t was way back in 2010, that Australian radiation oncologist, Dr Bronwyn King, found the ideal trigger to champion tobacco-free investment. On supper one evening, she learnt with horror that her money was being invested in tobacco, one of the biggest causes of cancer in India, and the world. Dr King, who visited Mumbai last month for a Tedex Gateway talk, says she learnt with shock that she owned shares of Philip Morris and British American Tobacco (BAT). It was her life’s biggest turning point, everything changed for Dr King who, since then, has been tirelessly championing tobacco-free investment, pushing the issue to boardrooms of financial institutions across the world.
“Tobacco is one of the greatest global challenges—particularly in India with more than 250 million smokers. Robust tobacco control should be uppermost on our minds. We need to protect and save lives,” says Dr King, chief executive officer and founder of Tobacco Free Portfolios that has helped redirect $12 billion of investment away from the tobacco industry over the past five years.
A million Indians are diagnosed with cancer every year, 680,000 die from a disease once regarded as an affliction of the West. Globocan, the international initiative on cancer data, says India’s cancer burden is expected to rise 70% over the next 18 years, from nearly 1 million new cases in 2012, to 1.7 million by 2035. Even this could be an underestimation, because there were 1.45 million new cases of cancer and 736,000 deaths in India in 2016, expected to increase to 1.73 million in 2030, with 880,000 deaths by 2020. The world is on track for one billion tobacco deaths this century.
This year, Finance Minister Arun Jaitley unveiled a unique “Modicare” insurance scheme for nearly half of India’s billion plus population, the government’s focus clearing on rising cases of cancer. Dr King says governments across the world, like in India, need to do more. She believes by engaging the finance sector, there is new hope in the global fight against tobacco. Boardrooms across the world must hear stories of tobacco victims and they must change their investment and lending patterns to go tobacco-free.
In India, a group of individuals, some of whom run the Tata Trusts, petitioned the Bombay High Court last year, asking why state-owned insurance companies and other government agencies should hold stake in any tobacco company, like the Kolkata-based ITC, for financial and investment reasons, especially when the government uses loads of moral and logical arguments—revolving around safeguarding people’s health—to rationalise its ban on FDI in tobacco.
But it is easier said than done. The biggest trouble for most people is to find out if your money is being invested in tobacco or not. India has very few Tobacco Free Portfolios increasing awareness of the issue, there is very little chance that other funds will follow suit.
At the same time, cancer is spreading like bushfire across India. Ongoing breakthroughs in cancer care involves personalised medicine because every malignancy is unique in terms of its genetics and genomics, one size (or protocol) cannot fit all but not all Indian hospitals are equipped to handle the situation.
“Cancer patients’ lives are extended by experimental drugs. In India, the problem is serious because of the word cancer itself, it brings an avalanche of worries. Treatment is expensive, hotels are few and patients rarely learn about treatment and consequences from other patients,” says Dr Devlina Chakravarty, CEO, Artimis Hospital, Gurgaon.
Dr Chakravarty says very few oncologists have data on the evolving tumours of each individual patient so that a way could be found to characterise the effect of various treatments on malignancies in humans at a molecular level. “India needs many more centres to design new types of clinical trials for cancer,” she adds.
In 2013, the Centre for Cancer Innovation was set up at the University of Washington, bringing together clinicians and researchers in information technology, computational biologists and statisticians. Huge databases were created, hypotheses about treatment were put on the cloud and experts across the world offered inputs and feedback.
Dr Siddhartha Mukherjee, in his book on cancer, The Emperor of All Maladies, calls the disease, organised chromosomal chaos: “Cell division allows us as organisms to grow, to adapt, to recover, to repair—to live. And distorted and unleashed, it allows cancer cells to grow, to flourish, to adapt, to recover, and to repair—to live at the cost of our living.”
