Success Amidst Challenge: A View of Radiotherapy in Kampala, Uganda

Shekinah Elmore Fulbright in Rwanda, Harvard Medical School

Shekinah Elmore
Fulbright in Rwanda, Harvard Medical School

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.

Matching Interest with Action: Developing Capacity to Support Canadian Radiation Oncology Electives in Global Health

Dr. Horia Vulpe, MD, CM

Dr. Horia Vulpe, MD, CM

In the last few decades, there has been a growing interest in global health electives – clinical or research experiences that are usually performed abroad –by medical students and residents. In 1978 only 6% of American medical students experienced a global health elective. Last year, this number was 30%. This trend has been similar in Canada, where a 2012 survey revealed that more than 20% of all residents planned to complete an international elective in global health. Historically international and global health projects have focused heavily on infectious and acute diseases and less on non-communicable and chronic diseases. Cancer, which spans both realms but is generally thought of as a non-communicable disease, has received little focus in global health. Further, as many low- and middle-income countries have no or limited radiotherapy services, radiation oncology has received even less attention. This begs the question: is there a role for global health electives in radiation oncology?

First, it is notable that more and more attention in the field of global health is being paid to the significant burden of non-communicable and chronic diseases, including cancer, diabetes, and cardiovascular disease. Cancer mortality is highest in low-income nations, where cancers are often diagnosed late and treatment infrastructure remains limited. Radiotherapy is required in about 50% of all cancer treatments. And, for large tumors where surgery or chemotherapy would be ineffective or impractical, radiotherapy often remains an option. Thus, sustained partnership between established radiotherapy centers and new or under-resourced radiotherapy efforts to build existing capacity is an essential component of global health efforts focusing on cancer care. The International Atomic Energy Agency and other academic and NGO partners are working to develop and strengthen such collaborations.

It is no surprise, then, that radiation oncology residents want to participate in this exchange of knowledge and skills. In a survey of Canadian radiation oncology training programs conducted in 2012, half of residents said there was interest in global health electives at their center. Surprisingly, only one Canadian resident in the last five years actually went on such an exchange.

Studies on barriers to global health electives tend to put finances at the top of the list. The ASTRO-AARO Global Health Scholars program has been financially supporting radiation oncology residents in pursuit of global health electives since 2011. In Canada, a workgroup of the Canadian Association of Radiation Oncology (CARO) has recently created a scholarship for the same purpose. The CARO International Communications (CIC) Global Health Scholarship will be rolled out later this year as a pilot program for one Canadian resident or fellow. As this program grows more trainees will be able to benefit from financial support from the CIC.

In radiation oncology, the complexity of the treatment makes partnerships and collaborations essential to achieve excellent care. As residents, we have the opportunity to build lasting relationships with the physicians, residents, physicists, therapists and other radiotherapy workers in countries we travel to. Our experiences will allow us broader perspective on barriers to health and healthcare. As the attending physicians of tomorrow, residents with global health experience will be better prepared to advocate for equitable access to radiotherapy for all.

Dr. Horia Vulpe is a resident in the department of Radiation Oncology at the University of Toronto.

GlobalRT has released it’s latest short film!

In less than 2 minutes, we highlight a few of the social consequences of untreated cancer. We hope that after watching the clip, you’ll be able to share it among your friends, family and colleagues in order to raise awareness of this important cause.


Kevin Tan

Kevin Tan, a radiation oncology registrar working in Gippsland, Australia and creator of this short film, had this to say about the film:

“I’ve found that some some of the most meaningful work we can do is often also the most humble. Combating cancer on a global scale needn’t be pioneering stuff, nor is it particularly sexy. It begins simply by counting, by framing the challenge, and advocating for interdisciplinary solutions. I am optimistic that the global community will rise to this challenge. But first, let’s get the agenda on the table! Help us spread the word!


A new perspective: Reflections from Mulago Hospital, Uganda

John Mac Longo

John Mac Longo

I spent the month of July working at the Radiotherapy Department at Mulago Hospital, Uganda’s flagship public hospital located in the teeming, rambunctious capital city of Kampala.  This is the only radiation oncology center in Uganda, a country of 36 million people.  The clinic also draws patients from South Sudan, Eastern Congo, and parts of Kenya. The workhorse of the clinic is a singular Cobalt-60 machine, originally installed in 1994. The cobalt source has not been changed in 12 years. In order to accommodate the patient load, the machine treats patients 24 hours a day, Monday through Friday, reserving most Saturdays for larger palliative fractions.

