Reporter Joanne Silberner interviewed Richard Horton, editor-in-chief of the medical journal The Lancet, on Nov. 28, 2012.

Q. Is cancer being ignored in developing countries, or is it a priority?

A. Cancer is certainly being underrecognized and neglected in low- and middle-income countries. We’re seeing a massive epidemic of cancer and heart disease and diabetes in the developing world, which is now creating a double burden of disease in addition to infectious diseases. And cancer is a very important part of that double burden. I think cancer is slowly becoming more recognized but there is a long way to go before it gets the attention it so urgently needs.

Q. Why has it been ignored?

A. I think cancer and other noncommunicable diseases have been underrecognized and they have been neglected, but that’s not a malicious neglect. It’s because there’s just been this overwhelming burden of other problems. In many parts of the developing world, particularly in sub-Saharan Africa, the overwhelming burden for many decades has been preventable maternal and child deaths, malaria, tuberculosis, and, over recent decades, HIV/AIDS. And that burden has been so overwhelming to families and to governments that it’s been very hard to see anything else through that very thick fog of death. But over the last five years or so, all of these epidemics have become much more under control, and the clearing of the mist that has taken place as a result of those successes has left in clear view that there is this new epidemic coming.

Q. Is cancer on the rise in developing countries?

A. Cancer is on the rise, both as a proportion of death and also in terms of its absolute numbers. That’s driven by many reasons. We’re saving people from dying from infectious diseases. And people are living longer, and as they get older they come into the range of being at risk from cancer. In addition to that we’re seeing many of the risk factors that drive cancer become more common in low- and middle-income countries. Just to take two examples, although tobacco use is in decline in high-income countries, it’s actually on the increase in many low- and middle-income countries, and that’s driving epidemics of lung cancer. And obesity is a major risk factor for cancer, and in many middle-income countries–for example China, Brazil, and India–the increasing rate of obesity is just driving epidemics of cancer. For many reasons we’re seeing this shift, which is deeply disturbing.

Q. Are donors interested in cancer?

A. I think donors actually have been asleep, donors have been almost deliberately and willfully unable to get to grips with the problem of cancer in the developing world. I think it’s an appalling example of neglect. And the reason why I think it’s happened is again a mix of causes. First, the risk factors for some cancers are what we sometimes rather unhelpfully call “lifestyle issues” such as smoking, obesity, and so on. Many donors see these risk factors as in a sense matters of individual choice, whereas if I get malaria or TB, it’s not because I’ve been indulging in practices that increase my risk. If I get bitten by a mosquito and get malaria, that’s very bad luck and I’m a deserving person to get a drug or a bed net. But I think donors have a much more skeptical attitude when it comes to cancer. They see this as something that isn’t a donor issue to address with a drug or any other intervention. They say this is something that rests more with a population in a country and perhaps more with the national government.

I think a second issue is that they have also been unaware for too long about the massive burden that noncommunicable diseases including cancer hold. So, for example, over the last decades or so with the [United Nations] Millennium Development Goals, the main driving force for development policy has been around a small number of infectious diseases that cause poverty. I think they have not seen the importance of cancer as a cause of poverty. But as we begin to defeat infectious diseases, noncommunicable diseases become more important, and we are going to see these diseases as being major causes of poverty.

It’s very easy to blame countries for being neglectful, but I think donors have been equally if not more neglectful of noncommunicable diseases.

Q. Are people in low income countries asking for cancer care?

A. Oh, my goodness, absolutely. If I just take two examples, we’re seeing steady increases with breast cancer and cervical cancer in low- and middle-income countries. It’s a desperate tragedy, they have nowhere to go. It’s not just no intervention or treatment, it’s no palliative care, no terminal care. So women are often dying in the most appalling poverty and the most terrible pain because we’re not providing any services whatsoever for them.

So this is a real issue around human rights and a sense of what we owe to our fellow human beings. We would never let a woman in the US or Great Britain die with untreatable pain from cancer, and yet that is happening to thousands and thousands of women right across the developing world today.

