Health Digest

THE
Issue 02 April - June 2012

Ugandas walk with

Cancer
Lung cancer

Ovarian cancer
Pancreatic cancer
Leukemia

Cervical cancer
Burkitts lymphoma Coloretal cancer Breast cancer
Skin cancer
Lympoma Carcinoma Sarcoma Myeloma

Kaposis Sarcoma
Prostate cancer

Inside This Issue

Editors Message Page 1 Uganda has one of the highest cancer rates Page 2 Uganda was once a World class leader in Cancer research Page 4 Cervical Cancer. A silent killer of Ugandan women Page 8 Rwanda; A model of Cervical Cancer equity for Africa Page 10 Birth control and Cancer: What you should know. Page 11 Prostate Cancer stelthilly killing off Ugandan men Page 12 PRICE PER COPY UG SHS 5,000 US$ 3 Call: 0772 491950 or 0712 685837

Over 13,000 deaths in Uganda linked to Tobacco use: Page 14 Pancreatic Cancer: Another silent killer Page 15 Could your childs toothache be a Cancer ? Page 16 Cancer with HIV Page 18 Ugandas walk with Cancer Page 20 The power of the spoken word in Cancer care Page 24 Amazing courage; Children fighting Burkitts lymphoma Page 26 Cancer control and prevention in Schools Page 27

Palliative care in Africa Page 28 Interview with Dr. Ddungu Page 30 Inefficient markets impede Cancer pain relief Page 32 Traditional and modern medecine merge in fight against Cancer Page 34 Social media efficacy Page 35 Cafe Scientifique Page 36 Cost of treating Cancer Page 39 Moment of truth: To take or not to take a Cancer test Page 40

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Editorial Team

Editors Message
Once again we are excited to present our next issue of the Health Digest, focusing on Cancer. Cancer is increasingly becoming a huge public health threat in Uganda, but at the same time it is shrouded in mystery, and compounded by ignorance and a stark lack of information. As health journalists, we explore this disease, taking you through the Uganda Cancer Institute from the 1950s to date, from one oncologist to 11. We bring you the expert opinions and interviews, including Dr Jackson Orem, the Director of the Uganda Cancer Institute, and others fighting the battle against cancer in an era where infectious diseases have taken centre, while Non-Communicable diseases such as cancers continue to claim lives unabated. We hope you will find most of the answers that you need about cancer from this edition, and most importantly that you will know that cancer can be defeated with the right information, and proper systems. As usual, the Health Digest is an important tool for journalists to connect with the medical practitioners and vice versa. From the editorial team, we thank the management and staff at the Uganda Cancer Institute, Mulago, and all the contributors who sacrificed their time to write articles. Enjoy! Annah Natukunda Editor, The Health Digest

Managing Editor Esther Nakkazi

Editor: Annah Natukunda

Senior Consulting Editor: Christopher Conte Consulting Editors: Marissa Mika Evelyn Lirri Juliet Nanfuka

Design/Layout Bagmuz Creations

Send all correspondence to: Plot 156-158 Mutesa II Road, Ntinda P. O. Box 4883 Kampala -UGANDA Tel: 256 704 292188 healthdigestUG@gmail.com Website: www.hejnu.com

Uganda has one of the Highest Cancer rates in the World

Cancer is fast becoming a big killer in Uganda. 80% of all newly diagnosed cancer patients in Uganda die. The Uganda Cancer Institute is still the only cancer centre in the country taking on this burden. Evelyn Lirri spoke to Dr Jackson Orem, the Director of the Institute on the challenges of managing cancer. How big is the problem of cancer in Uganda? According to results from the cancer registry we see about 200 new cancer cases per every 100,000 people. By international standards thats a very high incidence. As far as prevalence is concerned, at the current rate of population growth we are talking of 40,000 to 60,000 people but thats also a conservative estimate. There are many people who are in our population who dont know that they are suffering from cancer and we have not made any diagnosis. When it comes to mortalityour country has one of the highest rates in as far as cancer is concerned. For every 100 newly diagnosed cancer patients, we actually lose 80. That means if youre in a cohort of newly diagnosed cancer, the chances that youre going to survive is only 20 percent Why is cancer mortality so high? Most of the cancers in Uganda are diagnosed late. Many people come when the cancer has advanced and late presentation is synonymous with poor outcomes. But also, its not a factor or blame that we can put on the population alone but the whole system because weve seen incidences where people have actually come early but their diagnosis was delayed by a system that could not detect that this is cancer. Patients come late because of lack of awareness and also a lack of health system that can provide them with the means of having early diagnosis because its heavily skewed towards diagnosis of infectious diseases. What are the more common cancers in Uganda? We are seeing different cancers in the population. Majority of the male patients have Kaposis sarcoma, Prostate, cancer of the stomach and liver. For females, its cervical cancer, Kaposis sarcoma and breast cancer while among the children Burkitts lymphoma, Kaposis sarcoma and Leukaemia are common. Why are these particular cancers common? Close to 40-50 percent of cancers in our setting are related to infection and the pattern of cancer reflects that background. This is why we should include cancer among the long-term effects of infectious diseases especially when it comes to cervical cancer and Kaposis sarcoma. Are these cancers treatable? The good news about these cancers is that they are highly treatable with the view of curing if patients present early. But the only thing that lets us down is that we dont have a proper system that should be able to help us aspire for the best of outcomes. So do you mean the Cancer Institute delays with the diagnosis? As a Cancer Institute, we are supposed

The Health Digest

to be at a referral level so patients should first present themselves at their nearest health facility and its from those facilities that they should be sorted out and those with cancer referred to us. But given the weaknesses in the system we are now providing primary elements of care by encouraging people who suspect that they have cancer to come directly to the Cancer Institute. As the only cancer centre in Uganda, how is this affecting the way you deliver services? It means numbers overwhelm us. Even if you have a good system in a short time, it will be overwhelmed. A case in point is the way we have been putting in place equipment and facilities but it seems we are not keeping pace with the numbers. What kind of system would help to manage cancer cases? First we need to recognise that cancer is one of the biggest causes of mortality and morbidly in our community. Then it should be followed by a policy for cancer. For instance our country does not have a policy where cancer is a notifiable disease. This means once you make a diagnosis, you must report by law. If you do that in the first place you are going to improve the statistics and then you are able to count all the cases and plan better. Right now most of the things we do are guess work.

big, this is like a drop in the ocean. We still need a lot of resources. Right now we get Shs5billion from the ministry of finance in a year but thats not even a tenth of the resources that is needed. We need to put in place infrastructure that is costly. Once you have infrastructure, the running cost gets cheaper. What about cost in terms of treatment? We have a fairly good system for provision of drugs but a good proportion of cost of care is still being born by the patients. And that is one of the reasons why we have bad outcomes. Most of the deaths are not because the disease is so bad but the socio economic circumstances that prevent patients from getting access to good care. We are trying to push government so that it can address the policy issuesput a cancer policy in place, and we want the institute to be enacted by an Act of Parliament so that its spread out in the country, mobilise resources locally and internationally--something we cant do effectively now. We have a pilot project where were working with regional hospitals in Mbarara and Arua to show us how best we can decentralise the system.

How well is the Institute equipped in terms of human resource? Is the Institute financially sound to treat and We need more people and thats why we need a manage cancers? policy. We want to be able to have the capacity to The government has started giving us resources train our own people and this requires substantial directly unlike in the past and this started in 2009. investment. At the moment we identify those who This was a big boost and what you see around here are interested and get places outside the country is the result of that including the new building. But to train them. If you had come here 5 years ago, given the fact that the burden of the disease is so you would probably have met only me but now we have 8 oncologists and we want to continue with that training for all cadres of cancer specialists. Oncology is a tough speciality and because the majority of patients who have cancer dont have that much money, if youre in the trade because you want a clientele of people who can pay for your services handsomely, youre not going to get it. Evelyn Lirri elirri22@gmail.com Incoming science editor, The Monitor Newspaper. The Health Digest 3

Uganda was once a World-Class Leader in Cancer Research

Profile; Professor Charles Olweny
By Esther Nakkazi In the not-too-distant past, Uganda was a global leader in cancer treatment an achievement championed by Charles Olweny a medical oncologist. A member of the first graduating class in Makerere Universitys Masters of Medicine program in East and Central Africa in 1968, Olweny went on to become the first Ugandan director of the Uganda Cancer Institute (UCI) in 1973 . At the time, science conference delegates and those attending the Organisation of Africa Unity (OAU) and other big conferences in Kampala routinely toured the Institute to see a model of an effectively and efficiently run Uganda institution. It was relatively hectic but enjoyable, said Dr. Olweny of those days. Previously, students who wanted to upgrade to a Masters Level in any medical field were sent to England. But then, Professor William Pressley from Virginia, USA, and the head of Makerere University School of Medicine introduced the Masters Degree of Medicine, Surgery, 4 The Health Digest Pediatrics, Obstetrics & Gynecology at Makerere University. With other young students, Dr (s) Lwanga, Mwanje, Peter Lobo, Batalye, Patel, Babigumira, Dr. Olweny joined the Masters of Medicine class, the biggest of the new classes. His research topic was typhoid fever, but even at the time it was a no brainer. I wrote my dissertation and took it to Dr. Pressley, and he said Charles, sorry there is nothing new in typhoid fever, you will never make a difference. Go and think again. The rejection came with advice about a new group from the USA headed by Dr. John Ziegler, who was treating children who had various Lymphomas- Lymphoma is a cancer of a part of the immune system called the lymphatic system-including Hodgkin Lymphoma disease at Mulago. At the time, nothing was known about adult patients with these afflictions. While they were treating children at the Lymphoma treatment centre, I was treating adults at Mulago hospital. Within two years, I had col-

lected enough data, and wrote my dissertation. It was approved without any amendments, says Dr. Olweny. All the students in his class graduated in March 1970. The following year, 1971, Dr. Olweny joined Dr. Ziegler, AC Templeton and CW Berard, a pathologist at the National Cancer Institute, to co-author a paper Adult Hodgkins disease in Uganda in a prestigious science publication called Cancer. That marked the beginning of his long career as a leading expert on liver cancer. A Flourishing Career In 1971, Professor Lutwama, the dean of Medicine at Makerere Medical School recommended Dr. Olweny for training with Prof. George Klein in tumor immunology at Karolinska Institutet, a medical University in Stockholm, Sweden. He spent a year on clinical rotations in oncology, the study of cancer, and a second year doing laboratory work. But just about halfway through his training, things went sour in Uganda. The message I received was, Better come back now. If you do not, there will be nothing to return to, said Prof. Olweny who returned in March 1973. Then-President Amin had given 90-days notice for all Asians to leave Uganda, and even those of non-Indian origin left among them Dr. Ziegler. When I returned, I reported to the head of medicine at the Medical School, John Kibuuka Musoke, Dr. Olweny recalls. He said, Charles, welcome back. You are going to run the Uganda Cancer Institute. Professor Sebastian Kyalwazi, the outgoing head of UCI, promised his support. He was one of the first and greatest surgeons in Uganda. True to his word, in spite of his busy schedule, Prof Kyalwazi came down to do ward rounds with Dr. Olweny once every week, allaying the young doctors fears. On a normal day, Dr. Olweny would leave home early in the morning, do administrative work from 8.00 to 9.00 am, and then the

rounds, first on the solid tumor ward and then at the Lymphoma treatment centre. He then would drive home for lunch, and spend the afternoon in the laboratory. It was a well-furnished laboratory at first but was later difficult to maintain because it lacked basic supplies like liquid Nitrogen and dry ice. It closed in 1975. In the afternoons, Dr. Olweny would pick up his children from Nakasero Primary School to retire home. He repeated the first half of this routine on Saturdays and Sundays every week. Until one day, that schedule was interrupted. He was summoned to the government office in Nakasero for questioning. Why are you selling Ugandas cancer drugs to Nairobi, a soldier asked. Could he be supplying anti-government agents with drugs? One staff member for UCI was detained. For three hours he tried to explain to the soldiers about a research study UCI was conducting in partnership with Nairobi University. At the time, Uganda had chemotherapy drugs- that treat and kill cancer cells-, while Nairobi had radiotherapy facilities. This way clinical trials on how to treat endemic Kaposi sarcoma were done. The trials involved sending Ugandan children to Nairobi for radiotherapy in exchange for drugs from Uganda. On a weekly basis, one staff member from UCI (who was arrested but later released) would go to the post office to send drugs to Nairobi. Unlike Mulago Hospital, which sometimes did not even have any Aspirin, UCI had a constant supply of drugs to treat cancer. Its budget had been fully funded by the US-based National Cancer Institute (NCI) until 1975. Later, it was fully funded with endorsement by the Ministry of Health. The ready supply of expensive drugs presented an opportunity. We were trying drugs, we would start with one drug and then compare it with two or three, said Dr. Olweny. With Burkitt Lymphoma an aggressive The Health Digest 5

lymphoma that occurs most often in children- a combination of the three drugs worked best. The same combination worked better for Kaposi Sarcoma, a type of cancer characterized by the abnormal growth of blood vessels that develop into skin lesions or occur internally. But for liver cancer, none of the combinations worked as well as the doxorubicin alone, which first became available in 1975 and remains the main stay of treatment of liver cancer today. We saw tumors shrink. That was very unusual. They had tried everything but nothing worked, said Dr. Olweny. UCI had to present its proposal to a local research committee, which invariably could ask if it had patients consent. That proved to be a challenge. Unlike today, many patients could not read and write. But after getting simplified with elaborate explanations, enough patients gave their approval with their fingerprints.

able to make diagnosis of liver cancer because we had excellent pathologists at the time, he said laughing away. Denis Wright and Michael Hut were pathologists working at Mulago then and played a critical role in diagnosis and research. Dr. Olweny also contributed to the formation of the Essential drug list for cancer in use all over the world. (A second, expanded list has since been developed.) Why UCI managed to Excel Apart from treating all patients, UCI followed up with every one of its patients. There were no mobile phones then, but nevertheless the institute traced every patient within a month of not showing up. Secondly, UCI mixed its own medicines. That could be time-consuming, but Prof. Olweny trained oncology nurses and brought on board medical students to do the job, freeing up most of his time. Some of the staff excelled. Philomena Nakawunde (RIP), a chemotherapy nurse, knew every patient by name, where they came from, their treatment regimens, when they last came in and more. Nakawunde was later to pick calls from Dr. Klein and Dr. Ziegler who had read in Newsweek that President Amin had wanted to change the name of Makerere to Amin University and a number of scientists, including Dr. Olweny, had opposed it.

