Mounting cancer burden tests Africa's health resources

Abstract

Many countries in sub-Saharan Africa lack well-trained oncologists and a well-educated public—two assets needed to stave off soaring cancer cases and deaths. John Maurice reports.Sub-Saharan Africa's cancer burden, which has long been one of the lowest in the world, is steadily catching up with the burden in developed regions, which has long been among the highest. This year, an estimated 12·2 million people in the world will develop cancer, according to WHO's International Agency for Research on Cancer (IARC). In 2030, IARC estimates the number will have doubled and the annual incidence of cancer will have risen from 914 000 to 1·4 million, a 57% increase.One factor epidemiologists invoke to explain the growing cancer burden in Africa is the rising life expectancy in most African countries, which brings more populations into the high cancer-risk age bracket. Other factors include better diagnosis and detection of cases and the increasing adoption by Africans of Western lifestyles, such as poor diets, lack of physical activity, and tobacco and alcohol use. Infectious diseases, too, that have begun to recede from high-income countries, are still prevalent in many African countries and cause 33% of cancers. But the main problem most quoted by cancer experts is a paucity of well-trained medical practitioners. Ian Magrath, president of the International Network for Cancer Treatment and Research, a non-governmental organisation, paints a pessimistic picture of cancer treatment services in most equatorial African countries: “To stem the growing burden of cancer in these countries”, he says, “you need well-trained doctors and nurses and above all you need well-trained oncologists. Many of these African countries have no oncologists or perhaps just one or two. Then you need to provide people and medical practitioners with education. This may be the single most important action needed to ensure early detection and treatment of cancer—early enough to raise the chances of survival. In some places people still blame evil spirits for what is cancer and women with breast cancer are still often branded as immoral. I'm not surprised that a word for cancer, seemingly, doesn't exist in any of the 2000 African languages. Nor am I surprised that instead of walking miles over harsh terrain to reach a health centre, about 70% of people in east Africa first consult a traditional healer in their village.”Momentum buildingJulie Torode, deputy chief executive officer of the Union for International Cancer Control (UICC) has a more optimistic perspective: “With the incidence of cancer predicted to take an unprecedented rise in Africa, many governments have started to take action. There's a real momentum under way. These countries need international support now for their efforts to bring their health systems up to scratch in order to provide much-needed cancer services. By 2025, we want every country to have at least one cancer centre of excellence fully functioning, with the needed skills, infrastructure, and connectivity with local communities, as well as a referral network and integration with other services for other diseases.”Some people wonder what WHO is doing about poor cancer treatment in Africa. Andreas Ullrich, senior adviser to the WHO's Assistant Director-General for Noncommunicable Diseases (NCDs) and Mental Health, explains: “Our priority is to build the capacity of low-income countries to develop and run competent cancer control programmes. For this purpose, we are working with several partners in the UN interagency taskforce and also with professional organisations, including the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (EMSO).”The momentum created by these partnerships has prompted ASCO to start work on developing guidelines for cancer management that are tailored to the limited resources and weak health systems of most African countries. ESMO, together with WHO, is working on a global survey of access to cancer medicines and will soon run another survey to determine the availability of human resources for cancer management.Essential medicines“A major WHO function”, Ullrich says, “is compiling, updating, and publishing, every 2 years, a list of essential medicines for cancer treatment”. The first essential medicines list was issued in 1977 and included six anticancer drugs. By 2013 it had 30. And on May 8, WHO published a list with 46 essential anticancer drugs. The list includes medicines to treat cancers that occur in Africa.Agnes Binagwaho, Minister of Health of Rwanda, is delighted with the revised list of essential medicines (panel). “I am particularly pleased”, she told The Lancet, “that for the first time WHO has produced a list of medicines chosen for their therapeutic effect on specific diseases”.PanelRwanda, a model for cancer management in sub-Saharan AfricaEven before the 1994 genocide, Rwanda was one of the poorest countries in the world and its health system one of the most fragile. Today, Rwanda's health system has in many respects become a model for African countries struggling to provide their populations with quality cancer care. Much of this recovery is due to generous donor funding, to material and logistic support from US partners, and, as many Rwandans