New cancer unit lights up patients

Each day, about 200 people report to the Uganda Cancer Institute (UCI) in Mulago for treatment, checkups and counseling about the devastating malignancy. Some of them travel miles from the Democratic Republic of Congo (DRC), Burundi and Tanzania because UCI is the only national and regional free cancer referral centre.

Outside the outpatient department, tens of patients try to find sits, floor space and tree shades to rest and wait because wards are full. When the sun sets, patients who cannot afford transport fare back home saunter into the wards to sleep. Christine Namulindwa, the institute’s publicist, says the prohibitive cost of cancer treatment in private facilities has led many to seek free treatment at the institute. The high cost of equipment and drugs explain the exorbitant cost of treatment.

“The cheapest cancer treatment is about Shs 14 million and majority of the patients cannot afford it, which explains the overcrowding here. However, we are also met with the challenge of limited skilled personnel as there are only 12 oncologists,” Namulindwa says.

Children afflicted with cancer find rest-Photo Credit/Nicholas Bamulanzeki

In the past few years, UCI has reported a spike in cancer incidence, particularly infection related cancers such as Kaposi Sarcoma, sending a wakeup call to government. Although there is no nationwide data, estimates obtained from UCI’s registry indicate that some 300,000 Ugandans develop invasive (advanced stage) cancers and over 10,000 of these die annually.

NEW PREMISES

In 2011, government invested Shs 10.4 billion to construct a new, modern cancer unit. Currently, some of the wards on this six-floor unit are up and running. For now, mainly children, patients admitted to the private wing and those going to be operated are using the facility. Majority of patients are still using the old block as the new block is short of medical equipment.  

The new cancer block-Photo credit/Nicholas Bamulanzeki

Inside the children’s ward on level four, hued caricatures painted across the walls are a fresh face to the children’s treatment. Accordingly, these play a role in keeping the little ones in high spirits. Six year old Jordan Kibirige from Mukono was admitted here one week ago.

He is battling Burkitt’s lymphoma, a potentially fatal cancer that has left him with a painful swelling on the left side of his face. The lymphoma, associated with malaria, is known to grow rapidly such that the tumours double their size in five days.

“So far, we have been able to get quick treatment and bed space at this new facility. I hope my boy will soon recover,” Kibirige’s mother forlornly says.

At least one doctor and nurses are on duty here throughout the day, a sign of relief to the over 20 patients here.

So far the journey is comfortable; clean toilets, lifts, regular electric power, piped water and free lunch. The theatre, on level two, is operational and Namulindwa says it has greatly reduced congestion at Mulago hospital’s general theatre. The building also has a mortuary, intensive care unit, private wing and an imaging and nuclear medicine department.

Inside the children's ward

However, Namulindwa expresses fear that with the swelling number of patients, this facility will soon be overwhelmed.

“The new centre is expected to accommodate 100 patients but we’ll be seeing more than these,” she said.

The new facility will officially open mid this year.

MORE DEVELOPMENTS

A comprehensive state-of-the-art research, training and outpatient cancer centre is currently in the final stages of construction. The Hutchinson Cancer Research Institute- Uganda sits on 25,000 square feet and will include an outpatient clinic, chemotherapy infusion rooms, research laboratories, molecular diagnostic labs, a training center and data centre among others.

This facility seeks to ensure the availability of medical care, overcome the social and economic barriers to completing treatment and improve capacity of the medical infrastructure to diagnose and care for patients. With the new premises, it is hoped that the five-year survival rate of cancers such as leukemia which is less than 40 per cent will be improved.

The centre, whose construction began in April 2013, is slated to officially open in May this year. It is supported in part by the United States Agency for International Development, American Schools and Hospitals Abroad Programme.

Namulindwa also told The Observer that plans are underway to construct a Radiotherapy and Nuclear Medicine Centre.

In spite of these developments, challenges of limited beds and equipment, medical personnel brain drain and forbiddingly expensive drugs are rife.

“Diagnosis equipment for examining biopsies is only available at Mulago Referral hospital and because of the limited number of pathologists, results take up to two weeks to return,” Margaret Okello, a volunteer counselor at UCI, notes adding that there is only one radiotherapy machine in the entire referral hospital.

Moreover, because of the limited number of oncology personnel, nurses have had to be trained on the job in order to administer drugs.

Okello and Namulindwa urge government to subsidize pharmaceutical companies that supply drugs in order to make them more affordable and available.

“We also appeal to government to adequately remunerate skilled personnel and invest in the purchase of modern equipment such as a magnetic resonance imaging machine,” Namulindwa says. 

This article first appeared in The Observer.

