Dire di­ag­no­sis


Southeast Asia Globe - - Feature - BY CRISTYN LLOYD

INa stark white of­fice on the sec­ond floor of the newly in­au­gu­rated Na­tional Can­cer Cen­tre (NCC) in Ph­nom Penh's Cal- mette Hos­pi­tal, Eav Sokha, di­rec­tor of the cen­tre, sits jovially sketch­ing a rough map of the King­dom on a scrap of pa­per. “In the fu­ture, we ex­pect to es­tab­lish a na­tional can­cer net­work tri­an­gle,” he says with a smile, pointing at the NCC and two fu­ture cen­tres planned in Siem Reap and the north- east­ern re­gion of the coun­try. “That is our dream. With these three can­cer cen­tres es­tab­lished, the goal is to cover 70% of our to­tal can­cer pa­tient pop­u­la­tion.”

The ground­break­ing NCC, a $36m project that opened at the be­gin­ning of this year, is one of only two fa­cil­i­ties where can­cer pa­tients in the King­dom can re­ceive treat- ment. The other, Ph­nom Penh's Kh­mer-Soviet Friend­ship Hos­pi­tal, could treat only about 500 out of 15,000 cases per year. The NCC can cur­rently treat 1,000 new cases per year, with a goal of 2,000.

More than 14 mil­lion peo­ple world­wide were di­ag­nosed with can­cer in 2012, a fig­ure that is ex­pected to come close to 25 mil­lion over the next two decades, with the burden fall­ing over­whelm­ingly on low- and mid­dle-in­come coun- tries, ac­cord­ing to the 2014 World Can­cer Re­port from the In­ter­na­tional Agency for Re­search on Can­cer, which forms part of the World Health Or­gan­i­sa­tion (WHO). It is es­ti­mated that about 60% of global can­cer in­ci­dence oc­curs in de­vel­op­ing coun­tries, and rates across South­east Asia are ex­pected to surge in the com­ing years, reach­ing lev­els 40% higher by 2030 than those in 2012.

Faced with ill-equipped in­fra­struc­ture and lim­ited re­sources, as well as nascent health­care sys­tems, Asean na­tions must act fast to com­bat a ris­ing health cri­sis. A 2015 re­port by the Ge­orge In­sti­tute for Global Health ex­am­ined the eco­nomic im­pact of can­cer in eight Asean coun­tries: of the 10,000 first-time can­cer pa­tients mon­i­tored over the course of a year, more than 75% of them ei­ther died or faced eco­nomic catas­tro­phe within that same year, their suffering com­pounded by low so­cioe­co­nomic sta­tus, lack of in­sur­ance and late-stage di­ag­no­sis.

One cause of the up­surge in can­cer cases comes as a nat­u­ral re­sult of eco­nomic devel­op­ment, par­tic­u­larly in­creas­ing life ex­pectan­cies and changing lifestyle habits cou­pled with poor hy­giene, says WHO. Yet ex­perts rec­om­mend tak­ing the ap­par­ent in­ci­dence in­crease with a pinch of salt – the lack of na­tional can­cer reg­istries across many South­east Asian coun­tries, plus im­prove­ments in di­ag­nos­tic ca­pa­bil­i­ties, means that in the past many pa­tients went un­di­ag­nosed, and ac­cu­rate num­bers are still lack­ing to­day.

“The med­i­cal tech­nol­ogy here [is] now much better,” says Sokha. “Now [that] we de­tect more can­cer, the in­ci­dence [has] in­creased. Be­fore, I think that the in­ci­dence [was] also high. But we don't know.” South­east Asia has the least num­ber of coun­tries with na­tional can­cer reg­istries, at 60%, ac­cord­ing to the 2014 World Can­cer Re­port, mak­ing it dif­fi­cult to plan and im­ple­ment ef­fec­tive treatment strate­gies.

The great­est chal­lenge to can­cer care, and an­other con­se­quence of devel­op­ment, is mis­placed govern­ment pri­or­i­ties, ac­cord­ing to Clar­ito Cairo Jr, pro­gramme man­ager of can­cer pre­ven­tion and con­trol for the Philip­pines De­part­ment of Health. Cairo takes is­sue with the $67m in­vested in the con­tro­ver­sial anti-dengue vac­cine Deng­vaxia. “The WHO's Mil­len­nium Devel­op­ment Goals did not in­clude non-com­mu­ni­ca­ble dis­eases like can­cer,”

he says. “That's why the lower mid­dle-in­come coun­tries like the Philip­pines did not pri­ori­tise can­cer. Only with the Sus­tain­able Devel­op­ment Goals [in 2016 did] our govern­ment [start] to pri­ori­tise can­cer.”

On a pol­icy level, the bur­geon­ing na­tional in­sur­ance schemes across the re­gion are slowly shoul­der­ing the weight of out-of-pocket ex­penses. In 2014, In­done­sia launched na­tional health in­sur­ance that it hopes will cover all cit­i­zens by 2019. The plan has al­ready led to a re­duc­tion in the num­ber of pa­tients treated out of pocket from 50% to 10%, says Soe­har­tati Gond­howiardjo, pres­i­dent of the In­done­sian Ra­di­a­tion On­col­ogy So­ci­ety and chair of In­done­sia's Na­tional Can­cer Con­trol Com­mit­tee.

