Cancer rates in Lebanon are rising and the illness has, or will, touch the lives of virtually everyone in the country. They are a lucky few that do not have a friend or family member that has had to tackle the disease. However, as treatments and awareness improve, people are increasingly coming to realize that cancer is not necessarily a death sentence, but is in a great number of cases a treatable disease like most others.
As the discussion moves from awkward whispers to confident debate there is a need to look at the role of the state in this national affliction. For thousands of cancer patients every year the treasury is the purse from which their treatments are purchased. However, a combination of weak government, pernicious corporate influence and slack policy are impeding the state from fulfilling its obligations.
Over the years a system of laws has been enacted that obligates the government to provide coverage for a number of “catastrophic” illnesses, the term the government uses on the basis of the financial burden of their treatment. The original ailments to fall in this category were dialysis and open-heart surgery, but as the net of state support has widened, cancer treatment has entered into this fold of government activity.
In theory, the state is now committed to providing support for the costs of cancer treatment for anyone who does not have a third party payer. Dr. Rahif Jalloul, president of the Lebanese Society of Medical Oncology, has recently compiled a data analysis of trends among cancer patients in Lebanon and he calculates that some 45 percent of cancer patients go to the ministry of health to fund their treatment, around 35 percent are funded from social security and the remainder are covered by professional or governmental cooperatives, or private insurance.
Even in cases where patients have a third party payer they can turn to the Ministry of Public Health (MoPH) for assistance if the cost of their treatment exceeds the limit of their coverage. In addition to having to cover 100 percent of the cost of chemotherapy treatment, Dr. Walid Ammar, director general of the ministry of public health, says, “The government covers 95 percent of costs for public hospitals and 85 percent in private hospitals, and we have a wavering system for the very poor who get 100 percent… What’s more, we cover radiotherapy when it is necessary.”
A disease in the dark
There is a general consensus that the incidence of cancer is on the rise in the country, but making an accurate assessment of the situation has been hindered by a lack of coherent and comprehensive data. In 2002 the national cancer registry (NCR) was launched in a collaboration between the MoPH and the World Health Organization (WHO), but was hampered by financial, bureaucratic and political impasses. In 2005 the NCR was relaunched as an institution of the MoPH. “The [national] cancer registry is your eyes. Without your eyes you don’t know what to do,” says Michel Daher, professor of clinical surgery at the University of Balamand and president of the Lebanese cancer society.
However, the nation’s vision has been somewhat obscured by the reluctance of hospitals to cooperate with the ministry.
“We are in a country where every hospital thinks they are an empire by themselves,” says Salim Adib, professor of epidemiology and public health at the University of Saint Joseph, and a key player in the development of the registry. “We can pretend to demand [data] but in reality we are just asking because we can’t force them.”
Dr. Ammar at the MoPH admits that initially there were big gaps in the statistics because physicians did not want to cooperate. However, by combining the figures with records kept at the central drug distribution center in the Karantina district of Beirut, the ministry has been able to build a more detailed assessment of the situation, even if it is far from an exact science.
Between 1998 and 2004 there was a sharp rise in the age-standardized rates of cancer in Lebanon, with an increase of around 60 percent in reported cases. According to Professor Marwan Ghosn, head of the hematology and oncology department within the faculty of medicine at the University of Saint Joseph, one of the main reasons behind the rising incidence of cancer in Lebanon is the nation’s aging population. However, he also warns that the figures should be interpreted with some caution.
“We think there is a real increase in the numbers but the data does not represent the real increase,” he reasons, on the basis that with improved detection and data collection systems the increases are exaggerated.
According to Ghosn, the cancers most prevalent in Lebanon — such as breast, lung, prostate and colorectal — reflect trends seen in the developed world (see chart). Between 7,000 to 8,000 new cancer cases are recorded every year in Lebanon, meaning there is an annual incidence rate of between 175 and 200 cases per every 100,000 people. Ghosn says this falls roughly between what is common in the developed world — 400 to 500 recorded cases per 100,000 people — and the lower rates in the developing world — of around 100 cases per 100,000 people.
The growing incidence of cancer in Lebanon is stretching the government’s ability to provide the coverage it is mandated to offer. This reality is compounded by the inexorable rise in the cost of newer and more advanced treatments.
