AORTIC: Global surgery

AORTIC: Global surgery

The use of technology has been discussed in many sessions in AORTIC.  Internet access is not comprehensive but the majority of people in Africa have a cell phone.  The problem with cell phone communication is that it is expensive.

How can cell phones (smart or otherwise) be used to improve patient care in a low income setting?

1.     Many patients get lost to follow up.  The reasons are multifactorial.  If a clinic has a contact number for a patient, they can be kept in the system.  There are several projects that have shown the successful use of cell phone communication with patients.
2.     Health information can be disseminated via phone.  In Zambia, in a project run by pinkribbon:redribbon,, they have partnered with Vodacom and have sponsored SMSes sending out health advice
In Tanzania, mobile technology has been used to tell women where to go to get health care.  (Vodacom also sponsored the transport for women to get to the appropriate clinic).
3.     In the radiotherapy session, a whole presentation was devoted to the use of smart phones in radiotherapy. 

The most interesting session I attended was called “An African Surgical Network”.  The speakers were all excellent: Dr Anderson , Dr Ousadden, Prof Gueye and Prof Smith.  The concept of global surgery was discussed.  Somehow, surgery has fallen down the list of global health priorities and as a result;
5 billion people do not have access to safe surgery.  
143m more surgical procedures need to be performed in LMIC annually if health standards are to be optimized.    
Less 5% of all cancer research is about surgical management.  
There is a paucity of specialists in Africa for example, there is 1 urologist in Nigeria per 3 m people.

What can be done?  What is being done?

There was a general consensus that there is a need for appropriate training to be done in centres of excellence in Africa.  It is not ideal for surgeon to have to go out of the continent for training.  Prof Gueye from Senegal discussed the plan for training centres in West Africa and gave examples of what has been achieved.  Technology can be integrated into the process of training.  He lamented the brain flight from Africa and said that Senegalese doctors end up working as nurses in Europe.

Research from LMIC must be published.  There was a general plea for international journals to accept studies from low income countries. (As an aside, even at AORTIC, which is an African cancer organization, only 36% of the keynote speakers of those in the plenary session were from Africa).

The relevant government departments must be lobbied. They must ensure visa requirements are appropriate for trainees. (Travelling with an African passport can be problematic even to neighboring countries.)  The DoH has a responsibility to provide the necessary environment for a specialist to be able to practice the skills that have been learnt.  A trained surgeon will leave for greener pastures if they have to constantly contend with shortages, poor administration and inadequate basic facilities. (We heard many stories of no electricity, toilets that don’t work, no paper to write notes).

Training programmes should be combined with service delivery projects.  For example, if a surgeon goes for an out reach programme, the opportunity to train local medical personal must not be missed.  Conversely, a training programme should be used to provide a service to the local community.

It was a refreshing and important session.   Many thanks to the organisers for including it in the programme.   

Lastly, the Breast Course for Nurses would like to thank Well Woman Diagnostics for sponsoring my travel.




AORTIC is not only an academic meeting but is also a chance to network.  One of the new networking groups that has been launched at AORTIC is PAWAS: Pan African Women’s Surgeons group.  The project has been spearheaded by Dr Miriam Mutebi(Kenya) and Dr Liz Travis (USA).

The aim of PAWAS is mentor women surgeons, to provide a collaborative framework for research and to promote women’s health in Africa.  The inaugural meeting was held at the Association Amal in Marrakech.  The association Amal is a women’s centre who empower vulnerable women and give them training in the hospitality industry.  We had a delicious 3 course meal and between courses were given topics to discuss: how to be a mentee and how to promote scientific research. 

The evening event was followed by a round table discussion attended by representatives of many American and European organizations as well as medical personnel from Africa. Dr Rayne started the discussion.  She was asked to prioritize the needs for promotion of health care amongst African women:
            Ensure appropriate resources
            Ensure electricity in health care centres
            Set pathological guidelines and standardize reporting
            Utilise Redcap system for collaborative research
She urged PAWAS not to concentrate exclusively on women’s health issues.

The rest of the meeting was spent discussing why women with breast cancer in Africa are diagnosed so late and what can be done about it.  The following points were made:

            The need to understand cultural issues:
Many women are fatalistic.  By addressing the lump in the breast, their natural fate may be changed so they may be reluctant to undergo invasive treatment while they feel well.  (The counter argument is that HIV patients agree to treatment before they are symptomatic)
The belief that breast disease is caused by social factors resulting in consultations with traditional healers.
Women should be asked why they have presented late so issues may be identified.

However, Africa is a huge continent made up of many cultural groups.  We should not assume that what is true in one area is true in another.

