Introduction: The Challenging Global Cancer Pandemic

To introduce the volume, Andrea Vicini, SJ, stresses the need to address the global cancer pandemic, while the world struggles with the ongoing pandemic caused by COVID-19. Cancer affects millions of people. It is the first or second cause of death in 134 countries, the leading cause of death in most high-income countries (i.e., 10 million deaths in 2020), and the leading cause of death by disease in American children. Cancer is also unjust. Striking inequities can be traced within and between countries in cancer incidence and survival by race, ethnicity, and socio-economic-status. Survival is much higher among the wealthy than among the poor. An overview of the volume introduces the following chapters.


Introduction: The Challenging Global Cancer Pandemic
Andrea Vicini, SJ To introduce the volume, Andrea Vicini, SJ, stresses the need to address the global cancer pandemic, while the world struggles with the ongoing pandemic caused by COVID-19. Cancer affects millions of people. It is the first or second cause of death in 134 countries, the leading cause of death in most high-income countries (i.e., 10 million deaths in 2020), and the leading cause of death by disease in American children. Cancer is also unjust. Striking inequities can be traced within and between countries in cancer incidence and survival by race, ethnicity, and socioeconomic-status. Survival is much higher among the wealthy than among the poor. An overview of the volume introduces the following chapters.
While the world is experiencing the tragically disruptive consequences of the global pandemic caused by the virus called COVID-19, it might appear surprising to invite readers to point their attention to what we consider another pandemic: the pervasive presence of cancers across the planet. One might wonder whether it could be wiser to focus on one pandemic at a time, at least to avoid being emotionally overwhelmed. Prudence is certainly an essential virtue, even when one reflects on global health. However, what challenges the health of populations requires attention, without delay. Human ingenuity and the commitment to promote what is good and just, strengthened by specific systemic and structural arrangements and reinforced by technological developments, testify to the human ability of facing health challenges as they come, even when they are represented by two pandemics.
Hence, this volume presupposes that health can be promoted in ethically just ways with great benefit for individuals, populations across continents, and the whole planet. Health is a comprehensive and inclusive good. What threatens health could be, at the same time, what stimulates in renewed ways the human capacities to rise to the occasion and protect, promote, and restore health. While this volume focuses on the cancer pandemic, the authors' contributions point to a holistic ethical framework. Everything concerning the health of individuals and populations is inseparably interconnected, as the stress on the social and political determinants of health exemplifies.

Cancer
Cancer is the first or second cause of death in 134 countries, the leading cause of death in most high-income countries (i.e., 10 million deaths in 2020), and the leading cause of death by disease in American children. 1 An estimated 19.3 million new cases of cancer are diagnosed across the world each year, and this number is expected to rise to 29 million by 2040. Most of the increase will occur in low-and middle-income countries, the countries least capable of confronting the cancer pandemic or affording expensive therapies. 2 Cancer is unjust. Striking inequities can be traced within and between countries in cancer incidence and survival by race, ethnicity, and socio-economic-status. Survival is much higher among the wealthy than among the poor. In the U.S., outcomes are much more favorable among Whites than among Blacks and Latinos. Moreover, scientific contributions and ethical inquiry should help civil society in identifying and naming these inequities and, at the same time, recognizing successful strategies to promote health and articulate further constructive proposals.

The Volume
To examine the cancer pandemic and its inequities, this book gathers a selection of contributions presented, in an initial form, at the international conference hosted at Boston College, on October 2, 2021, by the Program for Global Public Health and the Common Good in partnership with the Schiller Institute for Integrated Science and  23, 1971. 5 The following pages feature the contributions of a distinguished group of scholars-from Boston College, across the United States, and internationally-in cancer prevention, global public health, economics, public policy, and ethics to the examination of the scientific and ethical challenges facing global cancer control in the 21 st century. In such a way, the volume aims to fill an important gap in the debates and literature on the cancer pandemic. Despite the clear connections between global public health and social justice, there has been surprisingly little scholarly exploration of the ethical challenges that confront global cancer control, which could further strengthen the emerging field of global health ethics.