The Health Digest

Making a Global Mark After intensive work with Prof. Kyalwazi and armed with pictures of liver scans to show tumors of patients shrinking, Dr. Olweny traveled to Brussels to present the first paper on the treatment of liver cancer using doxorubicin. It caused a storm the world over, since The publication wrote that as a result, his body nobody knew that this disease could be treated. had been found lying in a Kampala street. In his own autobiography yet to be published, In the next big conference he attended, held this story goes under the heading dead but still by the American Society of Clinical Oncology answering telephone calls because he was on in New Orleans in 1996, a presenter disputed duty and talked to Dr. Klein the day the story whether UCI had actually successfully done was published. research on liver cancer treatment. In a break out session attended by about 600 people, Dr. I had dedicated staff. We had to train the Olweny sat at the back and listened. He then nurses to mix the medicine and give the treatwalked to the front and introduced himself. ment, which freed a lot of our time. The medical students were in charge, but they would I had evidence, showed them pictures of liver call on me anytime day or night. They all did a scans which showed (patients) before and after wonderful job, said Dr. Olweny with a wide (treatment), and assured them that we were smile at his home in Uganda Martyrs Univer-

sity Nkozi where he is a Professor of Medicine and Vice Chancellor at Uganda Martyrs University. It is the ability to delegate that helped me get work done; the medical students helped me run the wards and the nurses helped take care of the patients. Some of the medical students were Dr. Alex Coutinho the executive director of the Infectious Diseases Institute of Makerere University in Uganda, Dr. David Serwadda a leading researcher in the epidemiology of HIV/ AIDS in sub-Saharan Africa and once a dean of Makerere University of School of Public Health which was later elevated to the School of Makerere University College of Health Sciences (MUCHS). Dr. Edward Katongole Mbidde the director Uganda Virus Research Institute (UVRI) and once a director of UCI as well as Dr. James Sekajugo the principal medical officer in charge of non- communicable diseases, at the Ministry of Health. All these medical students went on to excel and are now at the helm of Ugandas health sector. They got exposure, prestige and real clinical practice. UCI maintained a very high standard of work. During those years at least four or five articles were published every year in high-impact journals. The boys worked dedicatedly even on Saturday and Sunday even though Dr. Olweny was the only doctor on call.

The Health Digest not matured or the very old, the immunity has waned. Most of the cancers in this part of the world are due to infections and can be prevented mostly through vaccination, according to Prof Olweny. Born in 1944, he now wishes that lay people could spearhead advocacy to make politicians understand cancer. In this, he says, the media should play a leading role in this. I would like the lay people to advocate for this disease. We are paying a lot of attention to infectious diseases, and yet cancer is the most common cause of death. Cancer kills more people after the age of 5 than malaria. Advocacy role is very crucial. We must have more people advocate for cancer. For instance why has it taken us long to have an elaborate radiation therapy facility? He wants to identify centres of excellence outside of Mulago Lacor, Mbale, and Mbarara hospitals, for instance and make sure that each of those centres has a cancer Register and has cancer essential drugs. Each centre will focus on an area that makes them unique, he explains. For instance, Nsambya hospital has added a cancer ward, which he says should concentrate on cancers of the cervix and breast. It is on our minds to decentralize and leave radiation at Mulago because it needs certain expertise, he says In Dr. Olwenys opinion, the headquarters for regional cancer control programmes should be in Uganda since it has a cancer register and facilities, know-how, and people who are willing to do the job like Tomusange who followed up all the patients, the late Nakawunde bless her soul and many other Ugandans at the Uganda Cancer Institute now.

Is Cancer a disease for the poor?

Cancer is not a disease for the poor, Prof Olweny asserts. After the age of 5, the leading causes of death are the same the world over. Whether you are in New York or Kampala, they are heart disease, accidents and cancer. Actually many people say the opposite that cancer is a disease of the privileged. In reality, the only difference between how the disease affects rich and poor is that for the poor it often is either diagnosed too late or not at all. Cancer affects the very young, the immunity has

Compilled by Michelle Nabukeera

The number of people newly diagnosed with breast cancer in Uganda has doubled over the past thirty years. The age group commonly affected is a decade younger thats 35-45years in Uganda compared to in the U.S.A 40-56 years. Morbidity and mortality is high with very poor five year overall survivals of only 46% compared to the US data of over 80%. The body has mechanisms to convert fat into estrogen hormones which then increase the breast cancer risk. Research indicates that eating foods with high cholesterol levels increase the risk of cancer. Although about 1% of men get breast cancer too, womens breast cells are constantly changing and growing, mainly due to the activity of the female hormones estrogen and progesterone. This activity puts them at much greater risks for breast cancer. In Uganda the youngest recorded patient diagnosed with breast cancer was about 16 years old. In the 1940s to 1960s mothers were encouraged to take a medication called diethylstilbestrol (DES) to prevent miscarriages; research has shown an increased risk of breast cancer among women whose mothers took DES during pregnancy. Mammography is effective in screening women above age 50, and less sensitive in women below age 50. Breast eczema contributes 2-3% of all breast cancers. 40% of patients with Pagets disease will present with a breast mass. Because people with Paget disease of the nipple also have underlying breast cancer, physical examination and mammography (x-ray of the breast) are used to make the diagnosis complete. Eight out of ten breast lumps are benign, or not cancerous. Each year its estimated that approximately 1700 men are diagnosed with breast cancer and 450 will die. Men can develop breast cancer, but this disease is about 100 times mire common among women than men. 80% of women who are diagnosed with breast cancer and who dont have metastasis (spread of cancer) will survive at least 5 years beyond their diagnosis, and many live even longer than that.

Fact File Breast Cancer

CERVICAL CANCER A silent killer of Ugandan Women

Adopted from IRIN

In the obstetrics and gynaecology ward of St Marys Hospital Lacor in northern Ugandas Gulu District, Apilli Kilara lies on the floor under a blood-stained sheet, staring at the ceiling. Kilara, 43, and the mother of seven children, is in the advanced stages of cervical cancer. I started experiencing funny itching in my private parts after my fifth delivery in 2007. In November 2011 when I delivered my seventh child, I began noticing an on-and-off sharp pain in my pelvis with sudden bleeding in between my periods, she told IRIN. The pain and bleeding didnt stop, thats when I started imagining something was wrong with me. If Kilara had sought medical help when her symptoms first started, she could have been treated successfully, but she knew nothing of cervical cancer at the time. As it is, the doctors fear she may not live much longer. Lying next to her is another patient diagnosed with cervical cancer; Akello* is 39, and when her symptoms started, she thought witchcraft was behind them, and sought treatment from a local healer. I had been visiting a traditional herbalist for treatment in vain, that is what women suffering similar ailments in my village do, she said.

The Health Digest

Cervical cancer is the most common form of cancer affecting Ugandan women, according to the UN World Health Organization, which reports that every year, 3,577 women are diagnosed with cervical cancer and 2,464 die from the disease. By comparison, 1,100 women die of breast cancer every year, according to the Uganda Womens Health Initiative (UWHI). To put this figure into further context, 2,594 people in Uganda died in road accidents in 2010. About 33.6 percent of women in the general population are estimated to harbour cervical human papillomavirus infection - the main cause of cervical cancer - at any given time. Limited treatment capacity According to Pontius Bayo, head of obstetrics and gynaecology at St Marys Hospital Lacor, the hospital is limited in its ability to treat them. We cant treat cervical cancer in its advance stage. We refer such cases to the Uganda Cancer Institute at Mulago Hospital in Kampala for further management, he said. Statistics obtained from St Marys Hospital Lacor indicate that 2 percent of all admissions at the maternity ward present with cervical cancer, most in advance stages; 11percent of deaths in the maternity ward are the result of cervical cancer. Few women in rural Uganda can afford the cost of treatment at Mulago Hospital, the countrys largest referral facility; many cant even raise the cost of transport to the capital. With little information on the disease available to women, health workers worry that it will continue to go undiagnosed and untreated. Its a concern in a situation where there is no adequate outreach programme for screening and treating the disease in its early stages, said Bayo. There is little information available on screening for cervical cancer, but a 2006 study conducted on medical workers at Mulago Hospital found that 19 percent of them had never been screened for the disease, and 78 percent said they never asked patients if they had been screened or referred for screening. Uganda Cancer Institute director Jackson Orem said a lack of funding was constraining the governments efforts to fight the disease. Hospitals are constrained with inadequate facilities and trained staff to treat patients, he said. UWHI, which conducts cervical cancer screening around the country, says even major referral hospitals do not offer regular screening. There is very high need for women and their husbands to be sensitized so that they know the symptoms of cervical cancer, said UWHIs Tom Otim, adding that many women mistook early symptoms of the disease - such as bleeding in between menstrual periods - as normal occurrences. Its a neglected area that requires attention, he said.(*not her real name) www.irin.com

Fact File Breast Cancer

The risk of getting breast cancer increases by 4% between ages of 40-59 and between the ages of 60-79, the risk is 7%. The first Ugandan to engage in oncology training a broad was Dr. Charles C. Olweny in the US in the early 1970s. Cancer registration has been in operation for close to sixty years making Uganda the only country in Africa with systematic cancer data on going for over half a century. The establishment of the Uganda cancer institute in 1967 was as a result of the collaboration of the national cancer institute of the United States with Makerere university medical school. There are currently more than 35000 cases of cancer per year in Uganda, of which 2200 are new cases, and 2000 die leaving only 2000 survivors of the newly diagnosed case every year. On average cancer treatment costs about USD1500 for drugs alone (per capita income of an average Ugandan is USD 320) there is no alternative funding mechanism in the country. Cancer is the worst face of inequity in health care access since the most affected are vulnerable groups especially the children and women from rural areas. On the contrary, sizable elite members of the population are treated for cancer abroad at a very high cost. Internationally, Uganda is already a signatory to the world health assembly declarations on cancer and has rectified the frame work convention on tobacco; it must therefore be seen to implement agreements by taking steps towards national cancer control. Counselors have found that several psychotherapies to reduce depressive symptoms in cancer patients are associated with longer survival time and reduced psychiatric symptomology. Just like women the life time risk of men developing breast cancer increases with age, the only difference is older medium age of 67years. Without the probiotics, the immune system would be left to clean the body alone, causing a work overload and probably not as thorough, thus the probiotics are good because they help the immune system to keep toxins out of or intestines.

The Health Digest

Rwanda: A CERVICAL CANCER Model for Africa

By Esther Nakkazi

Rwanda could become a study case for Africa in cervical cancer vaccine effectiveness and equity, as it becomes the worlds first low-income country to attain universal coverage for the life saving vaccine. Results of a national Human papillomavirus (HPV) vaccination programme done in 2011 and published last month in the World Health Organisation Bulletin show successful roll-out and lessons that could motivate other countries to adopt the HPV vaccine during their child health immunization days.

Parents and guardians were encouraged to accompany their daughters to school on the first day of administering the first of the three doses. If there was no show by the parent or guardian the girl did not receive the vaccine.