Q. What’s your solution?

A. I think the lessons from the Millennium Development Goals are severalfold. Number one, countries need to come together and make cancer and cancer care a globally agreed priority. Number two, you need to have a significant political leader take up the issue of cancer and be willing to be a fantastic social advocate for doing something. If I look at the past decade, it’s been individual political leaders who’ve taken up specific issues, whether that’s been malaria or AIDS or maternal health or child health, and they have gone to G8 meetings or United Nations meetings and they’ve stood up and spoken passionately and movingly for that particular issue. When you have a president or prime minister own a health issue like that, he or she can persuade other presidents and prime ministers to start spending money.

So for cancer we need to have a political leader, we need to have someone stand up and run with this issue. Right now, we’ve not been able to do that, we’ve not been able to identify somebody who will do that. I think if you have that person then they can begin to galvanize the global community to start spending some money, to start making some commitments.

Number three, we also have to have countries themselves take up the issue of cancer as a major problem and start allocating domestic financing to cancer care–not just treatment but also prevention. So that does mean things like tobacco control. And we need to see a much stronger response from countries.

Finally, we need to see spending bodies like the Bill and Melinda Gates Foundation that have enormous power but have traditionally not invested in cancer take the issue of cancer much more seriously than they have done to date.

Special Series
Cancer’s New Battleground — the Developing World

Joanne Silberner is a freelance reporter and artist-in-residence at the University of Washington in Seattle. For 18 years, she covered health issues for NPR. Silberner has an undergraduate degree in biology from Johns Hopkins University and a master’s degree in journalism from Columbia University. She spent a year on a fellowship at the Harvard School of Public Health, and has also had fellowships from the Kaiser Family Foundation and the Carter Center.

Follow @jsilberner

In an open ward at Mulago Hospital in Uganda’s capital city, Kampala, an elderly woman named Joyce lies in the fifth bed on the left.

She’s twisted the sheets around herself, her face contorted by pain. Joyce’s husband, thin and birdlike, hovers over her.

Joyce has cancer – it has spread throughout her body – and until a few days ago, she was on morphine. Then it ran out.

“She’s consistently had pain,” says a nurse. “And she describes the pain to be deep – kind of into her bones.”

The Ugandan government makes and distributes its own morphine for use in hospitals, but poor management means the supply is erratic.

“We’re in a very difficult situation,” says Lesley Henson, a British pain specialist on duty at Mulago Hospital. “[We have] patients who’ve been established and well controlled on morphine, and running out and not having access to that medication now.”

Global Divide

In many ways, morphine is an excellent drug for use in developing countries. It is cheap, effective, and simple and easy to administer by mouth.

Yet according to the World Health Organization, every year more than five million people with cancer die in pain, without access to morphine.

“The fact that what stands between them and the relief of that pain is a drug that costs $2 a week, I think is just really unconscionable,” says Meg O’Brien, head of the Global Access to Pain Relief Initiative, a non-profit that advocates greater access to morphine.

O’Brien says in well-off countries like the United States, there’s enough morphine to treat 100 percent of the people in pain. “In low-income countries, it’s just eight percent,” she says.

In many low- and middle-income countries – 150, by some counts – morphine is all but impossible to get. Some governments don’t provide it, or strictly limit it, because of concerns that it will be diverted to produce heroin.

And many doctors are reluctant to prescribe morphine, fearing their patients will become addicted – something that studies have shown rarely happens.

Click on the image to view large version. (Graphic: Kim Ducharme, Zia Sobhani)

Land of Haves and Have-Nots

In India, whether you can get morphine depends largely on where you’re treated.

Tata Memorial Hospital, a modern and well-equipped medical center in Mumbai, has no problems getting morphine for patients.

“We have all the medicines [that are] necessary,” says Dr. Mary Ann Muckaden, head of pain relief at the hospital. “We never run out.”

But in other parts of the country, it’s a different story. Muckaden estimates only one to two percent of Indians with cancer pain get morphine.

