The politics of healthcare: China Cure reviewed

The China Cure

Ruby Wang, who has worked as a physician in the UK and as a health policy advisor in China, begins her examination of the rise of China's biotech industry with the story of her grandmother.

When Wang's grandmother was diagnosed with a rare type of stomach cancer in the early 2000s, there were few domestic treatment options beyond surgery to extend life expectancy by a few months.

The drug of choice, Gleevec, produced by the Swiss pharmaceutical company Novartis, cost over US$90,000 a year and was not yet widely available in China, which was still on the "receiving end of global pharmaceutical innovation".

Wang's family's plight was so common that it even became the plotline of the 2018 Chinese dark comedy, Dying to Survive, which revolves around a "hustler hero" who smuggles in generic cancer drugs from India for Chinese cancer patients.    

Unlike many ordinary income Chinese families, however, and in what Wang describes as a fortuitous "chain of contingencies" and sheer perseverance, Wang's mother, then a PhD student in the UK, came across a relatively unknown clinical research programme in Switzerland providing free access to international patients with rare cancers.

"It was against every impossibility that my grandmother finally became one of the few patients in China to receive Gleevec for GIST cancer – and to receive it free of charge," writes Wang.  

Wang attributes her own career in medicine and health policy to this experience, and it is here that I should also confess that my interest in reviewing Wang's book is beyond that of a Western observer of China.

My dad was diagnosed with a rare type of skin cancer five years ago that saw us having to pay out-of-pocket for the immunotherapy drug, Keytruda.

The treatment, as with Wang's grandmother, was successful, but the chain of contingencies that meant we could scrape together the money only emphasised the inequities that exist within the political economy of healthcare. 

Just over two decades on from her grandmother's cancer ordeal, however, Wang paints a very different image of China's biotech and health care landscape.

"In a remarkably short span of time," writes Wang, "China has emerged as one of the most consequential sites of health innovation anywhere in the world."

The impact of this transformation, Wang argues, goes well beyond those who directly interact with China's health system. 

Ruby Wang

Not only does China now boast large-scale digital health infrastructure that helps streamline access to care, but by 2016 it had become the world’s leading source of impactful biotech publications and by 2024 was carrying our 1,900 innovative-drug clinical trials per year (having surpassed the US in total trial numbers in 2023). It is also a global supplier of critical medical components and devices, as well as key pharmaceutical ingredients.

Wang notes that a major breakthrough happened towards the end of 2024, when a phase three clinical trial found the immunotherapy drug ivonescimab, developed by the Guangdong-based biopharmaceutical company Akeso, to have better survival outcomes for people with lung cancer than the bestselling Keytruda.

For countries in the Global South, Wang illustrates that China offers a partnership and a model of healthcare that can be better suited to realities on the ground.  

The dramatic transformation of China's biotech and health system, Wang points out, has been necessitated by the country's demographic challenges and structural changes: a rapidly aging population, the impacts of which won't be buffeted by the same gains in income that blunted that of similar demographic shifts in the United States, Japan and Europe.

Compounding this is the rise of chronic diseases and illnesses that have accompanied China's rapid urbanisation and economic growth, as well as the persistence of infectious diseases, such as tuberculosis and HIV, in lower income areas.

What is more, China has a notable doctor shortage. Compared with an OECD average of 4.5 doctors per 1,000 people, China has just 2.9, and fewer than two in many rural areas. 

It is against this backdrop that officials have been motivated to employ "every lever available, from state coordination and long-term policy planning to industrial mobilisation and cut-throat market competition, in order to build and integrate health innovation into core national health infrastructure". 

Wang describes how central authorities have used five-year plans, which set out the country's social and economic priorities and key initiatives, and national strategies, such as Made in China 2025 and Healthy China 2023 (launched in 2015 and 2016 respectively), to elevate the role of drug innovation and biotechnology within China's broader economic trajectory.

Such national planning measures, along with reforms that have increased firms' access to capital and the return of overseas Chinese talent and technical experts, biotechnology parks have emerged in cities such as Shanghai, Shenzhen and Suzhou. These parks allow universities, firms, hospitals, laboratories and investors to collaborate in close proximity, at lower cost and increased speed. They have also helped foster local expertise.  

The other factor that has helped expedite drug innovation, Wang points out, is China's vast population itself. While the US recorded 2.4 million new cancer cases and just under 700,000 deaths in 2022, China recorded 4.8 million new cases and 2.6 million deaths. Such patient numbers make recruiting for clinical trials far faster than elsewhere.

