India records five lakh cancer deaths annually, which is likely to increase in the near future as an average Indian is set to live longer. Utpal Kumar looks at the issue in the wake of the Novartis controversy
Cancer begins and ends with people.
— June Goodfield
Aleksandr Solzhenitsyn, in his novel Cancer Ward, introduces us to Nikolayevich Rusanov, who in his mid-40s discovers a tumour on the side of his neck. He is taken to a hospital where the diagnosis of cancer turns into a death sentence for him, stripping him of his identity and assuming absolute control over his life. Here the patient, like a prisoner, is “stripped of his outer bark and ready to be planed”. So much so that Rusanov believes he has entered a medical gulag — a state even more insidious and invasive than the one he has left behind.
Solzhenitsyn, through this book, might be trying to showcase life in the erstwhile Soviet Union, but ask someone suffering from cancer — or even the family members of the victim — and the feeling won’t be too different from that of Rusanov. Ruchika is one such person. She still remembers the day her mother was diagnosed with cancer. And in no time, Ruchika’s world turned upside down which continues to remain so more than three years after that ill-fated incident.
“In summer 2009, we were planning to go abroad for a couple of weeks. It was one of the finest moments of my life. After years of cajoling my parents, we were all set to set our feet on Greece,” recalls Ruchika with a smile on her face but eyes deep, dark and sad. She remembers the day her mother was getting ready to go to the visa office. “It must be around 10 am when she started feeling uneasy. She had been getting bouts of headache for quite some time. But that day was different: She could feel a sort of numbness in her head. And she knew there was something terribly wrong with her,” says she. The next few days were quite taxing. Everyone was busy conducting one test after another. Tension was in the air. So was uncertainty. “Things just never got normal thereafter,” says Ruchika. Her mother, the doctors said, had the last stage of leukemia, a kind of blood cancer, and could barely survive for 14 months.
leukemia is cancer of the white blood cells, but what sets it apart from others is its rapid, often explosive, growth. It is, as Siddhartha Mukherjee writes in his ‘biography’ of cancer The Emperor of all Maladies, “terrifying to experience, terrifying to observe, and terrifying to treat”. Instead of normal white cells, the blood is packed with millions of large, malignant white cells — ‘blasts’, in the vocabulary of cancer.
Today, in the wake of the Supreme Court’s verdict denying pharma multinational Novartis a patent for its ‘wonder’ drug for blood cancer, Glivec, Ruchika is back in the emotional turmoil. She is relieved that the verdict will help many cancer victims survive longer, but she grumbles with her eyes moist and voice choked with emotions. “I wish the judgement had come a few years earlier. My mother wouldn’t have been dead by now,” says she, feeling guilty that the family couldn’t afford the medicine at that time.
Ruchika remembers doctors telling her father that Glivec would cost around Rs1.25 lakh a month, while the same drug manufactured by Indian companies was available at a monthly cost of Rs8,000. Her mother couldn’t get the generic version of Glivec as Novartis had been since 2006 busy fighting a legal battle to protect its patent on the drug. last week it lost the case, as the apex court believed that the multinational firm in question was guilty of ‘evergreening’ (minor modifications in the original patented drug to claim it is a new product and thus secure a fresh patent) Glivec to keep the pill costly and out of reach from most people. India’s 2005 law guards against such evergreening, by laying down conditions, in Section 3(d), that require the incremental invention to possess both novelty and a significant increase in drug efficacy for it to be eligible for a patent.
“We are well-off, but still not good enough to spend over Rs1 lakh per month,” says Ruchika, adding her family didn’t belong to the ‘95 per cent’ of the cancer patients who were supposedly provided Glivec free of cost through the company’s donation programme. “Even if I accept the Novartis’ data, what about five per cent of families like oursIJ Don’t we deserve to get a chance to fight cancer, just because we are neither too rich, nor too poorIJ”
Dr Harsh Dua, an oncologist with Indraprastha Apollo Hospitals, agrees. “The landmark decision by the Supreme Court is bound to give a boost to domestic generic drug manufacturers as they can now sell copies of the drug at a lower price in India. The generic drug is sold in India at around one-tenth of the price of the branded drug in the country which comes as a relief to patients who could not afford the patented drug,” says he, even questioning the patent rights given to a company for 20 years. “Ideally, the duration of such patents should not exceed 4-5 years,” he adds.
