Poverty + Cancer = Early Death

Poverty + Cancer = Early Death - If you are poor and you get cancer, you’re pretty much doomed.

While this dreaded disease strikes without caring how much money you have in the bank, the realities of life dictate that there is a big gap in how the poor and the rich are able to manage this condition.

“We’re actually finding out that people who are poorer tend to come with cancer far later.

“When they come in the later stages of the disease – stages 3 or 4 – they tend to die.

“So being poorer when you get cancer is associated with you dying far earlier than when you’re rich and having cancer,” says public health specialist Dr Murallitharan M.

The National Cancer Society Malaysia (NCSM) medical director adds that this is something unforgivable as it reflects badly on the entire healthcare system in Malaysia, which has achieved universal healthcare.

According to the Asean Costs in Oncology (Action) Study, cancer patients with low income are five times more likely to die from their disease than high-income patients.

Conducted between March 2012 and September 2013, the researchers followed 9,513 patients across Asean who were diagnosed with cancer for the first time for a year.

The study also found that patients who were initially diagnosed with stage 4 cancer were five times more likely to die than those who came in with stage 1.

This is likely due to the fact that treatments for a number of cancers are considered curative if they are administered at stage 1 or 2 of the disease.

For example, when breast cancer, which is the most common cancer among Malaysian women, is caught at stage 1, almost all patients (99%) are still alive five years later – a statistic also known as the five-year survival rate.

This is in comparison to the one to two survivors for every 10 patients with stage 4 breast cancer.

As for stage 1 colorectal cancer, which is the most common cancer among Malaysian males and the second most common among Malaysian females, around seven in 10 stage 1 patients are still alive five years later, compared to around one in 10 for stage 4 of the disease.

Dr Murallitharan notes that those in the upper-middle class are likely to have steady jobs that offer medical benefits and leave days, or are able to afford their own insurance that will cover the cost of a medical check-up that includes cancer screening.

In contrast, those from a lower socioeconomic status are unlikely to have jobs with medical benefits, or are self-employed and depend on daily income.

Why we don’t screen

Cancer, cancer screening, low income, Star2.com

Accommodation is one of the extra costs that may be incurred while seeking cancer treatment, and as can be seen in this filepic, does not come cheap, even for budget hotels in Kuala Lumpur.

While all Malaysians need only pay a minimum amount to undergo cancer screening at public hospitals and clinics, there are barriers that prevent them from doing so.

Says Dr Murallitharan: “I will be honest and tell you that it’s not that the Government is not doing its best. It’s just that the way the system is structured does not easily allow people to get access to cancer screening.”

Giving the example of a nasi lemak seller, he observes that she would have to first go to a Klinik Kesihatan (health clinic) to get a referral letter to a hospital, then travel to the hospital – which may or may not be near her home – to get an appointment letter for the actual screening around three to six months later because of the long waiting list.

After going for the testing itself, she would have to come back around six to eight weeks later to speak to a doctor and get the results.

“That’s four days of work (and income) gone, and that’s not even considering the cost of transportation and food,” he says. And when you are living day to day, even a few ringgit makes a difference.

In addition, he notes that there are three mindsets in Malaysia that affect the perception of the need for cancer screening.

The first is Malaysians are not really happy with negative test results, even for cancer.

“This is really funny, but it’s like ‘Aiyo, I pay so much and like that’,” observes Dr Murallitharan.

“So what happens is, this actually acts as a kind of deterrent for future testing.”

People think that as they have already undergone screening once, they need not waste money doing it again.

The second is “out of sight, out of mind”, where the lack of symptoms means there is no reason to get tested, especially considering other daily priorities for those of lower income.

The third contains elements of both the second mindset and a form of denial.

According to Dr Murallitharan, the thinking is “I don’t want to open this Pandora’s box. What if I find out it is positive?”

From NCSM’s screening programmes with underprivileged communities, he shares: “What we are finding out is that they know what cancer entails and they know that a diagnosis of cancer is going to impact their life in a big way, so they don’t want to do testing, just in case.”

And he notes that this is solely financial-driven, from the thought of treatment costs, not being able to work and not being able to support their children, among others.

“It’s very sad that these kind of priorities have to take precedence over life-saving measures, but this is real, and this is actually the battle of inequality,” he says.