Cancer to hit 24m Cases annually in 20 years

One the eve of World Cancer day, a report released on from the International Agency for Research on Cancer (IARC) shows some disappointing figures for the global fight against cancer. By 2030, cancers are expected to jump from 14 million in 2012 to 21.6 million a year, and overall deaths are expected to increase from 8.2 million to 13 million annually.

 Lung cancer is the biggest killer, and the report criticizes tobacco companies' push into poorer countries. It said a smoking “epidemic” is “potentially impeding human development by consuming scarce resources, increasing pressures on already weak health-care systems, and inhibiting national productivity.”

The world is facing a "tidal wave" of cancer, and restrictions on alcohol and sugar need to be considered, say World Health Organization scientists.

It predicts the number of cancer cases will reach 24 million a year by 2035, but half could be prevented.

In Uganda, some 3000 new people afflicted with various cancers will have presented themselves at the Uganda Cancer institute (UCI), the only cancer referral facility in the country for treatment by the end of 2014. 

This is because of the increase in infections malaria, HIV, Hepatitis B, Human Papilloma Virus (HPV) and typhoid. Infection-related cancers include Burkitt’s lymphoma, associated with malaria and affects children between four and seven years, Kaposi's sarcoma caused by the Human Herpes Virus 8 (HHV8) whose risk increases dramatically in people with HIV infection and Hepatocellular Carcinoma (cancer of the liver) caused by the Hepatitis B Virus (HBV).

The UCI director, Dr. Jackson Orem says HIV has accelerated the burden of cancer in the country so much so that 60 percent of cancers in adults at UCI are related to HIV.

“Thirty percent of cancers in developing countries are related to infection. Most cancer patients in Uganda are young and in their prime as opposed to elderly population in the developed world,” he said in an interview with the Observer.

Dr. Orem adds that institute is seeing an influx of children afflicted with Burkett’s lymphoma, a potentially fatal and disfiguring cancer that often develops in the jaw or abdomen caused by the Epstein-Barr virus that is as a result of frequent and ill-treated malaria.

Other infection related cancers include; blood, cervical, bladder and stomach cancers.

Worldwide, cancer kills more people than AIDS, tuberculosis, and malaria combined and has become a leading cause of death in the world. (WHO) estimates that by 2030 more than 12 million people could die from cancer related diseases. About 80 per cent of these deaths are likely to occur in low-income and middle-income countries such as Uganda.

Currently, according to information from the Non-communicable disease unit of the health ministry, 300 people per every 100,000 are estimated to have cancers

Last year, UCI recorded a total of 2800 patients with infection related cancers last year accounting for more than 50 per cent of the cancer burden in the country.

“If the infections are not reduced sooner than later, cancer is going to be the next big epidemic in the country,” Dr Fred Okuku, a senior oncologist at UCI warns.

The WHO said there was now a "real need" to focus on cancer prevention by tackling smoking, obesity and drinking.

The World Cancer Research Fund said there was an "alarming" level of naivety about diet's role in cancer.

Fourteen million people a year are diagnosed with cancer, but that is predicted to increase to 19 million by 2025, 22 million by 2030 and 24 million by 2035.

The developing world will bear the brunt of the extra cases.

Dr Chris Wild, the director of the WHO's International Agency for Research on Cancer, told the BBC: "The global cancer burden is increasing and quite markedly, due predominately to the ageing of the populations and population growth.

“If we look at the cost of treatment of cancers, it is spiralling out of control, even for the high-income countries. Prevention is absolutely critical and it's been somewhat neglected.”

The WHO's World Cancer Report 2014 said the major sources of preventable cancer included:

·         Smoking

·         Infections

·         Alcohol

·         Obesity and inactivity

·         Radiation, both from the sun and medical scans

·         Air pollution and other environmental factors

·         Delayed parenthood, having fewer children and not breastfeeding

For most countries, breast cancer is the most common cancer in women. However, cervical cancer dominates in large parts of Africa.

The human papillomavirus (HPV) is a major cause. It is thought wider use of the HPV and other vaccines could prevent hundreds of thousands of cancers.

One of the report's editors, Dr Bernard Stewart from the University of New South Wales in Australia, said prevention had a "crucial role in combating the tidal wave of cancer which we see coming across the world".

Dr Stewart said human behavior was behind many cancers such as the sunbathe "until you're cooked evenly on both sides" approach in his native Australia.

He said it was not the role of the International Agency for Research on Cancer to dictate what should be done.

But he added: "In relation to alcohol, for example, we're all aware of the acute effects, whether it's car accidents or assaults, but there's a burden of disease that's not talked about because it's simply not recognised, specifically involving cancer.

