Article by Mark Chataway, Managing Director at Hyderus
Here’s a controversial view: the world can make real headway in the fight against cancer in the developing world over the next decade. In fact, some lower middle income countries will do better than their richer counterparts in adapting to the way that cancer treatment is likely to change.
Things are terrible now
I might just be deluded: the picture is pretty awful today. A 2020 study found that only about half of women diagnosed with breast cancer in five African countries were still alive after three years. By contrast, the five-year survival of women diagnosed with breast cancer is 85–90% in high-income countries. Worse still, the five countries in the 2020 study included Namibia and South Africa, which have relatively sophisticated health systems. Women in those countries had a much higher chance of survival than those in Uganda, Zambia or Nigeria. (Shockingly, in relatively-rich Nigeria women treated in a private clinic had the lowest rate of survival).
The experience of cancer-related death is much worse in developing countries too. Only about three million of the 20 million people a year who need palliative care get it, and most of them are in the advanced economies. Concern about the misuse of opioid medicines — legitimate but very harmful in this context — is responsible for much of the resulting pain and suffering. The developing world only accounts for about 6% of global morphine consumption, despite being home to almost 80% of the world’s population; incredibly, more than 150 countries have no access to morphine at all.
Further evidence of my possibly delusional state comes from prevention trends. For example, India accounts for about a quarter of the cases of cervical cancer in the world and the disease kills about 70,000 Indian women a year. Over 90 percent of cases in the decades ahead could be prevented by HPV vaccines. Thanks to the wonderful work of Gavi, the Vaccines Alliance, these vaccines are now deployed routinely in countries across Africa; India has only a couple of insultingly-small demonstration projects. The reasons for this would require a few thousand words of explanation and probably get me sued for defamation — let’s just leave it at this: a well-intentioned but unwise demonstration project became fodder for a group of politicians and activists who were more concerned about overturning the capitalist system or protecting domestic interests than about stopping cancer. Sadly, they were very effective.
So there we have it: cancer prevention, diagnosis and care is appalling throughout most of the developing world. That will, though, change.
Most current discussion focuses on stuff that doesn’t matter much
Often the debate about cancer treatment in the developing world descends rapidly into a discussion about the price of cancer treatments, and whether patents should be waived or donations increased to lower them. It usually misses the point or, rather, it focuses on the treatment of the few who can sometimes get access to care.
Three senior oncologists serve 100 million people in Ethiopia. One of them told researchers in 2019, “Cancer patients have poor awareness on the disease. …. They immediately look for holy-water or traditional medicine. They seek orthodox medical care after attempting all these means of treatment. As a result, they come to our cancer treatment centre after the cancer has metastasised and passed its curable stage.”
The situation will not get better until treatment is widely available. The ever-wise Dr Samuel Mwenda of the Christian Health Association of Kenya told me that few people in Kenya took free HIV tests before treatment for AIDS became accessible. Why, Mwenda asked, would you want to know that you had a fatal disease if you could do nothing about it? The lack of awareness about cancer, he predicted, will not change until there is a reason for people to know its symptoms.
Little has happened because so little is spent. Nigeria, for example, has long starved its public health system. In 2018, for example, it spent 0.58% of GDP on public health (compared to 8.26% in France). Other major developing countries do almost as badly — 0.77% in Ethiopia and 0.96% in India, for example. There was a year in which subsidies to Air India came to more than a quarter of India’s central health budget.
These shortages in health professionals and resources are made worse by a refusal to invest in, or support, robust regulation of the health sector. Without people, money and rules, the price of medicines is a problem, just not one of the major problems.
But, I still think that cancer prevention and care might improve very rapidly in some developing countries: technology may make up for some of the shortages of resources and the level of resources devoted to health will increase very fast in the COVID-endemic era. These systemic changes will happen in parallel to important advances in oncology diagnostics and treatments.
Reason to be optimistic 1: technology and money will go into health systems
Technology is changing the way that health systems are being run. We lost two big pitches for communications work last year because we told European clients that their big ideas about nurturing health innovation in developing countries weren’t actually inherently very exciting. Technological innovation in health doesn’t require well-meaning Europeans to nurture it: it’s bursting out all over the place. There’s an Uber-like system for calling ambulances in Nairobi, intensive care units are being run remotely throughout India’s Gujarat state and hospitalisation rates for stroke and heart attacks are falling fast in São Paulo as gyms and hairdressers measure blood pressure (in fairness, that last one does have lots of involvement from the Basel-based Novartis Foundation, but they were very early movers).
COVID has sped up the adoption of technology — partly by sweeping away protectionist measures that were designed to protect entrenched interests. There are fewer entrenched interests in the developing world, so it has a chance to leapfrog over Europe and North America. There’s a celebrated example in India: a Bangalore hospital has developed a production-line way of doing open heart surgery that costs about $2,000 a procedure and has about 30% lower mortality rates than similar procedures, which cost up to $100,000 in comparable patients in the US. The INSEAD case study hyperlinked here was written in 2012, but no hospital in the West has yet adopted the Bangalore methods. The median salary for American cardiothoracic surgeons is about $500,000. Don’t hold your breath.
