March 9 — Cancer Care in Zimbabwe

I’ve paid extra attention to the subject of cancer care during this visit to Zimbabwe. Economic conditions have improved in the country since my 2009 visit. The economy has stabilized somewhat, the shops have food for those with the U.S. dollars to purchase it, and there are many cars, many new cars, on the roads. Yet, power cuts are common; fuel can be difficult to find; Harare’s water remains unsafe to drink, and some suburbs are not being supplied; and unemployment runs above 90 percent, leaving many people, particularly in rural areas, without cash for food, school fees, and other necessities.

So, how does cancer care fit into this situation?

First, a broad picture for government and mission hospitals as I have pieced it together (I have no information on private clinics, except that conditions are said to be generally better):

  • There are two national referral centers for radiotherapy, chemotherapy, and specialized surgery, Parirenyatwa Hospital in Harare, and Mopelo Teaching Hospital in Bulawayo.
  • There are three oncologists remaining in the nation, with two more to be certified in June.
  • One doctor noted that two curable cancers in the country are cervical cancer and lymphoma, and that it is possible to identify those who are curable, but the cost of drugs is a problem.
  • Radiation therapy is available mainly at the referral hospital in Harare, but it is very limited, expensive, and patients may wait many months for treatment.
  • Chemotherapy is limited. Patients or families must purchase the drugs themselves and bring them to the doctor. Only a few drugs are available, and 90 percent of the patients can’t afford them, or they may purchase enough for one course of therapy when several courses are needed.
  • Morphine is used for pain control, but supplies are erratic and the drug is sometimes unavailable.
  • Health workers feel overwhelmed because they have few resources, and patients keep returning as their cancer progresses. As one doctor put it, “They keep seeing patients who don’t get well. It is not easy.”
  • Programs are needed for education, screening, and early detection. This is particularly true for cervical cancer, which is detectible at an early and curable stage (the incidence of this cervical cancer is also increasing due to HIV infection). Breast cancer is often detectable early, and its early removal can improve quality of life and extend life.

Here is what I learned at the local level:

  • One mission hospital is using telemedicine to diagnose cervical cancer and other malignancies. They biopsy a mass, cut thin sections from the biopsy and stain the sections, scan these under a microscope, and transmit the digital image to colleagues in Switzerland for diagnosis.
  • Pap smears for early detection of cervical cancer are not done because hospitals lack reagents for the involved staining process.
  • Cervical cancer occurs in women aged 35 to 60, and it is usually advanced at diagnosis. The younger women are generally HIV-positive.
  • When a woman is told she has cervical cancer and that her uterus must be removed, she will say she must confer with her family and then return to the hospital. But some women don’t return for three to six months. Some wait two years. “When they have blood as an oozing discharge, then the woman is frightened and she returns.”
  • Women with breast cancer are usually aged 55 to 65, though some are in their 30s. The women arrive at the hospital “with a wound that has not healed. These patients are referred to Harare Hospital for mastectomy, but they are scheduled for surgery one or two years in the future, and some die in the meantime.” (Many rural patients who are referred to Harare do not go because they lack even the money for transport.)
  • When a woman is told she will lose her breast, she is likely to go to a “prophet” or a traditional healer who will use magic and say that she is cured. But when the wound worsens, the she will return to the mission hospital hoping for help. “But all we can do is provide some morphine for the pain and give her a dressing that helps with the bad odor.”

If anyone has ideas for how we can work together to ease the suffering caused by cancer in Zimbabwe, please pass them along.  Thanks, and I hope all is well. Darrell

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26 Responses to March 9 — Cancer Care in Zimbabwe

  1. http://www.squidoo.com/cervical-cancer-symptoms says:

    It’s nice to read personal stories with additional details, when i also have changes and ‘symptoms’ but I’ve little idea if they are related to cervical cancer or not- .. like We’ve upper back pain, pelvic pain, some slight adjustments to bleeding and pain during intercourse and more frequent urination however the descriptions of symptoms are so general which it really causes it to be hard to not worry or higher respond to every little pain. (I’m having a colposcopy the following month)

  2. Darrell Ward says:

    To the woman above, Our thanks for your comment. It is good that you are getting a colposcopy, and we hope all goes well and that you will receive the care you need to relieve your symptoms. Please consider keeping us informed about your treatment and how it goes. If you wish, please email me at dward@betterhealthcareforafrica.org.

