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Tikur Anbessa (Black Lion) Hospital

Black Lion Hospital is the largest general public hospital in Addis Ababa.

Ethiopia is a landlocked East African nation with an estimated land area of 1.1 million square kilometers. It is the third most populous country in Africa with a population of 79 million—of whom 80 percent live in rural areas. While 86% of the population is reported to have access to basic health services, doctors and nurses are in very short supply: the doctor-to-population ratio is, at most, 1:20,000 and the nurse-to-population ratio 1:3,000.

Women and children comprise nearly three-quarters of the Ethiopian population. Few Ethiopians live to see old age: one in ten children dies before his first birthday. The average life expectancy for women is 53 years.

With more than 70 percent of childhood deaths attributable to communicable diseases and malnutrition, Ethiopia’s healthcare resources have been directed primarily to treat and prevent diseases such as malaria and diarrhea. Only recently has the government recognized the growing burden of cancer. The Federal Ministry of Health estimates that there could be more than 150,000 cancer cases in Ethiopia each year, but available data is limited.

As the nation’s sole cancer referral center, Black Lion Hospital is treating only about one percent of these patients. Health experts explain that many Ethiopians with cancer never seek medical treatment and, of those who do, they may not be referred to the cancer center in Addis Ababa.

Affiliated with the Addis Ababa University’s School of Medicine, Black Lion Hospital is the training center for undergraduate and postgraduate medical students, dentists, nurses, pharmacists, laboratory technicians, and others who shoulder the health problems of the community and the country at large. Postgraduate medical education is also available through the Department of Internal Medicine.

Only in the last few years have noncommunicable diseases, including cancer, received attention as public health issues. The Federal Ministry of Health recently created a task force to address the issue of non-communicable diseases. Members of the task force support endeavors that address the control of cancer, including community research, diagnosis, treatment and palliative care. At present, government resources for cancer care are limited to treatment only.

According to data from the hospital’s oncology unit, more than 500 adult and pediatric cases with hematologic malignancies are seen in the hematology clinics every year. Many patients with cancer are also seen at the surgical, gastrointestinal and gynecology clinics. The most common adult cancers are cervical, breast, sarcomas, head and neck, and colorectal cancers, while leukemia, lymphoma, retinoblastoma and osteosarcoma constitute the bulk of pediatric cancers.

Black Lion Hospital aspires to become a center of excellence in the diagnosis, treatment and care of patients with cancer. With the support of Ethiopia’s governmental institutions, NGOs and international partners, including INCTR, the hospital is hoping to develop a comprehensive cancer care program, including cancer registry, early detection, prevention, standard treatment and palliative care.

As a significant step in that direction, INCTR US A, in collaboration with Georgetown University, is launching a fellowship training program in January 2012 in collaboration with the Black Lion Hospital’s Departments of Internal Medicine and Pediatrics. Aziza Shad, Chief of Pediatric Oncology at Georgetown University Hospital, Washington DC, and President of INCTR US A, is spearheading the initiative to improve capacity in pediatric and adolescent oncology in Ethiopia. An oncology nurse training program will run in conjunction with the two-year fellowship program for young doctors chosen by Black Lion Hospital. In addition, training will also be provided in pathology through the INCTR i-Path program in an effort to improve diagnostic services.

Dr. Shad has put together a team of visiting faculty that includes doctors and nurses from Georgetown University as well as experts from several INCTR branches, the University of Rochester, Harvard University, and the Hospital for Sick Children, Canada, among others. Their mission: to train pediatric oncologists, nurses, pathologists and pharmacists, improve survival for curable childhood cancers and introduce palliative care.

“In addition to faculty from Ethiopia, we plan to have visiting faculty on the wards and clinic, providing hands-on teaching,” notes Dr. Shad. “We will also institute protocols for treatment and ensure the availability of drugs. By improving diagnosis, providing training, and improving supportive and palliative care, we hope to make a difference in the survival of children with cancer.”

Resources at Black Lion Hospital

Total Beds: 600
Beds Devoted to Cancer Care (at the oncology center): 18
Staff Physicians 201
Nurses 627
Dedicated Oncology Nurses 26
Pathologists >10
Hematologists 2
Medical oncologists 4
Radiotherapists 4
Pediatric oncologists 1
Specialized surgical oncologists 2
Oncologists in Training  
General and specialist surgeons >30
CT scanners 1
MRI scanners 1
Cobalt radiotherapy units 2
Linear accelerator units None

Patients seen in 2010

Total Patients 266,975
Total Outpatients 251,560
Adult Cancer Patients >2000
Pediatric Cancer Patients >200
Pediatric oncology nurses on the unit at Tikur Anbessa (Black Lion) Hospital in Addis Ababa, Ethiopia.

The initiative in Ethiopia began with The 1st Pediatric and Adolescent Oncology Symposium, a three-day training workshop held last October in Addis Ababa. Emphasis was placed on diagnosis and management of common pediatric cancers, supportive care, palliative care and family support.

“We have benefited tremendously from INCTR’s visiting experts program,” says Dr. Amha Gebremedhin, head of the Department of Internal Medicine, who has since lobbied the hospital to devote a unit to cancer patients that is not in close proximity to infectious patients.

Dr. Amha has achieved good outcomes in the treatment of patients with chronic myeloid leukemia (CML), thanks in part to a relationship forged in 2004 with the Max Foundation. “As a result,” he says, “our patients have been enrolled in the Gleevac International Patient Assistance Program (GIPAP). For patients, both adults and children, who have been treated with Imatinib mesylate, their quality of life has normalized and early deaths have been diminished.”

INCTR’s international team of doctors, working with Dr. Amha and Dr. Damte Shimelis, head of the Department of Pediatrics at Black Lion Hospital, hope to see similar outcomes on the pediatric cancer ward.

“What we are hoping is that after two years there will be a group of four-to-six well-trained pediatric oncologists who can then become trainers themselves,” notes Dr. Shad. “In addition, we plan to collect outcome data in order to track survival rates, and hopefully, demonstrate a significant improvement. We will focus on providing patients with curable cancers, such as ALL, lymphoma, Wilms tumor and retinoblastoma, with effective therapy. We will need to ensure there is enough chemotherapy available to see patients through to the end of their treatment and provide family support to reduce the problem of abandonment of therapy, that is all too frequent in low resource settings.

The availability of chemotherapeutic agents is just one of many challenges at this government-supported teaching hospital. The School of Medicine was initially intended for fewer than 50 undergraduate medical students. Today, approximately 1,000 undergraduate students and 300 postgraduate students are educated in these facilities in Ethiopia. With such large numbers of students, and limited resources, there is shortage of space and teaching aids including books and journals, and access to information technology services.

By addressing the shortage of medications and meeting the growing demand for oncology-trained doctors and nurses, hospital leaders are optimistic, that with the support of international partners such as INCTR, Black Lion Hospital can become a model cancer center and take the lead in improving Ethiopia’s response to its increasing cancer problem.

Amha Gebremedhin,
Damte Shimelis,
Tesgaye Aster,
Aziza Shad and Marcia Landskroener,
Black Lion Hospital, Georgetown University Hospital and INCTR

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