Some medical experts even trash the issue of high cost involved in an innovation. “There is enough evidence to show that major pharma companies recover more than the cost of innovation of a drug in a single year from the American market alone. It’s, therefore, wrong to charge so much in the name of innovation,” says a doctor seeking anonymity.
A Curse of modernity
Each era has the tendency of casting illness in its own image. According to Slovenian philosopher Renata Salecl, the 1970s saw the “object of horror” shifting from the external to the internal. At the height of the Cold War in the 1950s, most people in the West, particularly America, were obsessed with communists, nuclear strikes, aliens, et al. By the 1970s, however, people were worried not so much from the outside as from the inside. The horror, as Salecl would like us to believe, was now located within society and by extension within human body. Cancer embodied this internal horror.
What, however, has really brought cancer to the forefront is the fact that it appears to be a modern disease created by our so-called modern lifestyle. It’s modern because it fits into our understanding of human body, made of millions of cells. And cancer, based on this understanding, is caused by uncontrolled growth of a single cell unleashed by mutations — changes in DNA specifically affecting genes that incite unlimited cell growth. In a normal cell, powerful genetic circuits regulate cell division and cell death. In a cancer cell, these circuits are broken, thus unleashing a cell that just cannot stop growing. “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. Cancer cells grow faster, adapt better. They are more perfect versions of ourselves,” says Mukherjee, emphasising what makes cancer both unique as well as deadly.
So, the easiest way to fight cancer is to find means to prevent these mutations from occurring in cells, or at least eliminate the mutated cells without endangering normal growth. The remedy, however, isn’t that easy. More so because cancer is not just one disease but hydra-headed. And, unlike most other diseases, they are not the byproduct of a single agent.
Cancer is also a disease caused by ‘modernisation’. It is, as Mukherjee reiterates, “imprinted in our society: As we extend our lifespan as a species, we inevitably unleash malignant growth. If we seek immortality, then so too in a rather perverse sense does the cancer cell”. In ancient times, lifespan of an individual was often curtailed by a host of diseases like malaria, tuberculosis, smallpox, plague, etc; most people then didn’t live long enough to encounter cancer, which has today become common because all other diseases have been either killed or contained.
A cursory look at statistics would reveal this link: At the beginning of the 20th century, life expectancy at birth in America was 47.3 years. Today, a century later, the median age at diagnosis for breast cancer in the US is 61; for prostate cancer it is 67; for colon cancer it’s 70. Also, the risk of breast cancer is about one in 400 for a 30-year-old, which increases drastically to one in nine for a 70-year-old! Cancer, thus, is the price we are paying for the technological/medicinal excellence we have achieved in the past 100 years.
Then, there is a unhealthy, sedentary lifestyle to blame for. Cancer, as American oncologist Harold Burstein famously said, “resides at the interface between society and science”. The first, the “biological challenge” of cancer, if Burstein is to be believed, involves “harnessing the fantastic rise in scientific knowledge... to conquer this ancient and terrible illness”. But the second, the “social challenge” — what we eat or drink, how we pollute our environment, how we age, etc — is no less significant.
With India recording over five lakh cancer deaths annually, thus making it one of 10 leading causes of fatality in the country and which is likely to increase considerably as an average Indian is set to live longer in future, this disease will become a major cause of mortality in the coming decades. It is going to be a reality with which most of us will have to live with. So, what do we doIJ Change the goalpost, as one doctor in the Capital suggests. Instead of looking for an outright victory over cancer, we should go for preventive measures. We have to realise that the enemy is here to stay. We can only scuttle its chances from appearing into our lives by being pro-active: lead a healthy life from the word go, and start cancer checkups the sooner you touch 50 — some say 40. Ruchika’s mother missed this opportunity. Can we afford to do the sameIJ