In 2008, the Union for International Cancer Control issued a World Cancer Declaration, in which many goals were mentioned, one of which was “By 2020, public attitudes towards cancer will be improved and rumors and misconceptions about cancer will be largely eliminated.”
Nowadays, rumors about cancer abound on the Internet, so in order to achieve this goal, I think every doctor should have the obligation to promote science to the public, so that the public can have a correct understanding of cancer, and thus the disease can be controlled more effectively.
There was a disinformation article called “Inside Story of Contemporary Cancer Treatment” circulating widely on the internet, which said that many medical data and magazines about cancer are only available to doctors, and ordinary patients cannot know about it; then it made up a lot of contents, and claimed that all the bullshit he said was inside information of doctors, so that it could attract people’s attention. This is obviously a nonsense. Medical journals are open to the whole community, only some of them cost money, which is not really a barrier; the real barrier is the language. For people outside of the medical profession, it is difficult to read professional books even in Chinese, let alone in English.
In April of this year, the Lancet Oncology published an article “Challenges to eff ective cancer control in China, India, and Russia”. This 40,000-word paper, of which about 1/3 is on cancer control in China, is a fascinating read. The article not only analyzes cancer control in China in terms of disease prevention and treatment, but also analyzes the current situation of medical care in China. It is said that the greatest use of learning English is to better understand our own country, and there seems to be not many translations of relevant professional English, so I will try to help translate some noteworthy data, both in Chinese and in layman’s terms, so that we can see what is actually written in the real medical professional literature.
At the same time, since this is my column, it is inevitable that I will have to express some emotions, so if you feel that my emotions are affecting your thinking (which is very likely, so I apologize in advance), then you can skip reading only the quoted part.
To begin with a general introduction, this literature examines the more macroscopic aspects of health care policy, primary prevention, and secondary prevention.
Briefly, let’s talk about tertiary prevention. Primary prevention is prevention in terms of etiology. For example, if environmental pollution is a high risk factor for cancer, then we should treat the environment; if smoking is a high risk factor for cancer, then we should promote smoking cessation. This is also similar to the prevention we usually know. If you really have the disease, then we should detect, diagnose and treat it as early as possible. For most of the diseases including cancer, there is a big difference between the early stage and the late stage of the disease, so it is a good way to prevent the disease by early intervention. Tertiary prevention is to minimize the damage of the disease as much as possible when it has already developed, such as reducing the damage of body organs, reducing the recurrence rate and so on.
For cancer, if one already has it, then one would be more concerned about secondary prevention and tertiary prevention; while for healthy people, primary prevention is equally important.
While primary prevention is prevention against the cause of the disease, I have introduced some general knowledge about the cause of the disease in How do scientists determine the causal relationship between two phenomena? I have introduced some general knowledge of etiology, which mentions proximal and distal etiology. Let’s say that aflatoxin has been proven to be carcinogenic, and long-term exposure to large amounts of aflatoxin can lead to liver cancer. Then aflatoxin is one of the causes of liver cancer. And the exposure to aflatoxin is most likely due to the contamination of ingested food or water sources, then food and water contamination is also a cause of liver cancer. In this way, aflatoxin is a proximal cause of liver cancer, while contamination is a cause of liver cancer as a cause of distal etiology. The proximal cause is more important to the medical profession, while the distal cause may involve more political, economic, cultural and environmental factors, which may not necessarily be solved by medicine alone. Although distal etiology, as an indirect cause, may not be as clear or direct as the causal mechanism of the disease, it involves a larger number of people and has a greater chance of prevention, and if certain factors can be improved, then it will be more effective in preventing the disease.
Much of this literature discusses this aspect, including the medical situation we are in, how individuals can be inspired by social and cultural aspects to prevent cancer and improve cancer treatment, rather than the treatment of a specific oncological disease. So, there is no need to read further if you want to know how specific certain tumors are treated.