According to the WHO Bulletin, Rwandas 60000 community health workers were mobilized for active tracing of girls enrolled in primary grade six or 12-15 years but absent on a vaccination day, as well as the small number of girls who were 12 years old but not enrolled in school. After being identified by community health We are encouraged by the promising initial results of workers, girls from both groups were vaccinated at the the HPV vaccination programme in Rwanda, which local health centre. has attained 93 percent coverage after the first threedose course of vaccination, said the WHO bulletin. Mrs. Kagame later held negotiations with Merck officials to partner with Rwanda. to offer at no fee the The example should motivate other countries to ex- Gardasil HPV vaccine for the first three years of the pand their vaccination programmes to include the HPV vaccination programme. HPV vaccine, with due customization according to their epidemiological, economic, political, and health The Gardasil vaccine, which would otherwise cost each system contexts, says the Principal Investigator of the girl $450 was given for free to all eligible girls after Mrs. study Agnes Binagwaho. Kagame secured in December 2010, a memorandum of understanding (MOU) in which, 2 million doses Rwanda becomes the first country to have a national were donated by Merck the vaccine manufacturer for HPV immunization programme in sub-Saharan Africa, the three year programme and promised concessional other countries are doing it at a small scale mainly be- prices for future doses. cause of the high costs of the HPV vaccine, which can cost up to $450. Merck has since promised to lower the price to $5 per dose for GAVI Alliance eligible countries including all Rwandas HPV universal vaccine coverage success is the states in the East African region in its immunizaattributed to the use of a multi-sector approach involv- tion package but is yet to implement it. ing the health and education sectors, with a designed school based strategy as well as community involve- Rwanda has also under the public-private community ment in identifying girls absent and not enrolled in partnership also adopted a National Strategic Plan for school as well as HIV and health workers engaged in the Prevention, Control, and Management of Cervical cancer care. Lesions and Cancer, which offers screening and vaccination programmes for women aged 35 and 45 years. Rwanda had the political will to support the programme. The first lady, Janet Kagame became an advo- Cervical cancer is the most common cancer among cate and icon in a countrywide sensitization campaign women in Rwanda. Studies from the Rwandas ministry undertaken prior to vaccine rollout as she engaged with of Health show that in 2010, they diagnosed 986 cases parents and children informing them about the new of cervical cancer and 678 women died from it. vaccine. But largely, Rwanda is also unique. For instance 98 perReligious leaders, local government officials, health cent Rwanda girls attend primary school and the girls workers as well as teachers were also involved in the targeted where aged the median age of sexual debut is crusade as a massive mass media campaign was carried 20.7 years. out through all outlets. Freelance Science reporter <estanakkazi@gmail.com> 10 The Health Digest

Birth control and CANCER: What you should know

Does your birth control pill put you at risk for cancer? Or, does it actually protect you from the disease? Recent headlines might have you wondering. Heres what we do know: oral contraceptives better known as the pill may impact a womans chances of developing breast and gynecologic cancers. In some cases, that means a bigger chance of cancer. In others, it means protection against cancer. But this slight increase is only temporary. And, your risk returns to normal about five years after you go off the pill. Plus, if youre in your teens, 20s, 30s or early 40s (the ages when most women take the pill), your cancer risk is low. So, that potenThe reason? Most oral contraceptives con- tial increased risk from taking the pill is even tain man-made versions of the female sex smaller for you. hormones estrogen and progesterone. And, taking the pill changes your hormone levels, Do you have a family history of breast canwhich can trigger or, in some cases, pre- cer? Take note: research shows that taking the vent some female cancers. pill doesnt increase breast cancer risk much for women with BRCA genetic mutations or Below, Ive broken down the pills protective a family history of the disease. benefits and risks. Protective perks include lower ovarian and endometrial cancer risks Dont lose sight of bigger cancer risk factors. The pill isnt the only thing that puts you at Taking the pill may help cut your risk of ovar- risk for cancer. And, its certainly not the bigian cancer and endometrial (uterine) cancer. gest thing. Thats probably because women who take the pill ovulate, or release eggs from the ovary, For instance, more cases of cervical cancer fewer times than women who dont take the are caused by the sexually transmitted human pill. The more times you ovulate, the more papillomavirus (HPV) than by taking the pill. hormones youre exposed to. So, be sure to protect yourself from HPV, get tested for HPV, and get vaccinated against The longer you take the pill, the greater the HPV if youre eligible. benefits. In fact, taking the pill for five years or longer may cut your ovarian cancer risk in And, aging, being overweight, along with half. That protection may last up to 25 years your reproductive history and family history after you stop taking the pill, says the Na- may also put you at higher risk for some gytional Cancer Institute. Studies even suggest necological cancers. the pill may protect against ovarian cancer in women with BRCA genetic mutations. Consider other health risks when choosing birth control Talk to your doctor and weigh And, thats not the only good news. Taking all of the pros and cons before deciding if the pill for at least four years may cut your the pill is right for you. endometrial cancer risk in half if youre at average risk of the disease. Even better: this After all, the pill may put some women at inprotection lasts for 10 years after you stop creased risk for other health problems, such taking the pill. as blood clots, heart disease and stroke. And, some women cant remember to take a pill Breast and cervical cancer risks are higher every day. but just slightly So, dont pick your birth control based on Have you been on the pill for several years? the cancer risks alone. The best birth control It may slightly raise your breast and cervical method is the one that works best for your cancer risks. lifestyle and your health concerns. The Health Digest 11

Prostate Cancer Stealthily killing off Ugandan men

By Shifa Mwesigye

I had been told about Timothy Lwangas familys misfortune with prostate cancer. But I was not prepared for the reply on the other end of the line when I called him to ask for an interview. I am not fine, I have just buried my father this evening, Timothy said. His father had succumbed to a cancer that he had been fighting for the past seven years since he found out in 2006. Timothy explains that when his father, Fred Lwanga walked into the doctors clinic complaining of pain when passing urine, he did not anticipate that he would he given the shocking news of cancer.

Then in late 2009, he started feeling pain while passing urine. Fred would lose his memory for days, get back pains and then eventually he started feeling excruciating pain all over his body.

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It was terrible seeing my dad go through so much pain, Timothy explains. Fortunately, all the while his wife was by his side, escorting him to attend treatments, holding his hand, talking to him and just loving him. When a doctor subjected him to a Prostate-Specific Antigen (PSA) test, they found that his PSA levels had shot to an all time high of 400. Normal levels for a human being stop below 4. We expected him to die in a few months. We The family was devastated; his was in the third started him on treatment and from them until he stage. He was given two options, to remove the died he has been fighting. The treatment gave him prostate or go for chemotherapy. He opted for three years of his life, Timothy says. the surgery and in Nairobi. Mr Lwangas prostate was removed. Fred who was a company chartered secretary died on July 2, 2012. He was 79 years old. He left four When he was sent home, Lwanga was given spe- children and a wife. cific instructions to continue with chemotherapy to kill off any cancerous cells that would have He knew he had found the cancer and removed stayed lingering in the body. it, what he didnt do was to continue with the chemotherapy because all those years he thought he He did not follow the advice and did not go for was fine. He didnt know that something worse chemotherapy. We dont know why probably he than the affected prostate had stayed, Timothy, feared its side effects, Timothy a Music Director the first born of the family says. at Sanyu FM says sadly. Dr Fred Okuku an oncologist at the Uganda CanHis life after surgery continued normally, there cer Institute says that what fails the fight against was nothing troubling apart of some mild head- prostate cancer in men in Uganda is the ignoaches and backaches. All through 2008 and 2009, rance of the disease. Many people do not even Fred was feeling very fine. know about their prostate, they do not know what symptoms to look out for and where to go The Health Digest

for check-up.

In the late stages of the cancer, a man will start passing bloody urine; feel pain in the bones, compression of The first aggressive campaign that brought prostate can- the spinal cord, recital dysfunction and weakness in the cer into the eyes of many Ugandans was the November lower limbs. Campaign done by Victoria University last year. Dr Okuku says that there are many treatments but when That campaign which raised some Shs 27 million for the cancer is detected early, a surgery can be done where research into prostate cancer opened the eyes of many the prostate is removed. This comes with complications men to go and have a check up. like urinary inconsistency. It is not that prostate cancer is not a big thing but in Uganda our priorities are not right. You cannot expect The second treatment is radiotherapy using random Uganda to put money into health care when we dont seeds or external beam or brachytherapy. have good roads, Dr Okuku says. In Uganda the incidence rate of prostate cancer is 45/100.000 people. In the late stages all we do is to remove the testis by castration. This is done because the cancer is driven Public needs to know by male hormones so when you shut down the testis The prostate is a tiny organ hidden beneath the urinary or remove it, the cancer becomes less aggressive, Dr bladder. It is shaped like an apple, though smaller in size. Okuku explains. The urethra and ejaculatory duct pass through it. Its function is to neutralize the acidity of both seminal and When it is removed, the man loses the ability of funcvaginal fluids. It grows to stationary size by age 20yrs tioning like a male. He becomes impotent, sometimes and remains so till 50yrs. This is the part that cancer breasts grow and he becomes fat. The bones become affects hence the name prostate cancer. It is the second weaker, lipids go up and he could develop hypertencommonest cancer among males in Uganda according sion. to Dr Okuku. A person cannot check selves; only a doctor can give an examination through the rectum to feel To prevent prostate cancer, one needs to go for a checkany growth. up at 40 years of age especially if they have a family history of the cancer. For other men, when they reach Prostate cancer is more common in Africans and less 50 years, they should go for a checkup. There is no vaccommon in Asians, Americans or Europeans because cine for this cancer because it is not a disease caused by of the difference in genetic makeup. Cancer of the an infection. Screening is offered at the cancer institute prostate is usually slow growing and most men will die free of charge. with and not from prostate cancer. We have prominent men in this country suffering from It is not that it is affecting more many today but the this cancer. Someone needs to stand up and spearhead a awareness is increased and people are coming for check- campaign to encourage men to check. We have facilities ups. They are not staying at home dying of a strange to detect and treat but when it is too late then it will not disease which they treat with witchcraft, Dr Okuku cure and one will die, Dr Okuku says. says. According to a paper published in the British Journal Even medical workers are becoming more familiar with of Cancer, the prostate cancer survival rate in Uganda it and with available ultra sound scans in major health stands at 47% compared to 98% in America because centres, it is easier to detect today. there, men go early for checkup. Men in Uganda die just A man will state developing the cancer between 40 and about 5 years after detection. 45 years. When the prostate becomes enlarged, it blocks the urethra and one cannot pass urine normally. Timothy Lwanga says that having watched his father go through the pain and cost of treatment, he is very cauWhen the bladder is blocked and urine does not come tious of his life now. out, it gets infected with bacteria and causes pain. The person will pass urine frequently. To treat his dad, one particular daily dose of medication cost about Shs 25,000 per tablet. This is not to mention One of the risks factors of getting prostate cancer is all other cocktails of drugs he was put on including pain age because as a man grows older, the chances are high- medications. In a month, the family spent some Shs 5 er. The second risk factor is family history where if a million to make Fred Lwangas life comfortable. father had prostate cancer chances are high that the son will get it. Every year I have to take a PSA test and any slight illness I get, I see a doctor because I have learnt not to Other risk factors are obesity, sedentary life style of be- take chances, Timothy says. Not to blame a man who ing docile, no exercise. Diets rich in red meats also in- has lost four relatives to cancer. crease chances of prostate cancer.
Shifa Mwesigye < shifamwesigye@yahoo.com > A reporter at the Observer newspaper.

The Health Digest

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Over 13,000 Deaths in Uganda Linked to Tobacco Use

By Halima Athumani

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Tobacco control experts claim tobacco and cigarettes do not contribute to the economy of Uganda, as the industry claims. Dr Possy Mugyenyi, the Manager of CTCA says the revenue that Thats why the centre for Tobacco Control in Af- the tobacco industry generates for the country is rica (CTCA) was established in 2011, to reduce offset by the public health costs resulting from consumption of tobacco products in five Afri- the tobacco-related diseases such as cancer. can countries. These are Uganda, Kenya, South Africa, Angola and Mauritania. Dr. Ndyanabangi also notes that the major challenge Uganda is facing is that tobacco is a globDr. Sheila Ndyanabangi, the Principal Medical al industry practicing cross border trade. This Officer in charge of Mental Health at the Min- makes it difficult to police not only farmers but istry of Health says the centre supports govern- also other countries that are benefiting through ments in implementing evidence-based tobacco the tax paid by the industry. control strategies in Africa. It is funded under a three year project from 2011 to 2014 worth Smoking is said to cause about 90% of all lung USD3.4M (about Ushs. 8.5Bn) and is hosted in cancer deaths in men and 80% in women. SmokUganda by the School of Public Health at Mak- ing has also been linked to several other types of erere University. cancer including cancer of the bladder, cervix, oesophagus, kidney, larynx, lung, mouth, throat, It (CTCA) will also increase and support re- stomach, uterus and acute myeloid leukemia. search which will be formatted in a manner that Research also shows that non-smokers exposed will be understood by policy makers locally, Dr. to second hand smoke are inhaling many of the Ndyanabangi added. same cancer causing substances and poisons as smokers. Smoking during pregnancy can increase The centres main focus areas include ensuring a the risk of miscarriage, stillborn or pre-mature smoke-free environment, raising tax for tobacco infants, and infants is associated with low birth products and placing graphic health warnings on weight and an increased risk of Sudden Infant cigarette packs. They also want to enforce a ban Death Syndrome. on advertising, promotion and sponsorship by tobacco companies as well as encourage alterna- Halima Athuman < email:haliasijo@yahoo.com > tive livelihoods for the tobacco farmers. Reporter with the Uganda Radio Network The Health Digest

If you have seen a cigarette pack, you probably know that smoking is harmful to your health. But thats not entirely true. What that pack didnt tell you is that smoking is not only bad for your health; its also equally dangerous to the health of everyone else that inhales the cigarette smoke, as the latest statistics clearly show. Six million people die every year worldwide as a result of tobacco use, 13,500 in Uganda, according to the Ministry of Health. 600,000 of these are passive smokers.

