Cancer care in East Africa amidst the Covid-19 pandemic.

Abstract

The Covid-19 pandemic has led to a massive disruption of cancer services throughout the world. Decreasing numbers of cancer patients in the hospitals and reduced screening services have already and will continue to lead to more advanced stage cancer disease and, eventually, reduced survival in many cancer patients. While this has been extensively discussed publicly, in academia and within professional organizations in high-income countries1, 2 little light has been shed on the recent situation of cancer care in low-and-middle-income countries (LMIC). As an oncologist practising since many years in Tanzania, I would like to draw attention to the situation in East Africa, where the public health strategies in response to the pandemic differ among the biggest countries. Uganda has imposed strict lockdowns and even curfews throughout the country to fight the pandemic that has cost 337 reported Covid-related deaths and approximately 40 000 cases of Covid-19 as of April 2021. At the same time, the repercussions for diseases other than Covid-19 have been severe. For example, public transportation was shut down impeding patients' access to hospitals, outreach programmes and screening services for cancer were put on hold3 with cancer care severely impacted with the interruption of ongoing cancer treatment. As Abila and colleagues from Makerere university wrote in their publication last year ‘the achievements in cancer control […] could be watered down’.3 With almost 22 000 reported cancer deaths in 2018 and 32 000 new cases4 in Uganda, cancer care needs to be prioritized in the country and should not be disrupted on this scale. In Kenya, where cancer is the third leading cause of death (7% of all deaths), pandemic countermeasures included lockdowns and – for a shorter period than in Uganda – curfews. Travels to urban centres, where cancer centres are located, have been difficult and even impossible for Nairobi due to a travel ban to the country's capital city. Operating hours of healthcare facilities were cut to only a few hours per day and therefore, have made it difficult for patients to access cancer services. Tanzania, having a cancer prevalence of 73 000 cases in 2020,5 on the other hand has applied a different approach to the pandemic with almost no concrete containment measures being undertaken in the country. With 509 confirmed Covid-19 cases and 21 deaths, the government stopped reporting cases to the WHO in April 2020.6 The recently deceased president Dr John Pombe Magufuli eventually declared the pandemic in the biggest country of East Africa over in early June 2020.6 The rather licentious explanation that ‘prayers and fasting’ helped to defeat the virus, had led Tanzanian society to continue life as usual and the previously declining numbers of patients seeking care in our cancer care clinic have rapidly increased back to usual numbers. However, assessing the number of cancer patients who have succumbed to Covid-19 in this setting is hard to assess. The National Laboratory is the only institution allowed to conduct PCR tests for SARS-CoV-2 and statistics remain under governmental restriction to date. With the new wave of Covid-19 in January 2021, the government eventually acknowledged the presence of SARS-Cov-2 and measures like wearing masks have been reintroduced at least in hospitals. During this ongoing wave, we have seen a number of cancer patients dying from respiratory insufficiency, but our service provision remained uninterrupted and continued as usual. Also, referrals to other centres for radiotherapy have not been interrupted. It remains challenging to compare these diametrically opposed policy strategies on the death toll among East African cancer patients with missing data especially from Tanzania. The negligence of the government in reporting Covid-19 cases unfortunately contradicts their efforts to not overemphasize the pandemic against other health and economic problems in the country. In addition, the risk of fast-evolving SARS-CoV-2 variants in Tanzania may have a large (and till now unknown) impact on cancer patients, health care workers and the population as a whole.7 Which conclusions can be drawn from the situation in East Africa so far? From my point of view, we have learned three lessons. Firstly, this pandemic has pronounced the shortcomings of fragile cancer services in LMIC. A lack of service provision outside bigger cities where patients need to be highly mobile to access services, coupled with a limited use of technology like telemedicine, virtual tumour boards or telepathology has meant that access to cancer care has become all but impossible for large swathes of the population.8 Secondly, the copied application of countermeasures from high-income countries in East Africa (and beyond) carries a high risk of doing more harm than good. Instead of following the blueprint of countries from the global north with all their resources, more tailored approaches are needed like focused protection of risk groups and timely anti-Covid-19 vaccination of personnel in the health sector, which is chronically understaffed. It is of utmost importance for LMIC to continue with the usual vaccination programmes and other preventive measures as well as early detection programmes, with cancer treatment and palliative care services. The interruption will lead to more patients presenting in the late stages of their disease and hence impose more workload on the already overstretched cancer services. And lastly, more research on Covid-19 related impact on the generally much younger population in LMIC is utterly needed to fully understand the impact it causes. Even though we cannot rely on strong evidence due to limited testing capacities and sparse data,9 but through our experience and the available data in East Africa, it seems that neither the previous nor the current wave of Covid-19 had posed such a thread in LMIC that would justify shutting down cancer (and other health) services on a large scale.10 If this continues, I am afraid the cancer mortality will rise unnecessarily and efforts to strive against the massive public health burden of cancer in East Africa will be thrown back for many years. The author has no conflict of interest to declare.