Since this is a macroscopic study, it will involve the government, doctors and the general public. Since the article is about “challenges”, there will not be too many good words in the article, but probably more about the problems. When facing the problems, we hope we can deal with them rationally. Cancer is a global problem, so it is normal for China to have its own problems, and other countries also have various corresponding problems, only the situation is different. The existence and development of human beings is the process of constantly generating problems and solving them. Therefore, it does not matter if there are problems, the key is to solve them. And only when the problem is identified and the direction of improvement is recognized, can we talk about solving the problem. Therefore, the various problems mentioned below, the purpose is to recognize them, and then try to solve, not to give everyone some targets, and then for everyone to scold. There is no benefit to scolding people and complaining, and it is not helpful to make moral judgments of “good” and “bad” when you see any problems, scolding the government for being unscrupulous, scolding doctors for being unethical, and scolding people for being ignorant. For example, when you see environmental pollution, do not rush to scold the government incompetence, first think about whether they have done the garbage sorting. Shifting the blame is the easiest and most popular thing to do, but, after understanding the problem, first introspection, think about what you can do, what can be improved, this is the right way.
Here is the main text.
Some basic facts about China related to cancer.
China’s urban population is currently 52.6% and is urbanizing at a rate of 2.3% per year. In terms of age structure, 12% of China’s population is currently over 60 years of age, which is lower than the 18.4% in the United States and 22% in the United Kingdom, but the trend is that the population over 60 years of age is expected to increase from 6% in 1964 to 24% in 2035, while the population under 14 years of age is expected to decrease from 40% in 1964 to 17% in 2035.
We know that many cancers are associated with high age and have a so-called high incidence age. Although there is a trend towards a lower age of cancer incidence, the current high incidence population is still the middle-aged and elderly. Therefore, the cancer incidence rate in China is expected to continue to rise just from the age structure of the country. With a shrinking proportion of young people and changing family structure due to urbanization, cancer as a “family disease” is likely to affect more people.
WHO estimates that infections and traumatic injuries already account for a minority of deaths in China, while non-communicable diseases account for the majority, about 80%. Among the NCDs, cardiovascular diseases and cancer occupy the top two positions, respectively. The proportion of deaths due to cancer in China is 167.6 per 100,000 people per year. The top five cancers in China.
Males: lung cancer, stomach cancer, liver cancer, esophageal cancer, and colorectal cancer.
Women: lung cancer, breast cancer, stomach cancer, colorectal cancer, and liver cancer.
The Chinese National Tumor Registry, established in 2002, covers approximately 200 million people, or 13% of the country’s population, while the corresponding institutions in the United States have a population coverage of approximately 96% and the United Kingdom nearly 100%.
In 2011, the eastern region had 5.22 medical staff and 3.96 inpatient beds per 1,000 people, while the central region had only 3.3 medical staff and 3.3 inpatient beds per 1,000 people, and the western region had 3.76 medical staff and less than 3.35 inpatient beds.
When we analyze the data, it is always important to understand what is going on behind the numbers. From this coverage, we can know that disease surveillance about cancer in the country has only just started recently, and due to the serious geographical imbalance in the country, I am afraid that even these available data do not fully reflect the real status of the country. The situation may be even worse in those regions that are not well monitored.
And the imbalance between regions, in addition to the data, I will give another example. Although a large number of medical personnel have been mobilized to support the west through the call for the development of the west, there is still a lack of resources. One of our hospital directors visited a Tibetan region in Qinghai for a private charity event, and she described a birthing center there that was responsible for a significant area of deliveries, but had no conditions for cesarean surgery, and even for flat births, this center did not even have its own laboratory, except for an ultrasound machine donated by an American, and could not even do basic lab tests like routine blood work.
In 2011, China spent 5.1% of its GDP on health care, ranking 125th in the world. Although China’s per capita health care spending increased over the decade from 2002 to 2011, it only rose from $54 per capita in 2002 to $278 per capita in 2011, compared to $8,607.9 in the United States in 2011.
In terms of health insurance, by 2011, the country’s health insurance coverage rate had reached 95.7%, which is a high level of coverage, but a low reimbursement rate. The average reimbursement rate is no more than 70 percent for inpatients and 50 percent for outpatients. In terms of actual costs, Chinese patients pay about 78.8% of their own expenses. Internationally, it is considered very dangerous when the out-of-pocket ratio exceeds 40% of a family’s disposable income; a significant portion of the Chinese population is above this danger line, so that 12.9% of families became poor due to illness in 2011.
