Paying for Livelihood

This research project starts with the examination of how a popular Chinese movie about Cancer Drug prices affect policy changes in China and then uses this as an anchor point to investigate how the price of cancer medications might be a problem world-wide. This ArcGis Story map is mainly how the project is presented. Within the story map, there are two ArcGis maps -- one animated, and one swipe map. The first animated map first tries to establish a negative relationship between the amount of money spent on health insurance and the mortality rate of stroke and heart diseases. Then it establishes a positive relationship between poverty and these mortality rates.This analysis contributes to the project as a whole by demonstrating that poor people may be more likely to lose their life due to their inability to spend on health care or health insurance. It illustrates that price of cancer medications may be especially burdensome for impoverished families, as the health care system is hostile to their situation. The swipe map is here to paint a fuller picture. While the research is done on Caner Medication prices, it is also important to note that Cancer is such a huge problem only in well-off countries. The swipe map shows a direct relationship between GDP and how important cancer is to the states. Thus, the astronomical price of cancer meds may not even come as a priority concern for many countries, since their main concern would be about other diseases, like AIDS.

Sudden weight loss, swollen glands, urinating blood... These are all symptoms that cancer patients suffer. While the disease itself has already brought a great amount of pain and suffering to these people, their sufferings do not stop there. In their journey of seeking treatment and survival, there's the soaring price and inaccessibility of medicine that adds to their burden. This project aims to investigate the current situation of cancer patients in a global, modern world with a Chinese Movie, "Dying to Survive".

Dying to Survive tells a story of low-income leukemia patients, who depend on the cancer drug "Glinic" for survival. Yet, because of patent protection, many leukemia patients cannot afford such an expensive drug. The protagonist, Cheng Yong, brings illegal Glinic from India and makes a profit by selling it to the patients. The movie traces the story from the perspective of Cheng, whose mentality of drug smuggling starts with profit-making, but ends with the genuine wish to help those patients. We as the audiences are able to follow Cheng's footsteps to see for ourselves how life has become a luxury for those people.

This clip from the movie illustrates how difficult it is for many people to have access to the drug that saves their lives.

The story of Dying to Survive is a real one. Many cancer patients in China is facing the difficult choice between draining the family's fortune, or death. Even worse, many people do not have this choice. Those who simply cannot afford the medicines are left no other way out but to die. The protagonist Cheng Yong in the movie is actually based on a real person named Lu Yong. He was diagnosed leukemia, and was unable to purchase the expensive medicine. The drug"Glinic" in the movie is referring to Gleevec, or Imatinib, in real life. As a leukemia patient himself, Lu has gone through the struggles that many are facing on their journey to fight against cancer. When interviewed, he mentioned that taking the medicine, which costs 23,500 RMB per month, for two years has destroyed his family's financial situation. Yet, his family was actually relatively well-off in the area he lived in. Many other patients, according to him, cannot spare enough money for Gleevec, and even if they do, they cannot afford to eat continuously.

The following video is a clip of Lu Yong's interview by CCTV.  The full interview  takes about 20 minutes, but has no English subtitle. I edited the following video to 3 minutes and added on English subtitle. This clip gives us a glimpse to his life battling against leukemia and to how he started using Indian Gleevec while helping others to gain access to this alternative.

With 453 million box office sold and many pained by this harsh reality, "Dying to Survive" was able to advocate for a real change in Chinese society. Chinese Premier, Li Keqiang, spoke to order cancer drug price cut after the release of the movie,

“If there is one cancer patient in a family, that family will devote all their resources to them. Even the entire extended family will need to help. Cancer has become the number one threat to people’s lives and health. We need to do whatever we can to save the patients and relieve their families’ burden. We need to solve this problem as soon as possible.”

By now, China has already taken measure to remove tariff on cancer medication and has included types of cancer drugs in the universal health insurance. In addition, because of Lu Yong's case, China has also altered the policies on unlicensed medications. With the changed law, carriers of unlicensed medicines would not be heavily charged as long as the amount is small and there is no severe side effects.

While the movie itself tells a detailed story of how Chinese patients are facing these struggles, the price of cancer or of health care in large is a global issue. “A global comparison of the cost of patented cancer drugs in relation to global differences in wealth” is a research that looks at the prices of different drugs in relation to each country's purchasing power. The phenomenon that Dying to Survive was portraying is reflected in this table as well. At the "Imatinib" row, we can see that is it a lot cheaper in India (really the cheapest option in India) than it is in China, a main reason for Yong to buy Indian drugs. By looking at the data set, we can see that India, China, South Africa, and USA all have relatively high and varied price for cancer drugs. Compare to these countries, countries with higher GDP per capita, like Israel, UK, and Australia have a relatively stable and lower prices. However, even in these countries, it can take around 3000 dollars for a month of drugs, which is a tremendous amount of money for people in poverty with no health insurance coverage.

“Capitalism characterizes a drawn-out process of social change that relies centrally on the production of commodities and the development of systems of commodity exchange”(Strohmayer 199).

