Published September 20, 2020
By Paula Derrow
A Rutgers Global Health Institute initiative combines advancements in telemedicine with lessons learned from earlier battles against HIV to increase cancer survival rates in an area that needs it the most.
Getting a cancer diagnosis is shattering, but in the United States, there is reason for hope when patients hear the dreaded words. In the past 25 years, cancer deaths here have declined 27 percent, primarily due to early detection, a drop-off in tobacco use, and improved treatments.
Not so in Botswana, which only recently managed to get on top of an HIV/AIDS epidemic that ravaged the country in the late 1990s. Now this African nation of just over 2 million people faces a second epidemic—cancer—and the potential loss of life is staggering. Worldwide, 70 percent of all cancer deaths occur in low- and middle-income countries like Botswana, where even potentially curable cancers such as cervical and breast are essentially a death sentence. “With cancer, we are where we were with HIV in the 1990s, when a diagnosis of HIV meant the end of life,” says Refeletswe Lebelonyane, M.D., senior education and research fellow at Rutgers Global Health Institute and adjunct lecturer at the University of Botswana School of Medicine.
Every day in Botswana and other African nations, patients die unnecessarily, many of them enduring a year or more of delays between the time they first see a health care provider at a local clinic and when they finally get diagnosed and treated. During that time, they wait—for an appointment with a specialist (there’s only one public-sector oncologist in Botswana), a pathology report (there are just 11 pathologists), a scan, surgery, an out-of-stock chemotherapy drug, or a broken infusion machine to be fixed.
Other barriers to treatment include fear on the part of patients and a host of practical challenges that prevent those in rural areas, in particular, from getting the help they need. “There are several reasons patients may not want to get treatment,” says Tlotlo Ralefala, M.D., head of the department of oncology at Princess Marina Hospital in Gaborone and the only public sector oncologist in the entire country. “Sometimes they don’t have the money for transport, or they can’t get someone to care for their children or grandchildren. Or they decide to see a local healer first because of religious reasons. Or they may simply believe that a diagnosis of cancer means months of painful treatment or certain death, so they go away and don’t return.”
It doesn’t have to be this way, especially with so many knowledgeable people within Botswana’s health care profession capable of improving cancer detection and treatment. Rutgers Global Health Institute, in partnership with the Botswana Ministry of Health and Wellness, is helping the country build sub-Saharan Africa’s first comprehensive cancer care and prevention program. The institute is working to identify the gaps in the country’s health care delivery system, which have been exposed by the COVID-19 pandemic even though Botswana is one of the few countries in Africa’s southern region that have experienced low community spread. While the cancer detection and treatment program still has a long way to go, it will eventually save countless lives and create a new model for nationwide cancer care in other developing countries.
Roadblocks every step of the way
Ashwin Chandar, M.D., now assistant professor of medicine at the Lewis Katz School of Medicine at Temple University, saw the gaps in Botswana’s health care delivery system firsthand during the fall of 2018, when he went there as a third-year hematology fellow at Rutgers Robert Wood Johnson Medical School. Chandar vividly remembers a patient with a very treatable form of head and neck cancer. “When she first got her imaging, the tumor was still at an early stage; you could say that it was curable. It could have been taken out with simple surgery.” Except nothing is simple when it comes to cancer treatment in Botswana. “Often, the person running a local clinic in a rural area—typically a nurse—sees 50 patients a day, and they may not be able to do everything that is necessary,” says Ralefala. “So they end up putting a bandage on the problem without getting to the root cause, because no one has the time to really look.”
That’s why it might take several visits to a clinic to finally get a referral to a regional hospital for a lab test—a visit that inevitably necessitates another lengthy wait. “The next question is when the pathology report will come in,” says Ralefala. “If a patient happens to live in one of the rural areas, the specimen needs to be sent to Gaborone, the capital, or to Francistown, and there is inevitably a backlog.”
By the time Chandar saw the patient with head and neck cancer, instead of simple surgery, “The tumor had grown to the point where she needed a tracheostomy so her airway wasn’t compromised,” he says. “By the time you get the imaging, by the time the scan is read, by the time the appointments are set up, it’s too late.”
And that patient was one of the lucky ones, simply because she survived. Anyone diagnosed with cancer in Botswana—no matter the stage or the type—has a 75 percent chance of dying from it. Ralefala recalls one elderly man who had seen a number of doctors at local clinics and hospitals for an ulcer on his tongue before finally getting it biopsied. The ulcer turned out to be cancer. “By the time I saw the man, nothing could be done to save him,” she says. “Yet he thanked me for allowing him to go home to die. I thought, ‘How can he be thanking me?! I’m part of the system that has failed him!’”
“In Botswana, the problem starts with detection,” says Lebelonyane, and it continues from there. One reason oncologists are in short supply, for instance, is that there is no oncology fellowship offered at the University of Botswana School of Medicine. Cancer patients who can’t afford one of the three private oncologists in the country or who don’t have the money to travel to South Africa for treatment must rely solely on Ralefala (as well as a few oncologists who occasionally rotate in from China, Cuba, and India).
An example of what is possible
Just as Botswana successfully marshaled its forces to address the AIDS epidemic with a coordinated government effort and international partnerships, Richard Marlink, M.D., the Henry Rutgers Professor of Global Health and director of Rutgers Global Health Institute, believes that the country, with Rutgers’ help, can develop a comprehensive national cancer program that will enable patients even in remote rural areas to get the care they need at the earliest possible stages.
Marlink is intimately acquainted with the global health challenges Botswana faces. He helped create the partnerships that enabled Botswana’s remarkable response to HIV/AIDS nearly three decades ago. Now, Botswana’s current president, Mokgweetsi Masisi, is similarly on board in terms of changing cancer outcomes. “Their Ministry of Health and Wellness and the head of the University of Botswana and the medical school are all partnered with Rutgers on this effort,” says Marlink.
The plan, facilitated by Rutgers Global Health Institute and various collaborators across the university and elsewhere, is to launch a four-pronged approach designed to 1) strengthen Botswana’s health system, 2) increase the number of health care providers, 3) use cutting-edge data and telemedicine to bring health expertise to every corner of the country, and 4) monitor the success of these efforts to produce a model that can be reproduced across sub-Saharan Africa.
Telemedicine, which has been ramped up in the United States during the COVID-19 pandemic, may be especially crucial in Africa, both for cancer care and the treatment of highly infectious diseases like COVID-19. “We cannot have doctors everywhere, so we need to deal with what we have on the ground,” says Lebelonyane. With cancer treatment, that means “oncologists can do telementoring from wherever they are,” she says.
The hope is that this program will become a model for every nation in the developing world, potentially saving millions of lives. Indeed, with COVID-19 now threatening the global population, it is perhaps more crucial than ever to solve some of the basic problems that are preventing people from getting the care they need, including inadequate supply chains and a lack of trained medical personnel.
“I’m optimistic,” says Lebelonyane. “I’ve seen when there was no hope with HIV and look where we are now.” Marlink shares that sense of optimism. “The stars are aligned,” he says. “Together, all of us can once again make Botswana the example of what is possible.”