would agree, to the efforts of the country's health minister, Agnes Binagwaho, and the new health policies she has introduced. “In Rwanda, we believe in the integration of health care across a broad gamut of ill-health”, says Binagwaho. Rather than building compartmentalised facilities, one for HIV, another for malaria, yet another for tuberculosis, and so on, the country is investing in the entire disease spectrum.” Likewise, Binagwaho's vision is for a country where everyone has the same chances to survive and thrive. “My philosophy is: if I get a penny to help my granddaughter, I'll make sure that penny also helps my grandmother. That philosophy has allowed us to establish a robust platform for service delivery from childhood to adulthood, service delivery that is resilient to changes in the disease burden, in life expectancy, and in the financial environment.” That philosophy has also produced impressive achievements.Since 1994, the country has restructured its health system and now has four provincial hospitals, eight referral hospitals, 35 district hospitals, and 478 health centres. It has staffed these facilities with more than 600 physicians, 8000 nurses, and 240 nurse midwives. Rwanda has only two oncologists but provides training in basic cancer medicine to health professionals and a Master of Science course in oncology to nurses. July, 2012, saw the launch of the country's first centre of excellence in cancer care, which is now treating more than 1000 cancer patients a year and saving hundreds every year. Rwanda was also the first African country to vaccinate girls against human papillomavirus infection, according to the GAVI Alliance; 93% of all schoolgirls in the country were vaccinated in 2011. And Rwanda's health insurance system, which covers nearly 90% of the population, ensures that no Rwandan is turned away from a treatment centre for lack of money.Some of the newly added drugs, however, are extremely expensive: a full course of treatment can be as costly as US$100 000 per patient per year. To which Binagwaho comments: “Putting a drug on the WHO list usually increases demand, which usually produces a fall in price. But I don't think we have to be blocked by financial issues and the accessibility of these drugs. Take HIV drugs, for example. In 2001, HIV treatment cost $11 000 a year per patient. Today, we can keep people alive with less than $200 a year”.One issue, though, that troubles Binagwaho is that too many adults seek treatment too late. “That is an issue”, she says, “partly due to poverty but largely to the fact that most people in Africa don't really know that cancer can be treated. There is clearly a need for educational campaigns to inform people of the early signs and symptoms of cancer and to convince them that for more and more people a diagnosis of cancer is no longer a death sentence”. Binagwaho recalls that until the turn of the century there was widespread ignorance about AIDS. “Education has changed that for AIDS. Now everybody knows it is treatable. Education will make that change for cancer.”Change, Binagwaho insists, is also needed on a global issue—the inequality and inequity of the resources given to poor countries struggling to improve cancer care. “Currently, only 5% of global cancer resources are spent in low-and-middle-income countries, which is astounding if you consider that 80% of all cancer deaths occur in these countries. No wonder Africa's armament for cancer treatment looks like America's half-a-century ago and no wonder most of the continent's countries still haven't figured out how to make access to cancer treatment equitable.” Many countries in sub-Saharan Africa lack well-trained oncologists and a well-educated public—two assets needed to stave off soaring cancer cases and deaths. John Maurice reports. Sub-Saharan Africa's cancer burden, which has long been one of the lowest in the world, is steadily catching up with the burden in developed regions, which has long been among the highest. This year, an estimated 12·2 million people in the world will develop cancer, according to WHO's International Agency for Research on Cancer (IARC). In 2030, IARC estimates the number will have doubled and the annual incidence of cancer will have risen from 914 000 to 1·4 million, a 57% increase. One factor epidemiologists invoke to explain the growing cancer burden in Africa is the rising life expectancy in most African countries, which brings more populations into the high cancer-risk age bracket. Other factors include better diagnosis and detection of cases and the increasing adoption by Africans of Western lifestyles, such as poor diets, lack of physical activity, and tobacco and alcohol use. Infectious diseases, too, that have begun to recede from high-income countries, are still prevalent in many African countries and cause 33% of cancers. But the main problem most quoted by cancer experts is a paucity of well-trained medical practitioners. Ian Magrath, president of the International Network for Cancer Treatment and Research, a non-governmental organisation, paints a pessimistic picture of cancer treatment services in most equatorial African countries: “To stem the growing burden of cancer in these countries”, he says, “you need well-trained doctors and nurses and above all you need