In 2005 I was trained as a doctor at Nkhoma Hospital in Malawi, one of the poorest countries in the world, in the south of Africa. At the end of 2019 I went back, now an oncological surgeon. The hundred-year-old mission hospital at the foot of Nkhoma Mountain still turned out to be that idyllic spot, contrasting with the local poverty.
On the way to the hospital, little seemed to have changed. Traffic participation remained a perilous affair, with children suddenly crossing the road, cows, goats and cyclists carrying high loads on luggage carriers. The hospital, built against the mountain, with its red open corridors, also seemed unchanged.
I thought I was needed as a general surgeon, but to my surprise, my oncological expertise turned out to be more useful. In 2005 I hardly ever saw cancer here, now I was confronted with it every day. In a country where an average of 83 euros per inhabitant per year is spent on health care (the Netherlands: 6,660 euros), providing care for cancer patients on location turned out to be a difficult task.
Knowledge about cancer limited
The patients who reached the hospital often came in late stages of their disease with large metastatic tumors. Often they had already been ‘treated’ by the local traditional doctor and turned out to be malnourished or had an infection that gave cancer free rein. In addition, the distance and the costs of hospitalization were an obstacle. For example, in Malawi, if you are admitted to a hospital, you must guardian bring along: someone who takes care of your food. So it is hoped that someone will stay at home with the family.
When these patients eventually reached the hospital, knowledge about cancer turned out to be limited. Doctors in Malawi are particularly knowledgeable about infectious diseases such as malaria, tuberculosis and HIV-AIDS. Due to lack of experience with cancer, they often made the wrong diagnosis.
How come cancer had increased so much in those fifteen years? This seems a harsh price for the explosive increase in life expectancy. Over the past twenty years, this has increased in Malawi from an average of 46 to 63 years; a huge increase. Many regions in sub-Saharan Africa numerically resemble the Netherlands around 1850 (or the United States around 1900). Then our life expectancy was 38 years. This doubled within a century and a half to almost 79 years in 1989. This was caused by improvements in hygiene, food, stability and vaccines and antibiotics. The same effects are now taking place in a much shorter period of time in these low- and middle-income countries where economies are growing rapidly. In Malawi, for example, there has been a drastic reduction in child mortality due to the improvement of vaccination programmes, the fight against HIV-AIDS and tuberculosis and a rising standard of living.
Radiation and chemo too expensive
The price that the country pays, partly due to the adoption of Western lifestyles, is a rapid increase in conditions such as cardiovascular disease, obesity, diabetes and therefore also cancer. In 2004, a quarter of deaths in sub-Saharan Africa were caused by these conditions, but that number will rise to more than half by 2030, according to the World Health Organization.
In Nkhoma Hospital, I saw many types of cancer. Although surgery is normally the only option, most of the time the disease was no longer treatable. Sometimes there were individual successes. For example, we removed a huge tumor from the leg of an elderly man so that he could walk home again. And on a young woman, we removed a large, deforming salivary tumor from the face.
Despite these being little more than drops in the ocean, these treatments do show that surgery for cancer will be the key to success. It is the most inexpensive, safe and efficient care. The need is immense. Published in 2015 The Lancet the forecast that by 2030, 45 million operations will be needed worldwide for curative cancer treatments, especially in low-income countries like Malawi. Chemotherapy and radiation are not a realistic alternative due to the cost.
:format(webp)/s3/static.nrc.nl/images/gn4/stripped/data79212597-ff5f1b.jpg)
Also read: While Africa focuses on corona, TB, AIDS and HIV continue unabated
Education, Education, Education
We increasingly have the opportunity to help our neighboring continent with this crucial knowledge and expertise. Through conferences and summer and winter schools, we can offer education, and also, increasingly, due to rapid digitization, high-quality webinars. By standardizing cancer care worldwide, creating training places and academic collaborations, we will also learn about this many-headed monster ourselves.
Coming from a continent full of old people, you mainly see young people in Malawi: everywhere children play and school classes are overflowing. In birth clinics, the light is seen thirty times a minute. Hans Rosling, the Swedish physician and epidemiologist who died in 2017, showed in his groundbreaking book Factual knowledge shows that contributing to health care and education are the most effective methods of curbing this explosive growth. If this is successful, the average number of children will quickly fall to under two.
Rolling up your sleeves as a doctor is tempting, but given these numbers not the right way. Education is the key. Last week, therefore, the first summer school for oncology was organized in Blantyre in Malawi. With a mixed Dutch/Malawian team, we spent a week sharing knowledge about cancer treatment with forty Malawian surgeons and gynaecologists in training. True to the old Chinese saying: give a man a fish and you feed him for a day; teach a man to fish and you feed him for a lifetime.