China’s large migrant population and migrant workers (approximately 170 million, or 9% of the population) are also a major challenge for health care. Only 19-45% of these migrants have access to health insurance in their place of origin, and 53% of them may not be able to access a doctor if they become ill.
China’s low investment in health care has been mentioned over and over again, and although it is increasing every year, the actual increase in health care investment is limited due to pressure to achieve economic growth rates. Although the last central leadership in power accomplished the task of providing health care coverage for the New Rural Cooperative, bringing the vast majority of the country’s population into the health care system. However, in the actual process of medical treatment, the actual reimbursement of expenses is very little, we have the name of medical insurance, but hardly enjoy the reality of medical insurance.
The importance of government investment in health care reflects the attitude toward life. In our values, the importance of individual life has been insufficient, and the contempt for life is reflected in the contempt for the value of doctors’ labor and the contempt for health care, which in turn is reflected in the lack of investment in health care. This is illustrated by the fact that China, the world’s second largest economy, ranks only 125th in terms of spending on health care. This lack of investment is a major reason why the country’s population has difficulty accessing good health care, especially in the area of cancer management.
A study on non-small cell lung cancer showed that the average medical cost of a non-small cell lung cancer patient in China is about $16,955 in the last three months, and even if some of that is reimbursed by health insurance, it is still far more than most Chinese families can afford.
It has long been said that many diseases, especially terminal ones like cancer, really cost money in the last three months. Although the patient may have undergone surgery, radiotherapy, and other treatments beforehand, those costs may only be a fraction of the cost, and the real bulk of the cost is at the end. In the last three months, the cost of palliative care, resuscitation, and nursing care all increase significantly. In addition, the more one reaches the end, the more one’s desire to live compels the patient and family to seek various methods in the hope that a miracle may occur, and the cost of these methods is often enormous.
It is because of the stimulation of many real-life events around us that cancer is considered by many Chinese people as a life-threatening disease not only for the patient, but also for the whole family. As mentioned in the previous data, a large number of families are impoverished due to illness, and cancer probably accounts for a large proportion of them. Therefore, Chinese people may fear cancer not only because it is a terminal disease, but also because this terminal disease of one person may drag down the whole family.
Regarding cancer treatment in China.
China’s lengthy and slow drug approval process makes it difficult to market drugs already approved for use in the United States and Europe in China. Bevacizumab for advanced colorectal cancer came to market six years later than in the U.S. Lenalidomide for myeloma came to market five years later than in the U.S. The HPV vaccine, which is used to prevent cervical cancer, was marketed in 2006 and is available in 140 countries and regions around the world, but has not been approved in China until now.
Since 2009, the state has been publishing the National Essential Drug List, a list of drugs that are provided by the state as basic health care coverage, meaning that the reimbursement rate is very high. Even in 2012, only 24 antineoplastic drugs and one opioid painkiller were included in the list.
In the 21st century, which has become a global village, all kinds of information from all over the world can be shared quickly. However, there are times when you can get the name and efficacy of a new drug online, but it is not available in your country, and the waiting time can be five or eight years or more. But how many 5 years does a cancer patient have to wait?
You may think that in drug approval, we should be cautious and careful, and we should not follow the clouds, and new drugs listed abroad may not necessarily be equal to good drugs, at least for Chinese people, who may lack corresponding clinical data, and for safety reasons, in order to obtain more reliable clinical data, the approval time should be longer. This argument seems reasonable, but if we really want to talk about clinical data support, there are so many proprietary Chinese drugs listed, and their approval does not seem to be that rigorous.
In fact, the bigger problem with Chinese drug approvals is the profit grab. Time is not primarily delayed in clinical trials, but in the lengthy process. Drug approval is also a part of administrative approval, which involves a process of power-seeking, as we all know. In China’s imperfect market economy, the hindrance of administrative power can be seen in every aspect.