Ahmed Ogwer the WHO Regional Advisor Tobacco control in Africa emphasizes that the tobacco industry is not a stakeholder as far as public health is concerned. He adds that they do not recognize the corporate social responsibility of the tobacco industry.

Pancreatic Cancer: Another Silent Killer

By Anne Mugisa

It began with a slight stomach ache in June 2011. That went away, but resurfaced the next month with a sudden, excruciating pain. Ambassador Vasta Rwankote, Ugandas Chief of Protocol, went to the doctor who promptly sent her for a scan, and then advised her to travel right away to India for an operation, believing that the problem had not developed into full-blown cancer. The operation was performed in September. Rwankote returned to Uganda in the second week of October. By the time her plane touched down at Entebbe Airport, she was vomiting. But she thought that was to be expected given that she was on preventive chemotherapy. Four days later, her health badly deteriorated until she succumbed to the deadly cancer on November 3. She was 60 years old when she died Her workmates say that before Rwankote travelled to India, one would hardly know she was sick because she was energetic. Like most victims of Pancreatic cancer, she had ignored the first signs because they were so mild it seemed hard to believe they could be a symptom of a lethal illness. A few months after Rwankotes death, the retired Bishop of Madi and West Nile, Dr. Enoch Lee Drati also died of pancreatic cancer. Pancreatic cancer is referred to as the silent killer because by the time symptoms are felt, the cancer has spread. The cancer grows for sometime before it causes pressure in the abdomen, pain or other symptoms. The initial symptoms also may be vague, and thus often are ignored. Thats why the disease often spreads without alarming the patient until it is too late. These early symptoms include dark urine and clay-coloured stools, fatigue and weakness, jaundice (the yellowing of the skin, mucous membranes and eyes), loss of appetite and weight loss, nausea and vomiting, and pain or discomfort in the upper part of the abdomen. Other symptoms include back pain, blood clots, diarrhoea and indigestion. Doctors

say that early detection and commencement of treatment can save the sufferer, but in most cases medical intervention is sought too late. Cases Increasing Doctors say that gastrointestinal cancer is increasing in Uganda. In addition to pancreating cancer, these cancers include: gastrointestinal tumours and cancer of the liver, oesophagus, stomach, gallbladder, colon, rectum and anus.

Researchers attribute the increase in gastrointestinal cancers to changes in lifestyle, habits like smoking, excessive alcohol consumption and poor diet, but the exact cause of pancreatic cancer has not been identified yet. Health experts, however say that it is common in people with diabetes, people who have suffered from inflammation of the pancreas for a long time and among smokers. 95% of the people diagnosed with the cancer do not survive for more than five years. The cancer is slightly more common in women than in men and the risk increases with age, experts say. A The Health Digest 15

small number of cases are related to genetic syndromes that are passed down through families.

Prevention Preventive measures include avoiding smoking, The pancreas is an organ located behind the stom- eating a diet high in fruits, vegetables and whole ach. It releases enzymes into the intestines that grains and exercising regularly. According to the help the body absorb foods, especially fats. The head of disease surveillance in Uganda, Dr. Issa hormones insulin and glucagon, which help the Makumbi, although the incidence of pancreatic body control blood sugar levels, are made in spe- cancer is increasing, many people die of this discial cells in the pancreas. ease unnoticed because other cancers and noncommunicable diseases often gt more attention. Treatment of pancreatic cancer includes surgery, chemotherapy and radiotherapy. According to the We have been concentrating so much on comMulago Hospital Deputy Director, Dr. Isaac Eza- municable diseases, yet the non-communicable ti, only one machine has been available at the facil- diseases are slowly taking centre stage. We need ity for detection of gastrointestinal cancers since to study the conditions so that we can draw up a 1995. He says the hospital needs at least two more programme for fighting them, Dr. Issa Makumbi machines to handle the increasing number of pa- says. tients with gastrointestinal cancers. Some patients do not bother to return for check up when they Anne Mugisa <mugisaanne@gmail.com> come once and find the machine down. Senior Journalist with The New Vision

Your Childs Toothache Could be a Cancer too.

By Rebecca Birungi

Eight-year-old, Nathan, developed a toothache. Her mother took him to the clinic for tooth extraction. Nathans mother says even after the tooth removal the boy could neither eat nor sleep. He was screaming and crying in agony every other day as the jaw grew bigger and bigger. Eventually his mother boarded a bus from Mubende district heading to Kampala. At the Uganda Cancer institute (UCI) Mulago, Nathan was subjected to a series of medical examinations and laboratory tests. The results from the laboratory tests showed that Nathan had cancer that was quickly spreading to other parts of his body.

During the period of tooth development young children are either playing or eating dirty things or soil and eventually this may be the time when a child actually becomes infected with the causative Epstein-Barr virus, Dr Omoding explains.

In addition, chronic malarial infections are still being studied in the causation of Burkitts lymphoma among children. This is because when a patient has repeated attacks of malaria, it tends to over-stimulate the childs immune system particularly the type of cells called B cells that are involved in immune functioning. The latter tends to over grow in numbers and over According to Dr. Abrahams Omoding, an populate lymph nodes consequently leading to oncologist at the Uganda Cancer Institute, lymphoma development. Nathan was suffering from Burkitts lymphoma, He appeals to parents to have regular check-ups a cancer that commonly involves lymph nodes of their childrens teeth by a qualified dentist. and the lymphatic system. In Africa where this Any toothache developed by a child should not cancer is endemic, it mostly involves the jaw in be taken lightly as this could be a red flag. 80-90% of all cases. Mainly affecting children between the ages of 7-14, this cancer is more First discovered by Denis Burkitt, a British common in boys than girls. In the western world, surgeon at Makerere Medical School during the the cancer usually presents with the swelling of 1950s and 60, the scientist noted that majority of the abdomen. 16 The Health Digest

Ugandan children were presenting with a unique children from poor families that are largely swelling of the jaw. Further studies established affected. that this swelling was a lymphoma of the jaw. For treatment to be started, a child must have a confirmation of cancer diagnosis by a biopsy of Symptoms the swelling that is then analyzed in a specialized The symptoms for the cancer may include a laboratory. The treatment involves a holistic toothache, a swollen jaw, swelling of lymph nodes, approach that begins with staging work up rise in temperature (fever), and loss of body weight consisting of several tests in order to understand among others. When the disease spreads to other the extent of the disease parts of the body especially the brain and the spine, children will present with failure to walk or stand, All these investigations are very important to understanding the extent of the cancer. Secondly and or failure to pass urine and stool. to determine the type of treatment to be used as He adds that Burkitts lymphoma commonly well as the outcome of the patient, Dr Omoding begins as a toothache among children between the says. ages of 7-14. The toothache more often than not ends with extraction. After the tooth extraction, Dr. Omoding explains that Burkitt lymphoma the childs jaw continues to grow big and bigger, is a potentially curable cancer in early stages becoming a huge mass that may bleed and become but 80-90% of the children are brought to the infected with offensive foul smell. The tumor then Uganda Cancer Institute when the cancer is in its advanced stage. Therefore the treatment given to disables the child from feeding. these children is palliative, aimed at controlling Burkitt lymphoma is an infection related cancer symptoms and progression such that they have a common in equatorial Africa in what is called the better quality of life. A patient is in stage A when Burkitt Belt which stretches from Kenya, Somalia, the tumor involves only one part of the jaw. Stage Tanzania, Mozambique, Uganda, and DR Congo B the tumor may involve both jaws and other up to the western coast of the African continent. lymph nodes while stage C is when the tumor is in the abdomen and lastly stage D, the cancer has Treatment reached the brain, liver or lungs. Omoding further says most children seen at the Rebecca Birungi <birungir@yahoo.com>. Health reporter UCI are referred from rural areas. The eastern, with Mama F.M under the Uganda Media Women central and northwestern Uganda are common Association (UMWA) regions where children come from. It is usually The Health Digest

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Cancer with HIV

HIV does not cause cancer, but only increases the risk of getting infected with cancer By Josephine Tusingwire HIV/AIDS patients with suppressed immune systems are at higher risk of many opportunistic infections including cancers. Some of the most common types of cancer associated with HIV may include cervical cancer, Kaposis Sarcoma, and non-Hodgkins Lymphoma. Others are Hodgkins lymphoma, and angiosarcoma, a type of cancer that begins in the lining of the blood vessels. People with HIV/ AIDS may also develop anal cancer, liver cancer, mouth cancer, throat cancer, lung cancer, testicular cancer, colorectal cancer and certain types of skin cancer among others. HIV does not cause cancer, but only increases the risk of getting infected with cancer. Research shows that HIV positive women are five times more likely to be diagnosed with cervical cancer than negative women. When a womans immune system is severely damaged, and unfortunately that same woman harbours the Human Papilloma virus (HPV) that causes cervical cancer, cervical cancer will rapidly progress to an advanced stage. Thats why HIV positive women are advised to go for regular cancer screenings. Kaposis sarcoma. One of the signs of Kaposis Sarcoma are skin lesions, which may be purple or brown, initially flat but later develop into nodules appearing as dark plaques. These can occur anywhere on the body. These symptoms may spread to other organs like the lungs, brain or the gastrointestinal tract. In Non-Hodgkin lymphoma, cancer cells form in the lymphatic system and start to grow uncontrollably due to the weakened immune system. HIV positive patients are said to be 70 times more likely to be diagnosed with these cancers. Treatment In some cases, cancers in HIV positive people, particularly Kaposis sarcoma, may heal with the right HIV treatment and adherence, especially if the treatment is started early.

But most cancers are not diagnosed early mainly because of the challenges in developing countries, says Lawrence Ssegawa, a Clinician with Nurture Africa, an organization that provides treatment to HIV positive children in Nansana, Wakiso District. Some of these One of the most common cancers in children challenges include lack of diagnosing gadgets, in East and Central Africa is Kaposis Sar- poor health facilities, lack of professionals, long coma. Diagnosis is confirmed by biopsy of distances to health facilities which directly imthe lesion and histological examination. Re- pact on adherence and follow up, among other searchers from the Fred Hutchinson Cancer things. Research Centre in the United States say the human herpes virus 8, is the primary cause of One form of treatment is to use Highly Active 18 The Health Digest

Antiretroviral Therapy (HAART). HAART is the name given to aggressive treatment regimens used to suppress HIV viral replication and the progression of HIV disease. The cancer, especially when it is still in early stages, often regresses with the initiation of HAART. When it has diffused, systemic chemotherapy is often required and anti-cancer drugs may then be given to the patient.

these, only about 500,000 people are getting antiretroviral treatment. But in order to reduce cases of cancer among HIV positive people, Corey Casper, an associate researcher on Vaccines and Infectious Diseases calls for early treatment of HIV and AIDS and routine cancer screening in all clinics countrywide.

But it should be noted however that HIV negaHowever, its still not possible to get all HIV in- tive people are also at risk of cancer. Other factors fected people to access antiretroviral therapy to may increase ones risk of getting cancer includreduce cancer infections. Only half of people liv- ing genetics, chronic medication, lifestyle, age and ing with HIV/AIDS that urgently need treatment chronic diseases like ulcers. are able to get it. According to the 2012 Uganda Health Demographic survey, an estimated 1.5 mil- Josephine Tusingwire <jktusingwire@yahoo.com> lion Ugandans are living with HIV/AIDS. Of HIV/AIDS Advocate and Counseling Psychologist.

