I immediately recognized the simple blue-green door marked with the words “RADIATION AREA” in bold, red letters. Recognize is perhaps too strong a word: I had seen it in a New York Times photograph. It was shut, as it had been in the photo, meaning that the machine was working, as it nearly always was.
“That door was shown in a very famous paper in the United States,” I said to Dr. Daniel Kanyike, one of the clinical oncologists who delivers both radiation therapy and chemotherapy to patients at Mulago Hospital in Kampala, Uganda and our tour guide for the day. “They did a story on breast cancer in Uganda, and talked a great deal about Mulago. Were you here when they visited?”
Dr. Kanyike let out an exclamation of polite surprise mixed with disinterest. Throughout the short time we’d spent getting to know him, he was always more interested in talking about patient care, particularly radiotherapy, than anything else. So, it seemed quite in character that he wouldn’t care to have a lengthy discussion on what a paper in New York had said about Uganda, even if his work was the subject. After a quick silence, he let out a burst of his infectious, unique laughter. “I had heard about that,” he said with bemusement. “But I was not here that day.” We discussed the article no further, moving on to the particularities of the brachytherapy treatment room, which was right next door to “RADIATION AREA.”
I had come to Mulago’s radiotherapy department along with Roshan Sethi, a fellow medical student who would be matching into radiation oncology in mere days, as part of a series of unofficial site visits to radiation facilities in Uganda and Kenya to get a better sense of how radiation therapy is provided for cancer care in the region. While I had visited and worked in a number of hospitals in Eastern and Southern Africa, I had never been in a radiation center in the region. In fact, I’d only visited two in the United States, and rather recently as I shadowed radiation oncologists to see if I would eventually join their field. Because of the high prevalence of cancer, medical students often gain a good deal of general oncology exposure, whether it’s clinical or basic science. However, very little exposure to radiation oncology is offered to those who aren’t looking for it. Radiation is considered so technical, so specialized, so rarified that it barely merits mentioning.
And yet, more than 50% of all patients with cancer will require radiotherapy as a core part of their treatment. That is surely something worth mentioning, if even in one or two lectures. Further, in the fight for global access to comprehensive cancer care, which has been gaining steam year by year, radiotherapy has also been marginal. Even though radiation therapy is an essential part of both palliative and curative treatments for cancer, arguments against its wider implementation have mirrored those that were initially made against access to other life and quality-of-life saving interventions like antiretroviral therapy and surgical care. In short, critics argue that radiation is too expensive, too difficult to implement, and that more “cost-effective” (read: lower cost) strategies, like cancer prevention, should be implemented in its place. While prevention is essential, it can never be held up as a substitute for treatment. Radiation therapy, like surgery, chemotherapy, and social and economic support, are all essential aspects of cancer care the world over.
While I still cannot tell whether Dr. Kanyike had read the article on Mulago, I know that I found things to be quite different than the New York Times’ report. Certainly, many of the facts matched up: a door to a radiation machine, patients, mostly women, waiting along its side for their treatments to begin. However, the feeling transmitted by the photograph and the article was spare, dire, catastrophic. While cancer itself is all of these things, Mulago’s radiotherapy unit struck me as no more and no less individually existentially challenging than the Dana-Farber in Boston. The resources, of course, were orders of magnitude less. That in and of itself is unsettling if not surprising, and calls us with clarity to a moral duty to do more, collectively.
But the radiotherapy care delivered at Mulago, by Dr. Kanyike and the other clinical oncologists, by the medical physicists, dosimetrists, and radiation therapists that work as a team, was impressive. Yes, the machine runs most of the day and most of the night, because it is the best way to treat the most patients. Certainly, the machine’s source, a piece of radioactive cobalt that emits the radiation that treats patients’ tumors, is older than would be optimal, but all of the staff and leadership are quite aware of this and are fighting through the complex series of steps to get a new source. To get a new machine, even, in good time, one that delivers a more modern type of radiation therapy. The entire treatment team here is working to provide radiation therapy to more than one hundred patients each day, care the currently can’t be acquired anywhere else in Uganda. Further, Dr. Kanyike and the other clinical oncologists at Mulago provide radiation therapy for patients with virtually every type of tumor possible, from women with breast cancer to children with brain tumors to patients with rarer malignancies still. This is something that most, if not all, American-trained radiation oncologists would be unable to do, simply because most eventually sub-specialize to treat only certain types of cancer.
As Julie Livingston describes in her book Improvising Medicine, which details the workings of Botswana’s first official cancer hospital, there are real resource constraints at play when considering oncology care in low and middle income countries, but there is also a tireless, caring, innovative and successful struggle against these constraints. Success amidst challenge was the main thing that I took away from my visit to Mulago’s radiotherapy center.
Visiting Mulago Hospital inspired me with a glimpse of what is possible for radiotherapy as a part of cancer care in Uganda, East Africa, and across the globe. Our charge is to leverage resources and build movements of global health solidarity that support the amazing efforts that already exist. We are lucky as students to have such wonderful models for the delivery of equitable cancer care that include equitable access to radiotherapy.
Acknowledgements: Many thanks to Dr. Daniel Kanyike for his time, and, moreover for his tireless dedication to patient care and to radiotherapy.