Last year, I had the opportunity to spend a week at a cancer institute in equatorial Africa. A colleague of mine, Waafa El-Sadr, MD, heads a Columbia University program establishing health-care units in African nations to treat HIV-infected people with antiretro-viral drugs. Waafa was initiating one such unit at the Ocean Road Cancer Institute (ORCI) in Dar el Salaam, Tanzania. When doctors there expressed a need for a visiting oncologist to update them on issues relevant to HIV-infected patients with cancer, Wafaa thought of me. She felt that my experience treating AIDS patients in the days prior to the elaborate regimens we now have would be particularly instructive in the ORCI setting.
I arrived in Africa the week of World AIDS Day in December 2005. Considering Tanzania's desperate lack of resources, ORCI was a surprisingly pleasant place. The institute faces the sun-drenched waters of the Indian Ocean. Built by the Germans more than a century ago as a provisional hospital, ORCI is a pearl-white structure of columned halls and wide-slatted windows designed to capture the ventilating air blowing off the ocean. In the crowded wards, elegant tiled floors are an oddly nostalgic remnant of Tanzania's colonial past. From the windows in the HIV clinic, patients can see the endless tropical sea.
On the first morning, I met with Dr. Ngoma, director of ORCI, and Dr. Lekey, the institution's host, as well as senior staff. After brief introductions, my week's agenda was outlined. I would deliver lectures, provide clinical monitoring, do ward rounds and needs assessment, conduct case studies, and suggest how to improve clinical care among patients with HIV-related malignancies.
Doing rounds in ORCI was an eye-opening experience. Compared with the UCSF Comprehensive Cancer Center, the Spartan simplicity of ORCI dramatizes the reality: There is so much need, and so few resources. ORCI is one of only three or four cancer-devoted facilities serving the vast regions of sub-Saharan Africa; the institution's catchment area extends well beyond its national borders. Another numbing statistic: Tanzania has only 800 doctors to care for its 34 million people.
ORCI has four wards: two for women, one for adult males, and one pediatric ward. There are two female wards because cervical cancer is the most prevalent diagnosis. About 80% of the inpatient women at ORCI are there for cervical cancer treatment. Naked-eye visual inspection with acetic acid is the only form of screening. Routine Pap smears, which save countless lives in the United States, are not available at ORCI. During an extensive tour of the hospital I found out why: They can’t afford a full-time pathologist; they don’t even have a good microscope.
But it was when I joined the incredibly busy Dr. Maunda on rounds in the Nightingale ward, where pediatric care is delivered, that I fully grasped the scope of this hospital's struggle to care for its patients. The beds in the children's ward are so close to each other they nearly touched. Many of the children have Burkitt's lymphoma, which is endemic in equatorial Africa. The children and their parents come from distant villages and virtually live in the hospital for up to 6 months. The mother sleeps with her child, and the father stays in the male ward. During my visit, things were so overcrowded that some patients were receiving chemotherapy while lying on a rubber mat on the floor. These families cannot afford to travel back and forth between chemotherapy cycles, although such travel could cost as little as one penny.
My week at ORCI was moving and provocative. I certainly came away with a greater appreciation of the medical resources that I have at my disposal. Oncologists are used to dealing with frustration. All of our patients are very ill, and many of them never get well. That is as true in America as it is in Tanzania. But in America, oncologists place patient care over costs; for doctors at ORCI, where a good microscope is a luxury, that is impossible.