The physicians, house officers, nurses, therapists, and staff embraced me from the moment I crossed the clinic threshold and quickly incorporated me into their busy practice.  As I arrived early each morning for LDR brachytherapy insertions, dozens of patients would be lined up.  Many of them had spent the previous night camped out on the hospital grounds. By the time the morning chart rounds and tumor boards were over and we were ready to start, new consultations, patients under treatment, and follow-ups filled every inch of the waiting area.

Clinic was ripe with both learning opportunities and challenges. I developed a level of comfort managing cervix, nasopharynx, and other cancers common in Uganda but less prevalent in the US. Seeing the radiation oncology zebras like endemic Kaposi’s sarcoma and penile cancer seared these sites in my mind. The neglected breast, rectal, or vulvar cancers called attention to the lack of screening and general cancer awareness in the country.


Soon after settling in, I was given my own cramped office and a stack of patient files to see each day. Although the physicians were available for help, they encouraged autonomy.  I was forced to overcome language barriers (60 tribes in Uganda, each speaking their own language), work around limited medical records, and navigate a foreign healthcare system. There were frustrating and stressful moments. But there were many more moments of the privileged patient provider connection that drove me to pursue medicine in the first place.


Exposure to 2D planning was a highlight. The clinic lacks a CT sim, so the majority of cases were planned using fluoroscopy.  Others were planned using tumor and bony anatomy alone. Field dimensions and separation were measured, recorded, and outlined with marker and torn pieces of plaster.  There were many times I missed the seemingly limitless planning tools and image guidance available at home but I also came to appreciate the simplicity, efficiency, and efficacy of 2D planning.  In between procedures, meetings, and clinics, I managed to deliver twelve radiation oncology -focused lectures. This teaching component enabled me to share educational resources and insights from the West. This peaked the curiosity of my Ugandan colleagues and generated robust discussions.

My experience in the Radiotherapy Department at Mulago Hospital was transforming professionally and personally. My commitment to working in resource-limited settings domestically and internationally has been solidified. I look forward to building upon the relationships I have made in Kampala and helping others in our field connect with cancer care providers around the world.

John Mac Longo is a fourth year resident in radiation Oncology at the Medical College of Wisconsin in Milwaukee, Wisconsin (USA).

Fighting Cancer with Numbers

What do you mean by that?

Margaret Chan, Director-General of the World Health Organization has said ‘What gets measured gets done’. One major challenge to cancer control is to understand what we’re up against. What needs to be improved, and by how much? How many cancers are there in each country and region? What are the survival and mortality trends? How is the cancer control system performing? Answering these questions requires counting and categorizing information about many individuals and situations. This information then needs to be interpreted to create useable knowledge. Once this sort of knowledge is created, it must get into the hands of the right people, at the right time.

TimHannaTell us about yourself

My name is Timothy Hanna, and I am a Canadian radiation oncologist involved in health services research. In my research, I investigate access to cancer care and quality of cancer care. The goal is to seek out ways to improve cancer control. These research themes are of global importance given the increasing incidence of cancer across the globe. Being a radiation oncologist, my work focuses on cancer treatment, particularly radiation therapy.

What are you working on right now?

There are a few things. As one example, I’m investigating the achievable benefit of radiation therapy in the general population. If we were able to get this cancer treatment to everyone that needed it, how many people would we help? The primary work focuses on Australia, but this will be adapted to other settings. I’m working on this with a team in New South Wales, Australia. This work will inform the investment framework under development by the Union for International Cancer Control’s (UICC) Global Task Force on Radiotherapy for Cancer Control (GTFRCC).

How did you get involved?

I have had a longstanding interest in global health. As a medical student, I spent some time in Niger. I was struck by the limited cancer treatment resources where we were, the late stage of presentation and social determinants impacting access to cancer care. That was an important exposure that helped me think about global disparities and inequities in cancer care and health care. In residency, I had the chance to work with an experienced radiation oncologist clinician scientist who showed me how health data could be used to shed light on inequities and other quality issues in cancer care. This led to my fellowship work at the Ingham Institute in Sydney, Australia, and ultimately to my work at Queen’s University in Kingston, Ontario where I work as a radiation oncologist and clinician scientist supported by the Ontario Institute for Cancer Research (OICR).

Why do you think radiation therapy is important?

Radiation therapy is an irreplaceable part of cancer control. Cancer is a global problem, affecting countries of all levels of economic development. Radiation therapy delivers outstanding value for money, and is especially important in contexts where there is a burden of advanced cancers requiring treatment. When radiation therapy reaches those who need it, lives can be saved, body function maintained, and quality of life improved. These are all exceedingly important to people diagnosed with cancer.