Dinesh Kumar Yadav, 28, has come to Tata Memorial – a 30-hour bus ride from his home – to get morphine for his wife.

He tells me she is bedridden with pain but can’t get morphine in the North Indian state where they live.

Dr. Muckaden says part of the problem is a stifling bureaucracy.

“Many physicians in the North, they don’t want to go through the rigorous licensing to store morphine,” she explains.

“Heaven on Earth”

There is a place in India where there are no barriers to morphine. But even here – at the CIPLA Palliative Care Center in the city of Pune – there are challenges.

You don’t see the challenges when you walk through the cool courtyard gardens with fountains and manicured walkways, or in the beautiful whitewashed buildings with large airy wards, each named for a flower.

“This is heaven on Earth,” says Asha Dikshit, whose mother came here last year in the last stages of breast cancer.

“She was in agony. Her shoulder had dislocated, it could not be fixed back,” says Dikshit. “She had pain in the back, and sometimes there were hallucinations.”

But she says her mother died – peacefully – on morphine.

Every patient here has cancer, and the care is free. Indian generic drug manufacturer CIPLA supplies the morphine and pays all the other expenses.

But even with all the center offers, the occupancy rate runs at only about 60 percent. One big reason, says director Priya Kulkarni, is a result of patients’ own concerns about morphine. They often think morphine equals death, and they recoil when doctors suggest it.

Amir Kazi, 18, entered the CIPLA Palliative Care Center in Pune, India, crying with pain. Morphine eased his discomfort. (Photo: Joanne Silberner)

Kulkarni says many local oncologists don’t want to send patients here for that reason.

“They don’t want to give up on [patients] when it comes to giving them hope,” she says. “And saying [to] them something like, ‘I am going to refer to a palliative specialist,’ is indirectly saying [to] them that there is nothing more I can do for you.”

Slow Change

Despite all the obstacles to morphine’s use in the developing world, Kulkarni and others say things are starting to move in their direction.

Overall in low-income countries, morphine consumption is up tenfold since 1995, according to the International Narcotics Control Board. And several countries where not too many years ago there was no morphine – like Uganda – have at least some today, even if the supply is unreliable.

Back at the hospital in Kampala – where the pharmacy ran out of morphine and Joyce, the cancer patient, had to go without – palliative care specialist Leslie Henson finds a bit of luck. After leaving her patient, she steps into an office, glances at a bookshelf, and sees a forgotten bottle of morphine. It’s enough to treat two or three people.

“Hopefully, we’ll go take this to her and see what we can do,” she says as she troops back to Joyce’s room.

Soon, a doctor administers the morphine.

Joyce smiles. Her face untwists. And her husband looks ecstatic.

I ask Joyce if she’s glad to get the morphine. Her husband answers. “Very much, indeed.”

Other people in the hospital will remain in pain – there is not enough morphine to go around – but for the next few hours, at least, Joyce will be pain-free.

This series was produced with support from the Pulitzer Center on Crisis Reporting.

Special Series
Cancer’s New Battleground — the Developing World

Joanne Silberner is a freelance reporter and artist-in-residence at the University of Washington in Seattle. For 18 years, she covered health issues for NPR. Silberner has an undergraduate degree in biology from Johns Hopkins University and a master’s degree in journalism from Columbia University. She spent a year on a fellowship at the Harvard School of Public Health, and has also had fellowships from the Kaiser Family Foundation and the Carter Center.

Follow @jsilberner

More than half a century ago, an Irish physician named Denis Burkitt moved to Uganda and opened a medical clinic.

He was quickly struck by the large number of children with grotesque facial swellings that often grew large enough to choke and kill. It was a type of cancer he had never seen back home.

The cancer came to be called Burkitt’s lymphoma.

Today on the pediatric ward at the Uganda Cancer Institute, the beds are filled with children with Burkitt’s. It’s the most common childhood cancer in equatorial Africa.

And it starts with an infection.