As innovations come in cancer care, they may well be adopted faster in developing countries — particularly ones with an appetite for innovation — than they are in advanced economies. According to a 2017 Kaiser Health News report, most women with certain types of breast cancer in the USA were getting radiation courses twice as long as those recommended by the American Society for Radiation Oncology in 2013. The patients paid more and suffered more as a result. “It’s an example of how our profit-driven health system puts financial interests above women’s health and well-being,” one representative of a people affected group told KHN. It is not a lone example: that KHN piece is well worth reading because it describes over $200 billion in health spending on antiquated or unnecessary procedures.
Sometimes innovation isn’t particularly disruptive or revenue curtailing in the West; it’s just not a priority. For example, the rheumatologist I see in Ireland is always willing to talk to me on the phone, seemingly for as long as I want to talk. But, he has no way of charging for phone consultations and it’s unclear whether our insurance company would reimburse me if he did. I realise it’s not sustainable for him to keep treating me for free and I value both his skill and his integrity, so I periodically drive two hours to Dublin to see, and pay, him. There’s nothing for him to examine or prod; we just discuss my blood tests and treatment options and I go home. In a country with much more pressure on the health system, he’d talk to me on Zoom, I would get five hours of my life back and the whole process would cost the reimburser less, presumably.
Contrast Ireland with India. I was invited to be in the audience last week for a Federation of Indian Chambers of Commerce and Industry (FICCI) roundtable on, A Road Map for Universal Health Care. (If you have an hour, you might want to listen to the whole fascinating discussion of a recent publication on universal healthcare by the Centre for Policy Research at the JK Lakshmipat University). I was struck by a few recurring themes.
- The Indian report’s authors recommend fewer hospital and intensive care beds per thousand of population than the WHO because they are sure that technology can reduce demand or transfer it to lower-tier facilities. It can, says the report, be accomplished with a national Digital Health Technology Mission which updates the model of the UK’s National Health Service for the 21st century, complete with AI-driven guidelines and digital monitoring of resource use and outcomes
- AI, telemedicine and other innovations will, the report says, allow for less skilled paramedical workers to do jobs that are currently undertaken by fully trained doctors, nurses and pharmacists. Robot doctors are a long way off, but human doctors may be able to supervise many more staff with a system of reliable exception monitoring and guideline enforcement
- The report addresses exactly the perverse incentives that lead to so much unnecessary care in countries such as the USA. “The more the number of tests and surgical interventions with full reimbursement by insurance companies, the greater the returns for the service providers. In turn the insurance companies can charge higher premiums with higher reimbursement caps. This becomes a mutually reinforcing trajectory of higher costs. The turnover and profits for both, the health care service providers and the insurance companies, grow in tandem.” Instead, they recommend incentives for insurers based not on reimbursement of all costs up to a cap, but on comprehensive insurance that covers any needed treatment for the insured patients. This would drive costs down and force competition. It looks like many European insurance-based models or US HMOs
- More money will be needed but the report’s authors estimate that it will be just over €60 billion a year in the medium term (6 lakh crore rupees if you want to double check my conversion). That is a lot, but it’s three percent of GDP or roughly what India spends on defence. Defence spending has a very low multiplier effect on the economy; health spending has a high multiplier effect so, it will make the economy grow faster. Employers may grumble at taxes to fund it, but they will pay. This kind of increase in investment will, I think, be common in middle-income countries after the pandemic — a very senior Nigerian official told me, “we, the élite, used to think we could just fly to Dubai or London or New York if we needed serious medical care. Now, we know that’s not always going to be possible.” The élite may want sophisticated tertiary care, but they won’t get specialty hospitals without spending on more basic facilities, at least in democracies.
Other money will come from development finance institutions. “Covid-19 is a wake-up call on the central role of health systems and infrastructure for inclusive economic growth,” said Dr Beth Dunford, the Vice President for Agriculture, Human and Social Development at the African Development Bank in November of last year. “Developing quality health infrastructure is a triple imperative – health infrastructure is fundamental to public health, has significant economic impact, and is of strategic importance for governments.”
Sometimes people think that money from development banks won’t go to cancer or other diseases that disproportionately affect older people: banks, after all, want to invest in productive capacity. But that’s not the way it works: families don’t leave a grandparent or great grandparent to die because she can’t work any more; they sell all that they have and go into debt to fund her treatment. That removes savings and capital from the economy. Besides which, granny is probably providing the child care and doing other chores that enable younger people in the family to earn.
Change will come to health systems. Some developing country governments are embracing it and, where they are not, voluntary providers or the private sector will. In Africa, up to 40 percent of healthcare is provided by faith-based groups and in India over three quarters of all health spending is out of pocket. Civil society and the market can drive cancer innovation much more effectively there than in countries with staid, comfortable health systems.
