Interview

‘A healthy country is a richer country’

CS Pramesh lists philosophy as one of his interests outside of work and that would surely help him rationalise the ups and downs of life as a cancer specialist. Director of the Tata Memorial Hospital (TMH), professor and head of thoracic surgery at the Tata Memorial Centre, and coordinator of the increasingly consequential National Cancer Grid (NCG), a network of 150 cancer hospitals in India, Dr Pramesh certainly can use such rationalising.

The societal implications of cancer and the means to battle the scourge are of particular concern for Dr Pramesh, among the most distinguished of the many fighting the good fight against what remains a relentless and deadly disease. He speaks here with Christabelle Noronha about cancer and the variety of subjects the treatment of it touches. Excerpts from the interview:

It’s getting close to seven years since NCG was established. Have the expectations from it been realised? What has been learned along the way?

When you look at the overall picture, NCG has far exceeded expectations but I wouldn’t make that an unqualified statement. In some areas we have progressed much beyond what we thought we would, but there are areas where we could have done better, where we encountered hurdles we did not anticipate. All said, the effort has been very, very fulfilling.

The attempt and the premise has been to standardise cancer care in India. However, given the way the grid has grown, it has expanded our vision significantly. We no longer look only at standardised care for patients but also at how we can help the centres in the network help one another with specific expertise and conduct collaborative cancer research. The number of initiatives that we have begun and their breadth have been remarkable. Where we have not done well is with data aggregation.

CS Pramesh

Which is the sphere where NCG has done well?

There are four spheres where we have done much better than we expected. First, we have made significant progress on standardising cancer care across India. Second, we have tackled the problem of multidisciplinary care and how this affects treatment. The third point relates to collaborative research and the final aspect that has panned out really well is our ability to negotiate with outside agencies as a group.

You co-authored a paper titled ‘Look beyond technology in cancer care’. In the context of India, where would you recommend looking, and why?

We published that paper in Nature and the title was deliberately provocative. I am actually a big fan of technology, but the way medical technology is going, we need to take a look at two distinct and different aspects of it. First, the so-called technological advances in patient care, by which I mean more sophisticated radiation machines, more sophisticated adjuncts to surgery, increasingly newer molecules in chemotherapy and certain molecular tests that are supposed to improve outcomes in cancer treatment. This aspect of technology is what we spoke out against.

The reason for the criticism is that all of this is very high-tech and cutting-edge, which automatically gets interpreted — by both physicians and patients — as superior. Unfortunately, since it is better technology and gets equated with superior outcomes, people have embraced this without hesitation. The result is that treatment costs have gone up exponentially whereas the actual evidence on the superiority of the outcomes has been marginal, if not nonexistent.

The paper also says that countries doing poorly on “cancer survival and mortality do so largely because of deficits at the political, economic and social level”. How can we even begin dealing with these deficits?

I think these are major issues that we need to discuss. They are very, very big problems but at some point we need to make a start. And that start would probably be to identify that there is a problem. Based on the experiences of several countries, we now know that the ideal public expenditure on healthcare is about 6% of GDP. In the United States it is 18% and most of Western Europe would be at 10-11% but it is countries like Thailand — which is at about 6% — that have hit the sweet spot. Their outcomes are comparable to countries that spend two-three times more.

In India overall health expenditure is 3.5% of GDP but even that is an overestimate because public expenditure is at only 1.5%. So forget 18% and 12%, where is it even close to the 6% Thailand has got to? That’s the target we should be looking at and this can happen only through political will. Fortunately, there has been a change over the last three-four years; more and more political parties are beginning to realise that health should be a priority.

A healthy country is a richer country. The utopian standard of universal healthcare — which means that every citizen of the country should be able to access free healthcare — is getting recognised more and more. The World Health Organisation [WHO] has come out strongly in favour of universal healthcare and that is adding to the pressure on governments around the world.

Burnout rates among physicians treating cancer patients are several times that of any other medical speciality... Suicide rates are highest among cancer physicians.”

Pharmaceutical companies haven’t exactly covered themselves in glory when it comes to cancer. If you had the chance to regulate pharma companies in the cancer-treatment ecosystem, how would you go about the task?

