ASCO 2011 Annual Meeting, 3—7 June 2011, Chicago

Health care issues in low and middle income countries.

Professor Peter Boyle - International Prevention Research Institute, Lyon, France

It was a good session, it was something I was delighted to see on the agenda; it was the joint ESMO/ASCO symposium and this year it was focussing on issues in low and lower-middle income countries.

Thanks to Sledge and Care leading the thing, the charge was terrific.

It was excellent. It’s a big change, and it’s a big change for two organisations like this just to focus down on something which is really out with their remit, actually. Just to focus on the issues of the poor in the world.

No-one knows better than you what they are, so just rehearse them for me, please.

My goodness. There’s big issues and there’s little issues.

The big ones.

The big issue is that the population of the world is going to increase by 2 billion, from 6 billion to 8 billion between the year 2000 and 2030. There are currently 1.1 billion people who don’t have clean drinking water; there are 2.6 billion don’t have sanitation; there are a billion people hungry in the world, and the cost of food has increased, doubled over the last ten years, according to the Food & Agriculture Organisation of the United Nations. The first thing with these 2 billion, the big issue is we’ve got to feed them and we’ve got to give them drinking water, we’ve got to give them sanitation. So these are huge issues. With this population growth, it’s not only growing, it’s growing older; and the next set of problems are the current diseases: diabetes, cancer. Cancer is going to more than double between now and 2030. We’re going to go from about 12 million cases per year now to about 26 million new cases per year in 2030. The worrying thing is the increase in the cancer obviously, but the bigger increases, we’re going to go from about 25 million people alive within five years of a cancer diagnosis, needing treatment to 80 million, by 2030, alive within five years of a cancer diagnosis, needing treatment. And this rapid increase is just going to swamp the healthcare systems of many countries but particularly the low and lower-middle income countries, who cannot cope with the current situation.

Cannot cope right now, never mind cope with what’s coming up.

And nobody knows how best to optimise, how to build an optimal system. We had a meeting in Lyon with 80 representatives from 35 countries who work in the cancer institutes all over the world, and they don’t know what are the optimal requirements to build an infrastructure for treating cancer in the low and lower-middle income countries. That’s the first thing we’ve got to address: we’ve got to have an infrastructure in place and a finance infrastructure in place, in order to treat all these patients we’re going to see.

But it’s not just a question of money, as I learned at that meeting, it’s also a question of intelligent and committed human resource. And I must say I was struck by a number of the studies which were reported. But the twinning project, from Indiana was really, really interesting, because that’s shown that it’s lasted the pace. Would you like to comment on that?

Well this was a fabulous programme. It started out as an AIDS programme 20 years ago, under the name of AMPATH, and it actually grew into looking after AIDS patients, then they built a hospital, and then they actually looked at the heuristic approach to the care. They just weren’t actually giving terminal care and some medication to patients with AIDS, they showed them how they could live off their land, they gave them all a little one metre by one metre block of land, and they could grow enough vegetables to feed themselves for a year. That eventually built into farms, and now they’re a commercial enterprise making mango juice, they’ve got a juicing factory. And at the same time they’ve built up the hospital and they’ve now got a cancer centre operating for five or six years.

With people from Indiana and from the university?

There are several universities involved.

Are there?

Indiana, Brown, they’re the leading ones just now. But Indiana, there’s a physician, a very, very brave young man; he took two years out of his post-residency programme, his career track, he’s on a professorial track, a tenure track, and he took two years out of that to take him and his young family, four kids all under the age of ten, to live in Kenya in a compound in Kenya for two years while he built up a cancer treatment programme, and the cancer treatment programme is remarkable. In 2010, the top eight sites of cancer, eight visits, there was 101 visits for acute lymphocytic leukaemia, there was about 180 visits for breast cancer, there was 275 for non-Hodgkin’s lymphoma, and there was 2900 with Kaposi’s sarcoma. And then you move on to say, Kaposi’s sarcoma, well we know what to do with that in western countries. These little red blemishes that you see in western countries, that’s not Kaposi’s in Africa, it’s all over. It’s untreatable, there’s no chemotherapy for it. There are 30 countries in Africa with no radiotherapy machine; there are 29 countries in Africa where it’s forbidden to import morphine and opioid drugs. I mean, how do you do terminal care? It’s all palliative and terminal care. How do you do pain control? These are huge issues that we’ve really, really got to address.

But then, you know, the point of airing this at ASCO, which is a very wealthy organisation with a wealthy constituency, and also ESMO, same again in Europe, and ecancer.tv goes to all of the 201 countries or so at the moment. The people who have got to put up their hand, and put their hand in their pocket at the same time, have got to be the people watching ecancer.tv.

I think so, I think everyone’s got a role to play. It’s like a watch: there are 150 components to a good watch. In order to get the whole thing running, if you imagine global public health is one of these very high quality watches, the big cogs are water and nutrition, and the next middle-sized cogs, that’s chronic diseases. We think cancer’s going to be a problem in low resource countries in the next 20 years, it’s going to be dwarfed by the problem of diabetes. They can’t cope with that. Life expectancy for a newly-diagnosed diabetic in parts of Africa is three years, it’s a death sentence.

So you’re talking about education programmes and that sort of thing? How do you think our organisations can begin to tackle this? We’re not going to stop the flood.

I think we’ve got to… the big thing we’ve got to do for the low resource countries is eliminate or reduce the stigma associated with cancer. Because it presents so late, the cancers that we typically see in the western countries are not representative at all of what you see in Africa. I recall some of these huge tumours that have been smelling for the last three months, that have been totally incurable. You know, the only treatment is to lop it off and make the patient feel a little bit better for the last days of their life. We’ve got to do something to reduce the stigma that stops them coming forward.

And that’s education.

That is education; that’s population education. The meeting we had with the cancer directors recently, in Lyon, we looked for what are the barriers to the implementation of targeted therapy in high resource and in low resource countries, independently. In the high resource countries it was money, money, money, and that’s fine, that’s resources, we can understand that. In the low resource countries, it was a very, very nice presentation by Clement Adebamowo and he said it’s education. We don’t have enough oncologists, we don’t have enough cancer doctors, we don’t have them educated enough and he raised a very interesting point that I’d never come across before: what is the return on investment of an African oncologist coming to a meeting like ASCO or ESMO. What’s his return on investment? The answer just now is it’s very poor, because these big meetings, these important meetings where everyone gets together, they focus on state of the art, cutting edge, rather than what you can do if you’ve only got five chemotherapy drugs and one doctor for 4,000 patients. So I think there’s got to be, there’s a need to move away to get education at a different level than we’re currently used to.

Peter, thank you so much for taking time out of the busy meeting, and this is the beginning of a hard slog.

It’s a hard slog.

We need all those components of that watch you were talking about.

We’ve got to do it, we’ve got to do it. Bonnie Tyler has one of my favourite songs, We Need A Hero, and there’s some heroes out there: there’s the AMPATH which we talked about; there’s Ann Merriman in Hospice Africa in Uganda doing for terminal care, fantastic. There’s the University of Dundee with their distance learning programme: they’ve graduated 700 nurses with a Bachelor of Nursing in Africa, who’ve never left Africa; capacity building without emigration. And then there’s what the Global Alliance, is going to get into now, they’re moving into cancer in women in the low resource countries. Some fabulous things happening but it needs everyone, everyone’s got a role to play, everyone can do something.

And ASCO and ESMO have really got to get in there and get in behind it, and ECCO too, and all the other European organisations.

I think so, I think they’ve got to do it.

Peter, thank you very much indeed, I really appreciate it.

A pleasure, thank you very much.