AfrOx revisited

Back in May 2007 we reported the launch of AfrOx, the Africa-Oxford Cancer Consortium, at the African Cancer Reform Convention held in London and attended by representatives of nineteen African health ministries, various international cancer experts and representatives of international organisations involved in cancer prevention and treatment.

It was noted that more deaths are attritutable to cancer than malaria, tuberculosis and AIDS combined. Whereas 80% of childhood cancers are cured in the developed world, the figure stands at 5% in Africa. I could go on ...

We haven't heard much from AfrOx since. However, it now seems to be getting off the ground. A revamped website with the conference's final report "Building Sustainable Cancer Capacity in Africa: Prevention, Treatment and Palliation" sets out the organisation's vision and strategic guidelines.

It is ironic that after the cruel deportation from the UK of Ghanaian myeloma patient, Ama Sumani, and her subsequent death earlier this year that AfrOx has chosen to collaborate with Ghana in its first project to develop a National Cancer Plan.

Professor David Kerr of the University of Oxford and Alan Millburn (Labour MP and Secretary of State for Health from 1999 to 2003) have just returned from a visit to Ghana (accompanied by two BBC reporters!) where they met with representatives from government, medical institutions (it seems there are only two consultant oncologists in the entire country), the Cancer Society of Ghana and civil society.

As well as developing a national cancer plan, or rather as part of it, AfrOx aims to facilitate training for doctors, nurses etc.

David Kerr and Alan Millburn's visit to Ghana was funded by a one-off donation by a rich benefactor. AfrOx does need to raise its UK fund-raising profile.

Ghana was chosen as a starting-point due to its political stability, its links with the UK - although a country with a population of 23 million. To make an impact on cancer in Africa - where do we start? I understand the choice of Ghana - its easy - but why not Sudan, Chad, Zimbabwe, Zambia, Kenya, Mali, Niger, Senegal, Congo ... ?

Small Steps

Yesterday the Macmillan nurse visited Kezia´s school (from September) to discuss her special needs with her future teacher (who just happens to be Jaime´s teacher this year – quite happy with this continuity – Gill already knows us, has met Kezia and knows of our situation). We are happy her Hickman Line is out, one less worry at school for both ourselves and Gill.

I do wonder though how Gill is meant to distinguish between and/or react to drug-induced bad moods or misbehaviour versus general childhood petulance. Kezia hits the kid next to her, steals his/her snack or goes into a corner and won´t talk and/or cries. I am sure Gill will be amazing as she deals with kids every day … but absent dad could do with some reassurance please!

On Thursday there is an “open day”, or rather hour, for September´s intake – a kind of familiarisation exercise, I guess, to help avoid tearful scenes on the first day of school. I don´t think this will be a problem with Kezia – at the moment she is impatient to start - “if Jaime can go to school, why can´t I?”. And I know Nanda is talking it up …

Kezia didn´t want to speak to me yesterday – she finished five days of Dexamethasone on Sunday and is moody. Lucia has often related how dreadful this drug is, has had to go on morphine due to the pain it caused so I can only wonder what Kezia feels especially with no means of verbalising it.

Last week´s medical blogosphere “event” seems to have been the bombing attempts in the U.K. by, at least, two NHS doctors (the other suspects, I should stress, innocent until proven guilty). NHS Blog Doctor´s very sensible post on the subject whipped up 97 comments – with particularly bigoted comments from someone called “american md”, I posted two or three of my own in reaction and whipped up Lucia´s support – the dedicated staff (Muslim or otherwise) of the Royal Manchester Children´s Hospital and the NHS must not be subjected to such abuse. I am happy to see that Dr. Crippen posted her comment in his weekly BritMeds.

However, judging by the BBC´s website (ok, it is not necessarily representative ..,), the issue seems to have dropped off the map. There was one headline (non-) piece in the Asia/Pacific section Monday about ongoing investigations in Australia, there was nothing in the U.K. section. Are the government and police not giving press statements and keeping mum or are we so used to terrorist attacks in the UK (international readers, remember what we went through with the Northern Ireland troubles) that non-successful attempts are no longer news?

And, blimey, no-one commented on my own post on the subject – the price of non-fame?

Penultimately, I will point you to two posts by bush doctor in the city about a kid in the Delta region of Nigeria with Burkitt's Lymphoma (here and here). This is what the AfrOx Project is about – don´t just throw emergency aid at healthcare in Africa or Asia but help us develop healthcare systems. Given the state of the NHS and US healthcare, perhaps you´re not so good at that …

Finally, congratulations are due to both Lucia and Fergus (Lauren and Rob´s son) for finishing chemotherapy. I don´t have a deity but will pray the other shoe doesn´t drop. In many ways this could be the most difficult stage – watching, waiting, lingering.

Please don't stop blogging - you are messages of hope for those of us behind you. Lauren and Rob - the photos of Fergus' last chemo and lumber puncture are both inspirational and useful (... and why didn't any of us think about this before?!). Thank you for sharing them.

AfrOx Update

AfrOx has now posted on its website several of the presentations from the Cancer Control in Africa meeting held in May.

Radiotherapy, Radiotherapists, Africa and the NHS

I’m learning a lot.

Percentage rate of various cancer treatments (in the U.K.) goes along the following lines according to therapy:

Surgery: 49%
Radiotherapy: 40%
Chemotherapy: 11%

Hence AfrOx/IAEA emphasising radiotherapy over chemotherapy for developing world treatment. There is no mention in the AfrOx or PACT literature on surgical or chemotherapy control and training.