Overview
The various chapters accompany the readers in engaging the rising global cancer pandemic by focusing on some of its significant components and, at the same time, exploring which responses and strategies of interventions are needed. While the book aims at comprehensiveness, not every necessary aspect is addressed. Hence, these pages become an opportunity for further developments in engaging the pandemic scientifically and ethically, by considering legal and economic aspects, by delving further in local contexts while continuing to consider its global dimensions and repercussions.
With its five parts the book examines the essential elements that characterize a critical assessment of the cancer pandemic globally, both scientifically informed and ethically inspired. In Part 1, first, Kurt Straif provides a historical and global overview on trends in cancer incidence, disparities, and social inequalities, with a particular attention given to cancer in children and adolescents. Second, by stressing that the majority of cancers can be prevented, Philip J. Landrigan focuses on the troubling consequences of pollution on individual, social, and planetary health, which are inequitably distributed, with the most significant increases in cancer incidence and mortality occurring in low-and middle-income countries-i.e., the countries least capable of confronting the disease and least well able to afford costly therapies. Third, Arvind Kumar and Raja M. Flores discuss the economic aspects that accompany cancer spending for prevention, screening, and treatment in the U.S. and examine health hazards in low-and moderate-income housing in New York City. Finally, the ethical imperative voiced by colleagues from the Universidad Católica de Chile (Lilian Ferrer, Rodrigo López, Francisca López, and María Isabel Catoni) stresses the urgency of providing universal access to healthcare services on a global scale because health is a social good and a social right.
Part 2 articulates critical approaches to healthcare within social contexts (Richard J. Jackson), including policy making and the contributions of non-profit organizations (Nsedu Obot Witherspoon). In reflecting on cancers, Richard Jackson stresses the serious social harms caused by inadequate prevention and, within the social fabric, he examines what he calls the "cancer accelerants": water, power, money, and greed. They are specific factors that require ethical attention. Water powerfully influences past and future health and well-being, for human beings and for the planet. Water conflicts and powers at play within the medical/industrial complex lead to further power imbalances in the social fabric, which are increased and worsened by structural racism and systemic impoverishment. Money further complicates any attempt to promote greater social justice whether one considers, on the one hand, financial interests and, on the other hand, lack of financial resources and poverty. Finally, greed poisons human and social interactions by inhibiting virtuous behaviors and choices, both at the personal and social level.
While the role of governments in promoting health policies and regulations to protect and support all its citizens, particularly those who are more vulnerable, needs to be reaffirmed, the work of non-profit organizations should be highlighted. As an example, Nsedu Obot Witherspoon discusses the mission, contributions, and actions of a national non-profit organization-the Children's Environmental Health Network-that strives to foster equity, protect all childrenand their health-from environmental hazards, and promote safe and healthy environments for children to thrive in. This commitment is challenged by the traditional approach to environmental health laws and regulations that is based on proving harm from environmental hazards, such as carcinogens, before measures are taken to protect all, especially the most vulnerable and, among them, children. The goal of fostering a cancer free society is a collective and shared endeavor, which requires acknowledging and addressing the troubling effects of systemic discrimination and racism on low wealth, Black, Indigenous, and People of Color communities.
In Part 3, focused on discussing ethical issues and practical approaches, Elizabeth A. Williams articulates a womanist approach that, while it denounces the racial disparities and inequities in access to preventive, diagnostic, and therapeutic services for Black women, shows how grass-roots organizations empower women and allow them to take back their health-for example by controlling and preventing breast cancer.
Conor M. Kelly further examines social inequities and, by strongly advocating for social justice, frames ethical priorities. In particular, he invites us to focus not only on what we do not know about cancer (e.g., in terms of scientific understanding and medical know-how), but also on what we already know about cancer's toll on human beings and societies, as well the continuing and even increasing inequities in cancer care across the planet.
Finally, in light of his experience as a clinical bioethicist in a healthcare institution in the U.S.A. (i.e., Anne Arundel Medical Center in Annapolis, MD), Christian Cintron reflects on concrete challengesfrom the COVID-19 pandemic to the increasing costs of cancer care for individuals and families-that test the ability of providing care to cancer patients and that demand policy reforms aimed at transforming practices in prevention and in providing care, while avoiding what he calls "financial toxicity." Moving from North America to other continents, Part 4 enlarges the horizon of reflection by turning to international perspectives. Rengswamy Sankaranarayanan discusses major cancer problems and prospects for prevention in Asia by showing, on the one hand, the diverse cancer incidence in various countries and, on the other hand, strategies to prevent, screen, diagnose, and treat that are implemented in these countries. To address, reduce, and eliminate the glaring inequities in cancer prevention and care between countries, political commitments should allocate adequate resources, implement targeted programs, improve health infrastructures, strengthen human resources, provide universal healthcare, promote efficient and socially conscious public-private partnerships, and develop efficient monitoring systems.