“It’s associated with a virus called Epstein-Barr virus,” says the institute’s Dr. Abrahams Omoding.

Epstein-Barr virus, which also causes mononucleosis, appears to initiate Burkitt’s lymphoma. Malaria may also play a role in triggering the disease.

Cancer-Causing Germs

“People usually think cancers are caused either by bad habits” such as smoking or alcohol use, Omoding says, or by eating the wrong things, being exposed to radiation or chemicals, or aging. But many infections can also cause cancer.

Bacteria called H. pylori, which cause ulcers, can sometimes cause stomach cancer.

The parasite responsible for schistosomiasis, a tropical disease, can lead to bladder cancer.

Cervical cancer is caused by the human papillomavirus.

Infection with the bacterium H. pylori is a common cause of stomach cancer. (Photo Courtesy: Dr. Nina Salama and Jennifer Taylor, Fred Hutchinson Cancer Research Center)

“We’ve [also] got liver cancer,” adds Omoding. “It’s associated with hepatitis B virus.”

And there’s Kaposi’s sarcoma, caused by a virus that attacks people with weak immune systems. In Uganda, where many people are HIV-positive, Kaposi’s sarcoma is in epidemic proportions.

“The list is long,” says Omoding. “These are the most common cancers that we see, and all of them are actually virus-related. [It’s] different in the US.”

In North America, only one in 25 cancers can be blamed on infectious agents. In developing countries, it’s one of every four cancers, according to a recent study in the medical journal The Lancet Oncology.

The reason? Poor sanitation in developing countries means greater exposure to germs. In addition, people in places like sub-Saharan Africa aren’t likely to be vaccinated against viruses that can cause cancer, such as the hepatitis B virus.

Deciphering the Link

8,800 miles from Kampala, in Seattle, Washington, scientists at the Fred Hutchinson Cancer Research Center are trying to figure out how viruses cause cancer.

In Mei Lei Huang’s laboratory, researchers get shipments from Uganda every other month.

“If it’s [a] blood sample or tissue, it will come in dry ice,” she says.

The samples go in freezers that line one wall.

The samples are part of a study of Burkitt’s lymphoma. Scientists want to determine how long the cancer takes to develop after a child is infected with Epstein-Barr virus.

Larry Corey, head of the Fred Hutchinson Cancer Research Center, says the work is aimed at one goal. “Can we intervene? Can we alter the underlying development of cancer by attacking the virus?”

The biological link between infections and cancers works like this: Invading organisms infect cells and disrupt the cells’ normal workings. The Epstein-Barr virus, for example, infects immune system cells called B cells and causes them to grow.

Human herpesviruses (indicated by arrows) exiting a cell. Two types of human herpesvirus are known to cause cancers such as lymphoma, nasopharyngeal cancer, and Kaposi's sarcoma. (Photo Courtesy: Dr. Soren Gantt, Fred Hutchinson Cancer Research Center)

“The more they grow, the more they divide,” Corey explains. “The more they divide, the more the chance there is of an alteration of the genetic material during the division phase.” That alteration causes cells to grow out of control and become cancerous.

The Goal: Prevention

But Corey says there is good news about infectious organisms and cancer: The link between the two can be broken.

“If you know an infection is the cause of cancer, if you attack the infection, you can actually prevent the cancer.”

That is already happening with the HPV vaccine, which protects against many of the viruses that cause cervical cancer and some other cancers.

Similar success is being seen with hepatitis B. It can lead to liver cancer—a leading cause of cancer death in China—but thanks to vaccine programs that began in the 1990s, liver cancer deaths in China have begun to drop.

There is no vaccine yet that can prevent children in Uganda from getting Burkitt’s lymphoma, but Corey’s scientists in Seattle and their colleagues in Kampala are working on it—together.

Corey’s long-term dream is to see vaccines against all infections related to cancer. If achieved, that would drop the world’s cancer death rate by about 20 percent.

This series was produced with support from the Pulitzer Center on Crisis Reporting.

