As in every year, February the 4th was celebrated as the ‘World Cancer Day’, across the world, in 2016, as well. Its main objective is to commemorate all the efforts done by the World Health Organization (WHO), the United Nations (UN), including the governmental and nongovernmental health organizations towards formulating a grand strategy to fight against cancer. The strategy is expected to span across cancer prevention, detection and treatment, for all. The key goal of this commendable initiative is to reduce illness and death caused by cancer by 2020, the world over.
The event also encourages to explore various ways to align individuals and groups to do their bit in reducing both the local and the global burden of disease related to cancer.
The last Thursday, the ‘World Cancer Day’ was celebrated in India too, albeit in a low key, as I could fathom, despite its alarmingly ascending trend in the country.
In this context, I would start with my first and a very small example of a sharply contrasting mindset to address the vexing issue of cancer between the largest democracy of the world – India, and the oldest democracy of the globe – America.
The United States (US) this year, like the previous five years on a trot, made this event visible for a large section of people to encourage them to think and act against cancer, in several different ways that they can. The imposing landmark in New York – the magnificent ‘Empire State Building’ was lit in blue and orange, the colors of the ‘Union for International Cancer Control (UICC’), the organizers of this annual event.
A brief recap:
Cancer is now one of the leading causes of death, not just in India, but across the world. Its rate is expected only to go up further in the years ahead, and that too at a brisk pace. Just as the disease is fast spreading across the socioeconomic spectrum, all over, so are the tough access barriers for effective cancer diagnosis, treatment and care, for all, increasing by manifold.
Urgent action is called for in most of the countries of the world by the respective Governments to save precious lives, by effectively overcoming most of these hurdles, soon.
With this backdrop, in this article, I shall explore what is happening on the ground in this direction, at present, drawing examples from the two greatest democracies of the world.
The largest democracy of the world:
Delivering affordable and equitable care for cancer to all, is one of greatest public health challenges of the largest democracy of the world – India. The country is required to face this challenge boldly and squarely, to mitigate the devastating socioeconomic and human costs that this disease is already costing our nation.
This point was reiterated by one of the lead authors of an article published by ‘The Lancet Oncology’ on April 11, 2014. The paper discussed the epidemiology and social context of the growing burden of cancer in India.
According to this paper, around 600,000 – 700,000 deaths in India were caused by cancer in 2012, with more than 1 million new cases of this life threatening disease being diagnosed every year.
Further, the World Health Organization (WHO) also reported that every year, around 145,000 women are diagnosed with breast cancer in India. Unfortunately, around half of them had succumbed to the disease, in 2008.
However, all these numbers should be taken into consideration carefully factoring in very low rates of early-stage detection and poor treatment outcomes in the country.
In this prevailing scenario, cancer is fast becoming a major public health concern in India, with the number of new cancer cases projected to nearly double within the next 20 years.
The average cost of cancer treatment in India:
According to the above ‘Lancet Oncology’ report, in India, the average cost of treating a typical patient with cancer at a government facility would come around US$593. Whereas, the average annual income per person is only U$ 1,219, with 27.5 percent of the population living on or below a daily income level of US$ 0.4.
Besides, most district hospitals, including the regional cancer centers do not have the requisite facilities required to provide quality cancer care to all those patients who need them.
Quoting experts, a newspaper report on June 19, 2014 also stated, around 50 per cent of the diagnosed cancer patients, who also commence their treatments, stop visiting hospitals after two or three cycles of chemotherapy, as they find the cost of treatment is not affordable to them. They also drop out from regular follow-up visits, say the doctors.
Low Government funding for healthcare:
As a result of abysmally poor public funding for healthcare in India, both by the Central and most of the State Governments, the cost of diagnosis and treatment of cancer is increasingly becoming out of pocket, and being catastrophically expensive, going beyond the reach of a large number of patients suffering from this serious ailment.
The socioeconomic impact:
This pathetic public healthcare system in India adversely affects not only the debt ridden poor and middle-class cancer patients, but also the welfare and education of several generations of their respective families.
Thus, cancer has a profound, both social and economic, consequences for the general population in India. This very often leads to family impoverishment and societal inequity, as the study points out.
