developed by the automobile industry—in which multidisciplinary teams worked together.7 Meanwhile, the use of cancer patients for medical experiments during the early and mid–twentieth century led directly to the development of the human subjects protocols in 1978 that now protect patients and guide all manner of research. At least half an episode of my film would be devoted to the first treatments for the HIV/AIDS epidemic, which were initially developed as experimental cancer treatments in the 1960s.
We would have to figure out a way to trace the forces at play in the appearances and disappearances of the corroding bodies that lie at the center of each of so many conflicting projects.
None of these facets of cancer-in-action are in the dictionary—but they would be in my documentary. So would the growth trajectory of the pharmaceutical industry, along a crucial vector starting with Jonas Salk’s 1955 claim that patenting the polio vaccine would be like patenting the sun and extending to Genentech’s proclamation in 2008 that it would charge the highest market rates for its cancer drug Avastin. (And it did so for three years, until the Food and Drug Administration [FDA] withdrew Avastin from the market as a breast cancer treatment, since it did nothing to improve survival rates.)8
The documentary would not, however, attempt the impossible project of unscrambling the too-quickly dividing cells from American history. Much as we might want to render cancer an external threat to be battled, it just is not so. Cancer is our history. Cancer has become us. Manifest within individual bodies—many, many bodies—it is also embedded within this country’s key industries, medicine not least among them.
The combination of a for-profit medical system, the rise of trials and institutionalized industrial methods of cancer research and treatment, and the enormous investments required for radiation and chemotherapy have created the perfect storm, turning the once-backwater specialty of oncology into a major economic force that ties together treatment, pharmaceuticals, insurance, law, and research. Cancer has the highest per capita price of the nation’s medical conditions.
In the last five decades, cancer has gained traction as a multibillion dollar business. The National Cancer Institute’s budget alone totaled $5.3 billion in the fiscal year 2011–2012; other federal agencies (including the FDA, Centers for Disease Control [CDC], and Department of Defense [DOD]) chip in a further $670 million for cancer research; and nonprofits, industry, and the state contribute several hundred million more.9 The National Cancer Institute (NCI) reports that the medical costs of cancer care add up to some $125 billion, with a projected 39 percent increase, to $173 billion, by 2020,10 while the National Institutes of Health (NIH) doubles that with an estimate for 2010 of $263.8 billion. Their accounting includes $102.8 billion in direct medical costs (or health expenditures), $20.9 billion for indirect morbidity costs (lost productivity due to illness); and $140.1 billion for indirect mortality costs (lost productivity due to premature death).11
While some methods of calculation find that cancer and its patients take up too many resources, from another angle, cancer patients are cash cows. Each cancer patient generates millions of dollars in revenues. If one wonders why we would extend the life of a pancreatic patient for a dozen days with a $16,000 drug, let’s remember that this money does not evaporate after twelve days; it continues to circulate in stock prices, salaries, and smaller crumbs of an infinitely profitable cancer pie.12 Just as the demon of communism justified the proliferation of a lucrative nuclear industry, so cancer fills the core of so many economies that if a cure were to be found, the economy might just crash.13
The medical industry has found a way to align (or perhaps it emerged from the alignment of) just enough ducks to be able to tart up a coercive economy in market terms. Putting a market value on health makes this possible. If you wanted my money, the best way to get it would certainly not be to rob me (I have only $43 in my pocket) or to take me to court (my insurance will offer you only $1 million if you slip on a banana peel in my apartment). Nor would it be to take me to the collection agency, offer me a mortgage, or get access to my life insurance. The best way to get my money would be to offer me many rounds of treatment for a deadly illness and make sure my insurance pays for them. For medical care—more than housing, childcare, education, food, fashion, transportation, or gym fees—an insured person can pay much, much more than his own worth. She can pay much more than any free market would bear. This economic skew creates a health bubble in which anyone with insurance, and especially anyone with both cancer and insurance, is a gift that just keeps on giving to those who can provide what he needs.14
The resulting distortion affects consequential definitions of health. My financial advisor, for example, might recommend that I take pills with a co-pay of $35 a month, rather than pay a gym membership fee of $99 a month. Costs remain high even for tests and treatments that have not significantly improved in the last decade, such as magnetic resonance imaging. It’s no surprise, then, that healthcare has become the most profitable industry in the economy.15 And most people will pay anything for a small chance at living longer. As one young man put it, “If they told me to eat pinecones, well, I would do it.” If oncologists started prescribing them, and insurance covered the cost, pinecones would become more and more expensive. One in five dollars in the economy goes toward this haphazard version of “health.”16
As many commentators have noted, a privately funded, for-profit medical system does not create the most likely scenario for the shattering of scientific frontiers. The pharmaceutical industry offers a case in point. With the cost of bringing a drug to market in excess of $800 million and low FDA approval rates for new cancer drugs, any investment in new drugs is highly risky. Simple math confirms that drugs with expandable markets will bring more profits than drugs for targeted illnesses impacting smaller populations. The annual top-ten list of most profitable drugs in the United States typically includes drugs with elastic definitions of diagnosis—depression, anxiety, insomnia, high cholesterol, sexual dysfunction: all markets that have been steadily increasing.
This market force disinclines private industry from working on subcategories of cancer. Various problems result. First, drugs are often tested on large and diverse subject groups in order to capture the largest populations. The results of such studies make it impossible for doctors to extrapolate just which individuals would benefit from any given treatment. Second, little incentive exists to produce generic drugs, which bring low profits. For this reason, for example, mechlorethamine, or nitrogen mustard, one of the original chemotherapy drugs tested in the 1960s in the treatment of childhood leukemia, has been in short supply. A recent study on the impact of the shortage found that the substitute drug significantly reduced survival, having “devastating effects on [children] with [otherwise curable] cancer.”17
Several common cancers, therefore, come under the purview of rare diseases, which the Orphan Disease Act of 2002 describes as affecting “more than 200,000 in the United States and for which there is no reasonable expectation that the cost of developing and making available in the United States a drug for such disease or condition will be recovered from sales in the United States of such drug.”18 This remains generally the case even with the rise of a few “boutique” drugs, in which extremely expensive drugs are profitable at the cost of excluding many from access.19 Ironically, what makes for good science makes for poor economics; subsets shrink markets, thus reducing the chances that companies will develop more specific treatments.
Thus, health resists market quantification. Putting health in market terms somehow crushes the notions of choice that undergird true market actors and give them an intimidating tinge (sure, you could refuse this $100,000-a-week incubator for your sick child). Such systematic market and health forces have nothing per se to do with ill intent. (I’m not saying that anyone is evil.) No one necessarily wants corporate interests to trump human well-being or important scientific research. But the chances that a sector whose binding legal concern is stockholder profit will lead to adequate research and better public health are slim. When the question becomes one of math, anyone can do it.
While
