Palliative Care in Africa

I originally wanted to combine this post with my previous post on palliative care. Not possible - personal and political.

In the UK there exists an extensive "hospice" network, largely funded by charity organisations.

Antonia is my best friend here - when I fell on some very hard times she put me up for more or less two years until she wisely told me to get out and get my act together.

Both Antonia's mother and maternal Aunt Gertrudes lived in her house. Both died whilst I lived there. Gertrudes suffered from what I imagine the medics call "dementia". But whilst she was physically able, she would make efforts to contribute to domestic life, sweeping the yard etc.

The palliative care in a home-setting was excellent but Antonia's family is relatively well-off. Here in Africa the quality of direct and extended family-care is very dependent on relative wealth, just as in the UK the provision of home-based palliative care is a greater hardship on the poor, although the closer proximity here of the extended-family certainly helps. However, there are no community nursing or social services. Fortunately for Antonia's mum and Aunt Gertrudes there was also a doctor in the family.

Inequalities of wealth have increased since I arrived in 1989. Back then we had a one-party state that had, since independence, tried with large amounts of foreign aid to provide the cradle-to-grave care that even we in the UK find an uphill struggle. The shops were empty.

But there were no old people begging on the streets, no street kids, rural-to-urban migration was low as people on the state-managed plantations were not allowed to starve, and as previously mentioned, we had an expensive primary and secondary healthcare system.

The collapse of the Soviet empire led to a massive decrease in foreign aid (although on the medical front Cuba still provides most of the best specialist doctors in the country). My Ukrainian dentist went home. Democracy came in 1992.

The IMF and World Bank hit us. Reform.

Now the shops are full. Old people begging on the streets, street kids, prostitution on the rise (although never a non-promiscuous society).

Home-based palliative care is becoming financially impossible for many families.

Sure, some sheltered-housing for the old has been built, there is a soup-kitchen for street kids in the city, financed by foreign aid and foreign charities ... but when you go town on a Saturday morning and see the lines of old people lining up outside richer shops awaiting a weekly charitable donation, when you see the street kids trying to sell you seed-bead necklaces or wash your car ....

One day Aunt Gertrudes couldn't get out of bed. She was dying. I cannot recall how many days it lasted but not long. One can often read the signs of imminent death in an old person, so as it approached, when she lost consciousness, immediate family was called.

I have no experience of death-scenes in any culture but what followed was weird, at least to me.

The family sat in chairs around her death-bed to watch her die. No movement, no conversation, no physical contact with Gertudes.

I was disgusted. I got a cup of water and a teaspoon. I sat next to her and gave her water drop-by-drop, wetted her lips.

Some 20 minutes before she died, Antonia told me to stop.

PS: I have just rung a friend to ask if this is traditional death-bed behaviour. No - it just depends.

PPS: There are some national palliatve care organisations aand centres in Africa but not many. The need is enormous - given the levels of cancer/HIV/AIDS/other diseases/physical problems on the continent. Visit here for the continental palliative care organisation.

Linux User Group

The first Linux User Group between Morocco aand South Africa held its inaugural meeting tonight. Six of us met up at a local Internet cafe - Bastien, a French man working with a local environmemtal NGO, Aguinaldo from the local telecomms company (CST), Aguinaldo the owner of the Internet cafe (Club Tropicana), Bernardina from the National Meteorological Institute (NMI), Valentim the director of a local primary school and myself.

We didn't actually do very much except have a few drinks and chew the rag. It turns out that we are mostly Ubuntu (in its various versions) and Debian users. As well as its inevitable Windows machines, the NMI has a Debian machine and Bernardina has had some experience of Ubuntu whilst on training courses in Brazil. She got me to download OpenOffice a couple of weeks ago via the Synaptic Package Manager – given our slow Internet connection I left it running and walked away ... the next day she told me it was working perfectly. Valentim has a legacy machine (donated by my employer) running Xubuntu. Aguinaldo from CST says his company is planning to transition to Unix/Linux servers, Aguinaldo, owner of Club Tropicana and partner with the owner of our national domain (one of Sweden's largest ISPs), is a great fan of Ubuntu but has been limited by non-Linux support for the thin-client boxes he has been using to set up thin-client networks around the country. I discovered last week that the company making his thin-client boxes has just produced beta Linux software to support these. Bastien has managed to procure a laptop for the NGO he is working with and it is now loaded up with Ubuntu and he says the users are having no problems at all using OpenOffice. I descrbed how I had just got my US Robotics “Windows” Skype phone working on Linux. Valentim asked me to look into a Portuguese spell-checker/dictionary for AbiWord. I showed Bastien Slax running off a USB pendrive.

All-in-all it was a great success.

The African Medical Brain Drain

... is apparently not significantly different from the African brain drain in other professions.

A new study quantifies in a more accurate way the origins and destinations of African doctors and nurses.