The Health Digest

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f you visit the Uganda Cancer Institute (UCI) on a Monday morning, you may be surprised by the sheer number of patients lining up for consultations with senior oncologists. The parking lot is jammed with vehicles-some belong to the medical staff at the UCI, but many of the vehicles are driven by relatives of jajjas or children seeking medical care for what appears to be a growing cancer epidemic in Uganda. Evidence from data collected by the Kampala Cancer Registry suggests that cancer incidence is increasing in Kampala and in Uganda. For instance, prostate cancer was a relatively rare disease in the 1960s, with an incidence rate of 3 to 6 cases per 100,000. According to data for 2002-2006, age standardized incidence rates for prostate cancer are now 39.6 per 100,000 men. A similar story can be told for breast cancer incidence. Breast cancer age-standardized incidence rates were 18 per 100,000 from the period of 1991-1995. From

Ugandas
By Marissa Mika progress.

walk with

This will serve as a new public in-patient cancer center, with its own surgical theatres, laboratory spaces, and consultation areas. Within a year, the landscape of public cancer services in Uganda will be quite different, thanks to this new building, and another one which will provide space for cancer research and training activities through a partnership with the Fred Hutchinson Cancer Center in Seattle, Washington, USA. These recent events mark an opportunity for Ugandan health journalists to report on the quickly changing infrastructure of cancer care in Kampala, to ask questions about how cancer services will be built for the rest of the country, to report on a number of new cancer research projects underway, and to ask why there is a growing cancer epidemic in Uganda. At the same time, journalists reporting on cancer should know that they are writing the latest chapter in an over fifty year history of biomedical research and care for cancer in Uganda. This is a unique history in sub-Saharan Africa, and one that continues to shape where cancer services and knowledge about cancer are created today. To provide greater context for those reporting on cancer in Uganda, the aim of this article is to provide some deeper historical context on the UCI, and cancer services more generally in Africa, since the 1950s. 1950s: Establishing the Kampala Cancer Registry In the 1950s, physician-academics at Makerere Medical College became increasingly concerned that their students

2002-2006, age standardized incidence rates were 31 per 100,000. It is unclear what is driving these increases in cancer incidence in the Kampala area, but researchers suggest that at least part of these increases can be attributed to urbanization, and the changes in diet, activity, and exposure to pollutants that accompany city life. At the same time, cancers that are usually considered endemic in east Africa, such as cancers of the cervix, liver and esophagus, continue to be serious problems. What is being done to address this growing cancer burden? Returning to the Monday morning scene at the UCI, if you look up the hill past the outpatient center, where patients congregate and wait for their names to be called under a tent, you will see a concrete building in The Health Digest

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Cancer
not only learn about tropical illnesses and infectious diseases, but that they also be prepared for working with a host of non-communicable diseases, especially heart disease and cancer. At the same time, growing interest to document the geographical patterns and distributions of cancer in Africa led the British government to invest in a population based cancer registry in Uganda. A population based cancer registry is responsible for recording all of the cancer cases in a set geographic region, which allows for calculating how many new cases of cancer are seen in that set population over a span of time. This number of new cases over a period of time is usually called an incidence rate. A population based cancer registry is different from a hospital based cancer registry, which records the cancer cases for that particular hospital, irrespective of whether or not that person permanently lives in the area. The Kampala Cancer Registry works by recording new cases of cancer that appear among those permanently living in Kyadando county and recording the data in the registry system. The cancer registrar finds cases of cancer by reviewing patient charts, or being notified of a case. When the Kampala Cancer Registry first started, this was done manually on cardstoday, the data is entered into a database and checked for duplicates. The Kampala Cancer Registry has shaped much of what we know about the distribution of cancer in Uganda and more generally sub-Saharan Africa for the past fifty years. The data from the registry also provides a valuable tool for journalists to access information about the cancer burden in Uganda and the rest of Africa. To access Kampala Cancer Registry data, you can visit the World Health Organizations online database

at: http://ci5.iarc.fr/CI5i-ix/ci5i-ix.htm. Other recent publications from the Kampala Cancer Registry can be accessed through searching for Kampala Cancer Registry at: http://www.ncbi.nlm.nih.gov/pubmed/. You can also schedule an interview with Professor Henry Wabinga in the Pathology department at Makerere, who has served as the head of the cancer registry since 1993. 1960s: Burkitts Lymphoma Research and the Founding of the UCI In addition to documenting the incidence of cancer around Kampala, the late 1950s and early 1960s in Uganda also marked a growing interest in a tumor that was remarkably rare in Europe and the United States, but was the most common childhood cancer seen at Mulago. A surgeon named Denis Burkitt first became interested in this tumor both because of its over-

whelming visibilitythe tumor usually manifests itself as an extreme swelling in the jawand because of the tumors inoperability. Chemotherapy, however, did an impressive job in shrinking tumors, with some children going into remission, suggesting that this tumor, which eventually became known as Burkitts lymphoma, was potentially curable with the right set of drugs. American researchers at the National Cancer Institute (NCI) were also increasingly interested in the role of chemotherapy in managing and curing cancers. A partnership between the American NCI and Makerere Medical Colleges Surgery department planned and established the UCI. In 1967, the Lymphoma Treatment Center opened, and in 1968, a ward dedicated to studying solid tumors like Kaposis sarcoma and liver cancers opened as well. The research units, two 20 bed wards that had been abandoned buildings at The Health Digest 21

Old Mulago, focused on providing care for selected cancers and also conducting randomized controlled trials on chemotherapy dosages and combinations of drugs. Many medical students from America, the United Kingdom, and Uganda came and learned at the UCI. Many of the combinations of therapies that we now use for Burkitts lymphoma and other cancers came out of the research that was conducted at the UCI in the 1960s and 1970s. 1970s: Continuing Cancer Research Under Idi Amin One of the most fascinating and surprising aspects of the history of cancer research and care in Uganda is that the UCI managed to stay open and viable during the 1970s. Much of this can be attributed to the energetic and passionate leadership of Professor Charles Olweny, who trained as an oncologist in the United States and returned to Kampala to run the Institute after it became clear that the expulsion of the Asians in 1972 also severely hindered the ability of American and British physicians to stay in Uganda. A vibrant staff also kept the X-ray department open and running, research staff still conducted follow up visits with patients, and chemotherapy came in regular intervals thanks to ongoing support from the NCI in the United States. As security and the overall state of Uganda continued to deteriorate, the UCIs funding streams and institutional support for drugs and staff were transitioned to the Ministry of Health. The doors 22 The Health Digest

of the UCI remained open during the Tanzanian invasion in 1979. 1980s and 1990s: Reconstructing Cancer Care in a Growing AIDS Epidemic In the early 1980s, clusters of young men in Europe and the United States started developing Kaposis sarcoma and a variety of terrible infections. In Uganda, symptoms of extreme wasting and infections in young men and women in Rakai district and elsewhere were also emerging. The AIDS pandemic and would wind up shaping both the experience of living in Uganda in the 1980s and 1990s and dramatically shape health care and international medical research throughout much of sub-Saharan Africa. Particularly in terms of cancer and care, the 1800s and 1990s marked a period of extensive research on Kaposis sarcoma and its relationship to HIV. Early publications, such as Further experience with Kaposis sarcoma in Uganda, by David Serwadda et al. for the British Journal of Cancer in 1986 documented cases of Kaposis sarcoma presenting at the UCI and efforts to treat Kaposis sarcoma with well-established chemotherapy protocols. Studies in the 1990s covered a range of topics, including childhood Kaposis sarcoma and its relationship to HIV status at the UCI, as documented by Edward Katongole-Mbidde and John Ziegler, and the relation-

ship of human herpes virus eight and its causative connection to Kaposis sarcoma. Also during this time, radiotherapy services were finally established at Mulago, providing much needed radiotherapy care for cervical cancer and others. Overall services for cancers at Mulago, however, remained under-funded and under-supplied, making it quite challenging to provide combination chemotherapy and supportive care at the UCI. 2000s: New Research Partnerships and Infrastructures Since 2004, a partnership between the Fred Hutchinson Cancer Research Center and the UCI has helped to revitalize training and research programs for cancer in Uganda. One of the cornerstones of this partnership has been to train a series of Ugandan physicians in oncology and public health. Where there was one oncologist for a population of over 30 million in 2000, there are now over eight practicing oncologists in Uganda. At the same time, better infrastructure for outpatient services, as well as greater financial autonomy from Mulago Hospital have led to a great uptake in cancer services here in Uganda. For health journalists reporting on cancer in Uganda, I hope this brief summary of some of the major periods of cancer care, particularly in Kampala, is helpful. What I take away from this history is that the way research for cancer in Uganda happened over the past 50 years or so has shaped the services that are provided for care and also our basic knowledge about

cancer epidemiology. The emphasis on chemotherapy, the centrality of partnerships and relationships with the NCI and the International Agency for Research on Cancer, and the fact that the bulk of public cancer services are offered in a cluster of old buildings at the top of Mulago hill, all impact and shape how cancer care is delivered in this country. On a final note, it is worth remembering that cancer treatments are intensive and intense, requiring that patients come for a series of chemotherapy infusions over time. Side effects need to be managed, distances need to be traveled, and regular consultations with physicians need to happen. Even as the UCI builds out a larger infrastructure for managing cancer care, challenges and opportunities remain as to how to extend public cancer services up country and beyond the rapidly changing infrastructure of the UCI. It will be interesting to see where and how the UCI expands its services beyond Mulago hill over the next ten years. And it will be equally interesting to see how the Ugandan health journalism community engages with reporting this ongoing story.

Marissa Mika is a Ph.D. candidate in African history and the history of medicine at the University of Pennsylvania. She is in Uganda for the year conducting historical and ethnographic research on how cancer care services in the country have been shaped by research projects and priorities. <mmika@sas.upenn.edu>

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The power of the Spoken word in Cancer care

by DON S. DIZON, MD Adopted from Kevin MD.com

In the language of medicine there are certain words and phrases that (no matter how carefully said) suck the air out of a room.

In oncology, there are certain words and phrases that (no matter how carefully said) suck the air out of a room, like you have cancer, youve recurred, incurable, terminal, and hospice. Such phrases require careful consideration before they are spoken, and most (if not all) oncologists understand the power of these words, and use them carefully. However, there are others that can be as powerful, yet remain in common usage in our field. I still remember my fellowship days at Memorial Sloan-Kettering Cancer Center (MSKCC) like they were yesterday. When I decided to pursue a career specializing in womens cancers, I joined the medical gynecologic oncology clinic of Dr. Paul Sabbatini. In addition to

being an amazing clinical researcher, he is a brilliant clinician and, as a fellow, I always sought to impress him. On one clinic day, I recall seeing a woman in her 60s with ovarian cancer. She had recurred despite treatment. I went in alone, talked with her, examined her, and then presented her to Paul. So, what do you think we should do now? he asked. Well, since she failed this regimen, I think she needs to start on a new salvage treatment. What about a combination? I recalled saying. Pauls expression changed, and I still remember it like it was yesterday. He looked at me

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kindly, but with a degree of exasperation. Donif theres one thing Ive learned, its that people do not fail chemotherapy. The chemotherapy didnt work, but no one failed; she didnt and I didnt. And, we dont salvage people. Salvage is what you do with scrap metal and trash.

I remembered being taken aback by this, primarily because I felt he was criticizing the common language of oncologists. Salvage and failure on treatment were words and phrases I had heard as a medical resident, and they were phrases used everywhere in oncology. Still, I respected Paul and his experience, and though I did not understand what he was talking about at the time, I was more careful during our clinical discussions after that. A quick search on clinicaltrials.gov using the search terms FAILURE and CANCER When I completed my fellowship, I was resulted in 145 actively accruing studies, 20 lucky enough to join the Developmental of which had failure in the title. In addiTherapeutics/Gynecologic Oncology ser- tion, a search in Pubmed.org using the same vice at MSKCC, and counted Paul as a col- terms resulted in 54 papers with FAILURE league. In my first year as an attending, I in their title, published in the last 5 years. took care of a young patient with ovarian While these overall estimates are low, I suscancer. She had just relapsed from first-line pect that in our everyday conversations, it is treatment and we had discussed where to go far more pervasive. next. I am hopeful treatment can help and pre- The language of medicine is a special one, vent the cancer from causing you symp- and in the context of a serious medical illtoms, I explained. Despite the failure of ness, this is especially true. The way we first-line treatment, there are many more communicate matters and even when we options for you. think our audience is our peers, in the era of social media, we must be cognizant of The words had barely left my mouth when the wider reach of our words, our lectures, the lesson Paul had tried to teach me came our publications, and our presentations. back in full force. My patient, already scared While our colleagues may understand what about her recurrence, became teary and we mean when we refer to treatment as salturned away from me. vage therapy, the same may not be said of how our patients or the public hear it. You make it sound like this was my fault, like I did something wrong! she said. Im sorry I failed chemotherapy, if thats what Don S. Dizon is an oncologist who blogs at ASCO you think, and Im sorry I disappointed Connection, where this post originally appeared. you. I was stunned. It was never my intention to place blame on something so devastat-

ing as a cancer recurrence, and I certainly did not mean to imply that she had failed. I remember using the rest of the visit apologizing, ensuring my patient she had done nothing wrong, and that she did not fail chemotherapy, but rather- chemotherapy failed her. These many years later, I still consider this encounter a watershed moment in my career as an oncologist. Since then I have been sensitive to words and phrases, particularly when they are used in reference to patients, treatment, and circumstances surrounding recurrent disease. I cringe when I hear someone referred for salvage treatment or how its too bad she failed therapy. Unfortunately, even today, it is still terminology that is part of the lexicon of oncology.

The language of medicine is a special one, and in the context of a serious medical illness, this is especially true. The way we communicate matters and even when we think our audience is our peers, in the era of social media, we must be cognizant of the wider reach of our words, our lectures, our publications, and our presentations.

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Amazing Courage
By Rachael Ninsiima

Imagine being six years old and then you are told you have cancer. Now imagine being told that the cancer you have is so dangerous that you have very slim chances of surviving. This is the trauma that Stella Ahaire (not real name) had to face when she realised she had cancer.

mia, painless lumps in the armpits and groin and breathlessness as the blood vessels get blocked by cancer cells.

Dr Orem says Burkitts Lymphoma is the commonest cancer affecting children in Uganda. Currently, the five-year survival rate in Uganda Jovas Nankunda, Ahaires mother initially is less than 40 percent. The institute receives passed off her daughters swelling stomach as between 150 and 160 children with the lyma simple illness that would heal with time. It phoma annually. These are admitted and did not. Instead, Ahaire lost her treated at the recently constructed Lymphoma appetite and developed a fever. Treatment Centre (LTC). I would wake up in the night to pass a wet cloth over my daughters body because she was over sweating and I also helped to position her well because she experienced difficulty in breathing, Nankunda recalls. Dr Fred Okuku, an oncologist at the Institute says at least 86 percent of the children admitted go into remission, meaning that the cancer signs disappear when treated with chemotherapy.

