publication date: Jun. 1, 2018
St. Jude commits $100 million to improve pediatric cancer care amid war zones, economic crises, and poverty
By Matthew Bin Han Ong
St. Jude Children’s Research Hospital is expanding its international outreach program with an initial investment of $100 million to improve childhood cancer survival rates worldwide.
The initiative, St. Jude Global, aims to improve access to care for children with life-threatening diseases as well as influence the care of 30 percent of children with cancer worldwide within the next decade, especially in low to middle-income countries.
“It was my feeling that we could do more, that we really needed to do more,” James Downing, president and CEO of St. Jude, said to The Cancer Letter. “It was really our moral imperative to do more, based on the way St. Jude is structured, and the way we raise money across the United States.”
St. Jude Global builds on existing partnerships established by the Memphis, Tenn., hospital’s International Outreach Program since 1993. In 2016, St. Jude formed the Department of Global Pediatric Medicine to accelerate its work to ensure that children have access to quality care and treatment—no matter where they live.
“We had a long history of our International Outreach Program; it had been in existence over two decades, and really had done fantastic work,” Downing said. “We had great success across Central America, South America, the Middle East, in China and regions of Southeast Asia and had set up 24 programs in 17 countries.
“When I became CEO in 2014, we reflected on that program. While were we very proud of it, we realized it couldn’t be scaled any larger. At its current capacity, it was reaching about 3 percent of the children with cancer around the globe.”
The St. Jude Global initiative creates a network of interactive programs and institutions, forming a global alliance focused on enhancing the quality of care children receive.
“St. Jude was founded under the premise that no child should die in the dawn of life, and so, there was no geographical limitation to that,” said Carlos Rodriguez-Galindo, executive vice president, chair of the Department of Global Pediatric Medicine, and director of St. Jude Global. “We have been able to show that we can cure childhood cancer through excellent care, research, education. Can we now explore that at a global level?
“That’s not something we’ll do in five or ten years, that’s something we’ll do in probably the next five or ten decades. What we are setting is basically the next chapter of St. Jude.”
A conversation with Rodriguez-Galindo appears here.
“Pediatric cancer knows no boundaries,” Downing said. “Children come down with pediatric cancer irrespective of where they are living—whether it be an incredibly poor country or a middle-income country or a developed country.
“Childhood cancer is a global problem and one that is increasing in scale and in scope—so it needs a global effort. St. Jude is in an unique position to step up, to lead this effort and to bring countries together across the world to learn from each other and advance our ability to care for these children.”
St. Jude Global will focus on three core areas:
Education: Training the clinical workforce needed to treat childhood cancer worldwide. Educational programs are being made available at the St. Jude campus in Memphis, Tennessee; at regional sites worldwide; and through online platforms.
Capacity building: Strengthening health systems and patient-centered initiatives across the continuum of care. Through the development of regional networks and a global alliance, St. Jude Global leaders are working with partners internationally to develop patient-centered initiatives that strengthen health systems and policies and establish standards and guidelines to improve patient care.
Research: Advancing knowledge of global pediatric oncology and hematology to sustain a continuous improvement in the level and quality of care delivered around the globe. St. Jude faculty will share their expertise and serve as mentors for St. Jude Global collaborative sites. The goal is to help facilitate research on a global scale, enabling members to perform high-quality and successful research projects, as well as implement some of the therapeutic protocols available at St. Jude.
The initiative is building on the relationships that St. Jude has established in other countries, including Brazil, Chile, China, Costa Rica, Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jordan, Lebanon, Mexico, Morocco, Nicaragua, Philippines, and Venezuela, and emerging relationships in regions that include Russia, Myanmar, Cambodia, and sub-Saharan Africa to establish regional networks to promote self-sufficiency and the sharing of knowledge, skills and best practices.
In Beirut, a 16-year collaboration between St. Jude and the Children’s Cancer Center of Lebanon at the American University of Beirut Medical Center has resulted in childhood cancer remission and survival rates that approximate outcomes in the developed West.