From 2008 to 2010 the MoPH bill for drugs rose from LL52.5 trillion ($35 million) to LL91 trillion ($60.6 million), an increase of some 73 percent in just two years, the lion’s share of which is swallowed up to pay for cancer treatments. Of all MoPH spending on drugs in 2007 (the most recent figure published by the MoPH), 63.6 percent was for cancer treatments, and a source within the MoPH told Executive that data from the Karantina dispensing center suggest that proportion is now likely to exceed 80 percent.
Doctor deals with Big Pharma
“It is not sustainable,” concedes the MoPH’s Dr. Ammar. “We have major problems with some physicians who are prescribing drugs which are very, very expensive and they are putting pressure on the Ministry of Health to purchase them. We know that the pharmaceutical firms are behind them.”
To have the director general accusing the pharmaceutical companies of actively lobbying and influencing physicians’ prescriptions is a damning reflection of the profession in Lebanon. Whilst a number of the doctors interviewed for this report denied this was the case, one senior oncologist told Executive, on condition of anonymity that, “Some doctors have got into a position of a conflict of interest whereby they have been co-opted by pharmaceutical companies to buy the more expensive medicines.”
Under the current system there is a “gentlemen’s agreement” between the doctors, pharmaceutical companies and the government, but the concern is that economic prejudices are too often overriding ethical imperatives. By Dr. Ammar’s own admission, “I can’t enforce [the agreement].”
With regards to which drugs can be administered in Lebanon, the government is the standard setting authority.
A registration board under the MoPH — including members from the order of physicians, the order of pharmacists and the universities — must give the green light to any drug before it can legally enter the Lebanese market. However, beyond this stage the government has virtually no control over what physicians are prescribing on their tab.
“The political aspect is that the government likes to be generous and there is a political commitment to cover the expensive drugs for the population for which they don’t have the resources,” explains Dr. Ammar.
There is no coherent system within the ministry to direct what drugs are being prescribed for what cancers at their different stages of development.
“They are buying more expensive products that are not more effective on the collective level, and there are no standards to say lets move from drug A to drug B,” says Dr. Adib of Saint Joseph. “We don’t have any standard operation approaches to doing things so it is whoever shouts the loudest that gets the money.”
Dr. Ammar at the ministry glumly agrees: “The health authority should have the authority to say ‘no’, but it doesn’t. The authorities in Lebanon do not actually have enough authority.” He cites an example whereby the ministry agreed to cover a prescription for the drug Gleevec at $4,000 a box, whilst “It wasn’t even being covered by the national [social] security in France.”
The impacts of excessive expense
There are two major consequences of this crippling expenditure on drugs. The first is a tragic reality encountered by many cancer patients when the stocks of the drugs they need run out and the government has no more money to buy the necessary medication.
“We give until it is gone, and when it is gone it is gone,” complains Dr. Adib. “So if you are sick in the second half of the year the chances are you won’t be able to get your medication from the drug dispensing center.”
At the ministry Dr. Ammar admitted that this was sometimes the case and that come the end of the year he simply does not have the money to keep the medication stocks replenished. Unlucky patients who get ill at the wrong time are forced to shop on the market themselves, where they may or may not find the medication they need let alone afford it.
In the second strain of the medication tab is that the government is unable to dedicate a sufficient amount of resources to prevention and early detection.
“Of course it is much more cost effective to invest in early detection and prevention — this is where we need to spend our money,” says Dr. Amaar, before adding, “If there is a politician and there is someone saying I am dying I need such and such a drug, yet on the other hand you have the director general telling him ‘please don’t put your money there and put it somewhere more cost affective and after a few years you will get results.’ He will not listen to me. He will listen to the patient who is crying.”
It is stated in the ‘Country Cooperation Strategy for WHO and Lebanon 2010 to 2015’ that, “The current financing structure, with the fragmentation of public funds, tends to focus more on curative care and gives relatively less focus to areas such as disease prevention and public health management in primary care.”