That’s a very good question — and not an easy one to answer. Pharmaceutical companies need to find it viable to research new drugs and new treatment options, and at the same time make such treatment affordable to patients. But one thing we fail to recognise, and the pharmaceutical industry has failed to recognise, is that unlike with products like televisions or mobile phones, its ‘customers’ are at their most vulnerable, especially those who have been diagnosed with cancer and similar conditions.

The common reasons — I call them excuses — that the pharma industry gives to justify the high cost of their products is that it takes a lot of money to create or develop a drug. I don’t disagree with the argument, but I still feel that the final price of drugs that come into the market is unaffordable for the vast majority.

A recent WHO study showed that for every dollar the pharmaceutical industry invests in research and development it makes a profit of $14. That is an obscene level of profit. A 14-fold margin extracted from a captive and vulnerable customer is, to me, unacceptable and exploitative. Clearly, and there are enough examples to prove the point, the industry is incapable of regulating itself.

What role do you see for philanthropic organisations, nonprofits and civil society as a whole in lending a hand to ease the cancer care burden India is buckling under?

Philanthropic organisations have a vital part to play and one of the best examples of this is the Tata Trusts’ partnership with TMH, which they set up 78 years back. That partnership has continued, the most recent example being our joint effort in establishing a cancer centre in Varanasi in remarkably quick time. I only wish we had many more such organisations.

What accounts for TMH’s standout achievements and reputation? What has it done right and why can’t similar institutions in India’s public health domain replicate the effort?

Of all the questions you have asked, I think this is the most difficult, and I probably will not be able to give a satisfactory answer. I believe we owe a lot to the heritage of this institution. TMH is a classic example of an organisation built not by concrete and equipment but by the quality of the people who populate it. And for this I credit every single employee who works here, from top to bottom.

I have been with several healthcare institutions and in many of them the final credit of a patient getting better goes to the doctor, which in an era of teamwork and team science is a big mistake. The difference with TMH is that every nurse, every technician, every ward boy, every sweeper believes he or she is contributing to the end goal of patients getting better.

I don’t know how this can be replicated elsewhere. Medicine in countries like India has an extremely hierarchical structure. Doctors are put on a pedestal and everyone else is subservient to them. It’s about time this outlook changes; doctors need to wake up to the fact that they would be nothing were it not for the teams supporting them.

Your primary clinical areas of interest are said to be the treatment of oesophageal and lung cancers and minimally invasive surgery. Why these streams?

These have been instinctive decisions for me. I cannot explain rationally why I made the choices I did, except that to me it’s challenging being in a field where outcomes are not great. It fuels hope that you could maybe help make these outcomes better. I find this a good in-between place to be, where the potential to improve is significant and you are in a niche area. That’s how I try to explain it to myself.

A cure for cancer appears to be as far away as ever. What hopes do you have that this elusive creature can be found in your lifetime? Or are incremental advances all that we can realistically expect?

The moment we start using terms like ‘finding a cure for cancer’ you get drowned in a lot of hype that is not justified. A more moderate term to use would be ‘to improve outcomes in cancer’. That is already happening in our lifetime and is likely to get even better in the near future. Between incremental advances and breakthroughs, what is likely to happen? I think both. You will have breakthrough discoveries which revolutionise how we treat cancer but the default option will be these small increments.

The Tata Memorial Centre in Mumbai, says Dr Pramesh, “is a classic example of an organisation built not by concrete and equipment but by the quality of the people who populate it. And for this I credit every single employee who works here...”

Cancer doctors must surely need a defence mechanism to cope with the patient distress that they encounter all the time.

Yes, cancer doctors do need a defence mechanism. Burnout rates among physicians treating cancer patients are several times that of any other medical speciality. That says a lot. You see physicians getting clinical depression because they are treating patients with cancer over and over again. Suicide rates are highest amongst cancer physicians, so it’s not a small problem.

I think each of us develops our own defence mechanism in our own way. One way I deal with this is to be sure that the treatment I suggest is based on the best evidence we have customised to the unique socioeconomic and cultural situation that a patient is in. I have come to accept that patients not doing well often has nothing to do with my competence or ability. I have learned this over time and it has stood me in good stead, primarily because you accept that just as your successes are not only because of you, neither are your failures.