For some na­tions, in­no­va­tive fund­ing meth­ods have paved the way to in­creased health cov­er­age. In the Philip­pines, the in­tro­duc­tion of a ‘sin tax' – col­lected through levies on prod­ucts such as tobacco – has boosted a cash­strapped health bud­get. “In 2010 we had around 10 bil­lion pe­sos [$19.2m], and then this year we have 180 bil­lion pe­sos

Talk­ing about in­sur­ance is some­thing new for Cam­bo­dia. Now, we look like a baby

[$3.5 bil­lion],” Cairo says. “The bud­get at the De­part­ment of Health has greatly in­creased. So the ac­cess to ser­vices for health has also en­hanced. The Filipinos will now go to hos­pi­tals with­out out-of-pocket ex­penses.”

In Cam­bo­dia, govern­ment in­vest­ment in a social se­cu­rity fund shows its com­mit­ment to pri­ori­tis­ing health­care, ac­cord­ing to Sokha, though the sys­tem is still in its in­fancy. “I think that talk­ing about in­sur­ance is some­thing new for Cam­bo­dia. Now, we look like a baby,” he says with a laugh. Sokha says the govern­ment re­mains un­sure how much treatment the in­sur­ance should cover. With tight bud­gets, he says, they should tread care­fully, as re­liev­ing the burden of out-of-pocket ex­penses may im­pact the qual­ity of care pa­tients re­ceive.

Sokha cred­its the In­ter­na­tional Atomic En­ergy Agency (IAEA) – an or­gan­i­sa­tion that pro­motes the safe and non­mil­i­tary use of nuclear tech­nol­ogy – for much of the new cen­tre's success. The agency has in­vested about $1.5m in the project, do­nated more than $700,000 worth of equip­ment and trained half of the NCC doc­tors un­der the IAEA fel­low­ship pro­gramme, on top of con­tin­ued tech­ni­cal sup­port. It even man­aged to con­vince the Cam­bo­dian govern­ment that the project was worth pur­su­ing amid hes­i­ta­tions and scep­ti­cism over the safety of nuclear tech­nol­ogy.

For In­done­sia's Soe­har­tati, the so­lu­tion lies in pri­vate­sec­tor part­ner­ships. With the in­creas­ing num­ber of pa­tients,

partly a prod­uct of im­proved cov­er­age as more pa­tients can now af­ford to come to the hos­pi­tal, turn­ing to the pri­vate sec­tor seems like a smart op­tion as govern­ment bud­gets are in­creas­ingly un­der pres­sure to sup­ply ad­e­quate equip­ment and drugs. “In my pro­fes­sion right now, around 15 to 20% of [ra­dio­ther­apy] equip­ment in the coun­try be­longs to the pri­vate sec­tor,” she says. “Some [pri­vate firms] set up their own pri­vate hos­pi­tals. But some of them, they put their equip­ment in the govern­ment hos­pi­tals… It works very well.” Hav­ing granted a con­ces­sion to pri­vate com­pa­nies for the oper­a­tion of the ma­chin­ery, the govern­ment will even­tu­ally own the equip­ment once the com­pany has re­couped its in­vest­ment, she says. The Na­tional Can­cer Con­trol Com- mit­tee is also en­cour­ag­ing pri­vate firms to set up in ar­eas that lack ad­e­quate fa­cil­i­ties – such as Pa­pua prov­ince, the Maluku is­lands and the west of Bor­neo's Kal­i­man­tan – so ad­vanced health­care will be­come much more ac­ces­si­ble to In­done­sia's mas­sive and sprawl­ing pop­u­la­tion.

Other such public-pri­vate part­ner­ships are sprout­ing around the re­gion, with coun­tries in­creas­ingly look­ing abroad for help in procur­ing up-to-date tech­nol­ogy and drugs. Takeda Phar­ma­ceu­ti­cals, a Ja­pan-based in­ter­na­tional firm and the largest phar­ma­ceu­ti­cal com­pany in Asia, partly funds can­cer drugs in Sin­ga­pore, Malaysia and Tai­wan for pa­tients who could not oth­er­wise af­ford them.

Sokha's ex­cite­ment is pal­pa­ble as he lists the state-of-theart fa­cil­i­ties at his new cen­tre; nev­er­the­less, he admits that in Cam­bo­dia, can­cer treatment is play­ing catch-up: “When we look to our neigh­bours, we are still far be­hind. Now we [have] started to move up with eco­nomic growth… [and are] try­ing to chase our neigh­bours in South­east Asia. We want to open ac­ces­si­bil­ity to our peo­ple, but with very good qual­ity of care.”

De­spite im­prove­ments in sys­tems and fa­cil­i­ties across the re­gion, it seems clear to those on the front­line that chal­lenges lie ahead. “It is not some­thing like mov­ing our hand,” says Soe­har­tati. “It takes time be­cause we have to change be­hav­iour – the be­hav­iour of the peo­ple as well as med­i­cal doc­tors and the de­ci­sion-mak­ers in the coun­try.”

Two-year-old Aldi Rizal smok­ing a cig­a­rette in South Su­ma­tra, In­done­sia. The archipelagic na­tion is renowned for its high smok­ing ratesSil­via, a 12-year-old child suffering from can­cer, at In­done­sia's Care forCan­cer Kids Foun­da­tionFour-year-old Hidha Ab­dulla Naushad from the Mal­dives be­ing treated in a Sin­ga­pore hos­pi­tal for acute lym­pho­cytic leukaemia

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