A New Organization for a New Century

by Ian Magrath

Patients outside the Uganda Cancer Institute where Dr Ian Magrath worked from 1970-1973.

As I sit at my desk in the new INCTR office suite, overlooking the fields and stables behind the Institut Pasteur in Brussels, I feel strongly the sense of being in the right place at the right time.

My personal journey began in Uganda in the early 1970s, where I first learnt something of the problems faced in developing countries and developed a lifelong interest in Burkitt's lymphoma. Burkitt's lymphoma, of course, is a wonderful example of a human tumor model—one which has provided a wealth of information relevant to the epidemiology, pathogenesis and treatment of many other tumors, as well as non-neoplastic diseases. But Burkitt's lymphoma serves as a model in another sense. The pioneers who demonstrated that this disease could be cured by chemotherapy alone not only saved the lives of hundreds of children in Africa, but provided enormous encouragement to those specialists who, against the prevailing opinion of the time, believed that widespread cancer might ultimately be cured by drugs.

There are numerous other examples of how work conducted in developing countries has contributed not only to improving the lot of patients with cancer in those countries, but to the global cancer knowledge base. Alas, because of the prevailing socioeconomic circumstances, many patients with cancer in developing countries receive little or no treatment, not even palliative care, and only a tiny fraction of global research on cancer takes place outside the affluent nations. Yet slowly but surely, cancer, already the second highest cause of mortality in affluent nations, is becoming a priority health problem in developing countries. This presents a major challenge to the health services of these countries, since effective cancer diagnosis and treatment can only be accomplished by a team of experts and is a much more expensive proposition than the handling of infectious diseases. While prevention may prove to be less expensive, this is a solution for the future, and will not help patients suffering from cancer today.

Agfa-Gevaert, a manufacturer of medical imaging products, donated two digital cameras to INCTR for documenting the extent of disease in patients with retinoblastoma in Mexico and Brazil. The cameras may prove useful in the early detection of this disease.

However great the challenge, it is also an opportunity for learning. Helping patients with cancer in developing countries will require building capacity for cancer treatment and research in these countries. Such efforts, which must be accompanied by research to determine the nature of the problems faced and the effectiveness of the solutions posed, will produce much new information of value to patients everywhere. It is often stated that research is a luxury that developing countries cannot afford—a statement made, naturally enough, by persons fortunate enough to enjoy the advantages of the efficient health care systems of affluent nations. Such a statement is patently wrong. We cannot afford not to take advantage of research opportunities in developing countries—both for the sake of the people in those countries and for the sake of cancer patients everywhere. It is the certainty of mutually assured benefit that underpins the process which must take place if cancer in developng countries is to be effectively addressed—collaboration between resource-rich and resource-poor nations.

Words like capacity-building and sustainability have become clichés, so widely are they heard in the context of human development. But they do get to the very nub of the problem—how to transfer knowledge and technology in such a way that it will permanently benefit the people of the recipient countries. Some of the requirements are an existing foundation, however small, upon which to build, a plan of what is going to be built, and the means to construct the edifice. A second personal note is illustrative. In 1976, soon after I joined the National Cancer Institute in the USA, I was visited by Drs Shanta and Krishnamurthi—pioneer oncologists from Madras, India. They were concerned that their results in the treatment of children with leukemia were very poor compared to those achieved in Europe and the USA. After exchange visits, a more intensive protocol, purposely designed for the setting in which it would be used and accompanied by strenuous efforts to improve supportive care, was introduced. Since then, a long-standing collaboration in the treatment of lymphoid leukemias and lymphomas has been built with the Cancer Institute in Chennai (Madras), which rapidly spread to several other centers in India and Egypt.

While this may represent a small contribution to the control of cancer in these countries, its effects go beyond the immediate benefits to the patients suffering from leukemia and lymphoma. We have worked for many years with numerous colleagues in developing countries on the design of protocols, the problems encountered in managing the patients, the collection, quality control and analysis of data, the publication of results, and the identification, based on previous results, of specific issues for future research. Moreover, many young physicians have been involved in the work, some of whom are now in charge of oncology programs in other centers where they continue to apply the principles they have learned. The dissemination of results has demonstrated to others who work in similar resource-poor settings that tangible improvements in the results of treatment can be achieved, encouraging them to join in the effort in order to benefit their own patients. There are doubtless other effects, many of which are difficult to measure—the broader impact, for example, of improvements in diagnostic facilities, supportive care, and the general principles of structuring treatment programs upon the management of other patients with cancer. Long-term collaborations of this kind will be an essential element of all INCTR programs.

There have, of course, been other kinds of efforts to transfer knowledge about cancer treatment to developing countries. Physicians from developing countries, for example, are often brought to major meetings of western-based professional societies, or workshops are held within the developing countries themselves. Both are valuable, but their benefits are limited by the brevity and consequently, superficiality of the interactions, coupled to the lack of local resources and therefore the ability to effectively apply new knowledge. A second, frequently utilized approach to deal with the paucity of well-trained physicians and scientists in developing countries, is to establish fellowship training programs, whereby young persons from developing countries are given opportunities to study in affluent countries. Unfortunately, many such individuals never return to their own countries, simply because of the limitations in opportunities there—the reason for leaving their country in the first place. Thus, helpful though such programs can sometimes be, much of the potential benefit to developing countries literally leaks away and the consequence is that affluent nations permanently profit from the transfer of the brightest and most motivated physicians and scientists from developing countries to their own pool of professionals.

An alternative approach, the establishment of training programs within developing countries which make use of visiting experts from affluent nations, has several advantages: it is considerably less expensive, and young people learn in the midst of the problems they must face in their own countries. Moreover, visiting experts reach many health professionals in developing countries, whereas only the one trainee who goes to the USA or to Europe benefits from the experience. It is with these considerations in mind that the INCTR has decided to emphasize in-country training and educational programs wherever possible.

The INCTR, of course, cannot hope to deal with the many-faceted problems of improving cancer control in developing countries alone. Fortunately, it is not the only organization with an interest in this problem. Challenge and ICEDOC are both organizations that have been created recently to address this issue, albeit in rather different ways, and other organizations, such as the International Union Against Cancer (UICC), view cancer in developing countries as a problem of increasing urgency. It is this quite recent recognition that there is a problem to be dealt with that suggests that the timing of the creation of INCTR is entirely appropriate. International cooperation has never been greater. It is for us to ensure that at least some of this spirit of cooperation is focused on the problem of cancer in developing countries. To this end, the INCTR plans to work closely with other organizations—either informally or through the development of consortia such as the Global Alliance for the Cure of Childhood Cancer, which will be described in the next edition of this newsletter—to achieve its goals.