RCP associate international director for Sub-Saharan Africa Professor Richard Walker discusses major challenges in the fight against cancer in East Africa and the impact of the RCP’s METAF programme with Dr Sadiq Siu, clinical oncologist at Tanzania’s Ocean Road Cancer Institute and Dr Georgina Wood, medical oncology registrar and METAF volunteer.
In 2015, the RCP was invited to act as technical partner on an East African Development Bank-funded programme designed to increase early detection and treatment of cancer and neurological disorders across East Africa. Our role was to work alongside local experts and the British Council to design and deliver a clinical skills training programme reaching 600 East African physicians working in Kenya, Uganda, Tanzania and Rwanda.
We’ve come a long way since then. Following a feasibility study to find out more about the national priorities of each of the participating countries, we designed a 4-year programme consisting of week-long clinical skills courses for junior doctors to strengthen capacity in both specialities, as well as ‘train the trainer’ workshops for more senior clinicians (oncology only) to reinforce teaching capacity and ensure sustainability. Now more than 2 years in, nearly 350 East African physicians have received training.
Below, Dr Sadiq Siu, METAF oncology faculty member, describes the major challenges in the fight against cancer in East Africa, while RCP volunteer Dr Georgina Wood shares what she found to be the most challenging and rewarding elements of teaching overseas.
Professor Richard Walker: Dr Siu, can you tell us a bit about your role and the hospital in which you work?
Dr Sadiq Siu: I am a clinical oncologist at the Ocean Road Cancer Institute which is the tertiary level hospital for cancer management in Tanzania. Among other duties, I manage patients with adult malignancies including prescribing cytotoxic therapy like radiotherapy and/or chemotherapy for curative as well as palliative purposes. We do not offer any surgical treatments at the Institute.
The hospital is a teaching institute so I also provide bedside teaching and coaching to medical students at different levels during their clinical rotations.
RW: What are the major challenges involved in fighting cancer in Tanzania?
SS: In my opinion, besides the obvious lack of financial resources, I think the lack of awareness among the general population and some medical professionals regarding the causes, risk factors and behaviour of malignant diseases poses a big challenge.
This is where METAF comes in. The programme is basically aimed at improving and raising the index of suspicion for cancer among junior doctors, especially those working at primary health care facilities. The emphasis is now more on improving awareness which in turn will enable us to capture cancer in the early stages and so improve our chances of providing curative treatment.
Currently, about 85% of the patients that we receive at the tertiary level hospital present with advanced stage disease (stage III and stage IV). The saddest news is that some of these malignancies can actually be cured if diagnosed at their early stages.
Earlier this year the government of Tanzania initiated a free mandatory HPV vaccination program to 13-year old school girls as a measure to control the number one malignancy in women in Tanzania; cancer of the cervix. But we’re still seeing patients with advanced-stage cancer of the cervix coming to us with vesicovaginal fistula (VVF) and rectovaginal fistula (RVF) as a complication of their metastatic disease. These patients have already had several visits to primary care facilities where they were repeatedly given antibiotics for ‘non-responding pelvic inflammatory disease’. We need more doctors to be thinking ‘it really could be cancer’ and not a bacterial infection!
RW: What sort of impact do you think the METAF programme will have?
SS: We have been providing these trainings to junior doctors working in the periphery. I taught on last September’s course in Bagamoyo where we trained junior doctors from the east and northern parts of the country. Recently in Mbeya, southwest Tanzania with Dr Wood, we had trainees from the Southern Highlands.
All the trainees were highly engaged during the training. There was a pre-training test at the very beginning of each course and a post-training test where the trainees had to answer a set of questions concerning various cases of cancer. There was a significant improvement in all trainees’ scores, indicating that the material enabled them to think more on the possibility and likelihood of cancer than they previously did.
I am confident that we will reach even more junior doctors in these primary health care facilities from all over the country and surely that will have a significant change on lowering the stage at which most patients present for treatment.
Professor Richard Walker: Now, Dr Wood, how did your experience teaching in Mbeya compare to your expectations?
Dr Georgina Wood: It surpassed my expectations! Tanzania is vast and absolutely beautiful. I was made to feel so welcome and during the course enjoyed great medical discussions, continual learning and fantastic food, not to mention lovely weather!
The course material was of a very high standard and the breadth of topics appropriate and tailored to cancer care in Tanzania. The participants seemed to especially enjoy the communication skills and ‘breaking bad news’ sessions that I taught – these were areas that they had not previously had training in. Pre-course and post-course test scores were a very helpful assessment of the knowledge that the participants gained during the course. Participants enjoyed the tests and were driven to improve their scores.
RW: What did you find to be the most challenging and rewarding elements of teaching overseas?
GW: I was a little apprehensive about travelling to a remote part of East Africa alone, however the amazing organisation by the RCP and the British Council made the process seamless.
There was an incredible buzz and enthusiasm from participants in the seminars which fuelled exciting and provocative discussion. The clinical day at the Mbeya Zonal Referral Hospital was a highlight – I felt very grateful to be able to go into the working environment of some of the faculty based in Mbeya. We saw a selection of cases that perfectly reflected the theoretical teaching sessions and therefore consolidated the important learning points. This experience was valuable for the participants and very informative for me.
It was an absolute delight to be able to contribute to these junior doctors’ knowledge of cancer and caring for oncology patients. The whole group bonded very well and I felt part of something special. It was extremely rewarding to receive some personal feedback from participants at the end of the course and I hope to have encouraged some potential future oncologists.
RW: Has the experience influenced the way you practice and teach in the UK?
GW: The expert teaching faculty from Tanzania were an absolute joy to work alongside. We carefully planned the programme together and worked well as a team. Their zest for improving cancer care was infectious and shone through in every teaching session.
An important aspect for all of the trainers was to ensure that the sessions were interactive and the vibrant seminar style encouraged this enormously. We used a very effective method of recapping learning points from the previous day, led by the participants. These are techniques that I have previously used when teaching but my experience in Tanzania has re-confirmed their utmost importance.
Observing healthcare in a resource-poor environment was hugely influential to me and made me realise how much UK and Tanzanian doctors can learn from each other. In the district hospitals of Tanzania, clinical acumen is often the only tool for diagnosis. While we are lucky in the UK to have access to state of the art facilities, it is essential to retain fundamental medical skills and the art of complex decision making in the absence of diagnostic tests.
Professor Richard Walker is the RCP’s associate international director for Sub-Saharan Africa. He has a long standing research interest in non-communicable diseases (NCDs) in sub-Saharan Africa and is a member of the Movement Disorders Society’s Task Force on Africa.