On the other hand, more new drugs on the market will increase the pressure on health insurance. The National Essential Drug List is frequently revised to keep new and effective drugs coming in. However, having new drugs come in means that the state has to spend more. Anti-tumor drugs, especially new anti-tumor drugs, are not good and expensive, so if health insurance is too much involved in these anti-tumor drugs, the burden is too heavy. As a result, not only are new drugs slow to come to market, but there are only a few old drugs (24 in 2012) that can be covered by health insurance. If patients want to use other drugs considering the efficacy and side effects, then they have to pay for them out of pocket. Because of this, although the health insurance coverage is high, the reimbursement rate for cancer patients is much lower for this really costly disease. This has further contributed to cancer becoming a huge personal burden and family burden, further increasing the nation’s fear of cancer.
It can be said that when many people hear that they have cancer, they are scared to death by the disease itself on the one hand, and by the expense of the disease on the other.
When Chinese doctors prescribe drugs, in many cases, they may exceed the indications of the drug itself. A 2011 study that looked at 2591 prescriptions for 1122 patients found that about 40% of prescriptions exceeded the indication.
In Europe, drug spending is not the main expense for cancer patients, with inpatient visits accounting for 56% of the cost and drugs accounting for only 27%. In China, however, outpatient drug expenditures account for 51.5% and inpatient expenditures account for 42%; physician visits account for only 29.7% and 26.7%, respectively.
Because of the high cost of many drugs and the high cost of highly technical testing equipment, the government has had to keep the cost of medical services artificially low so that the public can still afford them. For example, the cost of inpatient care (including all technical procedures) is only 10-36 RMB ($1.6-5.9) per day, so low quality services, excessive drug prescriptions and tests are common.
What is “over-medication” and “over-testing”? How can they be avoided? How can you protect your legal rights under the current healthcare system? I have explained some of the problems of over-medication in this article. The over-medication involved here, such as prescriptions that exceed the indications and the high proportion of drugs and tests in the cost, is mainly due to the profit motive. As I have analyzed in the article, the value of doctors’ labor is artificially low, so in order to get a high income, doctors tend to pay more for drugs and tests, but ignore their own treatment skills.
Here is a little explanation of the “drug-based medicine”. Rather, it means that the government recognizes that the fees for medical services are low and that doctors’ labor is undervalued, so it allows hospitals to sell drugs at a certain percentage of the acquisition cost, which is used to subsidize doctors.
But from the doctor’s point of view, they actually prefer cheaper drugs and higher fees for medical services, because that’s what makes the doctor’s labor worthwhile. Moreover, even if the price of drugs is low, there are costs, while medical services are actually “zero cost”, it is dependent on the doctor, its cost is the doctor’s intelligence and labor, is the cost of human resources. Therefore, the main cost of medical care for European patients is the labor paid to doctors, which accounts for more than half of the cost.
With this distorted ratio of health care costs, the patient spends a lot of money, but not much of it actually goes to the doctor. And suppressing the cost of health care services has other problems besides distorting the proportion of health care costs. For example, such a low cost of hospitalization makes the patient stay in the hospital for a day, received the related care services, and spend money in turn cheaper than staying in a hotel. For example, the cost of hospitalization in Hangzhou’s third-rate hospital is 30 yuan per day for a multiple room (greater than 3 people), 60 yuan for a triple room, and 120 yuan for a double room, and this includes the cost of doctor visits and nurse care. You should know that the cheapest room in a hotel in the same area of Hangzhou is more than 120 RMB per day. Moreover, the government requires that the total number of double and single rooms in public hospitals should not exceed 20% of the total number of beds in the hospital. That means that most of the hospital rooms cost less than 100 yuan a day, even if they are fully self-paying. In this way, even if a patient meets the criteria for discharge, he or she still prefers to stay in the hospital to “recuperate” and be cared for by professional staff, which is more psychologically secure. This leaves patients who really need to be hospitalized unmet and unable to stay in the hospital, resulting in an irrational distribution of medical resources, and doctors are responsible for discharging patients. Moreover, in order to subsidize the loss of these too-low hospitalization costs, “excessive drug prescriptions and testing programs become common.”
Another reason for doctors to prescribe more than the indications may be the lack of doctors’ knowledge about diseases and drugs. Due to the lack of professional knowledge, it is thought to be beneficial to prescribe in this way, but in fact it increases the financial burden of the patient, while at the same time may also take more risks in treatment.