Special Series
Cancer’s New Battleground — the Developing World

Joanne Silberner is a freelance reporter and artist-in-residence at the University of Washington in Seattle. For 18 years, she covered health issues for NPR. Silberner has an undergraduate degree in biology from Johns Hopkins University and a master’s degree in journalism from Columbia University. She spent a year on a fellowship at the Harvard School of Public Health, and has also had fellowships from the Kaiser Family Foundation and the Carter Center.

Follow @jsilberner

Cervical cancer used to kill more women in the United States than any other cancer. Today, deaths in the US are almost unheard of thanks to a decades-old test called a Pap smear, which allows for early detection and treatment.

In India, however, tens of thousands of women still die each year from cervical cancer.

“It’s just not possible for us to provide [the Pap test] as frequently as it is done in the West,” says Dr. Surendra Shastri, a cancer specialist at Tata Memorial Hospital in Mumbai.

The Pap test requires trained personnel and well-equipped labs, which many parts of India do not have.

“So what do we do?” Shastri asks. “We can’t let the women die.”

It turns out there may be a simple answer. It’s a cheap and easy test developed by scientists at Johns Hopkins University and other institutions. And it relies on something you probably have in your kitchen.

Acid Test

I came to the village of Dervan in the Indian state of Maharashtra to see how the test works.

Doctors had set up a temporary clinic in the shell of an empty store. A sheet hung from the ceiling to provide some privacy. There was no electricity—not even a light bulb—in the storefront.

About a dozen Muslim women in headscarves had come for the test. One was on the exam table, her long brown skirt pushed aside. With her friends sitting nearby, she looked calm and ready.

Dr. Surendra Shastri, cancer specialist at Tata Memorial Hospital in Mumbai. (Photo: Joanne Silberner)

Dr. Archana Saunke took a cotton swab and applied a clear liquid to the woman’s cervix.

“We wait for one minute, and we see if there is any patch—yellowish patch,” she explained.

If the liquid makes the normally pink cervix turn white or yellow, that means there are precancerous cells—cells that could become cancer.

Within a minute or two, the doctor had some good news for her patient.

“It’s normal,” Saunke said. The woman smiled broadly.

When tests yield bad news and show precancerous cells, those can be removed on the spot with a squirt of liquid nitrogen. No return trip is needed.

So what is this clear liquid Dr. Saunke applied?

“Acetic acid,” she says. Common household vinegar.

Overcoming Resistance

The tests being done here are part of a trial program being run by Tata Memorial Hospital and Walawalkar Hospital, where Dr. Suvarna Patil is medical director.

Patil says when the vinegar test was first brought to the villages, women were not interested, even though it was free.

“Whenever we used to go to their houses, they used to shut the doors. They would say, ‘No, we don’t want [it]. You go away.’”

Patil says many women found testing a bother. They were embarrassed to have a vaginal exam, and for what? They didn’t think cancer could be treated.

India being a country of high- and low-tech solutions, Patil sent out health workers with computers loaded with PowerPoint presentations. They put up posters around town and performed plays. They talked to students in schools and to village leaders.

Still, Patil says, the women wouldn’t come.

“Muslim ladies, they will never come because it’s their culture,” she says. “Even Indian ladies, they are very shy. So first what we did is we appointed [an] all-female staff.”

Dr. Suvarna Patil, medical director at Walawalkar Hospital. (Photo: Joanne Silberner)

The staff got awareness training. They were taught to test not just for cervical cancer, but also for high blood pressure, dental problems, diabetes, and other diseases women were worried about. Men were also invited for those other screenings—and male support for the program was a key factor for the women.

All that got women in the door. Then it was a matter of time for attitudes to change.

Positive Results

Patil says it made a big difference when women saw other women actually beat cancer.

“Now they are seeing the results, because if the cancer is picked up in early condition, the patient is doing well,” she says. “People are coming to us and telling us, ‘Please arrange a cancer screening camp for our ladies.’ But it took eight years. It was so difficult.”

It is evident that those eight years have paid off.

