Strategic vision for healthcare development in Nigeria

1. Strategic vision for healthcare development in Nigeria Soji F. Oluwole, MD FACS NNOM Columbia University College of Physicians & Surgeons

2. Demographical data for various countries WHO, 2008

3. Health expenditure of various countries WHO, 2008

4. Nigerian THE* & some selected indicators *THE: Total Health Expenditure; ‡EOH: expenditure on health; Source: Computed from Soyibo et al (2005)

5. Ave annual Nigerian Government EOH‡ ‡EOH: expenditure on health; *FGN: Federal Nigerian Government; Source: Computed from CBN/IFS/AAS)

6. Rank of most common cancers in Nigerians

7. Some other cancer trends • Nigerian men • Prostate cancer is the #1 cancer killer • Prostate cancer is underestimated in Nigeria • Liver cancer resulting from cirrhosis is a major killer • Nigerian women • Breast and cervical cancers are 2nd and 3rd major killers • 5-yr survival rates for breast cancer is 5-15% cf. 84% for American women • Colorectal cancer in Nigeria • Has highest incidence in West Africa with 62.4% of cases diagnosed in 2000 • From 1960 to 2000 rates have increased

8. 5-yr overall relative SR for breast cancer *SEER Report +Freeman HP (1989) ‡Oluwole SF (2003)

9. Breast cancer stage at diagnosis ‡Oluwole et al, JACS 2003. *Oluwole et al, BJS 1987. +Adesunkanmi et al, Breast 2006

10. Staging Classification of Breast Cancer Stage I Early disease tumor confined to breast (node-negative) Stage II Early disease tumor spread to movable ipsilateral axillary node(s) (node-positive) Stage III Locally advanced disease tumor spread to chest wall; involvement of ipsilateral internal mammary lymph nodes Stage IV Advanced / metastatic disease metastases present at distant sites, such as bone, liver, lungs, brain and including supraclavicular lymph node involvement

11. 1986 Locally advanced breast cancer 2006 2006

12. Poverty acts through the prism of culture Poverty Culture Decreased survival Freeman, H. P. CA Cancer J Clin 2004; 54:72-77.

13. Reasons for establishing Nigeria NCC - National Cancer Center • Large pool of medical professionals • Few limited cancer treatment facilities • Numerous Nigerian media outlets • Strong Nigerian medical associations and advocacy groups

14. Reasons for establishing Nigeria NCC • No current national cancer control plan • Existing National Health Insurance Scheme • Strong economic power with rich natural resources Largest Black population / democracy in the world – a legacy for all people of African ancestry

15. Goals of National Cancer Center (NCC) To establish Nigeria as the African leader in the fight against cancer • Increase awareness • Increase early detection • Provide excellence in treatment • Decrease mortality rate • Improve quality of life for cancer survivors

16. Aims of NCC Develop a National Cancer Education & Outreach Program • Raise public awareness of early detection, prevention and treatment of cancer • Coordinate education and screening programs to increase early detection • Develop culturally sensitive outreach programs and educational materials; i.e., Muslim and Christian communities require different strategies • Establish a physician education program including CME courses for oncologists and other clinicians • Develop regional and national tumor boards to ensure standardized treatment

17. Aims of NCC A National Cancer Center will: • Establish a National Tumor Registry that coordinates/supervises existing regional registries • Develop a central DNA, tissue and tumor bank to encourage research of novel therapies and attract pharmaceutical funding • Recruit leading national and international researchers • Establish research fellowships in Nigerian colleges and universities • Contribute to the international literature in the science and treatment of cancer

18. Nigeria can take the lead for Africa Early detection and treatment for cancer saves lives…. There are 9 million cancer survivors in the US

19. Impact of Research on Vision 20/20 • Biomedical research is the basis of virtually every improvement seen in health care • Throughout history advances in science and biotechnology have • Strengthened the economy • Raised standard of living • Enhanced global leadership • Prolonged human life