In a long-term study published in the journal Cancer, AUB researchers showed that childhood cancer is highly curable and, through collaboration, effective treatment is possible, even in an area affected by a humanitarian crisis.
For St. Jude, the Lebanon partnership is a template for addressing cancer and other non-communicable diseases in other regions in the world.
Since the war in Syria began in 2011, more than 1.5 million refugees have poured into Lebanon. With refugees making up more than 25 percent of the population, Lebanon has the highest per capita number of refugees anywhere.
Between January 2011 and May 2017, 58 percent of 275 non-Lebanese children treated at the Beirut hospital have completed treatment and were in remission. Of that group, 62 patients had been in remission for more than two years since completing treatment.
“The Children’s Cancer Center of Lebanon, when it was initially established, was set up after the example of St. Jude,” said Raya Saab, acting director of the Children’s Cancer Institute and the director of the pediatric research program at AUB. “The idea was that no family would pay out-of-pocket expenses, and the same applies, whether the child is Lebanese or non-Lebanese, irrespective of their nationality, social status, or third-party payer, or the availability of insurance or governmental coverage.
“Prior to the Children’s Cancer Institute, the care for kids with cancer was very fragmented,” Saab said to The Cancer Letter. “Now, kids in the region can get access to treatment similar to what they would in the Western developed countries with similar cure rates, for the most part.”
A conversation with Saab appears here.
“Most children with cancer across the globe aren’t being treated. They’re dying of their disease. So, how do we change that statistic?” Downing said. “We are looking at opportunities right now that will bring additional investments into this, and we’ll be announcing some of those before the end of the year. It’s a $100 million commitment right now, but I anticipate that will grow.”
St. Jude is leading by example, said Patrick Loehrer, director of the Indiana University Melvin and Bren Simon Cancer Center, and associate dean for cancer research at the IU School of Medicine.
“This is an incredible commitment to global oncology that I think serves as a shining example for other institutions around the world,” Loehrer said to The Cancer Letter.
Loehrer helps run an oncology health care system in Eldoret in western Kenya. In 2009, he co-founded the Academic Model for Providing Access to Health Care, which focuses on building a sustainable cancer and chronic disease treatment program.
“The AMPATH oncology program has a model of leading with care. We screen about 1,500 women a month for cervical cancer, 1,000 women a month for breast cancer, we’re seeing about 10,000 patients with cancer a year,” Loehrer said. “We are still awaiting the implementation of radiotherapy equipment, which we are promised will be soon, but we have an unprecedented opportunity of building the workforce in western Kenya.
“I think the important aspect is a strong partnership with the host country, and they have to lead. We can serve as advisers, but it really is up to them to enact the health care policies that will provide long-term health care for patients. We can put a spotlight on the possible and we can facilitate it, but in the long run, it’s got to be led by the host countries. What we want to do is increase the workforce to address the huge crisis of cancer in the world.”
St. Jude Global is one aspect of Downing’s vision to boost the St. Jude budget by 50 percent and spend $7 billion over six years for an expansion of clinical and research programs (The Cancer Letter, May 19, 2017).
The overall plan involves over $1 billion in construction, an increase in staff and faculty, as well as an expansion of basic science and clinical programs, with an emphasis on non-malignant hematologic programs.
“We have such a unique hospital where the patients and family do not pay for any aspect of their care, of their travel, housing, or meals,” Downing said. “We have to raise a significant amount of money each year to cover those costs to the tune of over $2 million a day.”
The American Lebanese Syrian Associated Charities, the organization that raises funds for St. Jude, declared revenues of $1.26 billion in 2015, the last year for which tax documents are publicly available.
“St. Jude Global extends beyond any individual department here,” Downing said. “It involves many of the departments from the department of oncology to radiation oncology, to diagnostic imaging, to pathology, to epidemiology and cancer control, to psychology.