Back at the temporary testing clinic, Sojata Sanjay Kapril said she was happy she underwent the screening. Her test result was negative, but she said if an abnormality had been found, “then we can cure it.”

The vinegar technique has been adopted in several countries now, and there’s another more expensive test for cervical cancer that some say may eventually prove to be even better.

These tests could save the lives of tens of thousands of women in India each year—as long as women continue to be convinced to use them.

Click on the image to view large version. (Graphic: Kim Ducharme)

This story was reported with assistance from Mahesh Savale. The series was produced with support from the Pulitzer Center on Crisis Reporting.

Special Series
Cancer’s New Battleground — the Developing World

Joanne Silberner is a freelance reporter and artist-in-residence at the University of Washington in Seattle. For 18 years, she covered health issues for NPR. Silberner has an undergraduate degree in biology from Johns Hopkins University and a master’s degree in journalism from Columbia University. She spent a year on a fellowship at the Harvard School of Public Health, and has also had fellowships from the Kaiser Family Foundation and the Carter Center.

Follow @jsilberner

This health clinic in Cange, Haiti, is run by Zanmi Lasante, a sister organization of the American charity Partners In Health. (Photo: Ansel Herz)

This story is part of a special series, Cancer’s New Battleground — the Developing World.

Haiti is the poorest country in the Western Hemisphere. Having breast cancer here often means no care at all, or care that’s too costly for any common person to afford, or a lot of initial missteps.

“I felt something in my breast that hurt,” says a woman who asked to be identified only by her first name – Merlyn.

She’s a big woman in tight braids, with a tough look on her face and a forceful way of speaking. But, she admits, she was scared.

“It hurt,” she says. “It formed a mass. I didn’t know what it was.”

Merlyn says the lump grew so large that it broke through her skin. Her clothes couldn’t cover it. Local doctors were no help.

Merlyn eventually got referred a clinic run by Haitians and Americans from Partners in Health, a medical charity that has launched a new push to fight cancer.

“The reason we’re taking it on is similar to the reasons we’ve taken on other illnesses,” says Dr. Sara Stulac, who heads the group’s oncology program. “People are suffering in the countries where we work, and there’s something we can do about it.”

Preparing for the Fight

In the little Haitian town of Cange, Partners in Health’s sister organization — known in the local language (Kreyol) as Zanmi Lasante — runs a clinic.

The clinic has been setting up cancer treatment rooms, lining up supplies, and training workers on cancer issues. They are focusing on breast and cervical cancers – the most common cancers among Haitian women.

Dealing with breast cancer in a place like Haiti takes effort and compromise.

The effort starts with the patients. When Merlyn showed up at the clinic with advanced breast cancer, she got a mastectomy. Now every two weeks she takes a 12-hour trip on one of Haiti’s creaky and overcrowded buses to get to the clinic for chemotherapy.

Merlyn says she is bucking what her neighbors say.

Doctors and nurses prepare the day's rounds of chemotherapy on cancer patients at Zanmi Lasante's clinic. (Photo: Ansel Herz)

“If you get cancer, people say you’re going to die because there’s no treatment for it,” she explains. “They say even if you see a doctor, you won’t find a solution. That’s the talk.”

The breast cancer statistics for women like Merlyn are grim.

“I don’t have a definite number, but I can say that it’s very bad,” says Dr. Ruth Damuse, who is heading the oncology efforts at Zanmi Lasante. “Like half of the women, they will die.”

Damuse says the biggest problem is women coming in late, long after they’ve noticed the initial lump. And a lot of women don’t come in at all. So Damuse takes every opportunity to preach early diagnosis.

Reaching Out

On International Women’s Day, Damuse traveled a few towns over from her clinic to attend a rally and teach-in. Several hundred women sat in the large lobby of a new hospital that was under construction.

Damuse took the podium and asked the crowd a question: “Which cancer most affects women?”

The crowd murmured. No one knew the answer.

“We’re going to talk about breast cancer,” Damuse continued.