We still administer the old combination, COM-Cytoxan, Oncovin and Methotrexate Hoping to save her daughter, that was developed forty years ago and are still Nankunda took her daughter to a seeing the same success in the same regimen, local hospital in Rukungiri where Dr Okuku says. she was given anti-malarial drugs. Even then, she did not get better He, however, notes that government is unable and her abdomen kept expanding. keep up with the growing population and paUnfortunately, due to Nankundas tients sometimes have to buy these drugs. limited income, she was forced to visit a herbalist, she says. It is Many of the patients cannot afford the costs only when she was brought to the of these drugs and as a matter of fact, many Uganda Cancer Institute by the do not seek early diagnosis and treatment. This local councillor in April 2011 that forces them to come when the cancer is in its Ahaire started showing signs of advanced stages, he laments. improvement. Peter Genze, the operations manager of Bless Children Burkitts lymphoma is a childhood cancer a Child, a centre handling cancer stricken chilfighting caused by the Epstein-Barr virus, a potentially dren says the challenge of delay in seeking Burkitts fatal and disfiguring virus that often develops medical assistance can be overcome through Lymphoma in the jaw or abdomen. It is also associated creating awareness. This awareness, he says, with malaria. The lymphoma is known to grow should target parents and local communities to rapidly such that the tumours double their size identify these cases early. in five days. The international community responds: A fast-growing tumour often develops in the The Burkitts lymphoma Fund for Africa jaw or abdomen that can interfere with breath- (BLFA) based in Seattle, Washington and Diing and make it difficult for young patients to rect Relief International (DRI) early this year feed adequately leading to malnutrition, Dr announced that the collaboration between the Jackson Orem, Director Uganda Cancer Insti- Fred Hutchinson Cancer Research Centre and tute says. the Uganda Cancer Institute (UPCID) was selected to receive grant funds and medicine. Other characteristics include weight loss, anae26 The Health Digest

Cancer control and prevention in SCHOOLS

By Ben Ikara
Uganda Child Cancer Foundation (UCCF) in collaboration with UCI is carrying out School campaigns on cancer control called the 3C (Children Caring About Cancer) Research from our school campaigns on cancer control and management show that more than 50% of the children in schools we visited confirm being affected by Cancer burden in many ways. Children Caring About Cancer (3C) is a UCCF initiative supported by House of Hope- Uganda (HoH) in partnership with Uganda Cancer Institute (UCI). Its a platform for children and young people to interact, form strategies and solutions to control and manage cancer in their own communities. The main objective is to empower children to create Awareness about Cancer, and to work to together with all stakeholders toward a shared strategic direction of controlling and preventing cancers in Uganda. Currently the activities of 3C are coordinated in Uganda by UCCF. Over 20 schools have joined the program with each school effectively implementing vital activities in cancer control and management The most outstanding contribution has been made by Mt St. Marys College Namagunga. They have taken this campaign seriously, not only doing awareness but they also practically support patients with cancer in their battle with the disease. This term the girls are supporting the 1.1/2 year old girl with that was abandoned by the mother at the cancer Institute. Uganda Cancer Institute (UCI) is trying its best to provide clinical care with the available resources, but if there is limited effort to create awareness in cancer Control and management to the public, the problem will continue to grow. Ben Ikara is the Operations Manager -Uganda Child Cancer Foundation, Cancer Awareness Advocate and National Coordinator Children Caring About Cancer Program ikaraone@gmai.com, benikara@uccf-ug.org

The funds are to aid in the treatment of 300 Ugandan children affected with Burkitts lymphoma for two years at the Uganda Cancer Institute.

sion to save the lives of African children afflicted with Burkitts lymphoma by improving diagnosis and treatment. It seeks to ensure the availability of medical care, overcome the social and economic barriers to completA grant of $128,000 (about 320million) was given ing treatment and improve the capacity of the medical to UPCID to cover a variety of costs for patient care infrastructure to diagnose and care for patients. and treatment, said Miriam Sevy, Board President of BLFA. Racheal Ninsima is a science journalist with The Observer Newspaper, ninsiima@observer.ug The fund which was established two years ago has a misThe Health Digest 27

Palliative care in Africa

Dr Anne Merriman Hospice Africa, Kampala, Uganda

The morphine that we make here in Africa is very affordable, it costs $1 for ten days treatment and it can be taken at home by the patient.

Palliative care was very slow to make a start until affordable morphine was available in Africa and over the last twenty years since we first brought it in, twelve more countries have taken it on whereas before there were two countries only in the previous twenty years, so that was a big move. It actually reflects what we all know, that until you can control pain you really cant practise palliative care. The morphine that we make here in Africa is very affordable, it costs $1 for ten days treatment and it can be taken at home by the patient, the patient is in control. So were able to then, once the pain is controlled, were able to go forward and look after their spiritual problems, psychosocial problems, their cultural problems, so many things that come up when we have time and we can sit and talk to them and try and help them and advise them on those things and take action on things that they have. So Uganda is an example, its now considered the model for this. We are now making morphine for the whole country from the hospice for the whole of Uganda and thats new, thats only started this year. As long as the money is coming from the government we wont have any stock outs but there have been terrible stock outs and its happening all the time across Africa. Countries just starting with morphine, theyre not getting it through first of all to the people on the ground and the very poor people, but then suddenly the

supply stops because they havent imported it in time and that causes terrible suffering as well. So were trying to prevent all these things which are coming forward. At first it was just get it into the country, now its get it through the country. Does this problem come from lack of production and risk management? Its probably mismanagement in ordering it in time. Somebody keeping and theres a lot of bureaucracy and theres a lot of people in the bureaucratic chain dont want to import morphine and if they can theyll block it. Its really sad because theyve been brought up to think its addictive and it shouldnt come into the country and trying to change them is very difficult. But the big thing for actually changing it is to get undergraduate training for palliative care into the undergraduate curriculums, particularly for doctors and nurses. Now weve been doing this since 1994 in Uganda and now every doctor and nurse thats come through since then knows what palliative care is. Its made a huge difference in the country

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but its very slow getting through. Weve got five universities in Nigeria and only one of them has an undergraduate curriculum in palliative care. In that huge country, 150 million people, it really needs help. Could you talk about your involvement with the National Cancer Control Program? Yes, theres six booklets from WHO on that and one of them is on palliative care. Theres a lot of concentration, in fact the two blend with each other on chemotherapy and radiotherapy which is terribly expensive but has to come in. It has to come in but the people doing radiotherapy and chemotherapy need to work alongside us, we need to be together from the start, from the diagnosis onwards in cancer. If we dont work together then the patients wont get the best care so they brought in palliative care because 95% of people in Africa now never receive chemotherapy or radiotherapy. In Uganda, where weve only got one centre when I calculated the numbers they are less than 5% of the people who need it are reaching them. But still were reaching less than 10% in palliative care and yet palliative care is cheap, its just a matter of increasing the knowledge and allowing the morphine to get through to them so that they can practise palliative care. What has the effect been with HIV related cancers? The HIV related cancers are actually changing because antiretrovirals are now so much more available. Theyre only available to people who can reach the centres and so there are still at least a third of the people with HIV who get into stage 4, which is AIDS, and cannot reach antiretroviral therapy because they cant even afford the bus fare, they cant even anything they have is going to take away from the food in the family, from the school fees for whatever. So they dont go for it and they will still die of HIV/AIDS. But the others, if they can have continuous supply of ARVs will actually die of something else. But the cancers have changed. Kaposis sarcoma was our number one cancer up until 2002/2003, now its about number

four. Cancer of the cervix is number one now and breast is second so its changing, the whole pattern is changing and we have to keep an eye on it and address the needs at the time, what is there. But for us in palliative care, the burden for palliative care is much higher in cancer than it is in HIV/AIDS, thats because AIDS is going down and cancer is going up. What can be done for the future of palliative care? I just feel its only through those we train that were going to spread palliative care throughoutfrica. We have now an institute of palliative medicine for Africa which last time I talked to you we didnt have, that was our education department thats now recognised as a university level. And we have a degree and we hope to have a Masters next year or the year after. This is for the whole of Africa and people are coming from all over the place which is wonderful. Its through those we train that the future of palliative care will be extended in Africa, not through the small numbers that we see but we must have perfect palliative care so that we can train people and show them how to do it right and how it can work in the African situation. Theres a tendency in Africa for everybody wanting to do training and to have another certificate in their portfolio but they dont actually carry it out afterwards. But if somebody does a training in palliative care and doesnt practise it, theyre de-skilled, they may as well not have done it. So were now looking more to see whether their employers are prepared to put them into palliative care after they come on the degree or after they come on a years course. We have a lot of short courses as well but for those longer courses which are expensive, we really need to put the money and the training into those people who are going to be leaders in palliative care in the future. AORTIC 2011, Cairo, Egypt Adopted from http://ecancer.org

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By Florence Naluyimba

Dr Ddungu; Walking in Pain with Cancer patients

To ensure that his plan went through, Dr Ddungu joined Hospice Africa Uganda for further training in palliative care where at the end he would offer end of life care to patients in their homes. Two years later, he decided to do a masters degree specializing in internal medicine at Makerere University and after 3 years his passion for palliative care drove him back to Hospice. While working at Mulago hospital, he got an opportunity to study hematology at McMaster University in Canada. He came back and helped push for the training of two clinicians at the same university as he advocated for hematology oncology for students studying medicinea rare speciality in Uganda. In fact Dr Ddungu says there are only four hematology oncologists working in the government sector. Equipped with all the knowledge there is to know about blood cancers, he is now a consultant with the Uganda Cancer Institute at Mulago. The fact is that blood cancer is a killer but I give my patients hope of death with minimal suffering, he explains. He has fond memories of some of his patients. A case in point is a

Yes, I knew they were supposed to die but I made sure they would die in comfort, he affirms in a soft voice but the conviction with which he says it, makes it loud enough for me to notice even as we drive through the streets of Kampala from Mulago Hospital. Henry Ddungu, before becoming Dr Ddungu, while pursuing his first degree in Medicine and Surgery at Makerere University during clinical rounds met many distressed cancer patients-dying in pain. As a young boy, he helplessly watched his own father being eaten up by cancer. He could do nothing to lessen his fathers pain till his death. Yet Ddungus intention as he started studying medicine at Makerere University was to be a general physician but in his fourth year when a doctor from Hospice talked of palliative care and offered him an introductory course, his interest was stirred. His sub specialty would be blood cancers like leukemia, lymphomas, bone marrow and failure syndrome among others. Understanding all aspects of blood would help me understand cancers better, he said. 30 The Health Digest

13-year old girl with leukemia who told him to allow her go back to the village and die. It was painful to hear her say that, but I gave her medicine and a year later she came back to thank me, I have never been happier, he says. But his job comes with challenges. For instance one has to always know the exact extent of the disease or exact cells. Working blindly is not the best. I know what to do but I cant do it,he notes. Dr Ddungu says that the Uganda Cancer Institute has most of the needed medicine to treat cancer but the novel targeted treatment is too expensive for even the more developed countries. The sadness he always lives with is knowing that his patients will sooner than later die because of lack of better medicine. Every doctor would love to catch a patients disease in its earliest stages but unfortunately patients present late. Its often not their fault, they are not aware of little lumps. This, he notes requires creating more awareness, the reason he has been hosted on several radio talk shows to talk about the disease.