The killer of women
Of all the forms of the disease, breast cancer kills more women than any other, and Lebanon ranks fifth in the world on the basis of the age standardized death rate for the disease. As such there has been a concerted effort to develop the infrastructure, practice and awareness for early detection in screening for breast cancer. The 2010 statistics from the MoPH show that 38.3 percent of cancer cases among women were breast cancer. Based on data accumulated since the early 1990s there are now national guidelines for women over the age of 20 to have a clinical breast examination performed by a physician every three years, and annually after the age of 40. In a 2008 study, a sample of 2653 women aged 35 or over, 77.7 percent said they had a clinical breast exam in the last 12 months.
“[The guidelines] are being implemented more and more,” says Dr. Adib, who is a member of the Breast Cancer National Task Force. “It has all been voluntary but increasingly there is more and more use of mammography as a screening tool.”
In most cases the government will only provide support in funding a mammography if it is prescribed as a diagnosis tool. However, for the month of October, breast cancer month, the MoPH works in conjunction with the nearly one hundred centers that offer mammographies to ensure the price is kept below LL40,000 ($26.7), whereas it would normally cost around LL150,000 ($100) or more.
However, Dr. Jalloul acknowledges that the country is not reaching its targets: “You have to push people to do this screening. We notice last year only around 10,000 did the screening and yet there are around 800,000 [susceptible] women. We are not hitting the target. We should have around 50 percent of our active females doing this mammography every year. Now it is closer to 10 percent.”
Less than the minimum
While the government now plays a minimal role in either prevention or early detection of cancers, Dr. Adib frets that in the future the ministry will be able to do less and not more in this area: “We are not going to be starting anything new in our current financial situation. We are all aware that if you invest in prevention it will give a return on investment but there is not the money there in the first place.”
One area where the government hopes to bring about a change in both culture and practice, while freeing up resources, is within palliative care. As defined by the WHO, palliative care “focuses on improving the quality of life and relieving suffering in patients with progressive chronic illnesses,” in other words, those cases where the illness will almost certainly be fatal. The understanding and provision of this kind of care remains very limited in Lebanon and its development has been identified as a priority for the WHO throughout the whole of the Eastern Mediterranean.
The reasons for the near non-existence of palliative care in Lebanon are several. “Lebanese patients and their families don’t like the idea of palliative care because they have misconceptions about it,” says Dr. Ghosn. “This is important because it means a lot of patients are not really aware of their real diagnosis or their real prognosis. You may have a very advanced cancer case where the patient believes he is going to be cured.”
Further to this, the MoPH’s Dr. Ammar argues there is a problem within the medical establishment itself: “The physicians don’t have the right training. They are trained to prescribe drugs. They are trained to prolong the life as much as they can, but they are not trained to look at the quality of life, at the dignity of the patient.”
Once again he points the finger at the pharmaceutical firms for influencing physicians’ decisions with “their bullshit evidence” to prescribe prolonged and often very costly treatments when patients should have moved onto palliative care, even if cheaper generic drugs do exist [see page 34].
In May 2011 the MoPH launched the National Committee on Palliative Care and the ministry’s Dr. Ammar says development of policy in this field is essential.
“We are working on making [palliative care] drugs more easily available,” he said. “Then to make reimbursement mechanisms for this kind of care, which currently does not exist, and thirdly to create awareness among physicians and the population at large.”
The Lebanese Cancer Society’s Dr. Daher argues that the reasons for developing palliative care are not just moral or clinical, but that there is also a financial rationale.
“Now you have a patient with advanced cancer so why spend thousands on every session of costly treatment?” he asks. “This is the way to ensure better quality of life, with less expense under the coverage of the government… [The savings] can be spent on prevention campaigns of screening campaigns. This is where you need to spend money.”
That the Lebanese government at least strives to provide coverage for the fundamental treatments of cancer patients is perhaps commendable. But as Dr. Adib warns, “There is no holistic strategy. We are working on a case-by-case basis.” Consequently, and by the admission of the director general of the MoPH, under the current system the government will not be able to continue fulfilling its mandate.
A ballooning bill for expensive drugs, lax oversight of which treatments to fund and a political unwillingness to tackle thorny issues of what the government can realistically offer have left the MoPH functioning as little more than a drug dispensing counter, and a failing one at that.