On two screens flanking the podium, Damuse showed pictures of breast cancer patients like Merlyn, with tumors coming out of their chests. She told the women how to check themselves for suspicious lumps. She said treatment makes a difference.

The women sitting next to me said it was all new to them.

Cancer care is a new thing in many developing countries. With all the other health problems facing the poor, there has been little interest in cancer treatment among local and international health experts.

Sara Stulac of Partners In Health says for a medical charity like hers, focusing on cancer means getting organized. “You do have to make sure that you have access to advice, to diagnoses, to medications.”

And patients need some sort of social support system to help them get to the hospital. That is no small order in countries with bad roads – or no roads.

With patients coming in so late, diagnosis and treatment often fail, so last year the Haiti medical workers received training in how to use painkillers and provide other comfort care for people dying of cancer.

Help from Abroad

Staffers at Zanmi Lasante consult about patients over the telephone with doctors at Dana-Farber Cancer Institute in Boston. (Photo: Joanne Silberner)

For medical advice, the clinic in Haiti relies on experts at the renowned Dana Farber Cancer Institute in Boston.

The doctors and nurses in Haiti check in once a week with Dana Farber. They gather around a speakerphone in a simple stucco house near the hospital.

During one call, seven patients were up for discussion. Four were women with breast cancer.

Dr. Lawrence Shulman, head of Dana Farber, joined the call from Boston. He had been sent the patients’ medical histories, lab results, and what X-rays were available.

One woman had had a mastectomy last fall, but the cancer returned. Shulman suggested a different kind of chemotherapy.

Another young woman had a breast lump removed. In the US, lumpectomies generally require weeks of daily radiation treatments after the surgery, but Zanmi Lasante doesn’t have any way to administer radiation. So Shulman suggested a full breast removal.

“She needs to go back and have a mastectomy,” Shulman said over the phone. “Then she needs five years of tamoxifen.”

The tamoxifen costs just pennies a day, affordable even in Haiti. And there are other opportunities to keep costs down. In Haiti – for unknown reasons – breast cancer mostly hits women in their 20s and 30s, and mammography does not work well in women this age, so Zanmi Lasante doesn’t offer it.

Cancer surgery, chemotherapy, and after-care can be costly, however. Partners in Health provides all of this for free and relies on donors to finance it.

Making Cancer a Priority

Sara Stulac, the head of Partners In Health’s cancer program, admits that her team is taking on a big challenge in a country with many other problems.

“I think some people would say we shouldn’t [tackle cancer], but the fact is people are suffering and dying,” she says. “We can’t save all of them, and we can’t save the same group of patients with the same group of diagnoses that we can in the US, but there is so much suffering that we can avoid, and there are so many cancers that we can treat.”

People used to say that AIDS drugs were too costly and too difficult to deliver in developing countries, yet millions of people with HIV in places like Africa and Haiti are now being saved. Stulac says there’s no reason that can’t happen with cancer.

This story was reported with assistance from Ansel Herz. The series was produced with support from the Pulitzer Center on Crisis Reporting.

Special Series
Cancer’s New Battleground — the Developing World

Joanne Silberner is a freelance reporter and artist-in-residence at the University of Washington in Seattle. For 18 years, she covered health issues for NPR. Silberner has an undergraduate degree in biology from Johns Hopkins University and a master’s degree in journalism from Columbia University. She spent a year on a fellowship at the Harvard School of Public Health, and has also had fellowships from the Kaiser Family Foundation and the Carter Center.

Follow @jsilberner

Jackson Orem is a busy man. He directs the Uganda Cancer Institute – the only dedicated cancer treatment facility in a country of 33 million people.

Yet he still finds time to see patients, like Musa Settimba.

“Good to see you,” Orem says as he enters a small exam room furnished with little more than a chair and table.

“Good morning, doctor,” says Settimba.

Settimba is here for a checkup. He has a type of gastrointestinal cancer that is often fatal, even in countries with access to the latest medical care.