The oldest democracy of the world:
The oldest democracy of the world – America, is one of the richest countries in the globe, having perhaps the best healthcare facilities and systems. All the latest drugs and diagnostics are also available there. Despite all these, there is a growing inequity in the cancer treatment in America too, with access to quality diagnosis and treatment for cancer patients becoming a major health, economic and political issue for the country.
‘Mayo Clinic Proceedings’ of August 2015, also expressed concern on the high prices of cancer drugs, which are affecting the care of cancer patients and eventually the American health care system.
The report does ring an alarm bell for high cancer care cost for many patients in America. The ‘Proceedings’ highlighted the following reasons, most of which are, quite interestingly, very similar to India:
- Cancer will affect 1 in 3 individuals over their lifetime.
- Recent trends in insurance coverage put a heavy financial burden on patients, with their out-of-pocket share increasing to 20 percent to 30 percent of the total cost.
- In 2014, all new US Food and Drug Administration (US FDA) approved cancer drugs were priced above US$ 120,000 per year of use.
- The average annual household gross income in the United States is about US$ 52,000.
- For a patient with cancer who needs one cancer drug that costs US$120,000 per year, the out-of-pocket expenses could be as high as US$25,000 to US$ 30,000 – more than half the average household income and possibly more than the median take-home pay for a year.
- Thus, cancer patients have to make difficult choices between spending their incomes and liquidating assets on potentially lifesaving therapies or foregoing treatment to provide for family necessities, such as, food, housing and education.
- This decision is even more critical for senior citizens who are more frequently affected by cancers and have lower incomes and limited assets.
- Because of costs, about 10 to 20 percent of patients with cancer do not take the prescribed treatment or compromise it. It is documented that the greater the out-of-pocket cost for oral cancer therapies, the lower the compliance. This is a structural disincentive for compliance with some of the most effective and transformative drugs in the history of cancer treatment.
- Given the rising incidence of cancer in the aging American population, high cancer drug prices will affect millions of Americans and their immediate families, often repeatedly.
General public wants the US Government to act:
‘The Mayo Clinic Proceedings’ findings were vindicated by the October 2015 Kaiser Health Tracking poll, which reported, 76 percent of the public believes that a top priority for the American president and Congress should be making high-cost drugs for chronic conditions affordable. Yet another Kaiser poll found 72 percent of Americans believe drug costs are unreasonable and 74 percent think that pharma companies, in general, care more about profits than people.
General public expectations and belief do not seem to be any different in India too.
I reckon, due to similar reasons in most countries of the world, an urgent action is required from the respective Governments to make cancer diagnosis and treatment affordable to all, sooner than later.
Different responses to the same problem:
Let me reiterate here again, that I am comparing India with America on this issue, not for any other reason, but just to give an example and a feel of how much the promised political intent, made for the benefit of the general population of the country, gets translated into reality in the world’s oldest democracy, as compared to the world’s largest democracy.
In India, despite high sound bytes emanating from various leaders of the principal party in power today, the fragile public healthcare system is still gasping for breath, starved by grossly inadequate resource allocations. This gets reflected on the details of national and state budgetary allocations for healthcare in India.
The delay in finalizing and then putting in place for implementation of the “National Health Policy”, which proposed making health a fundamental right and denial of health an offense, also seems to be of low priority for the national Government, at present. If so, this will indeed be quite contrary to its earlier firm promises on improving healthcare in India.
In the United States, as well, similar promises were made by senior politicians during the last national election campaign. The Presidential candidate for the party, which is now in power, created as much hype with matching sound bytes for healthcare reform in America, while seeking votes.
However, the sharp difference between the two similar situations is, having come to power on November 4, 2008 President Barack Obama, fulfilled his promise with a path breaking healthcare reform in his country. On March 23, 2010 he signed into law the ‘Affordable care Act’. It’s a different matter though, like most political decisions, this one also faced its own share of criticism from the American opposition.
Zeroing in specifically to address the agony of cancer patients in America, President Obama has recently initiated a ‘National Mission’ in this area. He has asked his Vice-President Joe Biden to spearhead this mission and get it done expeditiously. Biden enthusiastically accepted to lead this noble ‘National mission’ for mankind and termed it ‘A Moonshot for Cancer Cure’. The White House also announced a resource commitment of US$1 billion on this effort over the next two years.