Dr Mukherjee says India needs to make serious effort to avert many of these deaths, nearly 50% by adopting healthy lifestyle choices such as avoiding tobacco and public health measures. Cancer, writes Dr Mukherjee, can be cured if detected early. “We need to understand the scale of the problem, and the data from cancer registries serve as a valuable tool towards this end. Cancer registries are of tremendous epidemiological and public health importance.”
Many say personalised medicine depends upon information technology and knowledge sharing to propose an alternative approach. Agree cancer patients who live on tarpaulin sheets across the footpath of Jerbai Wadia Road at the front and rear of Tata Memorial Hospital’s Homi Bhabha Wing in central Mumbai. The 77-year-old hospital—India’s leading referral centre—is run by the Department of Atomic Energy, considered the ground zero of the nation’s unfolding cancer crisis. Life on the footpath is tough, patients pay cash to use toilets and bathe in public restroom. The hospital canteen offers free drinking water. Taj Hospitality, a part of the Taj Hotels group that runs the Taj Hotel near the Gateway of India, provides free lunch to about 300 patients. Similar help comes from other NGOs.
“The government’s programmes for cancer care for its poorest patients are woefully inadequate,” says Suresh Kumar, 51, a patient of lung cancer. He says India just does not have the mechanism to check the spread.
India’s most common cancers are oral and of the oesophagus, stomach and lung for men; in women oral and of the cervix, breast and oesophagus. It is half the world average—94 per 100,000, compared to 182 per 100,000—and a third of the incidence in developed countries (268 per 100,000), but the worries lie elsewhere. The nation has less than 250 dedicated cancer-care centres (0.2 per million population in India) and nearly 40% of these are in eight metropolitan cities and fewer than 15% are operated by the government.
As a result, nearly 80% of India’s cancer cases are detected at an advanced stage and nearly 70% of patients with cancer die of the disease in India, compared to 33% in the US. India also has 0.98 oncologists per million as compared to other Asian nations (China 15.39%; Philippines 25.63%; and Iran 1.14%).
“The poor has very few means to tackle cancer,” says Subhas Chandra, who is associated with an NGO working with cancer patients in the villages. As per available data, cancer patients from the Indian hinterland must travel great distances to only 27 government cancer referral centres and 250 cancer centres nationwide.
There are other issues. Public expenditure on cancer in India is less than $10 (Rs 650), compared over $100 (Rs 6,500) per person in high income countries. Worse, care at many cancer centres is often measured by available facilities. Many centres do not have access to radiotherapy. There are, on an average, 2-5 million people per radiotherapy machine, ten times more than the 250,000 people per machine in high-income countries.
“Maybe things will change with the new Modicare policy that is actually aimed at diseases like cancer, the poor will have more cash in hand to pay the hospitals and not crowd government hospitals only,” says Chandra.
Many rush to Tata Memorial Hospital because of the brand value and trust and also because there is a generous government funding that keeps the price structure at a low. “Private hospitals charge ten times the cost,” says Rajendra A. Badwe, director of the Tata Memorial Hospital.
Bawde says cancer in India differs from western countries, nearly 50% are associated with tobacco use and 20% associated with infections. Social factors, especially inequalities, are major determinants of India’s cancer burden, with the poor more likely to die from cancer.
India’s assessment of the burden of cancer as a national effort started in 1982 when six cancer registries were set up by the Indian Council of Medical Research (ICMR) as the National Cancer Registry Programme (NCRP) in Bengaluru. This now runs under the National Centre for Disease Informatics and Research (NCDIR), which manages disease databases and informatics for cancer, cardiovascular diseases, diabetes, stroke and other major non-communicable diseases.
India has 31 population-based cancer registries (PBCR) and 29 hospital-based cancer registries (HBCR), which serve as the primary source of credible data on cancer.
But still it’s not enough for growing cases of cancer. The ICMR’s Cancer Registries cover less than 10% of the country’s population.
That, actually, is a shame for a billion plus nation.
To be concluded