Dr Ddungu is however perturbed by the fact that for a long time, cancer has not been given precedence especially in terms of supportive care. The need for blood is so high in this country but cancer patients are not prioritized for blood transfusion. More doctors, at least specialists are needed. Some doctors dont have lunch and work nonstop on patients who sit from morning till late and even some go home without treatment, he reveals. But even with these challenges, Dr Ddungu appreciates governments effort to construct a new cancer building, making available free cancer medicines to patients and setting up diagnostic laboratory services. Away from work, the 40-year-old doctor loves music. He plays a trumpet and is aspiring to master a saxophone, an instrument lying in wait in his house. Music he says gives his patients hope and spiritual healing. When a patient tells me, doctor I slept peacefully, that makes my heart smile, he says with a grin. Florence Naluyimba <f.mujaasi@gmail.com> A health reporter with NTV The Health Digest

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Inefficient Markets Impede Cancer Pain Relief

By Meg OBrien, PhD March 1, 2012, Volume 3, Issue 4

The potent analgesic property of morphine was first isolated in 1804, and after more than 2 centuries morphine is still the gold standard for moderate to severe pain. It is relatively easy to produce, and compared to most pharmaceuticals, morphine is dirt-cheap. Therein lies the cruel conundrum: Morphine is widely available in Western, developed nations, but in resource-constrained countries, comprising about 80% of the worlds population, market conditions have grossly inflated the drugs price, leaving the majority of the worlds poorer cancer patients suffering in severe pain because they cant afford analgesic relief. A Ugandan Model It is important to distinguish between cost and price. The cost of morphine is pennies per dose; the inefficiencies within the market drive the exorbitant prices. In Uganda, what we needed was a way to bypass many of the supply and demand issues that created access barriers to pain medication and left the country without any morphine for more than 6 months in 2010. For years, a nongovernmental hospice in Uganda, Hospice Africa Uganda, has been producing its own liquid solution morphine. Over the past year, the Global Access to Pain Relief Initiative (GAPRI) has been working with the Ugandan Ministry of Health and local palliative care stakeholders in Uganda (including the Palliative Care Association of Uganda and the African Palliative Care Association) to scale up Hospice Africa Ugandas production and certify them as a drug manufacturer. The hospice now sells 32 The Health Digest

morphine solution to the government at a cost 40% less than the cost of importing the drug from an international supplier. This process also makes the local market more efficient. Since Hospice Africa Uganda produces its own liquid morphine, they actually manufacture on demand, taking only a week to fill an order. They are able to produce three different incremental dosages in real time; the expiration clock starts ticking at the time they mix it so they can hold the raw powder for much longer, giving more shelf life than an imported finished product. Most importantly, the raw powder does not need to be registered, meaning that they can procure the raw ingredient from the supplier that gives them the best price. Win-Win Situation This is one of the newer approaches that can actually produce and deliver morphine to cancer patients in pain for literally pennies a day. The pain treatment costs in the Ugandan model are about $1 per week. And because it resulted in the government getting heavily discounted morphine, in turn, the Ugandan government has agreed to pay for annual orders up front, allowing the hospice to better plan procurements. The government also pays for morphine for all pain patients in the country for free. That includes thousands of patients being treated by hospice programs across the country that previously had to purchase their own morphine out of pocketan untenable expense for most. Hospice Africa Uganda used to spend over

$40,000 per year on morphine; now theyre making a small profit on every bottle they sell to the government. And all their patients get treated for free. It is a win-win situationthe overall price has gone down across the board, the efficiencies are up, were wasting less product, were not having to toss expired product, and all the patients are getting their pain medications when they need it. This is an example of a creative, cooperative approach by a hospice that was willing to take on a risky endeavor for their patients, local partners who supported them, a proactive government that believed in and invested in local solutions, and a small international organization that is helping them both to cut through bureaucratic hurdles. This collaboration is circumventing the challenging market inefficiencies endemic in much of the worlds poorer regions, and by doing so, we have helped relieve unnecessary pain and suffering. Addressing the global tragedy of needless pain is a continued work in progress, and the Ugandan model is continuing to be refined, but it represents a point of light on the horizonhope for affordable, government-led solutions to unnecessary suffering. . Dr. OBrien is Director, Global Access to Pain Relief Initiative, a joint program of the Union for International Cancer Control and the American Cancer Society. Adopted from http://www.ascopost.com/

On the day we CURE cancer

by JAMES C. SALWITZ, MD On the day we cure cancer I will rise in morning dark. I will stand in last night cold, and watch stars fade. The light will come and a following breeze blow. On that incredible dawn, there will be brilliance. I will make sunrise rounds on the day we cure cancer. I will stay late and breakfast with my wife. We will talk about flowers, kids and books. I will stand out and see children with parents laugh and scurry almost late to a bus. Mothers on porch steps. Grandfathers there for early stroll. Families whole. I will see life on the day we cure cancer. At the hospital, we will drink coffee and eat donuts. Make new syringes into trash. Pour harsh drugs down drains. Turn radiation monsters into kaleidoscopes and planters. Dull scalpels. Plan vacations. Have wheelchair races. Give out beds to homeless. We will smile quietly on the day we cure cancer. I will call the insurance company and wish them well. Thank the lab tester, blood drawer, x-ray taker, pharmacy mixer, front desker, researcher, bill sender, educator, social worker, floor cleaner, food cooker, CT scanner, doctors and every disease task doer. Congratulate all on victory day. I will salute the soldiers on the day we cure cancer. I will cry, I will cry, and I will finally cry. I will recall fallen millions. The men and women and moms and dads and sons and daughters and leaders and followers and smart and dumb and good and bad and weak and powerful. I will curse waste, loss, pain and fear. I will replay battles fought and won or lost. Honor the harsh bravery of victims. I will remember them on the day we cure cancer. I will call survivors. Make sure they are all right. Tell them it is OK to come out. No need to cower. They are whole. It is safe. On the day we cure cancer. I will fish. I will read. Fix the swing. Hold warm earth. See art without darkness. Enjoy a lunch meal. I will live without struggle. On the day we cure cancer. At end I will be home and walk in joy with those I love. We will hold hands too tightly. Feel the emptiness of the loss, the fullness of the saved and the hope of not again. I will not watch the setting of the day. I will hold the brightness. The glory of the day we cure cancer. Adopted from Kevin MD Conns. The Health Digest 33

Tradition and Modernization

By Dismus Buryegera

Brother Anatoli administers herbal medicine alongside modern drugs to treat Cancer symptoms

Brother Anatoli, pitured above, shows off the large room where he keeps an assortment of dried leaves, tree barks, roots and other items. They look like big bales of cloth ready to be sold off. All these will be finished within a month, he says pointing at them.

courages his patients to report cancer early to make treatment easier which is a major problem that the conventional doctors are struggling to preach. Early diagnosis is key in the treatment of cancer. The problem is that some of our people think that they have been bewitched when they develop cancer and this complicates matters, I have written books against the dangers of believing in witchcraft,he said.

Every month he treats more than 10,000 patients with various ailments, including cancer. As a forest owner in Rakai, he harvests most of the herbs for his patients from here He also advises the public to desist from and has managed to keep a list of plants and certain foods that may increase their risk of suffering from cancer. Other risk factors trees and what they cure. associated with cancer are genetics, HIV/ Brother Anatoli gives his patients specific AIDS, smoking, and alcohol. dosages, just like modern doctors, to be taken at regular intervals. Some of his pa- Even as a herbalist, Brother Anatoli contients and others who are curious about his curs that cancers can only be treated using a combination of herbal medicine and modresearch come from overseas. ern drugs. He promises to make more herbs The aging Anatoli now 86 years old has that can be exported and believes some traclinics in Rakai, Masaka, Ibanda, Kisoro, ditional medicine is even more potent than Nyamitanga, Kibuye, Mbale, Kiteredde and modern drugs. Kampala. He claims he can treat about 90 diseases, including complicated ones like The problem, as he sees it, is that herbal cancer and has recruited and trained several medicine is sometimes buried into taboos assistants to handle most cases in his ab- and superstition. Brother Anatoli, a twin, has been a priest for over 60 years, the second sence. Banakaroli brother to be ordained. The OrLike all herbalists, Brother Anatoli has em- der was founded by Bishop Henry Streicher braced referral and refers the majority of in 1927. He started herbal research in 1971 his patients suffering from advanced cancer on the request of his diocesan superiors. to referral hospitals like Masaka, Kitovu, and the Uganda Cancer Institute (UCI) at Mulago, and continues to supplement their Dismus Buregyeya <dburegyeya@yahoo.com> treatment with herbs. Brother Anatoli en- Works with The New Vision based in Masaka.

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Social Media Efficacy

By Dr Sabrina Kitaka

A powerful tool in cancer awareness

The World Health Organisation (WHO) Human Papillomavirus Information Centre of 2010 reports that the Human papillomavirus (HPV) that causes cervical cancer has the highest rates of infection in the age group 15 to 24. In Eastern Africa, about 33.6% of women in the general population are estimated to harbour cervical HPV infection at a given time. Cervical cancer is the 2nd most common cause of cancer worldwide, but it affects mostly women in developing countries. Immunization is a key important way in which HPV can be controlled, with subsequent reduction in the incidence of cervical cancer. In Uganda, HPV vaccination is not yet available in the public sector and yet there is a growing awareness and demand for it. We developed a vaccination campaign which was aimed at enabling the public to access the HPV vaccine through the private sector and also to increase the demand and awareness for it. health workers and the participants and sharing these stories with the public to raise more awareness. During the vaccine drive, HPV talks as well as sexual health talks were given and a standby paediatrician answered any questions that the public had. The results: The immunization drive was mainly carried out around Kampala city. The information is estimated to have reached over 800 people. Between August 2009 and March 2011, the campaign was able to mobilise 500 young women for immunization and had 180 females immunised. The age range of those immunized was 9 years to 46 years. Those who completed their 3 doses were 166 (92%). The commonest reason for falling out of schedule was pregnancy.

Conclusion: The use of internet social networks and email is a powerful tool in promotCampaign strategy: In August 2009, the ing child health campaigns such as the cerviUganda Paediatric Association working with cal Cancer Vaccine Drive. The availability of staff from the GSK country office developed a technical person to answer any questions a vaccine drive for the HPV vaccine. The increases the confidence of the potential recampaign mainly used the electronic media. cipients and increases up take. A strong partMobilisation messages and announcements nership involving school teachers, parents, for upcoming immunization drives were health workers, policy makers, politicians, made through email, Facebook and SMS me- corporate organizations and pharmaceutical dia. There was a multiplication effect as each industry can facilitate professional organizaemail or Facebook message recipient was tions such as the UPA in making a big impact asked to forward to a circle of friends or post among the young women of this nation by notifications on other walls. SMS media was protecting them from Cervical cancer, while mainly used to serve as reminders. equipping them with knowledge and skills in making healthy choices. During the vaccination drives various media agencies were engaged in interviewing the <sabrinakitaka@yahoo.co.uk> The Health Digest

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Talking Cancer at Malwa Science Cafe

By Esther Nakkazi

Forty eight year old, Juliet Tiperu, has been selling Malwa, a local brew made of millet for the last 20 years. Most of her customers at Sheraton restaurant are men who start strolling in at 5.00 pm and drink until happiness stops for Ush 3,000. This Sheraton is a grass-thatched hut with no doors and windows. The meeting point in the hut is the malwa pot where long straws congregate. On a warm Sunday afternoon, music is booming, a small television sitted on a hill of old furniture is showing almost nude dancing girls dancing to Bolingo Congolese music. People are happy. Arguments are about politics or even girls and the few around the pot, smile sheepishly, but voices get louder, punctuated with a sip of Malwa as happiness hours extend. Except for one day in a month, today, when the group holds a science Caf. Today at Tiperus there are visibly more people. It is not about the Gorogoro- a bonus jerrycan of Malwa for all? Many people want to hear what they are talking about. Today we shall dis36 The Health Digest

cuss cervical cancer and a vaccine in the science Caf, said Tiperu as she refills the pot with hot water. Science Caf(s) are modeled around French Philosopher Marc Sautets Caf Philosophique that took philosophical discussions to French coffee houses. Later British Science journalist, Duncan Dallas promoted the concept to create science Cafs in 1998. In Uganda, in one of the models it is done at convenient timing, in a non-academic location and relaxed informality with high caliber scientists, says Christine Munduru, a public health worker and volunteer leader of the project, entitled Taking Science to Rural Ugandan Communities. Science Caf in Operation: Uganda has another model of science caf for journalists and scientists, held once month on a Friday and coordinated by Kirunda Kakaire. Population Reference Bureau (PRB) based in the USA sponsors it. These ones are targeted at journalists in an informal setting like a bar, caf or restaurant.

Dr. Agnes Bukirwa, is a medical officer at Mildmay, she will talk about cervical cancer at the Science Caf today. She introduces herself as Mama Naomi and points at Tata Naomi, her husband. The World Health Organization (WHO) estimates that more than 7 million Ugandan women of reproductive age are at risk of developing cervical cancer; every year about 3,600 women are diagnosed and almost 2,500 die from it. There are a lot of myths about the HPV vaccine among those aware of it; most people dont know it exists. People dont have information and that poses serious danger to womens health, says Munduru. How many people know how cervical cancer is transmitted? Pause. How many know how it is prevented? Pause. No answer. Back home you have women who may have cervical cancer, continues Dr. Bukirwa. A phone is passed around for members to view the cervix. Men shake their heads. Some laugh. Dr. Bukirwa goes ahead to explain the HPV and how men can transmit it sexually. She speaks for only 30 minutes; adult learners do not want long talks. Some women are standing outside the circle. Chicken are pecking at the grains from the pot that pour out when more hot water from a small yellow jerrycan is added and it overflows. Children that have come with their mothers chase each other around playfully. It is question time. To ask one, you need to introduce yourself and which Malwa group you belong to if you are not a member here. My name is Ghadafi of Uganda, everybody laughs loudly. If cervical cancer is for women, how do men infect women? he asks. Whenever my sister had sex with her husband, there was blood. Now she has cervical cancer. How can you help her when she is already sick? asks Judith Etonu. During the cafe, members can ask questions in any language and it is translated. So one question and answer could be translated in four languages.

