supply of medical specialists in Colombia with the capture-recapture method. Rev Panam Salud Publica 2001; 9: 393–98.) ) (32)Cardona JGL. An indecent proposal to medical and surgical postgraduates in Colombia. Http://www.udea.edu.co/portal/page/portal/librarySedeDependencies/academicunits/FacultadMedicina/BilbiotecaDiseno/Archivos/actuality/Tab/una_propuest_indecente_a_los_posgrados.pdf (accessed Feb 14, 2013). In many countries, patients migrate to cities for cancer care, which can affect the demand for cancer care services in cities and could skew statistics Of cancer. For example, in Brazil, the incidence of cancer in 2012 in men was 319 per 100,000 in the state capitals, and 268 per 100,000 in the states in general. (33)5 INCA (National Cancer Institute). Brazil (Consolidated). Http://www.inca.gov.br/estimativa/2012/tabelaestados.asp?UF=BR (accessed Jan 11, 2013). What The same happens with women: the total incidence was 323 per 100,000 inhabitants in the state capitals compared to 260 per 100,000 in the states..
An adequate medical infrastructure to carry out cancer prevention, diagnosis and treatment is not available or not accessible in various regions of Latin America. The availability of medical devices per 100,000 inhabitants is as follows: mammography 4.73 (range from 0.42 in Paraguay to 12.97 in Saint Vincent and the Grenadines), MRI 0.199 (with a range of 0 in Dominica, Saint Kitts and Nevis, and Saint Vincent and the Grenadines at 1.16 in Saint Lucia), CT scanners 0.68 (range of 0 in Saint Vincent and the Grenadines at 1.93 in Saint Kitts and Nevis), PET scanners 0.001 (range of 0 in 16 countries to 0.012 in Mexico), and other nuclear medicine devices, such as emission CT for bone scans, 0.032 (range from 0 in nine countries to 0.124 in Cuba). Radiotherapy units are available at 0.128 per 100,000 population (range 0 to 0.57). (34)WHO. Medical devices. Country data. Www.who.int/medical_devices/countries/en/ (accessed Jul 15, 2012). In contrast, Australia and Switzerland have 0.5 accelerators per 100,000 population, and France is 0.6. (35)IAEA. Radiotherapy in palliative cancer pain: development and implementation. Vienna: International Atomic Energy Agency, 2012.
Most Latin American countries have a list of cancer drugs considered essential by the WHO. In 2008, essential drugs (that is, drugs that meet the priority health needs of a population, including cancer drugs and vaccines) were available to 57.7% in the public sector and 65.1% in the private sector. (36)WHO. World health statistics 2011. http://www.who.int/whosis/ whostat / 2011 / en / index.html (accessed Jan 3, 2013). In 2010, the WHO reported that tamoxifen it was not available for breast cancer in Bolivia, El Salvador, Nicaragua, Paraguay, and Saint Kitts and Nevis, despite being available in most countries at a price of US $ 0.10 per tablet. (37)8 WHO. Global health observatory data repository. Http://apps.who. Int/gho/athena/data/GHO/NCD_CCS_Insulin,NCD_CCS_Aspirin,NCD_CCS_CC_CD_CC_BS_CC_BS_CCS,NCD_CCS_Thiazide,NCD_CCS,NCD_CCSNCD_CCS_Statins,NCD_CCS_OralMorph,NCD_CCS_Nicotine,NCD_CCS_Salb,NCD_CCS_Prednis,NCD_CCS_Steroid,NCD_CCS_Hydrocort,NCD_CCS_Ipratro.html?Profile=ztable&contacted=COUNTRY:) cancer, but the lack of universal availability of tamoxifen in Latin America suggests that the problem of access to medicines is widespread.
