Monday, May 21, 2007

The London Declaration

I post here the “London Declaration on Câncer Control in Africa”. My own comments are in brackets and bold. My first comment though is here … no African cancer patient or carer attended.

I am totally supportive of this project. Our daughter, Kezia, could/would be one of the 95% non-survivors in Africa, if I had not been able to take her to the U.K. to receive treatment under the U.K. National Health Service.

The entire London Declaration is below, my commentary is in square brackets and bold.


Over 130 leaders in all aspects of World Health and Cancer Control gathered in London for a 2 day meeting, chaired by Prof David Kerr [head of Department of Clinical Pharmacology, University of Oxford], the Rt. Hon. Alan Milburn [former UK Secretary of State for Health] and Sir John Arbuthnott [microbiologist and Chairman of Greater Glasgow NHS Board] [why not an African chair member?], to discuss how best to bring comprehensive cancer care to African countries. This meeting built on two previous international conferences, held in 2006, that addressed the issue of the cancer burden in all developing countries (The Cape Town Meeting organized by the International Atomic Energy Agency, IAEA and the World Cancer Congress in Washington DC organized by the International Union against Cancer, UICC). There is a growing awareness of the magnitude of the cancer problem in the developing world and a sense of urgency regarding the need to take immediate action. Prof David Kerr, University of Oxford, has recently set up a new organisation to enable the delivery of comprehensive cancer care to African countries, AfrOx, whose mission is to enable the delivery of comprehensive cancer care to African countries.

Impending African Crisis

African countries will account for over a million new cancer cases a year and they are the least able of all developing countries to cope, having few cancer care services. Lack of resources and basic infrastructure mean that most Africans have no access to cancer screening, early diagnosis, treatment or palliative care. Life-saving radiotherapy is available in only 21 of Africa’s 53 countries [and chemotherapy?], or to less than 20% of the population [much less than 20% I suspect given that such facilities will be concentrated in private medical facilities in large cities], and consequently cancer is a sentence to a painful and distressing death. At the same time over one third of cancer deaths are due to preventable causes such as viral infections, poor nutrition and widespread tobacco use [and the other 66%?]. Cancer in the developing world knows no age limits. It is estimated that 100,000 children die unnecessarily fom cancer in the developing world each year. In Africa, on average 5% of childhood cancers are cured, compared to nearly an 80% cure rate in the developed world [WAH! There goes our daughter Kezia!]. In terms of cancer care, the disparities between the standard of care in developed and developing world countries couldn’t be greater. In addition, in many African countries the combined effects of of cancer, poverty, deprivation and infectious diseases hinder the development of a sustainable population and consequently a sustainable future.

The only way to effectively prevent, detect, and treat the rising number of cancers in the developing world is to develop broad and effective partnerships of research institutions, international organizations, NGOs, national governments in developed and developing countries and the pharmaceutical industry. Strong local and international leadership is essential.

The relevant organisations and individuals, with funds from governments and private donors, must be brought together to develop achievable and sustainable national cancer plans that are evidence based, priority driven and resource appropriate for African countries, and we are committed to doing this.


The purpose of this London Declaration is to raise awareness of the magnitude of the cancer burden in Africa and to call for immediate action to bring comprehensive cancer care to African countries.

It builds on the World Health Assembly Resolution on Cancer Prevention and Control (2005) and on previous Declarations from the International Atomic Energy Agency (Cape Town Declaration on Cancer Control in Africa, Dec 2006) and the International Union Against Cancer (World Cancer Declaration, July 2006). [only now? How long has it taken for the international professional health community to wake up? Better late than never].

We are calling on research institutions, international organisations, the pharmaceutical industry and national governments and civil society in developed and developing countries to unite and work together to enable the delivery of comprehensive cancer care to Africa. To establish comprehensive cancer care programmes in Africa requires the integration of clinical and public health systems so as to be truly comprehensive. A comprehensive cancer control strategy must bring together prevention, early detection and diagnosis, treatment, palliative care and the investment needed to deliver these services in terms of trained staff, equipment, relevant dugs and information systems, as well as public education. Any cancer control strategy must be guided by the needs of the country. Our vision for cancer control in Africa is a model authored by the Member State , with technical, policy and financial support provided by inter-agency alliances and governments in the developed world. African governments must be the driving force behind implementing cancer control in their countries with support at every level provided by the international alliance. Only in this way can achievable and sustainable national cancer plans that are evidence based and resource appropriate for African countries be developed.

There are grounds for optimism. With concerted early action cancer in Africa is a disease that can be tackled.

There are a number of fundamental areas of cancer control that form the cornerstones o f comprehensive cancer control programmes. The Six Essential Steps are:

Cancer surveillance/registries and national cancer plans

  • Cancer surveillance programmes, including population based cancer registries, are required to collect and analyze data on the scale of the cancer burden in each country. They provide essential information on the incidence, prevalence, trends, mortality and survival rates which is required to help develop a realistic and sustainable national cancer plan. In addition, they help to evaluate the impact f prevention, early detection/screening, treatment and palliative care programmes. Such programmes must be fully supported by governments to ensure that they are complete and comprehensive.