Orem has arranged for Settimba to get Gleevec—a very effective and costly new cancer drug—for free, courtesy of the manufacturer. There’s paperwork involved, and drugs for only a few cancers are available this way. It’s a godsend for Settimba, who has been doing very well.

“You are getting one of the best treatments for this disease,” Orem tells his patient.

Unfortunately, Settimba is the rare exception.

Discouraging Statistics

The survival rate for patients who make it to the Uganda Cancer Institute is astonishingly low.

“We get about 22,000 new cases [annually],” says Orem. Of those, 20,000 die within a year.

Orem says most Ugandans don’t have a real concept of cancer as a set of diseases that can be diagnosed and treated. In some tribal languages, there is no word for cancer.

“People are dying because they don’t have a system,” Orem says. “They don’t have early diagnosis. They don’t actually even know that they have cancer.”

And the people who do realize they have cancer often hide it. They fear being stigmatized, and “once you are diagnosed with cancer, they think that it’s already a death sentence,” says Orem.

Inside the Uganda Cancer Institute. (Photo: Jacqueline Koch)

They’re partly right. Most people don’t come in until the very last stages of cancer. At that point, no doctor anywhere could do much for them.

Lack of Attention

Orem studied oncology at Case Western Reserve University in the United States and then came back to Uganda to head this government-owned cancer institute in 2004. For several years, he was the only oncologist in the entire country.

“It was really very, very demanding,” he says. “I can’t explain how I was managing, because actually I was doing everything.”

Orem doesn’t complain about the hard work, but some things make him cringe. One of them is a comment he’s heard expressed by people from developed countries—that cancer doesn’t hit poor people.

“People think that malaria kills [and] other diseases are killing people from a low socioeconomic status. But cancer is the same,” he says. “The truth of the matter is that cancer is a disease of the African person just like any other person elsewhere in the world.”

The perception that cancer is not a problem of Africans leads to a lack of money, he says.

“When you ask for funding for cancer, nobody is going to give [it to] you. But if you ask for funding for these other diseases, they say, ‘All right, your priority is correct, we are going to give you some funds.’ I think that is actually the reason why things are the way they are.”

There is also a perception that cancer is too expensive to treat, and treatment is too high-tech, to be done in poor countries. Orem says that’s not necessarily true.

A New Push

Orem takes me for a walk up a hill so we can see the Uganda Cancer Institute’s expansion plans.

The Ugandan government is putting up what will be a modern 200-bed cancer hospital to replace the 120 bare-bones beds of the current Institute down below.

“You see that expanse of a building with a blue roof?” Orem says, pointing. “That is the outpatient department.”

In that building is a clinic like some you might see in the US, where patients receive chemotherapy through intravenous lines. There is also a building with the beginnings of a modern pharmacy.

None of the buildings include a gamma beam generator or a robot that can do surgery, but some conditions can be treated as successfully here as in the US.

And now Orem has the help of five Ugandan cancer specialists who recently received training in Seattle, at the Fred Hutchinson Cancer Research Center.

What keeps Orem going is that people in the West are beginning to take interest.

Last year, the United Nations urged that more be done to detect and treat cancer in the developing world. George and Laura Bush recently toured Africa to bring attention to breast and cervical cancer.

“People are much more receptive to our messages than before,” Orem says. “It looks like we are beginning to make an inroad.”

Still, he says, when it comes to fighting cancer, Uganda is just at the starting point.

This story was reported with assistance from Jennifer Bakyawa. The series was produced with support from the Pulitzer Center on Crisis Reporting.

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Cancer’s New Battleground — the Developing World

Joanne Silberner is a freelance reporter and artist-in-residence at the University of Washington in Seattle. For 18 years, she covered health issues for NPR. Silberner has an undergraduate degree in biology from Johns Hopkins University and a master’s degree in journalism from Columbia University. She spent a year on a fellowship at the Harvard School of Public Health, and has also had fellowships from the Kaiser Family Foundation and the Carter Center.

Follow @jsilberner