Meet Mei Ling Yap

Mei is a radiation oncologist in Sydney, Australia and has written Global RT’s inaugural blog post. Learn about how she has combined a career in radiation oncology and global health.

Who are you and where do you work?

Mei Yap

Mei Ling Yap

My name is Mei Ling Yap and I am a radiation oncologist from Sydney, Australia. My clinical practice is at Liverpool and Macarthur Cancer Therapy Centres, in the South-western region of Sydney. It is a unique part of Australia, very culturally diverse – so I see an interesting case mix of patients. My clinical sub-sites are lung, breast and gynecological cancers. As well as my clinical role, I keep busy through research, undergraduate and post-graduate teaching and my role as the director of registrar (resident) training.

Why radiation oncology?

I decided to specialize in oncology as I feel that it’s a very ‘human’ specialty. My patients and their families are so inspiring. Working in oncology, one has the potential to help people through what is an important and challenging time in their lives, and that truly is a privilege.

I chose radiation oncology in particular as I felt it was a field where we can make a difference for patients. Radiotherapy is often the primary treatment used to cure patients, in sub-sites such as head and neck, prostate and cervix cancer, to name a few. Achieving cure for cancer patients is a wonderful outcome. Equally as important, I feel, is the ability to palliate incurable patients from potentially distressing symptoms such as pain and bleeding – with radiotherapy able to achieve that in usually more than 2/3 of cases.

How did you become involved in global health, and in particular global access to radiotherapy?

Global health has been an interest of mine since my medical student years at the University of New South Wales, where I was involved in an Australian medical student-run aid organization (MSAP), and did a posting in Chennai, India. It was alarming to witness upfront, the lack of access to medical treatment, which exists in many parts of the world.

In 2008-9 I did part of my radiation oncology training at the National University Cancer Institute in Singapore. I found it interesting to manage a different case-mix of patients (e.g. High incidence of nasopharyngeal cancer), and learn the different cultural perceptions of cancer, which exist there.

It was while I spent a 2-year fellowship at Princess Margaret Cancer Centre (PMCC) in Toronto that I realized that my passions for radiation oncology and global health could be united. Dr Mary Gospordarowicz, at that time the head of PMCC and now UICC, was harnessing members of the radiation oncology community who were interested in tackling the issue of global access to RT. After returning back to Australia, I was fortunate enough to be given the opportunity to work alongside my GTFRCC mentor, Professor Michael Barton, who is an extremely prolific researcher in global cancer health research, as part of his team at CCORE.

What is your role in GTFRCC?

My role in the GTFRCC is as part of the burden and outcomes working group, which is working to define the scope of the need for radiotherapy in low and middle income countries, as well as estimating the benefit in outcomes that radiotherapy would add to these countries. The work that we are performing will be a significant part in the GTFRCC ‘white paper’ to be launched at the UICC meeting in Melbourne in December. I am also part of the GTFRCC Young Leader’s program.

What research are you doing in global health?

At present, I conduct cancer health services research as part of CCORE, Ingham Medical research, Liverpool. The CCORE team, under the direction of Professor Michael Barton, developed an evidence-based model, which estimates the optimal utilization of radiotherapy in a developed country. We are currently adopting this model to low and middle-income countries to measure the optimal utilization of radiotherapy in those countries, with projections up to 2035. We are also estimating the differences between what should be, and what is currently available, in terms of radiotherapy resources – and comparing the present deficit to that of a decade ago.

Why do you think advocacy for improved access to radiation is important?

Advocacy for improved access to radiation oncology will play a central role in achieving the goal of closing the gap in terms of radiotherapy resource provision. We have made huge gains in term of cancer outcomes in high-income countries, but unfortunately cancer in low and middle-income countries has gone largely ignored. This cannot continue! The statistics are harrowing – 70% of cancer deaths occur in low and middle income countries, and cancer causes more deaths worldwide than malaria, TB and HIV put together – yet majority of people are unaware of this. This is where I think globalRT will make a huge difference. We need to communicate these facts, particularly harnessing social media – twitter, facebook etc etc. So readers, go ahead and spread the word!

Where is the most interesting place that your global RT work has taken you?

There have been many interesting visits, but my most recent was to Imam Khomeini Hospital in Tehran, Iran. The radiation oncology department, headed by Professor Peiman Haddad, is currently in the process of some exciting developments. It was especially nice to meet the radiation oncology residents, currently 10 of the 13 are female.