20. Distribution of Nigeria’s Health Expenditures Source: Computed from Soyibo et al (2005)

22. Differentiation of ESC into organs Nuclear transfer of host DNA from somatic cells Enucleation of donor oocyte Donor oocyte HostDNA 4-cell stage Blastocyst ESC culture containing DNA from adult host Germ cells Hepatocytes Pancreatic cells Bone marrow Skin Hematopoeitic cells Cardiomyocytes Neurons

23. Induction of tolerance by SC without immunosuppression Source: Oluwole SF. NNMA Award Winners’ Lecture, Abuja, Dec 5, 2007

24. Clinical experience with ESC transplantation Source: Oluwole SF. NNMA Award Winners’ Lecture, Abuja, Dec 5, 2007

25. Challenges facing ESC Therapy in Tx • ESC are laboratory devices not fully mastered • Defining mechanisms that regulate ESC after transplantation to avoid transformation into tumor • Defining optimal conditions for in vitro cell growth to reduce physical insult • Defining rules governing ESC transplantation • Done by research institutes and government • Regulatory issues • Safety, compliance, protocols and quality control • Addressing political and ethical concerns about ESC resulting in human cloning

26. History of NIH in USA • 1778 • Established by act of Congress as Marine Hospital in New York to care for sick and disabled seamen • 1930 • Designated Hygienic Laboratory by act of Congress • Expanded & redesignated Laboratory of NIH • 1935 • Moved to Bethesda MD • Now occupies 306.4 acres of land • 1944 • All institutions consolidated into NIH • Empowered to conduct and support research into diseases and disabilities of man

27. The Mission of the NIH is to uncover new knowledge to improve the health of all Americans by conducting and funding medical research This is accomplished by Probing the unknown to gain new knowledge Communicating and transferring new knowledge to the public and health care providers Training investigators Managing and supporting the people, systems and facilities necessary to carry out research

28. NIH Goal Through research support to prevent, diagnose and treatdisease and disability

29. NIH Core Strategic Vision Contains four pillars, the four Ps • Pre-emptive • Transform medicine and health from a Curative to a Pre-emptive paradigm • Predictive • Support basic research to identify the earliest molecular stages of disease in complex biological systems • Personalized • Accelerate translation of findings from the bench to the bedside to the community • Participatory • Provide the evidence and knowledge base to allow for a rational transformation of healthcare system to one that is patient-centered and pro-active

30. Transformation of medicine by four P’s • Pre-emptive • Design preventive & therapeutic drugs • Vaccines • Wellness assessment • Predictive • Molecular finger-printing • Development of organ specific blood biomarkers (~500 / organ) • Early detection & diagnosis of disease at molecular level • Control of disease progression

31. Transformation of medicine by four P’s • Personalized • cDNA encoding antibody library • Organ-specific blood biomarkers • Participatory • Educated patient makes informed decisions • Informed patient together with physician make choice of therapy • Delivery of care in patient-friendly, efficient manner

32. National Institute of Health

33. NIH Budget

34. US President’s NIH Budget Request 2009 $29,457 Billion

35. Grants process at-a-glance Planning, writing, submitting Planning: collect preliminary data Writing Submitting: Division of Receipt & Referral Receipt & Referral: Mths 1 – 3 Center for Scientific Review: review & funding consideration NIH Institute / Center & Scientific Review Group assigned Assigned to reviewers & readers Peer Review: Mths 4 – 8 1st level: review & evaluate applications for merit Priority scores Summary statement 2nd level: Advisory board reviews applications Award: Mths 9 – 10 Pre-Award Process: final administrative review & negotiation of award Notification of Award Congratulations: project begins Post-Award Management Administrative & fiscal monitoring, reporting & compliance

36. Improving health and saving lives Medical discovery Nobel Laureates NIH Achievements

37. Improving Health & Saving Lives NIH research & national programs contributed to • Increase in life expectancy from 47 yrs in 1900 to 77 yrs in 2000 • Fall in death rates due to heart disease and stroke by 51% between 1975 and 2000 • Improved 5-yr overall survival rate for childhood cancers from <60% in 1970s to 80% in 1990s • Prevention of infectious diseases like rubella, whooping cough and pneumococcal pneumonia with vaccination • Fall in AIDS-related deaths by >70% between 1995 and 2000

38. US Mortality for 2000 put into perspective Source: US Mortality Public Use Data Tape 2000, National Center for Health Statistics, CDC, 2002.

