Cultural, Social and Economic aspects of managing global health in a multi-polar world - from the eye of an oncologist

The world has thrived on hierarchy and polarity from its inception, but the last few decades have seen it becoming more multi-polar than ever before. With this multi-polarity, come new healthcare challenges — of which COVID-19 and its management enigmas are just one example. At the same time, we have seen new technology bridging gaps and creating what is perhaps the most unifying attribute of the world today. I suggest, as some have before, that technology can and will bring socio-cultural health harmony in the world, and I propose an economically driven route to achieving this goal.

According to GBD 2019 Diseases and Injuries Collaborators, the global health burden has steadily decreased over the past 30 years, as measured by age-standardised disability-adjusted life year (‘DALY’) rates. However, this has not resulted in a reduction in health expenditure — which, by contrast, has steadily risen and is expected to continue rising. Further, while the global health burden has decreased, the nature of the burden has shifted, with increasing chronic cardiovascular and cancer illness in the East as well as the West . To make matters worse, developing countries are struggling, and will continue struggling to cope with the provision of increasing healthcare, as maintenance of the health infrastructure and delivery of healthcare have traditionally involved exceptionally high costs compared to the maintenance of other forms of infrastructure and the delivery of other public services. In fact, even in the richest countries of the world, health expenditure has had a serious impact on fiscal balances and on economic growth.

For decades, the East has looked towards the West for the discovery of healthcare solutions — especially in oncology, where research has almost always been entirely driven by countries like the USA and the UK. However, advanced Western countries have themselves faced huge challenges related to cost of research; this has resulted in very heavy prices for new therapeutics and diagnostics, which have impeded the delivery of the latest, highest quality oncology healthcare. In most cases, countries like India have been virtually deprived of legitimate access to such expensive new treatments, resulting either in under-par oncology outcomes or violation of patent laws and the sanctity of research. This has caused huge debates about innovation and affordability, with myriad interpretations of principles of ethics and morality.

Interestingly, though, while the past few decades have seen an increase in polarity and a disruption of socio-economic structures caused by healthcare cost and delivery issues, these decades have also seen a huge change in the globalisation and equalisation of the IT and internet sector. From aviation to retail, and elections to rock concerts, we have seen digitalisation as a central and unifying theme. The gaps between different countries in IT technology are far smaller than in the past, and there has been an amalgamation of talents globally in each field required to develop and run these technologies. In these ways, digitalisation has strengthened our global socio-cultural structure and has broken down many of the traditional hierarchies and geo-social segregations.

It is notable, however, that — despite the huge impact of IT and AI on our lives, many aspects of healthcare delivery, including the delivery of oncology, have not utilised IT to the fullest possible extent. Healthcare delivery systems at large have tended to embrace IT technology for communication, but not completely for research and therapeutic services. While machine learning is aptly applied to the aviation industry, we as medical professionals are behind the curve.

The key problem has been the confidence of health delivery based on studies involving small numbers of participants. As we speak, methods of statistical amplification are being validated that will help to understand effects and treatment outcomes, using a small number of data points and amplifying their statistical value by applying new models. But these methods can be successfully applied only once the validation of the models themselves is completed by employing large arrays of underlying data.

As we continue to dive into this complicated downward spiral of problems, let's change course to look at solutions that can lessen polarity and disparities and enable the achievement of common goals through common discoveries. The key will lie in methods of combining the strengths of systems at the opposite ends of the spectrum.

I propose that we should begin by treating huge populations as an asset rather than as a burden — an easy concept with enormous difficulties in its execution. Initial steps should revolve around discovering the help that the common middle-class smart-phone-savvy person needs in order to provide improved healthcare for his or her family. The steps that follow involve richer healthcare systems developing open-source systems that make life easy for ordinary people to employ IT in this way, and requesting permission from large populations to collect, collate and analyse data, so that their healthcare can be improved. This is the route not just to big data but to the biggest data.

I also propose that this process should start with a consortium of thinkers, philanthropists and innovators in the West developing an open source data capture system that bridges at least 25% of the gap between oncology healthcare in the developing world and oncology healthcare in the developed world. The tenets of the products should be usability, ease and targetting at improving the lives of huge IT-savvy populations — for example, middle-aged, middle class Indians with smart phones in their hands.

Let’s explore this further with an example of lung cancer. There are 70,000 to 90,000 new lung cancer patients in India each year. Unlike in the USA, where the majority of lung cancer patients will be covered by private insurance or by state funding, almost 90% of Indian lung cancer patients will be paying out of their own pockets. The majority of these Indian patients will not be able to pay for the sophisticated diagnostics and therapeutics that have significantly changed the outcome of lung cancer patients in advanced healthcare systems over the last two decades. It is now well established that lung cancer can be treated with targeted therapies and immunotherapies over and above chemotherapy radiation and surgery. However, matching the right treatment for the right patient requires sophisticated and expensive testing. These factors make the treatment of lung cancer effective yet prohibitive for the majority of Indian patients. Interestingly, however, the situation in the USA is not much better. While the treatment and diagnostic costs are borne by the insurer or the state, the result has been a serious socio-economic structural breakdown, where a major part of the population is working principally to keep their health insurance intact. The solution, needless to say, lies in lowering the cost, and the question is how the East can help the West to do just that.

Considering a few options exclusive to the developing world:

• Open source data collection - prompting patients to store data to help others and providing a platform for assimilation of complex data in streamless and organised fashion;

• Promoting talent search amongst the millions of young biology graduates by structuring their goals towards common incentives;

• Utilizing the mobile number as a unique health identity, and then following the footsteps of health and disease with a constant focus on the affordability of prevention and cure;

• Deriving stronger AI, with highly variable presentations, approaches, treatments and affordability;

• Embracing the world of generics and biosimilars but with caveat of data as royalty;

• Conducting phase 4 studies in millions of patients rather than thousands, by bringing the cost of treatment closer to the marginal resource costs of pharmaceutical companies costs, and leveraging the results against strength of evidence and increasing prescriptions in the West;

• Availing philanthropic funds to provide health insurance that enables people to detect cancers early, as earlier diagnosis saves costs; and

• exploring amalgamation of traditional Eastern forms of medicine with present day allopathic treatments to see if toxicity can be reduced, thereby lowering the additional cost of treatments.

We need to consider all of these options, in order to discern how one or all of them can benefit both East and West by marrying sophisticated open-source Western IT to the large numbers provided by the East, and by combining both with the exhaustive costing of oncology treatment.

I believe that ideas like this have the strength to change the world and change it forever.

In my presentation I will be giving examples of how each of these propositions can be a reality rather than a fantasy, and can help to advance the cause of providing uniformity of healthcare for all in a multipolar world.