    If you are in Zimbabwe or another African country, please add your comments about the problem of cervical, breast or other cancer in your area. Please tell us as much as you are comfortable about yourself and location, your country, city or town. What care is available to you? How is cancer perceived where you are? What would you like to see done to ease the suffering caused by cancer in your area?
    Thank you and take care…Darrell

  3. kay huebner says:

    I found this survey of cancer care possibilities in Zimbabwe absolutely stunning. Fixing things would mean starting from the ground up. I so admire the people who work for health care in Zimbabwe, who don’t despair at the enormity of the problems, but every single day do what they can to help.
    I wonder if girls are/will be getting the HPV vaccine that could in the near future save so many from cervical cancer. I wonder if there is some foundation fund (Gates maybe) that might help with getting such vaccines where they are desperately needed. Do the doctors at your mission hospital have access the the HPV vaccine to protect young women against cervical cancer?

  4. Darrell Ward says:

    Thanks for your comment, Kay. The HPV vaccine that could protect girls from developing cervical cancer in the future isn’t available in Zimbabwe (unless perhaps at private clinics). Cost aside, the vaccine requires a cold chain — it must be constantly refrigerated. That would be difficult in Zimbabwe, which experiences frequent, rolling, unscheduled power outages.

  5. Russell Kanyera says:

    I’m in Zimbabwe and involved in Health care though on the Lab side of things. I’ve gone through a lot of papers on the HPV vaccines and I honestly do not see it being a viable option for Zimbabwe as routine Pap tests are not accessed by over 90% of the female population. and since the vaccines will not protect against most genotypes that are associated with cervical cancer. even after vaccination women still need to get pap smears so in my view it’s better to promote Pap smears first then move on to the vaccines.

  6. Darrell Ward says:

    Many thanks for writing, Russell. Why do so few Zimbabwean women obtain Pap tests? Is it that women in Zimbabwe are not aware of testing, or that they are can’t affort the test, or that testing is not widely available? My recent experience indicated that many hospitals have stopped doing Pap tests because the reagants needed to do the test are expensive and that the staining process is complex. Can anything be done today, at moderate cost, to help ease the burden of cervical cancer in Zimbabwe?

  7. Russell Kanyera says:

    I can say the relative lack of cervical screening is a combination of many factors greatest of which is awareness. Before I started my HPV project I was not aware of the HPV burden in Zim and as such most people let alone women don’t know they should be screened. Add to that the low number cytologists and the availability question becomes another big factor. In my view what is crucial to reduce cervical cancer is awareness and the introduction of a nationwide cervical screening programme. There has been talk of introducing the vaccines in around 2 years but that will not help the women who are already sexually active or HIV infected. Countries with low cervical cancer rates have a strong screening programme so I think that would help the best. And the price of the vaccines may be prohibitive if you consider it’s at least US 300 to vaccinate one person! So there is no easy answer to the cervical cancer problem here in Zimbabwe.

  8. kay huebner says:

    Of course you are correct, Russell, about the importance of screening to help the many women for whom the vaccine is too late. But if we consider the HIV picture, drug companies have been willing to reduce prices drastically in order that they might be provided to many African patients at reduced costs. Could not something like that be envisioned for the HPV vaccine in countries where cervical cancer is a huge problem? I know it will not happen overnight, but if large numbers of young girls (and even boys are now being vaccinated, I understand) could be protected, it seems worth working toward.
    Of course you know much more about the reality in Zimbabwe where, as Darrell says, refrigeration is a problem. I will read more about the current vaccines and plans for improvements in production, numbers of types covered and improved stability.

  9. Russell Kanyera says:

    Thank you Kay for your comments, but really I was looking at the broader picture of the things that some people don’t sometimes consider about the vaccines, not just a Zimbabwean view.
    There is a programme called GAVI which seeks to ensure that children allover the world have equal access to vaccines. From what I understand it helps on the financial side of acquiring vaccines and luckily Zimbabwe can the covered in that programme from what I know. How far that can help is anyone’s guess really.
    But even if getting the vaccines is easy, awareness and logistical hurdles will be the greatest problem. I’m currently part of a group that will be looking at the HPV burden in Zimbabwe, mainly cancers associated with HPV. I think after a few months we will have a better view of the situation and the major problems.