Integration of health services
Combine breast and cervical screening with HIV testing.  Models that have been shown to work elsewhere should be employed initially.  Any interventions should be assessed.

Important to combine PAWAS projects with advocacy groups.
Should educate scholars: teenagers could become cancer ambassadors

Health Personnel
Doctors and nurses need to be educated.
There need to have access to journals
Doctors need help with writing manuscripts and doing research

Thank you to Dr Mutebi and her team for setting up this initiative.

AORTIC 15 Friday 20/11/15


The introductory keynote speaker for the morning on Friday 20/11/15 was Dr Wild from IARC.  He presented an overview of cancer in Africa.  Although his presentation contained many maps of incidence and mortality of breast cancer in the world, he reminded us that the situation is dynamic.  We need to look at the changing pattern of cancer in developing countries.  He said that 30% of cancers in Africa caused by infectious diseases. (My understanding is that in Southern Africa it is nearer 60%)  That contrasts with an incidence of 1:25 in the USA. 

His summary statement was that we have a duty of care to the patients of today and the populations of tomorrow.

The breast plenary session started with Dr Anderson from Breast Health International.  He advocated for resource stratification when planning a cancer control strategy. 
What therapies are essential for cancer treatment?  Surgery + Basic drugs
Other  drug therapies should be considered as 2nd tier resources. 
As a third tier, some resources are desirable and may make cancer treatment more acceptable eg, facilities to carry out breast conservation therapy. 
The finale tier of resources do not make any difference to out come and should not be lobbied for in LMIC eg MRI/PETscans.

KNOWING WHAT NOT TO DO IS IMPORTANT when planning cancer care policy.

In the breast cancer workshop session, I discussed the challenges faced by the breast course for nurses.  The following speaker was Dr Ophira Goldburg from WHO.  She spoke about WHO initiatives and started by challenging some commonly held perceptions.  Breast screening is not easy.  Clinical breast examination is difficult and screening is more than buying a machine.

Dr Brinton presented a very interesting epidemiological study from Ghana. Women with breast cancer were asked to fill in questionnaire about lifestyle and asked to give saliva and blood samples.  The preliminary results suggest that prolonged breast-feeding has an important protective effect in Ghanaian women.  It may be more important than in Caucasian women.  Much more data will come out of the study.

In the afternoon, I attended the session on cancer control policy.  The first presentation outlined the NCI guidelines.  They have set up a portal, which aids any country planning to set up a cancer control policy document.

RSA has spent a lot of time discussing a breast cancer policy.  At present, there is no comprehensive plan.  Salome Meyer has been at the forefront of the discussion.  She is advocating for a 4P approach: patient, public, private partnership.  She lamented the lack of a coordinated approach to breast health policy and research in RSA.  In summing up, Prof Stefan said she felt that RSA had tried to get a perfect policy and in the attempt at perfection, had failed.

On the positive side, having heard that Nigeria (population 200 m) has one working radiotherapy machine at present, Cape Town, with 6 working radiotherapy machines available to state patients seems to be in a fortunate position.



AORTIC: the impact of inequity on cancer care

AORTIC: the impact of inequity on cancer care
The 10th   AORTIC Conference is being held in Marrakech, Morocco.  This morning started with round the table discussions: meet the expert.  I attended the session on the impact of inequity on cancer care.  It was chaired by Lyn Denny, Ophira Ginsburg and Renga Sankar.

Prof Lyn Denny opened the discussion and suggested we should concentrate identifying “outrage points”.  She asked us to consider the downstream effects of premature deaths from cancer.   What is the impact of diagnosis of breast cancer on children?  (In Bangladesh: children have a 25% chance of living to age of 10 if the mother dies before the child is 10 years old.)  Prof Stefan, a paediatric oncologist, said that history would judge us by how we look after our children.  Childhood cancers are thought of as being very rare but they can often be successfully treated and as about half of Africa’s population are children, there are about 50 000 new cases per annum.

As the discussion opened up, many contributors stressed the importance of integration of quality resources. It starts at the primary level: the clinic should be clean.   Health care workers must be well trained.   Centres of excellence have been shown to be essential for improved outcome from cancer.  There is a need to discuss resource utilization: there was some debate as to whether we need further specialists or whether competency should be accepted. 

There is a need for clear appropiate guidelines for the management of breast cancer.

Dr Smith reminded us that alleviation of poverty must be addressed.  There is no point in having good health care services if patients cannot afford to access them.  Even in countries such as Tanzania where most of the health care is free, 60 % of women do not get the chemotherapy they should.  Why not?  The physical, financial and social toxicity of the treatment means that the majority of people will not complete their treatment.  On average, one course of chemotherapy costs 70% of annual income in Tanzania.  More discussion has to be had with Pharma about pricing policies.