well-trained oncologists. Many of these African countries have no oncologists or perhaps just one or two. Then you need to provide people and medical practitioners with education. This may be the single most important action needed to ensure early detection and treatment of cancer—early enough to raise the chances of survival. In some places people still blame evil spirits for what is cancer and women with breast cancer are still often branded as immoral. I'm not surprised that a word for cancer, seemingly, doesn't exist in any of the 2000 African languages. Nor am I surprised that instead of walking miles over harsh terrain to reach a health centre, about 70% of people in east Africa first consult a traditional healer in their village.” Momentum buildingJulie Torode, deputy chief executive officer of the Union for International Cancer Control (UICC) has a more optimistic perspective: “With the incidence of cancer predicted to take an unprecedented rise in Africa, many governments have started to take action. There's a real momentum under way. These countries need international support now for their efforts to bring their health systems up to scratch in order to provide much-needed cancer services. By 2025, we want every country to have at least one cancer centre of excellence fully functioning, with the needed skills, infrastructure, and connectivity with local communities, as well as a referral network and integration with other services for other diseases.”Some people wonder what WHO is doing about poor cancer treatment in Africa. Andreas Ullrich, senior adviser to the WHO's Assistant Director-General for Noncommunicable Diseases (NCDs) and Mental Health, explains: “Our priority is to build the capacity of low-income countries to develop and run competent cancer control programmes. For this purpose, we are working with several partners in the UN interagency taskforce and also with professional organisations, including the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (EMSO).”The momentum created by these partnerships has prompted ASCO to start work on developing guidelines for cancer management that are tailored to the limited resources and weak health systems of most African countries. ESMO, together with WHO, is working on a global survey of access to cancer medicines and will soon run another survey to determine the availability of human resources for cancer management. Julie Torode, deputy chief executive officer of the Union for International Cancer Control (UICC) has a more optimistic perspective: “With the incidence of cancer predicted to take an unprecedented rise in Africa, many governments have started to take action. There's a real momentum under way. These countries need international support now for their efforts to bring their health systems up to scratch in order to provide much-needed cancer services. By 2025, we want every country to have at least one cancer centre of excellence fully functioning, with the needed skills, infrastructure, and connectivity with local communities, as well as a referral network and integration with other services for other diseases.” Some people wonder what WHO is doing about poor cancer treatment in Africa. Andreas Ullrich, senior adviser to the WHO's Assistant Director-General for Noncommunicable Diseases (NCDs) and Mental Health, explains: “Our priority is to build the capacity of low-income countries to develop and run competent cancer control programmes. For this purpose, we are working with several partners in the UN interagency taskforce and also with professional organisations, including the American Society of Clinical Oncology (ASCO) and the European Society for Medical Oncology (EMSO).” The momentum created by these partnerships has prompted ASCO to start work on developing guidelines for cancer management that are tailored to the limited resources and weak health systems of most African countries. ESMO, together with WHO, is working on a global survey of access to cancer medicines and will soon run another survey to determine the availability of human resources for cancer management. Essential medicines“A major WHO function”, Ullrich says, “is compiling, updating, and publishing, every 2 years, a list of essential medicines for cancer treatment”. The first essential medicines list was issued in 1977 and included six anticancer drugs. By 2013 it had 30. And on May 8, WHO published a list with 46 essential anticancer drugs. The list includes medicines to treat cancers that occur in Africa.Agnes Binagwaho, Minister of Health of Rwanda, is delighted with the revised list of essential medicines (panel). “I am particularly pleased”, she told The Lancet, “that for the first time WHO has produced a list of medicines chosen for their therapeutic effect on specific diseases”.PanelRwanda, a model for cancer management in sub-Saharan AfricaEven before the 1994 genocide, Rwanda was one of the poorest countries in the world and its health system one of the most fragile. Today, Rwanda's health system has in many respects become a model for African countries struggling to provide their populations with quality cancer care. Much of this recovery is due to generous donor funding, to material and logistic support from US partners, and, as many Rwandans would agree, to the efforts of the