  10. Darrell Ward says:

    Hi, Russell. If you have a moment, would you write more about the project to investigate the HPV burden and related cancers in Zimbabwe? What cancers are you looking for? Cervical, no doubt, but recent research has linked some cancers of the throat (i.e., the oropharynx) to HPV as well. How will you investigate the problem? Will it be an epidemiological study? What do you hope to do with the data once you have it? In your first comment above, you mentioned the need for a nationwide screening program. Is there a chance that could happen in the next few years? ? Thanks…Darrell (dward@betterhealthcareforafrica.org)

    To other readers in Zimbabwe or in southern Africa:
    Please post a comment (or write to me at the address just above) about the problem of cancer in your community. Do people understand the causes of the disease? Is it common problem? What kinds of cancer are most common in your area? Is there a stigma associated with it? Thanks, everyone…Darrell

  11. Russell Kanyera says:

    Hi Darrell. Well, HPV has been identified in to be associated in a very wide variety of cancers. It’s estimated that HPVs cause up to 5% of all cancers with cervical cancer being the big problem. HPVs are also associated with other anogenital cancers like penile, vulvar, vaginal anal and others like ocular, oropharyngeal (like you point out), nonmelanoma skin cancers and other diseases like genital warts and laryngeal papillomatosis. We are a small group so we can only cover a few cancers. But our focus really is on characterising the cancer cases associated with HPV other than cervical.

    About the screening programme, to be honest I’m not sure if there are plans for that right now. I would hope that there are plans for such a programme though.

  12. Darrell Ward says:

    Thanks again, Russell, for another intersting post. And thank you for alterting me to the WHO/ICO publication “Human Papillomavirus and Related Cancers: Zimbabwe. Summary report update. Sept. 15, 2010.” This publication is available for reading or to download at http://www.who.int/hpvcentre/en/. This free publication provides a very good over of the problem of cervical and other HPV-related cancers in Zimbabwe.

  13. kay huebner says:

    I looked up the WHO site provided by Darrell above and it does indeed have lots of information. It looks as if the Gates foundation does have interest in the HPV problem, so maybe an attempt to gain funding for vaccination would not be hopeless.
    I was surprised to see (at the WHO site) that the use of oral contraceptives is considered a huge cofactor in the spread of HPV, I guess because it frees people from the use of condoms for birth control, clearly not a desired side effect.

  14. Russell Kanyera says:

    Thank you Kay, for your comment. It reminds me of the one sided view that some ‘health awareness campaigns’ may take. For example it’s deemed acceptable sexual behaviour to perform oral sex as long as you do not have bruises in the mouth as you probably won’t contract HIV. Result: oral cavity and throat infections with other STIs, including HPV and HSV. It’s the same with oral contraception and increased risk of breast cancer and inconsistent use of condoms being riskier than total abstinence from condon use as condoms cause bruises that make infections far much easier. Sad thing is most people don’t know these things.

  15. Darrell Ward says:

    Hi, Russell, and thank you for another interesting comment. You mentioned earlier that you were coming at the problem of cancer from the lab side, so I wonder if you can answer a question for me. During my March visit to Zimbabwe, I learned that many hospitals had stopped doing Pap tests some time ago. Can you please tell me why? Are Pap tests difficult to do in a resource-limited setting or are the reagents especially costly? Were Pap tests done formerly? If so, about when were they discontinued?
    Thanks…Darrell

  16. Russell Kanyera says:

    Hello, well Pap tests as far as I can tell never had a formal national structure in terms of a government policy or procedures or awareness. Again, I am new to this so I may be wrong. Pap smears are difficult to implement right now because of cost and the low number of cytologists who can grade the smears to identify precancerous lesions. Interestingly, studies here in Zimbabwe in the late 90s showed the applicability of other screening methods that are quite cheap with the only reagent needed being acetic acid! Why that wasn’t implemented or at least tried is anyone’s guess.

