By Noah Smith
MAPUTO, Mozambique — Eighty percent of children with cancer in the United States and other developed nations survive, while many lower-income countries have mortality rates that exceed 80%, according to a 2019 paper published in Infectious Agents and Cancer.
But a small number of doctors spread throughout Africa, some of whom are backed by a $50 million grant, have seen outcomes begin to approach Western numbers. This has led to hope that widespread improvements — for cancer treatment and beyond — could be attainable within years.
“We realized that some of these cancers are highly, highly curable, and the kids bounce back fast,” said Dr. Fredrick Chite Asirwa, who established a program in Kenya with Takeda Pharmaceuticals, Indiana University, and Moi University that brought survival rates above 80% and has overseen the oncology training of about 700 doctors, nurses, and physicians assistants, in addition to “spotters” who are taught how to identify tumors in residents of remote villages.
“In Kenya, everyone thought cancer was a death sentence. There were not many survivors,” Asirwa said. His work in western Kenya has led to vastly improved access to pediatric cancer care. The number of patients his programs treat has grown from 400 people in 2011 to 10,000 people in 2017.
Though differing challenges face health care providers, as well as patients and their families throughout Africa, some commonalities include a lack of oncology-trained doctors and nurses, misdiagnoses, financial impediments, and a lack of access to authentic, high-quality medicines. But enterprising doctors who have implemented new protocols and training have allowed more children to be accurately diagnosed and treated.
Notably, only 50 years ago, the United States had a 90% pediatric cancer fatality rate, according to a 2008 Seminars in Oncology report, giving hope that immense improvements can be had in Africa as well.
In Tanzania, Dr. Trish Scanlan, in partnership with the local government, has overseen the treatment of thousands of cases, and all at no charge to the families involved. About half of children diagnosed with cancer survive at Muhimbili National Hospital, one of the facilities she works with. They have accomplished this without even having a cold storage room, which is needed for certain medicines, and which Direct Relief is helping them build.
“There are so many problems that already have solutions. We’re not inventing something… This is imminently solvable in a very, very short period of time,” she said, referring to pediatric cancer cure rates.
And in Malawi, one of the poorest countries in the world, Nigerian-born Dr. Nmazuo “Maz” Ozuah is leading the way for Global HOPE, a Texas Children’s Hospital program that is using a $50 million grant from the Bristol-Myers Squibb Foundation to build capacity throughout Africa. His program hopes to treat 4,000 new pediatric cancer patients in Malawi during the next five years.
Despite only being in-country for a few months full-time, Ozuah has already seen positive changes, both in pediatric cancer care and in other types of medical treatment.
“I see that our presence here has strengthened the whole system. In order to treat children with cancer, you need a strong health care system,” he said at the AORTIC Conference in Nov. 2019, noting that solid laboratory work, training, and public advocacy, as well as awareness, are all critical.
Ozuah, who completed his residency and fellowship in the United States, said he was acutely aware of the deep systemic problems facing pediatric cancer care during his internship in Nigeria.
“As an intern, once you said a patient had cancer, you were left off the hook. No one expected you to explain why that child died,” he said.
Aiding Global HOPE’s potential ability to bring massive improvements in this area, Teva last week became the first pharmaceutical company to donate medicines to the program. Starting with a limited pilot program this year, their products will be delivered by Direct Relief to Global HOPE programs in Malawi and then Botswana and Uganda in 2021.
“Somebody (Direct Relief) cracked how to do safe deliveries of these medicines. So our sense was that it would be interesting to partner with Global HOPE,” said Amalia Adler-Waxman, Teva’s Vice President of Social Impact and Responsibility, on why the company decided to engage.
While there are bright spots, creating a sea change will require addressing problems that have been present for decades or longer, in some cases.
Asirwa said that one of the most damaging issues is the pervasive ignorance facing fundamental elements in treating pediatric cancer. One example, he shared, was a belief that survival rates are low in Africa because patients only come after they are in the later stages of the disease.
“Most patients see 8-10 health care professionals before the correct diagnosis is made,” he said, adding that one of the reasons behind this is that African doctors often have to go abroad to receive training in oncology — and once in those countries, they tend to stay.
Even when a correct diagnosis is made, high costs also delay treatment. Asirwa said that, even though Kenya has national health care, it doesn’t cover all aspects of cancer treatment. An accurate diagnosis can cost $250, and so many patients have to delay the process until they can raise the cash.
Drug shortages and costs also play a role, and Asirwa said he saw a child recently who was only taking three out of the five required medicines for his condition.
While HIV/AIDS treatment is often seen as a template for how to treat cancer in Africa, Asirwa urged caution, noting that HIV is one disease, whereas cancer consists of many diseases. Still, there is some value to the general idea of creating effective protocols and then exporting them, he said.
“If you use that model and take it to cancer, it will be much easier to improve the system.”
Dr. Asirwa, along with Scanlan and Ozuah, referenced the multidisciplinary approach needed to improve outcomes for pediatric cancer care. Asirwa said in an American Society of Clinical Oncology-published essay that this also extends to the janitors, in his experience.
Patients in Kenya often wait for hours to be seen by a doctor, he wrote, and in that time they can become emotional and nervous. Such a patient could turn to the only clinic staff who is constantly around — the janitor — and ask, “Have you seen any patients like me here at this clinic being treated?”
“Yes,” the janitor answers.
The next and most important question is asked: “How did they do? Did they get cured?” Asirwa wrote, and included that he thinks janitors should be educated on the different kinds of cancers, that some can be cured, the importance of getting a biopsy, and, “that they are IMPORTANT to the team!”
The underlying issue gets at one of the most difficult problems to solve, namely, public perception. But Asirwa has a plan for that, too.
“There is nothing more powerful than actually seeing a survivor,” Asirwa said. “You can actually start making people believe that cancer can cured.”
Direct Relief, Global HOPE and Teva Pharmaceuticals are partnering to expand access to cancer treatment in sub-Saharan Africa. Under this partnership, Global HOPE determines the specific medications needed at its clinical sites for treating cancer and blood disorders in children. Those medications, in turn, are provided by Teva to Direct Relief for delivery. The collaboration is the latest in a series of Direct Relief efforts to connect cancer treatments to patients around the world, including support for pediatric cancer patients in Mexico, and the Philippines, as well as cancer initiatives in Haiti, Nepal and Peru. Direct Relief is also a member of the Union for International Cancer Control, and an implementing partner in the UICC’s City Cancer Challenge.