39. Change in US Death Rates* by Cause Death Rate / 100K HeartDiseases CerebrovascularDiseases Pneumonia/Influenza Cancer • Age-adjusted to the 2000 US standard population. • Source: US Mortality Volume 1950, National Vital Statistics Report, 2002, Vol. 50, No. 15.

40. Medical Discovery NIH is at the forefront of research that improves understanding of how the body works and that gains insight into diseases and disorders • Sequencing of the genome • Prevention, diagnosis & Rx of bioterrorism agents • Improved body imaging technology • Making vaccines for diseases like HIV, TB, malaria & for potential bioterrorism agents • Understanding immunology and searching for cure for diabetes, arthritis, asthma and allergies • Searching for cancer treatment that targets abnormal proteins in cancer cells

41. Nobel Laureates 111 NIH-supported scientists have won Nobel Prizes between 1950 & 2007

42. British Medical Reseach Council (MRC) • 1913 • Established to tackle tuberculosis • 1914 • Committee set up a central research institute at Hampstead with hospital beds for clinical research • 1920 • Opened MRC National Institute for Medical Research • 1962 • 2nd campus, Cambridge Lab, MRC Laboratory of Molecular Research 13 of 27 British Nobel Prizes won by MRC-funded scientists

43. Medical Research Foundation • 1967 • MRC agreed to act as managing trustee of the Fleming Memorial Fund for medical research • Fund was raised by subscription, donations and bequests in honor of Sir Alexander Fleming, discoverer of penicillin • 1968 • MRC registered Medical Research Foundation as a charity to hold and manage its donations, bequests and trusts received from the public Medical Research Foundation, division of MRC, has funds of over £39 million

44. Mission of the MRC • Encourage and support research to improve human health • Produce skilled researchers • Advance and disseminate knowledge and technology to improve the quality of life and economic competitiveness of the UK • Promote dialogue with the public about medical research

45. Structure of the MRC • Council directs scientific strategy & corporate policy • Five Research Boards decide which scientific proposals to fund • Training & Development Board distributes funding for training scientists • Management Board manages the organization • MRC Technology works with industry to translate discoveries into treatments and technologies • Medical Research Foundation receives funds from the public to support medical research

46. Current research priorities • Clinical & public health • Infections & vaccine • Global health • Biomarkers • Ageing • Sustaining capability in areas of strategic importance

47. MRC Research Portfolio Has been divided into four scientific areas, each of which is represented by a research board • Infections and Immunity Research Board • Molecular and Cellular Medicine Board • Neurosciences and Mental Health Board • Population and Systems Medicine Board

48. MRC spending by portfolio 2006 / 2007 Research spending £537M Spending in millions of £ Source: 2008 MRC Facts and Figures [www.mrc.ac.uk]

49. MRC spending by type 2006 / 2007 Research spending £537M Source: 2008 MRC Facts and Figures [www.mrc.ac.uk]

50. MRC achievements over past decade • Ageing with better QOL & longevity • Stem cells use in therapy • Cancer screening & improvement in survival • Heart disease, statins & antithrombotics • Infections • Research in Flu to AIDS • Respiratory diseases • Asthma, COPD & Cystic Fibrosis • Brain & its diseases • Like autism & schizophrenia • Nutrition & metabolism • Diabetes, obesity, etc. • Sight & hearing • Newborn hearing program