It is not surprising that the African countries from which, percentage-wise, most African doctors and nurses originate are countries with current or recent conflicts, but what is interesting in the difference in countries of origin between the two professions:

Doctor top 6 origin list:

Mozambique
Guinea-Bissau
Angola
Liberia
Equatorial Guinea
Sao Tome e Principe

Nurse top 6 origin list:

Liberia
Burundi
Gambia
Mauritius
Sierra Leone
Sao Tome e Principe

Clearly, in our Doctor List the first four are from conflict countries. No. 5 is probably the most repressive in Africa.

In our Nurses List I am not surprised by nos. 1 and 2 and 5. Again conflict zones. But nos. 3 and 4 are calm and collected.

Oh, and no. 6 in both lists ... no fucking comment.

The differences must be based on socio-economic and educational differences in different countries.

A few off-the-cuff remarks:

- Gambia and Mauritius nurses are probably well-trained in good programmes in their own countries.

- it is easier and cheaper, and a wiser healthcare strategy, to train nurses than doctors when you want to spread basic primary healthcare. Drs Rant and Crippen have made many criticisms of Nurse Practitioners in the UK but it does make sense in Africa.

- I am surprised that the D.R. Congo is so far down both the Doctors' and Nurses' lists given its recent history.

- on the recent Ama Sumani case, certain UK politicians have pointed to the deficiencies in the Ghanaian healthcare system and that the solution to cases such as Ama´s should lie in improvements to the Ghanaian health system. I couldn´t agree more ...

I will draw their attention to the DWIB Leukaemia Fund which is struggling to support the establishment of bone marrow donation and transplants in Ghana.

I will also draw their attention to the fact, as did the BBC´s Correspondent, that 56% of Ghanaian doctors, and 24% of Ghanaian nurses work overseas. 590 doctors (20,1 % of Ghanaian doctors) and 2381 (16% of Ghanaian nurses) are working in the UK.

Cancer in Africa

Our regular reader, Rosie, whose daughter Leonie has ALL, posted this comment regarding a paediatric oncologist friend of hers currently work in Tanzania. It speaks for itself …

“… I’m trying to get more drugs out to her after Christmas, I bought a case load from the hospital here and sent them out with a doctor friend of the pharmicist ( Ireland is just the right size to bypass all the necessary paperwork to do things like this). She lost a little patient recently as there was no money to pay the taxi to take the blood from the blood bank to the hospital. However she had a little girl like Leonie and Kezia with ALL who had gome blind and for weeks was having seizures in a semi coma. After consulation with the docs here she kept plugging away with the treatment until one day she woke up looking for her breakfast ! Hardened oncologist she wept with the other staff- this is what keeps her going. She is a marvelous young woman called Trish and Tansania is lucky to have her.”

The DWIB Leukaemia Fund

My attention has by chance been drawn to another cancer charity with an emphasis on Africa, the DWIB Leukaemia Fund.

Founded by two expatriate Ghanaians with leukaemia, Danny Whyte and Ivor Burford, the charity’s principal aim is to establish the first bone marrow donor register in sub-Saharan Africa and get it linked to the Global Bone Marrow Register. As Danny and Ivor (who has since died of leukaemia) state, only 2.3% of potential bone marrow donors in the U.K. are African/Caribbean and ethnic-matching is important. 1 in 5 bone marrow matches are found in white people, 1 in 250,000 in black people.

To date, according to its website, an initial donor recruitment campaign in Ghana resulted in 1020 donors.

The charity has also managed to raise funds to equip the haematology unit at the Korle-Bu Teaching Hospital in Accra with a devoted space for patients with leukaemia and with the equipment to diagnose and treat them.

I do wonder if Ghanaian, and more generally, sub-Saharan African bone marrow donors will be eligible to enter the global register. When I looked at the Anthony Nolan Trust bone marrow register criteria for donation, you had to be out of a malarial zone for six months (which counted me out but counts Nanda in).

I don’t understand the science of this at all, as although bone marrow type is established through a blood sample, I don’t see what this has got to do with malaria parasites. If malaria is truly a factor, then any African bone marrow register will have problems entering the global register - and most of the world’s population lives in malarial regions.

A 38 year-old brother of a colleague has recently died from undiagnosed but suspected leukaemia. Three transfusions, as Kezia …We have a system here to evacuate any “urgent” case to the ex-colonial European power. But the “system” cannot deal with an emergency, it has to be considered by a committee. So our doctors told us to just get out as fast as possible … and because of my privilege, we were able to get Kezia out.

The United States of Africa

Sunday morning and there is a typical Sunday morning talk show on the radio. The journalists, who have nothing else to do on a Sunday, get paid well for appearing on a Sunday morning. The BBC has one as well.

One of the subjects today is the recent discussion at the African Union summit of President Gaddafi´s proposal to make “a United States of Africa”. USA … hmm …

Let me start by being rational …

It has taken Europe to arrive at the current European Union (area 4 million square km and 27 countries, population 500 million) 50 years to arrive, since its start as the EEC, at its present state. We still don´t agree with each other.

Africa has an area of a 30 million square km and 53 countries, a population of 900 million. They were colonised by eight countries. The first one to be “decolonised” was in 1956, and the last in 1980.