Inequalities in Cancer Detection and Care Services Affecting Outcomes in Rural Populations
Access to cancer treatment varies between regions within a country. Data provided by Deloitte Access Economics, an Australian health economics consulting firm, suggests that lack of access to health services is associated with worse outcomes for patients living in non-metropolitan areas. (38)Deloitte Access Economics. Access to cancer treatment in nonmetropolitan areas of Australia. Http://www.deloitte.com/assets/Dcom-Australia/Local%20Assets/Documents/Industries/LSHC/Deloitte_Amgen_final_report_270112.pdf (accessed Aug 16, 2012). In Latin America, cancer outcomes vary by region, depending on economic development and infrastructure. For example, in Brazil, breast cancer mortality trends are stable in states with higher socioeconomic status and more urban development, compared to rural areas, such as northeast Brazil. (39)Freitas-Junior R, Gonzaga CM, Freitas NM, Martins E, Dardes Rde C. Disparities in female breast cancer mortality rates in Brazil between 1980 and 2009. Clinics (Sao Paulo) 2012; 67: 731–37. In Mexico, Colombia and Brazil, cervical cancer mortality rates are low in urban areas and high in rural regions, which have lower social and economic parameters. (8 Baena A, Almonte M, Valencia ML, Martinez S, Quintero K, Sanchez GI. Trends and social indicators of both mortality breast cancer and cervical cancer in Antioquia, Colombia, 2000–2007. Salud Publica Mex 2011; 53: 486– 92 (in Spanish). (40)Palacio-Mejia LS, Rangel-Gomez G, Hernandez-Avila M, Lazcano-Ponce E. Cervical cancer, a disease of poverty: mortality differences between urban and rural areas in Mexico. Salud Publica Mex 2003; 45 (suppl 3): 315–25.
Mortality differences between cervical cancer patients in urban and rural areas have been attributed to lower levels of education, underemployment, and lack of social security coverage. (41)Palacio-Mejia LS, Rangel-Gomez G, Hernandez-Avila M, Lazcano-Ponce E. Cervical cancer, a disease of poverty: mortality differences between urban and rural areas in Mexico. Salud Publica Mex 2003; 45 (suppl 3) : 315–25. Possible reasons for patients presenting with advanced cancer in rural areas include low participation in screening programs and delays in diagnosing and starting cancer treatment. Low participation in screening has been observed in areas where health services are geographically distant or difficult to access. (42)Bingham A, Bishop A, Coffey P, et al. Factors affecting utilization of cervical cancer prevention services in low-resource settings. Salud Publica Mex 2003; 45 (suppl 3): 408–16. (43)Agurto I, Bishop A, Sanchez G, Betancourt Z, Robles S. Perceived barriers and benefits to cervical cancer screening in Latin America. Prev Med 2004; 39: 91–98. For example, a study conducted in Mexico showed that it is much less likely a woman to have a Pap test and a mammogram if she lives in a marginalized rural community. (44)Sosa-Rubi SG, Walker D, Servan E. Performance of mammography and Papanicolaou among rural women in Mexi They have been reported similar results for childhood cancer, with worse survival rates in regions with worse socioeconomic conditions, more rural populations, and among those furthest from specialized cancer care centers. (45)Perez-Cuevas R, Doubova SV, Zapata-Tarres M, et al. Scaling up cancer care for children without medical insurance in developing countries: the (46)Ribeiro KB, Lopes LF, de Camargo B. Trends in childhood leukemia mortality in Brazil and correlation with social inequalities. Cancer 2007; 110: 1823–31. In the northern and northeastern areas of Brazil, where a large proportion of the population lives in rural areas, approximately 40% of women in 25 years or older undergo mammogram; in the southeast region, which has a more urban development, 65% of women received a screening during 2008. (47)de Oliveira EX, Pinheiro RS, Melo EC, Carvalho MS. Socioeconomic and geographic constraints to access mammography in Brazil , 2003–2008. Cien Saude Colet 2011; 16: 3649–64 (in Portuguese). The use of mammograms is highly correlated with the level of education, which tends to be higher in urban areas. (48)de Oliveira EX, Pinheiro RS, Melo EC, Carvalho MS. Socioeconomic and geographic constraints to access mammography in Brazil, 2003–2008. Cien Saude Colet 2011; 16: 3649–64 (in Portuguese).