Advocacy groups are vital in getting change.  To talk about awareness is not enough.  (How do we measure awareness?)   Policy makers have to be committed to change.  In Tanzania, the government workers are not allowed to leave the country to get medical treatment.  This is bound to result in an improvement of care. 

In conclusion, we should not have 3rd rate care for 3rd world countries.


Breast Course for Nurses: Johannesburg Day 1

The first Breast Course for Nurses has been run without me (Jenny Edge) being there!  The following is an account of the day from Sr Lieske:

Last Thursday, I spent the day in Johannesburg as part of  the Breast Course for Nurses. This course is being run by Dr Sarah Nietz (a breast surgeon at Charlotte Maxeke Hospital) and Sr Sheila Correia (a private Registered Nurse from Cape Town). Sr Colleen Davis of Medi-Clinic will be assisting with the course admin. I spent the day there to assist where needed. We had over 70 health care workers attending! This is one of the biggest groups we have ever had! There were health care workers from Charlotte Maxeke, Helen Joseph, Pholosong, Edenvale, Baragwanath and many more.

The day started with registration followed by sponsored tea and snacks. We then got going with the day by allowing each nurse to introduce themselves. It is always very exciting to have men in the group and we had 3! Sr Portia introduced herself and explained how spreading knowledge is the key to saving lives.
Joanne Robinson and Michelle Bibby of Novartis

Dr Sarah Nietz presented the challenges of managing breast cancer in Southern Africa. She mentioned that currently, Johannesburg has 3 specialist breast units but if you went according to the population of Johannesburg, you would need over 25 of them to actually cope with the breast cancer burden. Sr Sheila followed with introducing and giving an outline of the Breast Course for Nurses and the PEP series.
Sr Colleen Davis of Medi-Clinic

After lunch, we went through the clinical examination of the breast followed by a practical session. Dr Nietz had very kindly arranged a few patients to be “models” for the nurses to examine. A brief overview of the patient was provided and then the nurses had the opportunity to examine the various patients. This was an excellent session and the nurses commented on how much they learnt. Thank you to the patients that volunteered for this.
Dr Thandu Tshume, Dr Sarah Nietz and Sr Sheila Correia

As always, a lot of hard work goes into a course like this. Thank you to Sr Sheila Correia and Sr Tumeka Nojoko for arranging the logistics before the course. Thank you to our sponsors: Medi-Clinic and Novartis. A very big thank you to Dr Nietz for organising the course in Johannesburg. We are very excited to see how the nurses use the information that they have learnt. We will return next year for the 2 day course.

Sr Lieske


Breast course for nurses: Oshakati Day 2

Another hot day in Oshakati!  We began with 2 lectures given by Dr Brown and Prof Mbangtang.  I asked Penda to give the vote of thanks for Dr Brown.   Instead of traditional applause, she asked us all the make clouds with our hands, simulate the rain and then clap as a clap of thunder!  It seemed totally appropriate applause in a country that hasn't seen any rain for many months.

The class doing lymphoedema exercises
We were joined for the day by Prof Peter Nyarango, the dean of the University Namibia School of Medicine  He reminded us about
the importance of the community.  He said that in Namibia, when you admit an individual, you admit the whole family.

Later in the day, we were honored to have a visit from Dr Haufiku, the Minister of Health.  He spoke about the governments's commitment to primary health care.

As in many parts of Southern Africa, there are no lymphoedema therapists available to state patients. Sr Lieske discussed the aetiology of lymphoedema and the importance of early management.

Prof Celestine Mbangtang ran the palliative care session: there was a lively debate about the role of the pastor in the management of terminally ill patients.   There were several points that came out in the discussion.
1. Palliative care starts with listening.  It is imperative to identify the needs of the patient before you can start managing them.
2. Communication may be done through the people used to communicating with the patient.
3. Ask the patient about her dreams: they may lead you to identify her fears.

Prof Celestine Mbangtang, Dr Haufiku, Prof Nyarango, Dr Benyera, Joshua

In the last session of the day, we had a group of nurses who have committed themselves to running a campaign.  We have asked them to tell us all about what they do.  They have promised to tell us by March 2016.  Thank you to Destiny Hotel, UN medical school, the Dept of Health, Novartis, Pathcare and all the students who attended both in Windhoek and Oshakati.  Lastly, thank you to Prof Celestine Mbangtang and Sr Lieske for their input.