According to Wang, "Discovery cycles in China can now run within 12 to 20 months, compared to 24 to 36 months in the rest of the world, and late-development trial recruitment can run two to five times faster than US and EU benchmarks."

Not only does clinical research recruitment at the various stages of drug development tend to be more efficient; early discovery, clinical development and late-stage trials are also often significantly cheaper than in places such as the US.

According to Wang, late-stage clinical trials in China cost around US$25,000 per patient, significantly cheaper than the US$69,000 per patient in the United States.

Drawing on research by BCG, Wang notes that drug discovery in China has been estimated to cost just 20 to 30 percent of that in the US.  

Over the past few decades, the ethics and robustness of China's clinical trials and scientific research have been called into question – many will recall the outcry sparked in 2018 by Shenzhen-based scientist He Jiankui after he claimed to have edited the genes of a set of twins in an attempt to make them resistant to HIV.

In recent months, news of the delayed disclosure of the deaths of two children involved in separate gene-editing trials has continued to add to ongoing concerns about the oversight of such trials.  

According to Wang, Chinese authorities are well aware of the longstanding concerns over the "consistency and credibility" of the country's clinical trial data.

"China was forced to confront its own weaknesses in medicine development, realising that, if it was to become more than the world's drug workshop, it has to prove that its science and its data could be trusted."

Consequently, Chinese authorities have embarked on major campaigns to overhaul its review and approval systems, and to bring them into better alignment with global standards.

Despite ongoing public concerns and suspicion, the rise in the number of clinical trials of frontier medicines is not the result of cutting corners, writes Wang, but the culmination of decades of reforms and investment. 

These innovative medicines are made widely available to Chinese patients through the country's National Reimbursement Drug List, overseen by the National Healthcare Security Administration, which is mandated to increase access to affordable healthcare.

“Inclusion is often essential if a product is to reach patients at scale, given the breadth of public insurance coverage in China," writes Wang.

"It gives the payer enormous leverage. The NHSA widens access through affordability, though it often does so by compressing prices, tightening budget discipline and pushing providers and companies to adapt around fiscal constraint."

The flipside of this approach, notes Wang, is that compressed domestic profit margins mean Chinese biopharma companies are incentivised to seek out-licensing deals with international counterparts in order to fund future innovation.   

Much of the latter part of Wang's China's health system evolution concentrates on the rise of integrated digital health platforms and tools, including AI avatar doctors. Such initiatives are likely to be a hard sell to readers inclined to give primacy to privacy, including those of minority backgrounds in countries such as New Zealand who, surveys have shown, are more likely to distrust their governments to handle their personal data.

Wang is careful to acknowledge that even within China such interventions are not without their limitations and controversies and emphasises that they have been able to gain traction due to unique circumstances: not only have the country's uneven economic development and doctor shortage rendered the need urgent, but China's socialist past and the extent to which digital platforms are already embedded in everyday life have helped garner public acceptance. 

For all the potential benefits to patients, practitioners and researchers the transformation of China's biotech and health system affords, Wang points out that its rise is often shrouded in a narrative of industrial rivalry, geopolitical competition and supply chain vulnerability.

In the US, the impact of this discourse can be seen in measures such as the recently enacted BIOSECURE Act and President Trump's executive order aimed at boosting domestic manufacturing of critical medicines.

As Wang notes, while the WTO has seen pharmaceutical products and active ingredients largely exempt from tariffs for member countries, Trump's repeated tariffs threats (including pharmaceuticals from the EU) challenge this precedent.

"Whether patients will be able to access and afford [frontier medicines developed in China] depends on far more than the therapies themselves." 

Chinese and US scientific collaboration has led to major breakthroughs in the recent past in a range of public health fields, writes Wang.

While she does not draw the connection herself, Wang's message calls to mind the example of the polio vaccine still used in eradication efforts today.

The vaccine's development, which saw trials conducted involving tens of thousands of Soviet children, was the result of "exceptional cooperation" between American and Soviet scientists during the Cold War, permitted despite the climate of mutual suspicion. 

Wang concludes the China Cure with a compelling call to maintain cross-border learning and collaboration that keeps patients front of mind.

"In their most vulnerable and painful moments of illness, patients do not care very much which national story others wish to project onto a molecule, device or platform, which regulatory philosophy defined it, or which flag stands behind a laboratory.

"They simply care whether treatment works, whether it is safe, whether it is available and affordable, and whether it can reach them when they need it." 

The Foundation's Asia in Focus initiative publishes expert insights and analysis on issues across Asia, as well as New Zealand’s evolving relationship with the region.