The Provision of Health Services in Remote Regions
The provision of health services in the certainly remote regions is a logistical challenge superior to that of the rural areas (figure 4). In Peru, for example, 2,250 communities along the Yanayaku River in the Amazon are isolated, without road access, and where the main means of transportation is by sea. (49)Gardner E. Peru battles the golden curse of Madre de Dios. Nature 2012; 486: 306–07
In this region, which is remote and inhabited by indigenous communities, 25% of people in a survey said that they had not seen a doctor in 5 years, and the main obstacle to care was the distance to a health center. (50)Nawaz H, Rahman MA, Graham D, Katz DL, Jekel JF. Health risk behaviors and health perceptions in the Peruvian Amazon. Am J Trop Med Hyg 2001; 65: 252–56. 0 In another study, 75 % of women with an abnormal Pap result did not have adequate follow-up due to residing in a remote location. (51)Gage JC, Ferreccio C, Gonzales M, Arroyo R, Huivin M, Robles SC. Follow-up care of women with an abnormal cytology in a low-resource setting. Cancer Detect Prev 2003; 27: 466–71 Likewise In Honduras, where only 20% of indigenous women have undergone annual Pap tests, the failure to perform the screening tests was attributed to remote location. (52)Price J, Asgary R. Women’s health disparities in Honduras: indicators and determinants. J Womens Health (Larchmt) 2011; 20: 1931–37 In remote areas, where patients do not have access to cancer screening and oncology services, patients often have more cases of advanced cancer and have worse outcomes. (53)Baade PD, Dasgupta P, Aitken JF, Turrell G. Distance to the closest radiotherapy facility and survival after a diagnosis of rectal cancer in Queensland. Med J Aust 2011; 195: 350–54. (54)Huang B, Dignan M, Han D, Johnson O. Does distance matter? Distance to mammography facilities and stage at diagnosis of breast cancer in Kentucky. J Rural Health 2009; 25: 366–71. Remote settlements also create barriers to care delivery high quality. For example, in San Martín, Peru, women who underwent a biopsy for an abnormal Pap test had to wait an average of 4-5 months to receive the Lima histology report. (55)Gage JC, Ferreccio C, Gonzales M, Arroyo R, Huivin M, Robles SC. Follow-up care of women with an abnormal cytology in a low-resource setting. Cancer Detect Prev 2003; 27: 466–71. This delay in diagnosis is worrying, since waiting 5 weeks or more before definitive treatment worsens the survival of cervical cancer. (56)EC, Dahrouge S, Samant R, Mirzaei A, Price J. Radical radiotherapy for cervix cancer: the effect of waiting time on outcome. Int J Radiat Oncol Biol Phys 2005; 61: 1071–77. Challenges have been described similar to provide high quality diagnostic services in Colombia. When Pap tests obtained in remote states were evaluated in a national laboratory, local results were inadequate: up to 61% of negative smears had abnormal results at the central review, and 13% had an insufficient sample. (57)Murillo R, Wiesner C, Cendales R, Pineros M, Tovar S. Comprehensive evaluation of cervical cancer screening programs: the case of Colombia. Salud Publica Mex 2011; 53: 469–77.
The main health inequalities in cancer treatment outcomes between urban, rural, and remote populations in Latin America are in part a result of the concentration of infrastructure, human resources, and other resources in urban areas. People in rural and remote areas have lower socioeconomic status, a lower level of education, as well as less health insurance coverage, and face significant barriers to accessing cancer care services. Regional research is necessary to identify the specific reasons for the barriers and the ways to overcome them. For remote populations, innovative technologies, including teleoncology, should be further explored (58)Hazin R, Qaddoumi I. Teleoncology: current and future applications for improving cancer care globally. Lancet Oncol 2010; 11: 204–10. For improve cancer treatment services.
The main health inequalities in cancer treatment outcomes between urban, rural, and remote populations in Latin America are in part a result of the concentration of infrastructure, human resources, and other resources in urban areas. People in rural and remote areas have lower socioeconomic status, a lower level of education, as well as less health insurance coverage, and face significant barriers to accessing cancer care services. Regional research is necessary to identify the specific reasons for the barriers and the ways to overcome them. For remote populations, innovative technologies, including teleoncology, should be further explored ((Hazin R, Qaddoumi I. Teleoncology: current and future applications for improving cancer care globally. Lancet Oncol 2010; 11: 204–10. For improve cancer treatment services.