They are also video recorded and played back. One challenge is that when people attend the cafes, they want treatment immediately. If they are HIV positive, they expect to get anti-retroviral therapy when the caf ends, says Geoffrey Angutoko the coordinator. So far this group has discussed male circumcision, discordance in marriage and many other HIV/AIDS topics. It is also important to come up with some intervention strategies when engaging very poor communities, said Ruth Wanjala from the Kenya Science Cafs. For instance, it should be important to organize for pap smears and mammograms for a community but organisers should be careful not to turn the Caf into a medical consultation session. Patrice Mawa is at the caf. A biomedical research scientist with Medical Research Council (MRC) based in Entebbe he started the idea of this model of science caf in Uganda in 2007. I used to go out and people would ask me a lot of questions about the research station. I came up with this idea to give back to the community, he says. Knowledge is power. Empowering them and engaging them will make a difference. This model captures more men who are the decision makers in Uganda and most do not know much about womens issues. But it benefits women more. We help them with the topics based on the problem we see in the community and link them to service providers, he explains. The Uganda project, which basically helps women, is one of five awarded $10,000 in April 2012, to educate developing country populations in need about disease prevention through vaccines and immunization. The five projects were in Pakistan, Uganda, Egypt, El Salvador and South Africa and were described as the most innovative and practical - chosen through a peer reviewed competition from among 60 applications from 25 low and middle-income countries to the Southern Vaccine Advocacy Challenge (SVAC), created and supported by the Canadian-based Sandra Rotman Centre. The Health Digest 37

Remarkably, it is the first time the challenge approach involving the invitation of innovative ideas from a community of stakeholders to address a problem has been used as a tactic to promote developing world vaccine education and use said a statement from Sandra Rotman Centre based in Canada. These projects and organizations are finding new ways to spread basic messages about health and vaccination and immunization that will have a profound impact on their societies, either by reducing child mortality or improving their quality of life, says Peter A. Singer, MD, and Director of the Sandra Rotman Centre.

With support from Cafe Scientifique UK, the Wellcome Trust and Burness Communications, the cafes have grown in popularity and the organisers have sought to build partnerships with scientific research organisations and individuals keen to replicate this public engagement model in Africa. But so far immunization levels have steadily increased globally over the last 30 years with 80 percent of the world population being vaccinated by 2006, preventing an estimated 2.5 million child deaths annually. Dr. Singer says: supply of vaccines is not enough. Success at preventing disease with vaccines in developing countries also depends on building demand. And for that we need voices from the global South to mobilize creative energies and new voices at grass-root levels. These initial SVAC projects represent an important and innovative step in that direction, filling a significant gap. Science Cafs are an excellent way to distill Scientific Research Information to the lay public. The informal relaxed setting and lively debates are quite effective in getting scientists and the lay public to talk to each other without hangs ups from either side.

And they do it in an amazingly effective way, by building the desire and demand for vaccines on the part of the people who need them most. In the Decade of Vaccines, a 10 year collaboration by the global health community to extend the full benefits of immunisation to all people, Innovative approaches to generating public awareness and demand are a critical component to realizing this vision, said Dr. Nicole Bates, Senior Program Officer, Global Policy & Advocacy at the Bill & Melinda Gates Foundation. 38 The Health Digest

I believe Science Cafes have a bright future in Kenya and Africa and that Public Engagement with Science can play a key role in accelerating the countrys and continents development, said Wanjala. Its different to speak at science cafes. Their questions are different. It is a group that is seeking knowledge, says Dr. Bukirwa as she walks home with her husband after the cafe. This is one of the weekend activities they engage in and it gives them time off their busy schedules during the week.

Cost of Treating Cancer

By Flavia Lanyero

Even with incresed access to drugs, the cost simply keeps growing higher
For some patients, when they feel better, they choose not to come back, but majority of the people who do not come back say they do not have enough money to (pay for) transportation back to the hospital or to sustain them when they come back, Dr Okuku says. Chemotherapy often requires many frequent, short reviews as often as every two weeks a requirement that is My sister has been taking care of me since I ar- difficult for the many patients who come from rived. Her husband works, and they both shoul- distant places. der the expenses here especially to buy food and other supplements like juice and fruits, says Ms Although nearly 70 percent of patients are covAneno who hails from Naguru in Kampala. A ered for chemotherapy, the remaining 30% presplate of food at the institute costs Shs 1,000 for ent with rare cancers whose drugs may not have two people, it would require at least Shs 4,000 for been ordered for at the National Medical Stores food in a day without other expenses like juice or or may be too expensive for either the patient and transportation. the government. Some drugs, especially secondline treatment, can go for up to Shs 50 million. Since I have not been working for a while, I do Very often also, patients are asked to pay laboranot know what I would have done if my sister tory tests of up to Shs 60,000; plus ultra sound was not here, she says. and x-ray for Shs 10,000 each. Those who cannot afford such costs just do not access treatment. With less than 60 beds for inpatients at the UCI, Aneno is one of the few patients whom the Insti- For now, the Cancer Institute has set up the tute can afford to hospitalise for chemotherapy, Uganda Child Care Cancer Foundation which leaving the rest to make endless trips for review. supports children diagnosed with the disease. Nearly 60% of the institutions cancer patients The foundation provides transport to and from fail to return to complete treatment, and even- Mulago Hospital whenever one has an appointtually succumb to the disease despite increased ment, feeds the children in addition to offering access to drugs, according to Dr. Fred Okuku, an palliative care. But no such service exists for oncologist at the institute. adults, even though, as Dr Okuku notes, care and support are fundamental if patients are to Things are much better now. At least over 70 recover from their cancers. percent of our patients are covered for chemotherapy. But the number of patients who com- Flavia Lanyero is a Health and Science Reporter with the plete their treatment has remained low, as few Daily Monitor. people return to the hospital for further treatment, Dr Okuku says. Alice Aneno, 35, has been hospitalised at the Uganda Cancer Institute (UCI) since February with lung cancer. Speaking with difficulty because she is in a lot of pain, Aneno narrates how she has never had to pay a penny to receive chemotherapy or for any other cost. But she has had to pay for her upkeep while at the hospital.

The Health Digest

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Moment of Truth: Cancer or HIV testing?

By Florence Naluyimbas When taking a mdedical test becomes a nightmare I nearly went for cervical cancer screening on Friday 08th June. I have two phones which I can set to the tune of 10 alarms and a third phone with one - all to guarantee that I would wake up between 5 and 6:30 am, giving me enough time to get prepared. I had made an appointment with my friend Ann to be at the cancer Institute by 7 am and chitchat while waiting for our names to be called out. All the alarms rang and I kept groggily switching them off. At 7:45 am I sent Ann a text message telling her of how I had failed to make it and that I had just completed my period. Nearing 10 am she was still in queue and from the confines of my bed, I encouraged her to be patient. It is not the first time I have wanted to do a cervical cancer test and failed. I remember when I was pursuing reproductive health stories in Masaka referral hospital in July 2011/last year, a midwife who wanted to show me that she did not only help welcome babies but multitasked, assured me that she could check me for cervical cancer. I wanted it so bad that even my colleague, Irene egged me on. But I have that ugly deterring voice which I unfortunately obey in most cases. It asked me the usual silly questions, are you shaved?, havent you just finished your monthly routine?, do u want a stranger to poke their way in your most private of parts?, are u sure u want to know the results? Endless questions with prompt answers, No, Yes, No and No. I wasnt ready! Would I ever be? I was to find 40 The Health Digest out in early 2012. An opportunity presented itself at Ugandas parliament grounds near my place of work. I was enthused - short lived it was. The same ugly voice, the same questions, the same answers. I walked away in shame. Now for breast cancer, I do get paranoid each time I think of going for a test. I start getting physical pain in my breasts, even now as I write, I reach for my left breast always a menace - indeed it is painful. It is that bad! I swear it isnt psychological. I even freak out each time that I do or rather attempt a home test of touching my breasts to feel for lumps or nodes?? I fear my body! Thats it! Sometimes I look at my teats and get convinced that they are not okay. Surely a cancer is slowly eating them away! Sometimes when I get a chance, I always check out other females breasts (I am straight) for solace - it never works. I live in worry when I allow myself to think of cancer. Guess thats why I havent done any breast or cancer stories and somehow, I always skip articles on the subject. But I know that Ill go for that test any time not soon. Surprisingly, I always go for HIV testing. Is it because I know I havent messed! In a year, I can even have three tests despite not indulging in any act that would bring me in contact with the abhorred AIDS virus. No safe or unsafe sex, no needle pricks and no blood transfusion. I havent seen anyone suffer from cancer first hand, save from movies or series like Desper-

Cancer Resources for Journalists

World Health Organisation (cancer section) http://www.who.int/cancer/en/ International Agency for Research on Cancer http://www.iarc.fr/

ate housewives. Now that I think about it, I remember my step sister having Kaposi sarcoma in 2009. I saw her once when what was left of her body could not even be fed to scavengers. A few days later after she died, I found out that for five years, she had never wanted to admit to being HIV positive. The best way for her to be in denial was not to take ARVs. She died believing she had been attacked by cancer and that the doctors wanted to put her on machines which would kill her. It is like she preferred cancer to HIV! This made me detest cancer the more. Yes, maybe I should take her example of denial as a lesson but the Musoga in me will not(there is a stereotype going on about my clan mates being level headed, Im beginning to believe it). Are there people who freak out like I do! I wonder! The unknown is always to be feared What you know not, hurts not are sayings by which I live when it comes to breast or cervical cancer (I havent given much thought to other cancer types but all cancers are to be taken as the enemy). However, I tell all my friends to go for screening. Do not practice what you preach, works well for me. BUT: I really believe I need to have those tests. Florence Naluyimba <f.mujaasi@gmail.com> A health reporter with NTV.

WHO cancer mortality and incidence statistics for all countries worldwide, http://globocan.iarc.fr/ Pan American Health Organisation (WHO) cancer http://new.paho.org/hq/index.php?option=com_content&task=vie w&id=5438&Itemid=3940 WHO Regional Office for the Eastern Mediterranean (EMRO) cancer (covers North Africa and the Middle East) http://www.emro.who.int/ncd/cancer.htm WHO Regional Office for Africa cancer http://www.who.int/topics/cancer/en/ International Union for Cancer Control (UICC) http://www.uicc.org/ UICCs members in 123 countries worldwide http://www.uicc.org/membership/list NCD Alliance (non communicable disease alliance chiefly cancer, heart disease and diabetes) http://www.ncdalliance.org/ UN NCD Summit: Draft outcome document of the High-level Meeting on the prevention and control of non-communicable diseases http://www.ncdalliance.org/sites/default/files/resource_ files/UN%20High-Level%20Summit%20Zero%20Draft.pdf International Atomic Energy Agencys Program of Action on Cancer Therapy (PACT helps equip countries with radiotherapy capacity) http://cancer.iaea.org/ Cancer Stigma and Silence Around the World: A LIVESTRONG Report http://www.livestrong.org/pdfs/3-0/LSGlobalResearchReport AfrOx Africa Oxford Cancer Foundation www.afrox.org Arab Medical Association Against Cancer http://amaac.org/01.htm International Network for Cancer Treatment and Research (builds capacity, among other things, for treating lymphoma in equatorial Africa and childhood leukaemia in India) http://www.inctr.org/ African Organisation for Research and Training on Cancer http:// www.aortic-africa.org/ Wisconsin Pain and Policy studies group (statistics and information on global and national policies on pain relief and opioids for most countries in the world). http://www.painpolicy.wisc.edu/ The World Cancer Atlas (Reliable, interactive, well-presented information on cancer from a global perspective, on geographic burden, risk factors, prevention, early detection, treatments, advocacy and more) http://apps.nccd.cdc.gov/dcpcglobalatlas/ Cancer World Magazine http://www.cancerworld.org/Home.html Euro-Arab School of Oncology http://www.easoncology.org/

The Health Digest

41

Thank You so Much

Friends,

from the Managing Editor

Welcome to this second edition of the Health Digest, a quarterly magazine, written by journalists passionate about advancing the public and media understanding of health and the role that positive policy plays in the future of a healthy nation. In this issue, we focus on cancer, which is killing more people than Malaria and HIV combined in Sub-Saharan Africa and more so in Uganda. What we have tried to do here is to add some voices for you out there hunting for Uganda cancer information on the Internet. It is not sufficient, certainly not at all. But we trust that as you read the magazine you send feedback which we shall put on our website www.hejnu. com. We have tried to track the story of cancer in Uganda right from the time the Uganda Cancer Institute (UCI) was established in the 60s and shown the strides Uganda has made with the Cancer Walk. While we still face a challenge in acquiring content and pictures, we persevere with the voluntary contributions that we have and keep our doors open to new ideas, perspectives, opinion and thought-provoking pieces. Our next issue will focus on kidney disease and the issues related to it. We are only just at the beginning of this journey through which we aim to educate and inform not only the public but also key figures and the media about early diagnosis, treatment and advocate for policy that supports positive impact when it cones to treatment and access to medication. Health Digest is currently only available online, however, should hard copies be required, orders can be placed at a cost of Ushs 5,000 per copy. We also invite advertisers who wish to be a part of this imperative initiative. We thank all members of the Health Journalists Network of Uganda (HEJNU) for their voluntary commitment through time and content but extend this invitation beyond to individuals who have a story to tell and wisdom to share. We welcome your input through mailing the editor at healthdigestUG@gmail.com or individual journalists whose emails are provided. We eagerly look forward wait for your stories in the next issue on kidney disease.

Health Digest
THE

Plot 156-158 Mutesa II Road, Ntinda P. O. Box 4883 Kampala -UGANDA Tel: 256 704 292188 healthdigestUG@gmail.com Website: www.hejnu.com