Reason to be optimistic 2: advances in cancer diagnosis and treatment
I’m an old journalist who has worked in health communications and policy for years, so you would not want to rely on my ability to forecast accurately how science will evolve. However, I’ve been lucky enough to moderate a couple of events with oncology thought leaders in the last year and to have worked as an editor with several cancer researchers. Rather than rely on my interpretation, you might want to look at one of the events. We should probably not expect many wholly new breakthrough treatments in the rest of this decade, but we should watch for several trends that will transform cancer care, if they are allowed to.
There’s a strong likelihood that cancers will be diagnosed much earlier in future. That technology may start out expensive but it will get cheaper fast. At some point, testing for micro tumours will become as common as testing blood for other anomalies. In the West, these blood tests are offered online but most get them bundled with an expensive office visit. There is a chance now for middle income countries to think about the kind of public-private partnerships that would make access affordable without inappropriate, aggressive marketing. Cancers that are diagnosed early are much easier to treat.
The diagnostics revolution will change treatment too. Last year, Dr Johanna Bendell of Roche wrote, “Maybe by looking at the evolution of the tumour — through multiple profiles taken over time — we can understand which changes drive the progression and which can be safely ignored. Then we will have an early warning system for clinicians and a set of new targets: new ways to treat those who are currently untreatable.”
Cancer treatment research is changing to recognise that old-fashioned clinical trials don’t reflect the uniqueness of every cancer. Instead, researchers want to look at a multidimensional categorisation of the disease that is based on the genetic makeup of both the tumour and the patient. “Pairing genomic data with deep, longitudinal clinical data allows researchers to make the critical connection between a genomic profile and patient outcomes,” wrote Dr Bendell. The bigger the dataset, the better researchers can identify new targets and test effectively new interventions. It can’t be done well without access to the extraordinary genetic diversity of people in Africa, humanity’s home, and in Asia, where half the planet’s population now lives. The winners in future research races will be those with access to the most data, so they have an additional reason to take a strong interest in access to care.
These future treatments are likely to be much easier to tolerate than most of today’s treatments: most will work by making the tumour visible to the patient’s immune system and then boosting the immune system’s ability to deal with that specific cancer. We have seen this immunotherapy revolution already in many haematological cancers and in some skin cancers; the immediate challenge is to make solid tumours vulnerable.
I’m not suggesting that cancer treatment will become like paint by numbers, but it will become much more driven by definitive diagnostics, data-driven protocols and globally-standardised guidelines that customise treatment to each patient and each tumour using algorithms. That will, at the very least, change the job of the oncologist. If the treatments work, it will mean that there will be many fewer cancers that require surgery and that will transform the working lives of many surgeons.
In middle income countries, all this may mean that most cancer treatment can happen in primary care settings. In advanced economies, the same transition could happen, but it is unlikely to — look at HIV, for example. Across much of the developing world, HIV is managed from clinics, largely by nurses. Pilots and studies from all over Europe show that treatment in primary care settings is not only feasible, it is often more successful. German people living with HIV, though, dutifully turn up to an appointment with an HIV specialist every three months; many Europeans get longer intervals, but few have the option of visiting the neighbourhood doctor to get prescriptions of safe and very effective one-pill-a-day therapies. No surprise then that a 2018 study of Italians diagnosed as HIV positive found that the median delay in getting them started on treatment was over two months, shocking in itself, while the poor and marginalised waited significantly longer.
Will developing countries be able to afford to treat cancer better? The FICCI panel concluded that most of the answer to the question lay with the ability of information technology to manage healthcare systems and professionals more efficiently. A secondary concern will be the affordability of those new diagnostics and treatments.
Just as I realised that free phone calls with my rheumatologist were unlikely to help my long-term health, middle-income countries know that financing must be sustainable: it can’t rely on donations or give aways. The models are, though, already there. Look at Egypt’s remarkable agreement with Gilead: in return for fast, easy and very high-volume access, Egypt secured a deep discount on treatment. Or, the much discussed “Netflix Plus” model: in return for a flat fee, a country can have access to as much of a medicine as it can use — an incentive to scale up access very fast. Or, a results-based pricing system that repays the cost of today’s treatments with the life years gained and economic activity enabled. That kind of payment was too complex in the past but, as countries such as India embrace universal digital patient records, it looks feasible now.
Reason to be optimistic 3: COVID has created nations full of health activists
Health has long been a matter of political life and death for the power hungry in Western countries, but it has been low down the list of political priorities for most people in developing countries. There are exceptions — Ghana or the south of India, for example — but most politicians reaped neither electoral rewards nor punishments based on how they dealt with health. That has changed.
Across Africa and Asia, health is near the top of presidential speeches and party manifestos. COVID has shown what can be done when there is political will and how much more difficult it is to get things done when systems are decrepit, over-stretched and under-funded.
This is where old journalists like me come in (and young ones too): it’s our job to make sure that broader access to healthcare remains something that is attainable, essential and worth fighting for.
(To be transparent, I have worked for several pharmaceutical companies on policy and communications issues linked to cancer medicines and diagnostics and for international organisations, including the WHO, on cancer prevention. I help run a consulting company that works for companies, universities, foundations and international organisations on health issues, including cancer. I did not discuss the concept or content of this article with any of those we work for or have worked for, and the views in it are mine alone.)