In Key Concepts of Geography, Strohmayer suggests that capitalism is relies heavily on commodification and the system of commodity exchange. Knowing how grave the situation of cancer drug is, it is disheartening to see that for pharmaceutical companies their profit through such commodification has triumphed over their compassion to the patients. In the movie clip above, "Dying to Survive" depicts a clash between the patients and the Swiss company, Novartis. With patent protection in China, it was "rational and legal" for the company to set a really high price, and the representative had no intention of lowering it. This image that the movie illustrated of the pharmaceutical companies might be exaggerated, but is not wrong. The World Health Organization also conducted a research on cancer drug price. In its research report, " Pricing of cancer medicines and its impacts ", the researchers expressed a similar concern of many companies.

"Pharmaceutical companies set prices according to their commercial goals, with a focus on extracting the maximum amount that a buyer is willing to pay for a medicine. This pricing approach often makes cancer medicines unaffordable, preventing the full benefit of the medicines from being realized."

The graph above demonstrates the motivations for a company to set a high price for medication. Compare to other ways of gaining profit, a 1% increase in price results in 11.1% of increase in operating profit, far exceeding the profit yielded by variable cost, volume, and fixed cost. And when companies try to earn the extra percentages of operating profits, many cancer drugs are set at an astronomical price, leaving many cancer patients financially desperate.

While these companies contribute to the setting of soaring prices, the inability of the patients to buy these drugs or the inaccessibility of these drugs can also be traced to inefficient healthcare policies. One reason for Gleevec and other cancer drugs being so expensive in China was because of Chinese healthcare system. Though China provides a universal health insurance, many treatment options for chronic diseases like cancer was not covered, but had to be paid by patients themselves. In this situation, the impoverished population would be unable to access cancer treatment.

In fact, the Chinese health care system is not the only one that leaves the poor out of the picture. The following series of maps aim to establish a relationship between healthcare expenditure, mortality rate, and poverty in the United States.

While we have been discussing the dire situation of low-income cancer patients, who suffer not only from the disease itself, but also structural oppression of pricing and accessibility, it is also important to acknowledge the different dimensions to the narration of caner and healthcare both historically and globally.

“Nationalist representations of historical societies mask key nuances from the geographical worlds of the past, including cultural complexity, hybridity and different scalar identities co-existing both within and beyond the nation” (Morrissey 77). When looking at the history in national concepts, it can be difficult to spot similarities in different countries that are so different in ideology. However, by examining the development of healthcare in the United States and China, both of them actually demonstrated a similar pattern in rise of healthcare cost, even though they have dramatic difference in cultural history and political ideologies. In both countries, healthcare expenditure rises dramatically in the recent decades, starting in the 1970s. In the 1980s, national health expenditures in China more than quadrupled from RMB 10.7 billion to 56.74 billion, and healthcare rate increases more than double the rate of inflation in the United States. With this in mind, we can put this drastic increase into the bigger picture: the start of technological advancement, aging of population, and economical advancement in parts of the world. The price increase of healthcare comes accompanying the recent arrival of modernization.

If the current healthcare issue is accompanying the problem of modernization, then places with different degrees of modernization are facing distinct challenges. Although this project mainly aims to discuss cancer drug prices as a global issue, it would be problematic to say that this is the most pressing issue for everyone. In Trever Noah's "Born A Crime", he articulates the sharp contrast between the widely-aware Holocaust and the negligence of many other brutalities of genocide. It was problematic for him that all know the disasters in the white history, but the disasters in other race and ethnicity groups are rarely discussed (Noah 195). This similar thought can be applied to the analysis of the healthcare system. So many of us, coming from a modernized sector of the world, sees cancer as the number one health issue around the world. However, though cancer tremendously impacts many countries and governments in modernized places, its scale of impact varies greatly, and in many other places around the world, there are more pressing diseases people are facing.

The swipe map above compares a country's national income with its ranking of cancer premature mortality. There is a closely related relationship between a nation's income and how impactful cancer is: Countries with more national income: the US, Canada, UK, Germany, and Australia all have cancer as their number 1 cause of death for premature mortality rate. However, for countries with lower national income, like India, Nigeria, Tanzania, Namibia, and many other states in Africa, cancer ranks between 5th to 10th place in their cause of death for premature mortality. Echoing the previous discussion on modernity and the emphasis of world awareness, the point here is not that cancer patients are not a problem -- the major portion of the project aim to articulate the challenges that they face, but is to remind people that cancer, for many, is not their scariest problem of healthcare and survival. AIDS in many Africa countries take a lot more lives than cancer, and as global citizens, we need to keep these factors in mind as we approach healthcare issues from an international perspective.

Anchored by the movie "Dying to Survive", the lives of many Chinese cancer patients came live to us. In addition to the symptoms of diseases, they are also confronted with huge obstacles just to stay alive. Yet, this seemingly local movie connects globally similar issues that many patients face, as a result of pharmaceutical companies' price setting and the inefficient healthcare system worldwide. At the same time, approaching the dire situation more appropriately with our current world, we should also keep in mind the many other perspectives in the world.

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Wen, Muye, director. Dying to Survive.

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