“It expands beyond the contexts of just the program, but really creates a mindset across the campus where many people are thinking how their efforts can contribute to the greater good around the globe.”
St. Jude’s success in Lebanon prompted the hospital to open a “twinning site” in Jordan, which is now part of a collaboration called the Pediatric Oncology East and Mediterranean Group, which includes physicians from about 72 centers in 23 countries.
“We help teach at those meetings. We bring physicians from those centers to St. Jude as part of our visitor program so they can learn and hear what we do here,” Downing said. “That program has really expanded the transfer of knowledge and the generation of new knowledge across that region.
“Then they were struck with the crisis in Syria and the influx of many refugees from Syria and surrounding regions into Lebanon. That put a major strain on the health care systems in Lebanon to treat those children who were coming across the border into Lebanon.
“We reached out and helped the clinic in Lebanon to cover the costs of care for some of the refugees. That was done as part of our overall global effort, but also for us to learn from the experience.”
St. Jude’s collaboration with the American University of Beirut grew the cancer program from a 10-bed inpatient floor and a limited outpatient department to a cancer center that provides comprehensive services.
“When I first came in 2002, this was really the first center of excellence at AUB. It was really thanks to a tripartite agreement between AUB, the local foundation that is the fundraising and the administrative body equivalent to ALSAC at St. Jude, and St. Jude,” said Miguel Abboud, chair of pediatrics at AUB and an oncologist at the Children’s Cancer Center of Lebanon. “At that point in time, there was pediatric cancer care in Lebanon, but it was really not very sophisticated. There were no pediatric bone marrow transplants, no autologous transplants.”
Sixteen years ago, the fledgling cancer center counted on significant financial support from St. Jude, up to about 50 percent of the budget, Abboud said.
“Among the innovative things that we brought in, just to name a few—it sounds ridiculous right now—but placing central lines for all the kids, doing all the procedures under sedation, allowing nurses to actually transfuse blood products,” Abboud said to The Cancer Letter. “We used to have almost weekly or monthly teleconferences with St. Jude to discuss difficult cases, particularly solid tumor cases and retinoblastoma cases, and we had a lot of technical backup from St. Jude.
“The important thing is this idea of having a major cancer center in the U.S., and St. Jude is unique in that respect, providing technical backup and support to centers in the developing world is critical, because really, even if we could do it on our own, it would take a much longer time. The technology that we have here and the methodology that we have adopted have a lot to do with direct input from St. Jude and the St. Jude physicians way back then.”
The survival rate of patients with leukemia in Lebanon went from 30 percent in 2002 to close to 90 percent in 2018, said Samar Muwakkit, professor of clinical pediatrics at the American University of Beirut and director of clinical affairs at the CCCL.
“After the Children’s Cancer Center of Lebanon opened, all medications became available, and patients were treated free-of-charge,” Muwakkit said to The Cancer Letter. “Our population, more than one-third of them are below the poverty line, so you need to support these patients. The improvement in survival skyrocketed.”
The biggest benefit that the St. Jude Global initiative will bring to health care systems around the world is the track record of sustainability demonstrated by the programs that St. Jude invests in, and the development of networks—a domino effect in improving regional standards of care for children, Muwakkit said.
“Collaboration is very important. Although we were pioneers in applying the St. Jude TOTAL XV acute lymphoblastic leukemia protocol in Lebanon and publishing our local results, the important thing is sharing and collaboration with others in the region,” Muwakkit said “I first was part of a group called Middle East Childhood Cancer Alliance, and now I’m part of the POEM group—it’s not only to apply things in your country.
“It’s to collaborate with your neighbors and countries in the region, because what applies to me most probably applies to my neighbor, and we are more close and similar than we are to somebody in North America. We have the same genetic background.
“I think the most important thing that we did is that we shared our experience with our neighbors in the region, and we are part of these groups. We hope that we will grow bigger and hope that we will apply what we learn to other countries.”