country's health minister, Agnes Binagwaho, and the new health policies she has introduced. “In Rwanda, we believe in the integration of health care across a broad gamut of ill-health”, says Binagwaho. Rather than building compartmentalised facilities, one for HIV, another for malaria, yet another for tuberculosis, and so on, the country is investing in the entire disease spectrum.” Likewise, Binagwaho's vision is for a country where everyone has the same chances to survive and thrive. “My philosophy is: if I get a penny to help my granddaughter, I'll make sure that penny also helps my grandmother. That philosophy has allowed us to establish a robust platform for service delivery from childhood to adulthood, service delivery that is resilient to changes in the disease burden, in life expectancy, and in the financial environment.” That philosophy has also produced impressive achievements.Since 1994, the country has restructured its health system and now has four provincial hospitals, eight referral hospitals, 35 district hospitals, and 478 health centres. It has staffed these facilities with more than 600 physicians, 8000 nurses, and 240 nurse midwives. Rwanda has only two oncologists but provides training in basic cancer medicine to health professionals and a Master of Science course in oncology to nurses. July, 2012, saw the launch of the country's first centre of excellence in cancer care, which is now treating more than 1000 cancer patients a year and saving hundreds every year. Rwanda was also the first African country to vaccinate girls against human papillomavirus infection, according to the GAVI Alliance; 93% of all schoolgirls in the country were vaccinated in 2011. And Rwanda's health insurance system, which covers nearly 90% of the population, ensures that no Rwandan is turned away from a treatment centre for lack of money.Some of the newly added drugs, however, are extremely expensive: a full course of treatment can be as costly as US$100 000 per patient per year. To which Binagwaho comments: “Putting a drug on the WHO list usually increases demand, which usually produces a fall in price. But I don't think we have to be blocked by financial issues and the accessibility of these drugs. Take HIV drugs, for example. In 2001, HIV treatment cost $11 000 a year per patient. Today, we can keep people alive with less than $200 a year”.One issue, though, that troubles Binagwaho is that too many adults seek treatment too late. “That is an issue”, she says, “partly due to poverty but largely to the fact that most people in Africa don't really know that cancer can be treated. There is clearly a need for educational campaigns to inform people of the early signs and symptoms of cancer and to convince them that for more and more people a diagnosis of cancer is no longer a death sentence”. Binagwaho recalls that until the turn of the century there was widespread ignorance about AIDS. “Education has changed that for AIDS. Now everybody knows it is treatable. Education will make that change for cancer.”Change, Binagwaho insists, is also needed on a global issue—the inequality and inequity of the resources given to poor countries struggling to improve cancer care. “Currently, only 5% of global cancer resources are spent in low-and-middle-income countries, which is astounding if you consider that 80% of all cancer deaths occur in these countries. No wonder Africa's armament for cancer treatment looks like America's half-a-century ago and no wonder most of the continent's countries still haven't figured out how to make access to cancer treatment equitable.” “A major WHO function”, Ullrich says, “is compiling, updating, and publishing, every 2 years, a list of essential medicines for cancer treatment”. The first essential medicines list was issued in 1977 and included six anticancer drugs. By 2013 it had 30. And on May 8, WHO published a list with 46 essential anticancer drugs. The list includes medicines to treat cancers that occur in Africa. Agnes Binagwaho, Minister of Health of Rwanda, is delighted with the revised list of essential medicines (panel). “I am particularly pleased”, she told The Lancet, “that for the first time WHO has produced a list of medicines chosen for their therapeutic effect on specific diseases”. Even before the 1994 genocide, Rwanda was one of the poorest countries in the world and its health system one of the most fragile. Today, Rwanda's health system has in many respects become a model for African countries struggling to provide their populations with quality cancer care. Much of this recovery is due to generous donor funding, to material and logistic support from US partners, and, as many Rwandans would agree, to the efforts of the country's health minister, Agnes Binagwaho, and the new health policies she has introduced. “In Rwanda, we believe in the integration of health care across a broad gamut of ill-health”, says Binagwaho. Rather than building compartmentalised facilities, one for HIV, another for malaria, yet another for tuberculosis, and so on, the country is investing in the entire disease spectrum.” Likewise, Binagwaho's vision is for a country where everyone has the same chances to survive and thrive. “My philosophy is: if I get a penny to help my granddaughter, I'll make sure that penny also helps my