In his ‘White House’ Blog Post of January 13, 2016 the Vice-President wrote about this project, very close to the ‘World Cancer Day’, which is basically symbolic, just as the ‘International Day of Yoga’, but this specific American ‘National mission’ against cancer does not appear to be so, by any stretch of imagination.
The key objective of this mission is indeed profound. With is effective implementation, the American Government wants to ensure that ‘the same care provided to patients at the world’s best cancer centers, is available to everyone who needs it.’
Joe Biden admitted, though several cutting-edge areas of research and care, including cancer immunotherapy, genomics, combination therapies and innovations in data and technology are revolutionary, all these are currently trapped in silos, preventing faster progress and greater reach to patients.
It’s not just about developing game-changing treatments. It’s about delivering them to those who need them the most. The community oncologists, who treat more than 75 percent of cancer patients, have more limited access to cutting-edge research and advances, even in America, Vice-President Biden elaborated.
Two key focus areas:
- Increase resources, both private and public, to fight cancer.
- Break down silos and bring all the cancer fighters to work together, share information, and end cancer, as we know it.
The goal of this initiative is to double the rate of progress by making a decade worth of advances in five years. He also outlined the details that he would follow to get this mission implemented on the ground within the set time frame.
“If there’s one word that defines who we are as Americans…” – Biden
Joe Biden concluded this announcement with his natural statesmanship, sans any drama, by saying: “If there’s one word that defines who we are as Americans, it’s ‘possibility.’ And these are the moments when we show up.”
The good news is, the project ‘Moonshot’, as the American Vice-President calls it, has already started with the full commitment of the American Government and backed to the hilt by none other than President Obama himself. The American President has already demonstrated to the world, from the very commencement of his Presidency, that he is a project implementer per excellence, as head of the Government.
Some key barriers to effective 'cancer care' in India:
Coming back to the Indian context, experts do indicate that one of the main barriers to cancer care, in the largest democracy of the world – India, is primarily lack of enough public facilities for early detection of cancer. Thus, even when it is detected considerable disease progression usually takes place. Moreover, most patients lack access to expensive cancer treatment and are compelled to give up the treatment for this reason. Consequently, as the data reveals, less than 30 percent of patients suffering from cancer in India survive for more than five years after diagnosis, while over two-thirds of cancer related deaths occur among people aged 30 to 69.
According to the data of the Union Ministry of Health, 40 percent of over 300 cancer centers in India do not have adequate facilities for advanced cancer care. It is estimated that the country would need at least 600 additional cancer care centers by 2020 to meet this crying need.
It appears to me, even meeting this basic need for cancer care will be extremely challenging with frugal public healthcare spending in India. As I said before, it gets well reflected in the successive annual budgetary allocations for the same, both by the Central and most of the State Governments. Added to this, the ‘National Health Policy’, which was first drafted and released in December 2014 by the Ministry of Health for the stakeholders’ comments, is yet to be put in place. The draft policy recommended, among many others, making health a fundamental right of Indian citizens.
According to ‘The World Bank’ report, the public expenditure for health as a percentage of GDP of the oldest democracy of the world is already hovering over 8, against around just 1 of the largest democracy of the world. On top of this, the present American Government has committed, even more resources to usher in a new era of hope for all cancer patients with its latest ‘National Mission’ – ‘A Moonshot for Cancer Cure’.
There is a lot to feel good about it, even as an Indian, as this health mission, termed as ‘‘A Moonshot for Cancer Cure’ by the American Vice-President assures that ‘the same care provided to patients at the world’s best cancer centers, is available to everyone who needs it.’ Its overall benefits could possibly reach even the Indian patients…who knows?
Like 2016, and the previous years, the ‘World Cancer Day’ would come and go with the turn of every calendar year. Hopefully, things will be quite different sometime in future. India would possibly initiate the much awaited health care reform in the country and more specifically effective ‘cancer care’ for all, with requisite budgetary provisions in place. Till then, do the cancer patients in India have any other choice, but to eagerly wait for it, hoping for the best outcome?
By: Tapan J. Ray
Disclaimer: The views/opinions expressed in this article are entirely my own, written in my individual and personal capacity. I do not represent any other person or organization for this opinion.