Develop cancer in Malawi, and you may have a long road ahead of you.
Let’s say you’re a rural farmer, as many Malawians are. You’re surviving on less than $1.25 a day, which means care of any sort is difficult to come by.
You ignore your symptoms until they become too painful. Then you make the miles-long trek, on foot, to your local health center, where a medical assistant conducts an assessment but can’t find anything amiss. When the pain persists, you make the trek again. Eventually, you’re sent to a larger district hospital.
Care is generally free at district hospitals, which are funded by the Malawi government. Biopsies aren’t. You pay around 10,000 Malawian kwacha (approximately $13) for yours.
Malawi has only about five pathologists and a couple of laboratories, so getting the results of a biopsy can be tricky. The diagnosis comes back several weeks later, but because of all the delay, the cancer is in an advanced stage. Surgery and chemotherapy won’t help much, and there’s no radiation therapy in Malawi right now. The expense of traveling to a nearby country to receive treatment is unthinkable. All your doctors can do is make you comfortable.
This story doesn’t describe any one patient. It could be many.
According to the World Bank, there are 18.6 million people in Malawi. There are only two Malawian oncologists. One of them, Leo Masamba, practices at Queen Elizabeth Central Hospital in Blantyre. (The other practices at Kamuzu Central Hospital in the capital city, Lilongwe.) Dr. Masamba estimated that, of the approximately 18,000 people who will develop cancer in Malawi each year, only about 20% will receive treatment. It’s even rarer for that treatment to be overseen by a specialist.
By contrast, a recent global survey estimated that there are currently 11,700 clinical oncologists in the United States. That’s about 3.57 per 100,000 people.
A changing landscape
The picture in Malawi is slowly beginning to change, thanks to increased awareness and intervention from both the government and other organizations. For example, the University of North Carolina (UNC) Project Malawi provides cancer and other care, conducts medical research, and works to develop hospital facilities in the country. The Baylor College of Medicine and Texas Children’s Hospital run a pediatric cancer care program as well. A national organization called the Cancer Association of Malawi has been working to raise public health awareness.
Malawi’s government is also building a brand-new cancer center on the campus of Kamuzu Central Hospital. Among other services, the center will provide radiation therapy, so patients who need the treatment will no longer have to leave the country – or go without.
Those aren’t the only shortfalls where oncology is concerned. There is no guarantee that a hospital will be able to access the medications a patient needs for treatments. “Sometimes you run out of growth factors, or sometimes you run out of cytoxins [a chemotherapy drug], or you have challenges in terms of accessing diagnostics – for example, there are limited CT scanners,” said Dr. Masamba.
Direct Relief has secured cancer medications for Malawi through a partnership with the pharmaceutical company Amgen. The organization has provided chemotherapies along with other supportive medications both to Queen Elizabeth Central Hospital and, through UNC Project Malawi, to Kamuzu Central Hospital.
“There are a lot of gaps and stopgaps. The support we get from Direct Relief fills some of those gaps,” said Innocent Mofolo, country director of UNC Project Malawi.
Shortages across the board
But access to quality care is still a serious issue. In Malawi, 75% of people earn less than $1.25 per day, and 83% live in rural settings, often far from a health center. Many Malawians only seek treatment when an illness becomes too severe to ignore.
“If it’s not painful, people will often tolerate a symptom in order to get on with everyday life,” explained Jane Bates, a UK-certified doctor who moved to Malawi to practice in 2002.
That means that a trip to a local health center – which Dr. Bates explained is generally staffed by medical assistants and nurses, not doctors – is often already delayed. A patient may be referred to a district hospital only to find that the wards are overcrowded and they can’t be admitted. A biopsy has to be conducted at one of the country’s few labs. According to Dr. Bates, it can take weeks for results to come back, and sometimes, they never do.
“If you are coming from a peripheral hospital, because of the many stages you have to pass through, usually you end up with a delayed diagnosis,” Dr. Masamba said. But if cancer is diagnosed in time, and radiology isn’t needed (it’s not yet available in the country) a patient can begin chemotherapy – which can then be interrupted if the right drugs aren’t available.
The medical shortages and delays aren’t unique to oncology. In general, Malawi doesn’t have enough doctors, and those doctors frequently can’t get a medicine or test that a patient needs.
“Salaries are lower in Malawi, and they can make more money somewhere else,” explained Mofolo.
Malawi does have a College of Medicine, but it’s relatively new, founded in 1991. Before that, people who wanted a medical career had to leave the country. Dr. Bates said class sizes at the College have grown and more doctors are joining the country’s limited workforce.
A new focus
But while it may be difficult for a doctor to get hold of a blood count test or a nebulizer for an asthma patient – the hospital where Dr. Bates was working was out of both at the time of this article – health initiatives funded by external donors have made some infectious disease drugs more available. “TB drugs and HIV drugs don’t go out of stock,” she said.
“The focus has been mostly on infectious diseases, as in most countries in Africa,” Dr. Masamba said. “Because of that, there hasn’t been a lot of capacity building in the area of cancer care.”
Cancer care is expensive, and, compared to something like a contagious-disease outbreak, it affects a limited number of people. When a country deals with endemic disease or medical crises, costly treatments like radiation therapy are often low on the list of priorities.
Programs like UNC Project Malawi are beginning to change that. There’s also been an increased focus on screening for cervical cancer – Malawi has the highest incidence in the world – through a test called “visual inspection with acetic acid” (VIA) – a low-tech procedure that nurses can be trained to do.
And the number of cancer doctors is slowly growing. A few oncology specialists will graduate soon from various regional universities.
Dr. Masamba is cautiously optimistic. “Things are slowly changing, although not at the rate I would love to see,” he said. “A lot still has to be done.”