These are all areas that need attention and improvement as physicians.
Another issue that seriously affects the quality of healthcare in China is the lack of adequate allopathic palliative care, rehabilitation and hospice support in China.
China lacks some essential drugs for pain relief. Morphine tablets, for example, are an essential drug for pain relief that is both safe and inexpensive, but are quite scarce in China. And in the 2012 National Essential Drug List, only one opioid pain reliever is listed in the list.
Due to traditional Chinese factors, Chinese families seem to be more reluctant to divulge details of the disease diagnosis to patients in the late stages of cancer, making it difficult for patients who should be receiving hospice care to develop good communication with their doctors instead.
Both allopathic palliative care and hospice care are not required courses in Chinese medical schools, and are only offered as electives in a few medical schools.
It was only when I read these paragraphs that I realized that I really did not have a systematic education in allopathic palliative care, rehabilitation and hospice care in school! My knowledge in these areas was actually very lacking. Even as a graduate student in oncology, with specialty training in oncology, my knowledge of hospice care was very lacking. In various textbooks, these related contents are mentioned in a general way and then passed by.
The reality is that due to the nature of cancer disease, there will be many patients who will face the need for hospice care because of this disease, but our physicians are really limited in their ability to do so. This leaves many patients who have cancer to first devote their families to seek treatment, and at the end of their lives, they have to accept a painful death without dignity. The more realistic cases like this, the more it increases the patients’ fear of the disease.
At present, our country does not pay enough attention to allopathic palliative care and hospice care, and a lot of work has just started. As a doctor, we should pay more attention to this problem earlier, and pay more attention to the quality of life of the patients, in addition to the indicators such as cure rate and survival rate.
Due to serious regional imbalances, there are 6.24 beds per 1,000 people for cancer patients in urban areas and only 2.8 beds per 1,000 people in rural areas. Thus, in order to have access to better medical facilities, many patients have to travel all the way to big hospitals in big cities, thus prolonging the time for diagnosis and treatment, and increasing the out-of-pocket costs for patients’ treatment.
The lack of sufficient oncologists in China is also a major problem in cancer treatment in China. 435870 medical students graduated in 2010, of which only 25600 were eventually registered as oncologists. The survey shows that Chinese oncologists are still doing a good job in terms of awareness of related specialties and following up on new advances.
Oncology is a second-level discipline alongside medical-surgical-obstetrics-gynecology-pediatrics, which has its own special perspective and approach to research problems. It is possible that surgeons and oncologists consider the problem from different perspectives and approaches when the same tumor is operated. Therefore, if it is cancer, it is recommended to find a specialist and listen to their opinion. You should know that the professional ability of Chinese oncologists is recognized by their foreign counterparts. The problem is that the number is too small and there is still a serious imbalance between regions.
Over the past decade, along with the reform of the medical market, the workload and work pressure of Chinese doctors have increased significantly, but their real income and social status have declined. For patients, who have spent a lot of time and money and therefore have high expectations for the treatment of their illnesses, the end result is often disappointing, leading to family dissatisfaction and even violence against medical staff.
In 2006, there were 9,831 reported incidents of violence against medical staff, of which 5,519 resulted in serious injury or death of medical staff. Over the next five years, incidents of violence against doctors continued to increase, and by 2010, the Chinese Ministry of Health reported 17,243 incidents of violence against doctors.
Violence against doctors in China has received widespread attention from abroad, including in the mass media like the BBC, and in professional journals like The Lancet, which have reported on it and expressed regret and even anxiety about the future of healthcare in China. I was stunned to see the Ministry of Health’s figures for 2010. 17,243 cases is what? That’s nearly 50 cases a day, 365 days a year, or at least one case a day in each province! I feel ashamed when such things reach the ears of outsiders, because it is a naked declaration to the public that China is a barbaric country.
There are problems with the medical system, and the medical professionals themselves do have things to improve, but after all, doctors are still a profession that treats patients and saves lives, and in no way should they be under the threat of violence like they are in China. So, when I see comments on the internet that promote violence against doctors, I silently black them out, and as a civilized person, I am ashamed to be associated with them.