grandmother. That philosophy has allowed us to establish a robust platform for service delivery from childhood to adulthood, service delivery that is resilient to changes in the disease burden, in life expectancy, and in the financial environment.” That philosophy has also produced impressive achievements.Since 1994, the country has restructured its health system and now has four provincial hospitals, eight referral hospitals, 35 district hospitals, and 478 health centres. It has staffed these facilities with more than 600 physicians, 8000 nurses, and 240 nurse midwives. Rwanda has only two oncologists but provides training in basic cancer medicine to health professionals and a Master of Science course in oncology to nurses. July, 2012, saw the launch of the country's first centre of excellence in cancer care, which is now treating more than 1000 cancer patients a year and saving hundreds every year. Rwanda was also the first African country to vaccinate girls against human papillomavirus infection, according to the GAVI Alliance; 93% of all schoolgirls in the country were vaccinated in 2011. And Rwanda's health insurance system, which covers nearly 90% of the population, ensures that no Rwandan is turned away from a treatment centre for lack of money. Even before the 1994 genocide, Rwanda was one of the poorest countries in the world and its health system one of the most fragile. Today, Rwanda's health system has in many respects become a model for African countries struggling to provide their populations with quality cancer care. Much of this recovery is due to generous donor funding, to material and logistic support from US partners, and, as many Rwandans would agree, to the efforts of the country's health minister, Agnes Binagwaho, and the new health policies she has introduced. “In Rwanda, we believe in the integration of health care across a broad gamut of ill-health”, says Binagwaho. Rather than building compartmentalised facilities, one for HIV, another for malaria, yet another for tuberculosis, and so on, the country is investing in the entire disease spectrum.” Likewise, Binagwaho's vision is for a country where everyone has the same chances to survive and thrive. “My philosophy is: if I get a penny to help my granddaughter, I'll make sure that penny also helps my grandmother. That philosophy has allowed us to establish a robust platform for service delivery from childhood to adulthood, service delivery that is resilient to changes in the disease burden, in life expectancy, and in the financial environment.” That philosophy has also produced impressive achievements. Since 1994, the country has restructured its health system and now has four provincial hospitals, eight referral hospitals, 35 district hospitals, and 478 health centres. It has staffed these facilities with more than 600 physicians, 8000 nurses, and 240 nurse midwives. Rwanda has only two oncologists but provides training in basic cancer medicine to health professionals and a Master of Science course in oncology to nurses. July, 2012, saw the launch of the country's first centre of excellence in cancer care, which is now treating more than 1000 cancer patients a year and saving hundreds every year. Rwanda was also the first African country to vaccinate girls against human papillomavirus infection, according to the GAVI Alliance; 93% of all schoolgirls in the country were vaccinated in 2011. And Rwanda's health insurance system, which covers nearly 90% of the population, ensures that no Rwandan is turned away from a treatment centre for lack of money. Some of the newly added drugs, however, are extremely expensive: a full course of treatment can be as costly as US$100 000 per patient per year. To which Binagwaho comments: “Putting a drug on the WHO list usually increases demand, which usually produces a fall in price. But I don't think we have to be blocked by financial issues and the accessibility of these drugs. Take HIV drugs, for example. In 2001, HIV treatment cost $11 000 a year per patient. Today, we can keep people alive with less than $200 a year”. One issue, though, that troubles Binagwaho is that too many adults seek treatment too late. “That is an issue”, she says, “partly due to poverty but largely to the fact that most people in Africa don't really know that cancer can be treated. There is clearly a need for educational campaigns to inform people of the early signs and symptoms of cancer and to convince them that for more and more people a diagnosis of cancer is no longer a death sentence”. Binagwaho recalls that until the turn of the century there was widespread ignorance about AIDS. “Education has changed that for AIDS. Now everybody knows it is treatable. Education will make that change for cancer.” Change, Binagwaho insists, is also needed on a global issue—the inequality and inequity of the resources given to poor countries struggling to improve cancer care. “Currently, only 5% of global cancer resources are spent in low-and-middle-income countries, which is astounding if you consider that 80% of all cancer deaths occur in these countries. No wonder Africa's armament for cancer treatment looks like America's half-a-century ago and no wonder most of the continent's countries still haven't figured out how to make access to cancer treatment equitable.”