Treatment versus cost

And this is exactly the scenario that plays out when someone with a low income is diagnosed with cancer.

“The costs of care often have very little to do with why people drop out; you can get cancer treatment for almost free (from public hospitals), but what you can’t get is transport, accommodation and food for free,” he says.

Giving the example of a two-week chemotherapy session in Hospital Kuala Lumpur, Dr Murallitharan notes that the patient may have to first travel very far from their home to get to the hospital, ranging from a suburb to another district, and even another state.

Because chemotherapy is usually given as an outpatient procedure, this means that the patient would also have to fork out money for accommodation. “There is no cheap hotel in KL for anything less than RM80 a night!” he says.

There is also the cost of food and drinks throughout the two weeks, and the daily travel to and from the hospital.

This is if the patient is well enough to travel on their own.

“When somebody has cancer, they are really ill. More often than not, whenever they travel, someone has to travel and stay with them.

“That’s that person’s day of work gone,” says the doctor, adding that this has much greater impact for those of lower income, especially if they rely on a daily income.

Another crucial point is that, based on qualitative data he has collected, Dr Murallitharan says that there is an almost 40% chance of being fired when a person has a cancer diagnosis in Malaysia.

“Legally, you can’t, of course, be dismissed, but they’ll say like ‘We’re restructuring’ or ‘The company’s not doing so well, so we decided to downsize your portion of the department’,” he explains.

That, of course, substantially impacts on the patient’s financial status.

The family’s ability to make adjustments to their lives is also a major factor.

“One of the really sad things that you hear from families of people with cancer is, ‘We thought after two months she would be dead’,” he shares.

He adds that it is not that the family stops caring about the patient, but that they are unprepared or unable to make the long-term adjustments to their lives, whether in terms of finance or care.

“There is no more money, I have to go back to work, my kids still need to continue going for tuition, there’s only so much the kind neighbours can do, how many times can I take leave?

“It’s like mother gets cancer and there are huge fights in the household over which kid’s turn it is to take leave to send her for treatment.

“Due to all this, people usually drop out of treatment or hide their diagnosis.

“And all of this most often happens in people who are much poorer,” he says.

Another inequality in cancer treatment is that the latest, more effective drugs – the targeted therapies and immunotherapies – are usually only available to patients in private hospitals due to their cost.

“It’s no fault of the Government, but the cost is just too high – even robust health insurance countries like Germany, Canada and Australia struggle with this, so to pay RM1 and expect the Government to give immunotherapy is unreasonable,” he says, adding that the cost can reach six figures for such treatments.

According to the Action study, low-income patients are six times more likely to suffer from financial catastrophe compared to high-income patients.

Financial catastrophe is defined as spending 30% or more of household income on out-of-pocket expenses for cancer treatment.

Early screening helps

The solution Dr Murallitharan feels is a combination of things, including creating a lot more access pathways for cancer screening.

“It’s very easy to just blame the Government – of course, there are things the Government can do, and they are doing it – but in these economically-troubled times, a lot of prioritising has to be done,” he says.

Here’s where the role of non-governmental organisations, like NCSM, and private corporations come in.

Dr Murallitharan shares that more corporations are now starting to understand the good effects for healthcare in sponsoring cancer screening programmes as part of their corporate social responsibility (CSR) activities.

“Sometimes, you don’t see the impact immediately or get a photo op. They’re in it for a long, sustained effort,” he says, adding that the sponsorship is usually for at least a year.

Another helpful factor is that cancer screening is becoming cheaper and easier to conduct.

Dr Murallitharan explains that only those who have a positive result need go on to have a more expensive and accurate diagnostic test that can confirm their condition.

“The only difference between a screening and diagnostic test is how sharp they are.

“So, by design, a screening test is much, much cheaper and sensitive enough to pick up anything ‘funny’ in a person.

“A diagnostic test is much more accurate, but because of its accuracy, it is inherently much more expensive to do.”

How we pay for our healthcare system also needs to be restructured.

According to Dr Murallitharan, the voluntary health insurance scheme the Government has been working on will help to address that.

He explains that under this scheme, a body will decide whether or not a person needs to go for certain types of cancer screening based on their risk factors, e.g. if they smoke or have a family history of cancer, The cost would, of course, be covered by the insurance.

“It’s a needs-based strategy, rather than an income-based strategy,” he says.