Last week we celebrated our Independence Day. The United States of America has one so why the fuck shouldn´t we? Along with every other country in the decolonised world.

We are one of the few countries in decolonised Africa to be considered a “model” democracy. So who did we invite to celebrate our independence? Presidents of three of our neighbouring tinpot dictatorships, one of which is considered possibly the worst in Africa.

Let us consider another USA – the United States of Asia. - I´ll leap some countries along the way …

Azerbaijan … Iran … Afghanistan … Pakistan … India … Myanmar …Vietnam … China … Japan.

Let us consider another USA – whoops, a name change, USSA – the United States of South America.

Mexico … Guatamala … Honduras … Bolivia … Venezuela … Brazil … Uruguay … Paraguay … Argentina …Chile …

Have either of these continents even considered some kind of common economic community, let alone a mega-country?

No.

Sure, there are customs and tariff agreements – MERCOSUR amongst the South Americans. Sure, they have regional summits, ASEAN, for some of the Asian countries. Have any of their leaders proposed a USA?

And I haven´t even got to the Middle-East (deity forbid) or the Pacific …

So let me start being irrational and I´ll leap some countries along the way

Egypt … Libya … Algeria … Chad … Sudan … Nigeria … the rest of west Africa … Somalia … Uganda and Kenya … Congo (both) … Zambia … Namibia … Angola … Zimbabwe, and South Africa (zig-zagging across a continent).

The African countries cannot organise the Economic Community of East African States, SADC etc

So at the African Union summit you waste time talking about President Gaddafi´s idea rather than discussing Darfur, Somalia, Eritrea vs Ethiopia, Zimbabwe or even an AU peace-keeping force?

I think President Gaddafi is mad! I think some of you are of the same opinion.

So why the fuck did you let it get on the agenda?

But hey let us have a continent wide election for a continental leader. I will vote for President Gaddafi. Will you?

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.

New Links

Via the Grand Rounds (link right) I come across an African medical blog other things amanzi who took me to the top 100 blogs on health and medicine which took me to a cause near to my heart a blog on Open Medicine.

AfrOx Update

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

On the Web

Courtesy of the most recent Grand Rounds a couple of blog posts on issues we have touched on ourselves.

Aetiology discusses the shortage of trained medical staff in Africa as well as the reasons why those trained head towards developed countries. (Our own post here).

We have mentioned many times on this blog the fiasco of the government's investment in IT for the health service. Healthline brings us a US perspective to the debate on the use of IT in healthcare.

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.

Small Island States

I would be interested to know about cancer control strategies for small island states. One radiotherapy machine in our own country, with a population of c.150,000, would bring us to a developed world ratio. Is this economically viable? The economies of scale make small island states, in every sector, very expensive.

Here we have an agreement with the ex-colonial power that serious medical cases are evacuated to Europe for treatment – this is clearly expensive and open to abuse and equally, the bureaucratic delays involved in such a system put the patient’s life at risk. Kezia would have been dead if we had had to rely on this system. Once a patient is within the healthcare system of the ex-colonial power, institutional racism often leads to unsatisfactory treatment.

But, even if cancer treatment facilities are to remain unavailable here, diagnostic facilities require vast improvement. The techniques/skills to accurately diagnose Kezia’s leukaemia were unavailable. A programme to promote PAP smear testing (or even vaccination) for cervical cancer (one of the most common forms of cancer in Africa) would be economically viable and effective.

I imagine in the Caribbean, with far more small island states than around Africa, the inter-state healthcare network is far more developed. But still the expense, both to the states involved and the individuals must be crippling. In the Pacific I imagine the far-greater distances involved make the challenge of providing adequate heathcare even greater.

I hope to look into this further.

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.

Cancer in Africa II

The ex-colonial power has been running its neo-colonialist Africa television channel here for 24 hours a day for several years. Today it took a programme from the television service of another ex-colony, much much larger than ours, and interviewed an African oncologist, working in his own country.

He certainly tried to explain as he best could to the general public the ins-and-outs of white blood counts and regretted that a haematologist had not also been invited on the programme. He described the limited facilities in his country. A country with a population of 14.5 million, a geographical area of 1.25 million square kilometres and only two hospitals in the capital city that can treat cancer.

Meanwhile the BBC here discusses a Medecins Sans Frontieres report (and press release) bemoaning the vast shortages of medical staff in Africa (albeit in the context of HIV/AIDS but it applies to all areas of medical care). It cites, for example, the fact that in 2005 in Malawi only 44 nurses qualified whilst 86 left the country. The shortage of doctors has led the head of MSF in South Africa to suggest that nurses be given the power to write prescriptions (you'd love that Dr Crippen!). The WHO recommends a minimum of 20 doctors per 100, 000 people - Lesotho has five, Malawi has two and Mozambique has 2.6. MSF points to the irony of donors loving to build new health facilities but who are unwilling to invest in the human resources to staff them and thus they stand empty.

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.