“The extent to which we modify the availability of alcohol, the labelling of alcohol, the promotion of alcohol and the price of alcohol - those things should be on the agenda.”

He said there was a similar argument to be had with sugar fuelling obesity, which in turn affected cancer risk.

Meanwhile, UCI has been chosen by the International Atomic Energy Agency (IAEA) to host the Virtual University for Cancer Control (VUCCnet)- a regional centre for excellence for Cancer training in East Africa.

Currently, the modern Lymphoma Treatment Centre is nearing completion and it is expected to accommodate 100 patients at any one time.

Mulago hospital in crisis of nurses, senior consultants

Patients, care takers, visitors, staff and non staff jostle for corridor space within Mulago Hospital impatient to get to their next destination. Time at Uganda’s largest referral hospital waits for no man because every day, more than 1000 patients are pouring in.

The emergency paediatric unit alone receives 200 patients daily whereas the Uganda Heart Institute (UHI) receives about 100 patients daily. The labour suite (5C) receives between 80 and 100 expectant mothers and of these, 35 need caesarean section. When I visited the ward, some women were sited on laid out lesus on the floor because the wards 20 beds were full. 

Women waiting to deliver at Mulago's labour suite

“There is a lot of advocacy ending in nothing because congestion and limited monitoring are still big challenges in the suite. There is need to address human resource challenges, skills and equipment,” Dr Eva Nakabembe, a gynaecologist said.

Dr Eva checks the health of a pregnant woman

Meanwhile, three to 10 children are received daily at the Mwana Mugimu clinic depending on the season.

The overwhelming number of patients is a great challenge to the hospital which is in need of 946 approved nurses. Dr Byarugaba Baterana, the hospital’s executive director says there are only 882 nurses currently.

In the Emergency pediatric unit, there are only four nurses per duty instead of the required eight.

“At night, there needs to be at least five nurses on duty but there are usually three and yet they have to handle 80 patients,” Dr Opika Opoka, the head of the unit told the observer in an interview.

The crisis is similar to what is in the Mwana Mugimu clinic where there are only 11 qualified nurses of the needed 25.

“There is a lot of work to do such as preparing therapeutic foods and feeding the children every two hours which cannot be done by only 11 nurses,” Sr. Julian Eyotaru, the incharge of Mwana Mugimu said.

At the Uganda Cancer Institute (UCI), more than double of the 52 nurses currently available is needed. This is because of the large number of in and outpatients the institute receives. Dr Jackson Orem, the director of the institute says that at any one time, the institute handles about 4000 patients.

Last year alone, UCI saw more than 34000 visits.

Human resource challenges;

Dr Byarugaba says there is need for government to recruit new senior consultants and increase their salary. Mulago hospital has only 30 and 15 more are needed.

“Although they are among the highly paid civil servants earning about Shs 2.1m, this is not commensurate with the number of years spent in school. They need at least Shs. 15m,” he said in an interview.

He adds that nurses should be paid at least Shs 530,000 a month.

The hospital has an approved structure of 2166 positions of which 1877 are currently occupied. It is only the medical officers that are full. Two senior medical officers and 283 health workers are lacking and more neurosurgeons, biomedical engineers and pharmacists are needed.

Dr John Omagino the head of the Uganda Heart Institute (UHI) attributes the shortage of human resource at the institute to the existing narrow structure.

“The structure does not allow for a mix of diverse skills and yet to carry out any operation, one needs these,” he says.

There is 192 staff (30 percent) at the institute currently and yet this is still below the bar. Dr Omagino says that the institute management is in the process of contracting other staff to bring the numbers to at least 60 percent

A child and his mother at the Mwana Mugimu clinic where he is being treated for malnutrition

He adds that there is need for government to recognize different specialities by approving them on the structure and their associated terms in order to enable management to attract retain and plan a decent exit. To have these, he urges on the need to build training capacity.

“As a country, we do not have facilities for training these specialists and are instead, we are sending them out at a very high cost. What we need is to build local capacity,” Dr Omagino urged.

Although UCI has 10 operating specialists currently compared to five that were there in previous years, Dr Orem says that it needs more than 100 specialists.

Dr Byarugaba attributes the challenges of inadequate human resource to the fact that Mulago Hospital is over centralized.

“The hospital is non-autonomous and because of over centralization, the appointed structure has no existent directorates with appointed heads,” he said.

Byarugaba adds that the hospital’s relationship with Makerere University is also not defined.

New developments;

Despite these challenges, new developments to upgrade the hospital have been made and others are underway. For example 40 CCTV cameras and electronic display boards have been installed within the hospital to beef up security.

Planned projects include construction of 100 units of staff houses and construction of a fully fledged women’s hospital.