The International Network for Cancer Treatment and Research, US A (INCTR USA,) in collaboration with the Division of Pediatric Hematology Oncology, Blood and Marrow Transplantation Program, Lombardi Comprehensive Cancer Center, Georgetown University Hospital, Washington DC, has entered into a partnership with the Federal Ministry of Health, Ethiopia, Addis Ababa University Medical Faculty and the Tikur Anbessa Hospital (Black Lion Hospital), Addis Ababa, to demonstrate that a significant number of pediatric cancer patients in Ethiopia can be cured when treated by physicians trained to recognize cancer early, diagnose it correctly, and treat it according to standard chemotherapy protocols and supportive care regimens specifically designed for developing countries.
The Pediatric Oncology Initiative in Ethiopia is the result of the desire of the Cohen family in Washington DC, to honor the memory of an extraordinary 16 year old young man from Ethiopia, who fought a valiant battle against metastatic osteosarcoma, in part at Georgetown University Hospital, where he was transferred after he was adopted by the Cohen family. He passed away more than two years ago. (Figure 1). Knowing that most children with cancer in Ethiopia die from their disease as a result of lack of resources and expertise in diagnosis and treatment, Mary Louise Cohen, a Board member of INCTR US A, decided to spearhead an effort to make a difference in the lives of children with cancer in Ethiopia.
Ethiopia has long been known to the outside world as Abyssinia. It is located in the North-eastern part of Africa, also called Horn of Africa and is bordered by Eritrea (N), Kenya (S), Djibouti and Somalia (E) and Sudan (W). (Figure 2).
Ethiopia is one of the world’s poorest nations. It has a population of 83 million people, with more than half the country under the age of 18 years; 49.7% are females, 44.7% of the population is less than 15 years of age, and 40% is under the age of 5 years (Figure 3). It rates as the 171st out of 182 countries on the United Nations Development Program’s Human Development Index. Most people live on less than $2 a day.
The Ethiopian Government is the country’s main health care provider with 138 hospitals and 635 health centers. Only two of these hospitals, Tikur Anbessa and Yekatit 12 in Addis, have dedicated pediatric wards. Treatment is provided free. However, with the per capita expenditure of $2.31/day on health (as compared to $9/day in India and $100/day in South Africa), resources are few and care sub-optimal. The doctor/nurse to population ratio is 1:42,700 and 1:4200 respectively. Neonatal mortality rate is 49 deaths/1000 live births and the under-five mortality rate is high at 77 deaths/1000 live births with 1/6th of the children dying before their 5th birthday. More than 70% of these deaths are due to communicable diseases such as measles, pneumonia, malaria, HIV/AIDS , diarrhea and severe malnutrition. Recently, with the institution of immunization programs all over the country, there is a trend towards decreased mortality from communicable diseases.
There is no cancer registry in Ethiopia. Extrapolation from clinical records from Tikur Anbessa Radiotherapy Center estimates that there are 120,500 new cancer cases/year, although Globocan estimates are much lower (51,000 per year). Most patients present with advanced disease, and there is a high rate of abandonment of treatment. Morphine is not readily available for cancer patients. The top 10 cancers are listed below. (Figure 4).
Based on extrapolating estimates from another East African nation, Tanzania, with an incidence of pediatric cancer of 134 cancer cases per million, Ethiopia probably has close to 6,000 new cases of pediatric cancer each year. The commonest childhood cancers seen at Tikur Anbessa Hospital include leukemia, lymphoma, retinoblastoma, Wilms tumor and bone and soft tissue sarcomas. Most children present late, with advanced disease, and in pain.
With a per capita income of approximately $2 a day, resources devoted to health and health care in Ethiopia are limited. Ethiopia has no pediatric oncologists. Mortality rates for most pediatric cancers are close to 100%. In contrast, in developed countries, the survival rate for children and adolescents diagnosed with the most treatable cancers, including leukemia, lymphoma, retinoblastoma and Wilm’s tumor is rapidly approaching 90%.
The situation in Ethiopia is similar to that of other developing countries where cancer patients often receive incomplete, inadequate, or no care and those with incurable disease are frequently sent home to die without palliative care. Ethiopia lacks the trained medical personnel, adequate facilities, a sufficient supply of essential chemotherapy drugs and simple pain medications necessary to treat cancer patients. As a result, there is little public awareness that cancer can be cured, little public demand that health systems address cancer, and consequently, few government medical resources devoted to cancer treatment.
However, all this is changing rapidly as the world slowly wakes up to the burgeoning problem of noncommunicable diseases (NCDs). Even though NCDs were not mentioned in the Millennium Development Goals written in 2000, NCDs were responsible for 60% of global deaths in 2005 (35 million), with 80% in low - and middle - income nations, and are projected to increase by an additional 17% over the next decade. Cancer is now recognized as an important health problem in developing countries. The WHO Assembly resolution WHA58.22 (2005) has done much to bring this about, and now even the governments of the poorest countries recognize that cancer is an important health problem. Resolution WHA58.22 urges countries to develop programs tailored to their socio-economic status, aimed at reducing cancer incidence and mortality and improving the quality of life of cancer patients and their families through the systematic, stepwise implementation of evidence-based strategies for prevention, early detection, diagnosis, treatment and palliative care.
Similarly, a 2006 Institute of Medicine (IOM) report also recommends focusing on pediatric cancers as an ideal target for capacity building in developing countries, as: a) most childhood cancers are highly curable if detected early; and b) successful, low cost, treatment protocols that utilize inexpensive, generic, chemotherapy drugs, adapted for use in low-income countries (such as the ALL and lymphoma protocols devised by INCTR) are readily available for use.
Eventual Goal: Establish a Center of Excellence for Pediatric and Adolescent Oncology at the Tikur Anbessa Hospital in Addis Ababa.
Goal: To officially initiate the two-year Fellowship training in January 2012.
This program has been the collective effort of numerous Ethiopian and INCTR faculty, administrative staff in Ethiopia, Washington DC and Brussels without whom this huge endeavor would not be possible. Finally, a special thanks to Mary Louise Cohen – it was largely her vision, enthusiasm and determination to make a difference in the lives of children with cancer in Ethiopia that led to the creation of the program (Figure 5).