  17. carl von essen says:

    I am interesated to know what radiotherapy facilities (machines) are actually operating now in Zimbabwe. There are conflicting reports.

  18. Darrell Ward says:

    Thanks for your question. Let me see what I can learn.
    Darrell

  19. Elizabeth Tepa says:

    hello Darrell
    Iv really enjoyed reading your articles on this forum. Im an oncology nurse specialist based in NZ and i want to do something for my country in terms of cancer especially gynae cancers. I find african women generally dont want to talk about gynae cancers. Could be why the prognosis of cervical cancer in Zim is not good coz women seek treatment when its too late to do much about it. Im trying to source equipment for smear tests will update u on my progress

  20. Darrell Ward says:

    Hi, Elizabeth. Many thanks for your comment, and I do hope you stay in touch regarding your efforts to help women with cancer in Zimbabwe. I agree that Zimbabwean women are reluctant to talk about gynecologic cancers, which keeps them from an early diagnosis. I do think Zimbabwean women can take heart that they are alone in this, though. I think it is difficult for women in many cultures to talk about gynecologic cancers. Many people find it difficult to talk about cancer of any kind. In addition to that, there is the intensely personal nature of gynecologic cancer. In Zimbabwe, these problems are intensified by an overall lack of cancer awareness and education, and the lack of Pap tests and early diagnosis. In addition, Zimbabwean women must cope with high unemployment, high levels of poverty and hunger, and unreliable public transportation — even if a woman can afford bus fare to a clinic or area hospital, the bus many not show up. This is not to say that the problem is hopeless. It should be possible to take education and simpler early detection methods out to the villages, for example. Thank you again, Elizabeth, best of luck in your efforts and please stay in touch.

  21. Signs of Cancer says:

    With cancer being the second leading cause of death, I want to see it destroyed. I don’t know if this is completely possible, but we do have a place to start. We can learn and teach the signs and symptoms of cancer in order to achieve earlier diagnoses. Some cancers are curable if found soon enough. This is why I desire to teach the signs of cancer! Thank you for this site and please continue to teach!

  22. Darrell Ward says:

    Dear Signs, Many thanks for your comment. You are correct that many cancers, including cancer of the cervix (the opening of the womb), can be cured if people recognize the signs of cancer, identify it early and seek treatment. The same can be true for breast cancer and a number of other cancers. Cervical cancer and breast cancer are a leading cause of death among women in Zimbabwe and many developing countries. A recent study found that two million women worldwide developed breast cancer or cervical cancer, and that 76 percent of cervical cancer cases occurred in developing countries, half of them in women under age 50. Education, early detection and early treatment can improve the quality of life for women and reduce deaths from these diseases. Early detection is particularly important in Zimbabwe and other developing countries because it is possible to treat and even cure early disease (especially cervical cancer), but far fewer options are available for treating advanced disease in resource-limited countries. Outreach programs that involve local physicians and hospitals, ministries of health, NGOs, and, ideally, traditional healers, are needed. Better Healthcare for Africa will continue to promote cancer awareness, education and early detection and treatment, and we are working to develop a pilot program to improve cancer care in Zimbabwe.

  23. lynda matthews says:

    Please email me.would like to discuss more on this issue.Iam from the Art of Being Humane Foundation.we are doing Awareness campaigns on cervical and breast cancer.thank u

  24. Washington mudini says:

    very interesting conversation. i will have u know that two years on there is some progress in terms of the availability of the hpv vaccine – albeit the initiative is only about two months old, only available in the private setting and quite costly. there is still not much in terms of a robust awareness programme to be done {that is comparable to the publicity that circumcision is receiving for example.} i intend to do a subtyping study of the current prevallent hpv subtypes~hopefully this information may be used in the tailor making of our own vaccines especially in this setting of HIV.

  25. Sally says:

    This site has been a well of information! Any idea what kind of Linear accelerators where delivered in 2012 in The two government hospitals?

  26. Darrell Ward says:

    Thank you for your comment, Sally. I do not have additional information about the linear accelerators at the moment, but I will try to lean more. Thank you again and have a good day today! Darrell

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