African countries must be supported and assisted in developing sustainable national cancer plans that are evidence based, priority driven and resource appropriate for African countries. It is essential that national cancer plans be integrated with wider development by African governments to ensure a balanced health system is put in place according to national priorities.

Prevention programmes
In 2002 in Sub-Saharan Africa, there were more than half a million cancer deaths and almost 40% of these deaths can be explained by chronic infection and tobacco usage.

  • Vaccination programmes against Hepatitis B virus, which causes liver cancer, and human papilloma virus, which causes cervical cancer, are effective ways to reduce the growing cancer burden and should be made widely available.
  • Similarly, reducing tobacco consumption will also prevent many cancer related deaths. While lung cancer is on the increase in Africa, there is a real opportunity to avoid a lung cancer epidemic by implementing effective tobacco control now. Countries should be encouraged to implement the effective strategies identified in the WHO Famework Convention on Tobacco Control (FCTC). Simple steps such as implementing a ban on smoking in the workplace and in public places can be very effective.

Early diagnosis and screening programmes

  • Effective treatments exist for many cancers and the chances of surviving depend largely on how early the cancer is detected and on societal awareness of early signs and symptoms of cancer.
  • National programmes to educate the public and healthcare professionals will result in earlier detection and better survival outcomes. Such programmes must be prioritized and driven by governments to ensure they are appropriate for the local population.
  • Screening programmes to identify at risk individuals, bringing them to curative care earlier, will prevent a large number of deaths.


  • It is thought that up to one third of cancers in the developing world are curable if treated early. In particular childhood cancers have a high cure rate.
  • Effective treatment programmes need to be put in place.
  • Access to radiotherapy facilities is essential for both treatment and palliation. [and what about chemotherapy?]

Palliative care

  • Palliative care is an essential part of the continuum of care of all adult and childhood cancer patients. For terminal cancers, palliative care is essential. Pain and symptom control, coupled with counselling and spiritual care, enables patients to die with dignity, preventing painful and distressing death.
  • Palliative care should be introduced as early as possible to produce effective pain abd symptom control during disease progression, terminal and bereavement care.
  • Palliative care must be introduced into health policies and be included in training at all levels.
  • Accessibility of pain relieving medication, particularly morphine, is essential.

Training and Research

  • A major obstacle tin the provision of adequate health care in Africa is the lack of trained health care professionals. The fundamental importance of having staff with appropriate training across the disciplines (clinical, management, logistics) cannot be overestimated, together with improved working conditions and increased job satisfaction.
  • Established international cancer institutes and other training and health institutions have a major role. They should establish and implements mentoring and training programmes for African health professionals and scientists and help with capacity building partnerships with African institutions. The Global Health Workforce Alliance is currently coordinating an international effort on training of heathcare professionals.
  • New local healthcare personnel must be trained so as to increase capacity and not drain the existing talent from other local needs in both the public and private sectors. This is necessary to ensure a long term sustainable workforce of healthcare professionals. African governments need to be helped to develop the much needed additional capacity.
  • Training and research is a multilateral issue that links into employment and salary issues that must be addressed by the WHO, the IMF, the World Bank and other similar organisations. Sustained funding is necessary to ensure sustained funding.

The London Declaration is a call to action directed at all organizations: governments, international agencies, research bodies, global funders, the pharmaceutical industry, individual benefactors and NGOs.


In addition to my, maybe somewhat flippant, inline comments above, I do have some additional commentary to add.

The emphasis on radiotherapy. Chemotherapy medications were not mentioned at all – our daughter Kezia is not receiving any radiotherapy at all but we have been led to understand that the medications she is receiving are expensive and that they would be beyond the heathcare budgets of most African countries. Cynically, I wonder if this was due to the presence of pharmaceutical industry representatives at the conference. There is no discussion of access to drugs, property rights etc in the declaration. Given that countries such as India, Brazil and South Africa are taking on the pharmaceutical industry over the issue of producing cheap forms of drugs used in the treatment of HIV/AIDS, I am somewhat surprised this was not an issue addressed in the conference´s final declaration. On the positive side I will note that AfrOx is talking to GlaxoSmithKline about making its HPV/cervical cancer vaccine available in Africa.

Employment, training and salary issues, addressed in the last clause of the declaration, are certainly serious. Typically a doctor here has received the minimum medical training in Cuba, Russia, China, Portugal etc. No specialist training. Specialists are usually provided by the donor community and are often not available. There is no oncologist here. And even if there were, many of the tools of the trade would not be available.

Lumping together chronic infection and tobacco usage as major causes of cancer mortality in Africa is not useful. Yes, tobacco usage and related cancers are a significant cause of cancer throughout the world – “chronic infections” is a whole gamut of things.

To conclude I am very happy to see this initiative. I sincerely hope the international community takes action along the lines indicated.

Update: AfrOx has now published the London Declaration here.

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