Similarly, Walter Ricciardi discusses challenges and strategies to address the cancer pandemic within the European context, by featuring initiatives across Europe-like the Mission on Canceraimed at supporting and strengthening national commitments to foster prevention, diagnostics and treatment of cancer, and the quality of life of cancer patients, survivors, and their families and caregivers, while continuing to support research efforts.
Finally, Michail K. Shafir examines the very different scenarios that can be encountered in Latin American countries by pointing to challenges in prevention, monitoring the incidence of specific cancers (i.e., breast, gastric, and cervical), tracing the uneven presence of cancer registries, providing healthcare services, and addressing social and national inequities in access to healthcare.
This international overview, while incomplete, confirms the urgency of further engagement in examining not only national data, healthcare systems and structures, and the quality of care that is provided but in expanding the critical assessment of the cancer pandemic at the regional and continental levels. Such an approach could highlight trends and devise shared strategies with beneficial impacts in providing a better picture of the cancer pandemic and in joining forces to address the multiple challenges of the cancer pandemic. 6 Personal narratives further expand our understanding of what cancer's diagnosis and treatment imply and what it means to become a cancer survivor. In Part 5, with their diversity, four contributions bring to light some shared experiential, emotional, and relational traits by pointing to commonalities that go beyond the age differences and the professional locations. A Boston College alumna, Bridgette Merriman, now medical student, and a Boston College alumnus, Woody Hubbell-currently employed in an investment bank and financial services company focusing on healthcare-describe their journey with cancer. While experiencing cancer in early childhood (Merriman) or during college (Hubbell), both their stories stress the outstanding care that they received and the remarkable support and accompaniment that they enjoyed. Care is more that diagnostic prowess, an up-to-date pharmacological arsenal, and targeted therapies. Care is also shaped by caregivers, families, and friends.
As a Boston College staff member, Laura Campbell vividly describes how cancer disrupted her life and, in very similar ways, the lives of any worker. It makes a great difference if the employer's healthcare plan and the working environment support patients in their ordeals and in the process of recovery. Hence, while personal narratives teach us about individual experiences, 7 they further highlight the ethical urgency of critically examining workplaces and healthcare systems with the services that they provide and by paying attention to those who are left out.
Finally, as a cancer survivor and a Boston College faculty member, James F. Keenan, SJ, stresses how considering cancer as a global health emergency is urgent and implies a necessary and beneficial change of perspective. In fact, cancer is usually experienced as a personal ordeal, centered on who is affected. As Keenan's indicates, shared accompaniment and advocacy-as presented by Elizabeth Williams in her chapter describing women's organizations of breast cancer survivors-further exemplify how new forms of collective support, social action, and lived solidarity contribute to change the patterns of cancers' stories by giving voice and agency to the patients and survivors who are voiceless and disempowered.
The volume ends by looking at what could be possible concrete ways to articulate strategies to address the ongoing cancer pandemic. What the future will reserve to us depends in large part by how civil society will deal with the cancer pandemic today and by which approaches are set in place now and in the years to come.
Striving to be focused and concrete, Silvia de Sanjosé offers a specific example to inform our present and future commitments by articulating a global strategy for eliminating cervical cancer, while highlighting ongoing challenges and stressing the existing opportunities for prevention, screening, and vaccination. In the closing chapter, I indicate how the ethical reflection stresses that addressing the cancer pandemic is hampered by the existing inequities and disparities in providing healthcare to citizens across the planet, which are further exacerbated by the global pandemic caused by COVID-19. Thinking about the future requires us to consider the social, cultural, political, and religious contexts where inequities limit efforts aimed at preventing, diagnosing, and providing care. Ethically, a multilayered approach that strives to promote research, prevention, and therapies, and that engages individuals, institutions, and populations in collaborative efforts seems to be promising and able to generate realistic hopes.
At Boston College, Andrea Vicini, SJ, is Chairperson, Michael P. Walsh Professor of Bioethics, and Professor of Theological Ethics in the Theology Department and an affiliate member of the Ecclesiastical Faculty at the School of Theology and Ministry. MD and pediatrician (University of Bologna), he is an alumnus of Boston College (STL and PhD) and holds an STD from the Pontifical Faculty of Theology of Southern Italy (Naples). He taught in Italy, Albania, Mexico, Chad, and France. He is cochair of the international network Catholic Theological Ethics in the World Church. His research and publications include theological bioethics, sustainability, public health, new biotechnologies, and fundamental theological ethics.