I also note that the IAEA is concentrating on the provision of Cobalt-60 machines. The numbers of the two types of machine in the U.K. are as follows:

Linear Accelarators: 199
Cobalts: 8

The report explicitly states “old cobalt machines”. So I wonder why the IAEA/PACT programme is concentrating on Cobalt-60 machines. Expense of LAs versus C-60s? Expense of maintaining LAs vs C-60s, simplicity of use or maintenance etc etc. I don’t know. But I hope the developing world is not being fobbed off …

So I’ll come on now to the NHS – there is no shortage of radiotherapy machines! Thank your deity etc …

Well, there is …

Radiotherapy capacity seems to be measured in MegaVolts per million population. I love that … visions of Frankenstein movies!

France: 6.12
England: 3.37

And when Italy (4.31 mV) beats England in the league tables, you have to be concerned!

The WHO recommends 5 machines per million. From 1997 to 2002 waiting times have became longer and the number of out-of-date machines has increased.

As in the rest of the NHS, there is a shortage of trained staff:

- a total of 431 of consultant oncologists with a shortage of 14%, and with an additional 262 clinical oncologists needed by 2010 taking into account attrition and increase in cancer occurrence. (Hi MTAS!)

- 17% shortage in therapy radiographers – “many departments are not able to use their full [equipment] capacity because of the lack of therapy radiographers”.

- 6.6% lack of physicists [essential for equipment maintenance] in some areas as high as 25%.

Need I say more …

Reference here.

International Atomic Nuclear Agency

We normally associate the IAEA with monitoring nuclear power and weapons programmes in countries such as Iran and North Korea. Its current head, Mohamed El-Baradei, ever the diplomat and much respected, is often seen on television talking about such issues. I have much respect for him, a voice of calm and reason in wars of rhetoric that seem to be on the brink of actual wars.

However, there are other aspects to the agency’s work. As its charter says, “the IAEA carries out programmes to maximize the useful contribution of nuclear technology to society while verifying its peaceful use”.

One little known activity of the IAEA is, therefore, the promotion of radiotherapy techniques, equipment and training for cancer treatment in the “developing” world through its Programme of Action for Cancer Therapy (PACT).

In most developed countries there is a ratio of one radiotherapy machine per 250,000 inhabitants. In developing countries it is more common to find ratios of one machine per several million inhabitants. Fifteen countries in Africa have no radiotherapy facilities at all. In Ethiopia the IAEA has provided one machine which serves a population of c. 60 million (i.e. comparable to the U.K. which has 207 machines, one per 290,000 inhabitants: reference). In its first four years of operation 1300 people were treated with a four year survival rate of 50%. The survival rate is not as good as the developed world, principally because diagnosis is frequently at a stage when the disease is far advanced. The IAEA is working with 22 countries (not ours) in Africa.

The IAEA estimates that $2.5 billion over ten years is needed to provide adequate facilities in the developing world with half that sum being allocated to training (refreshingly given Friday´s post on human resources).

The recent Cancer Control in Africa conference (posts here, here and here) was a joint initiative between AfrOx and the IAEA.

Reference here.

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.

Background

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.

Purpose

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.

Treatment

• 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.

Commentary

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.

AfrOx Conference Update

Apparently last week's conference on cancer in Africa issued the London Declaration setting out aims for developing an action plan. I cannot find the declaration yet but if/when I do, I promise to link/publish it. Link here to report from VOA.

Friday Update: I have just received the London Declaration from AfrOx. They will be posting it next week with other details of the conference. Apparently it is already in the public domain so this weekend I'll get a posting written. Watch this space on Monday.

AfrOx and AORTIC

AfrOx now has a website here. I am informed the London Declaration will be posted tomorrow.

Another notable organisation (site here) is the African Organisation for Research and Training in Cancer. Given the vast problems in cancer prevention and treatment in Africa it is heartening to read about innovative projects taking place across the continent.

I have linked to both on the right.

Cancer in Africa

Yesterday and today see a major conference in London on cancer in Africa.

We see so many reports on "African" illnesses - malaria, HIV/Aids, malnutrition, guinea worm etc etc - it is easy to forget that people who live on this continent are just as prone to cancer as people in the "developed" world.

Kezia's story might even be considered typical - to a point. Born in Africa, growing up in Africa, seriously sick but no means available to diagnose what is wrong and even if there were, no resources to treat her leukaemia. She was lucky - her dad is British and had the resources to get her back to the UK for diagnosis and treatment. Otherwise she would be dead.

The University of Oxford's Africa-Oxford Cancer Consortium (AfrOx), set up by Professor David Kerr has organised the conference along with the International Atomic Energy Agency's Programme of Action for Cancer Therapy.

The Cancer Control in Africa conference brings together health ministers or their representatives from 22 African countries, donors, healthcare professionals, the pharmaceutical industry, cancer charities, research organisations and others aiming to begin creating an action plan for cancer control in Africa.

As David Kerr says "People don’t perceive cancer as a developing-world problem, but more than 70 per cent of all cancer deaths occur in low and middle income countries ... This figure is rising due to increased life expectancy, increased tobacco use and chronic viral infection. Survival rates for cancer in the developing world are often less than half those of more developed countries, and there is little pain relief. In Africa, cancer is a sentence to a painful and distressing death."

Mirroring yesterday's post on access to cancer drugs David Kerr announced in an interview with last Sunday's

Observer that exploratory talks had begun with GlaxoSmithKline (GSK), about how to make its new vaccine for cervical cancer, Cervarix, available in Africa. The vaccine, Cervarix, is not yet available in Britain on the NHS!

Photo: Child with a tumour in the jaw due to Burkitt’s lymphoma cancer. Credit: Dr MA Ansary/Science Photo Library.