Dana-Farber Researcher’s Work with Partners in Health Brings Quality Cancer Care to Rwanda

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[Our goal is] to work with the Rwandan ministries in developing the policies and infrastructure needed for this work to take place throughout the country, and for it to be sustainable. Why should these people die of cancers that could be cured in Boston?

— Lawrence N. Shulman, MD

Lawrence N. Shulman, MD, Chief Medical Officer at Dana-Farber Cancer Institute, grew up in New York City. A product of the public school system, Dr. Shulman entered Syracuse University as a history major, only to realize that studying the past, although important, wasn’t for him. “I wanted a field that interacted with people and science, and medicine seemed to be the perfect combination,” Dr. Shulman said.

By the end of his first year at Syracuse, Dr. Shulman had switched his major to chemistry, which led to premed and an acceptance to Harvard Medical School. It was 1971, a tumultuous time of transition in the United States. The Vietnam War was raging through its final stages as President Nixon signed the National Cancer Act—billed as the War on Cancer—into law, which finally brought the disease out of the closet and onto the national stage.

“It was right around the time Nixon signed the National Cancer Act that I took my first course on hematology/oncology. It was a very exciting period; we were actually seeing clinical successes in previously incurable diseases such as acute lymphoblastic leukemia, Hodgkin lymphoma, and large-cell lymphoma. By the end of my second year at Harvard Medical School, I was pretty convinced that I wanted to do something in oncology,” Dr. Shulman said. During his fourth year, Dr. Shulman was involved in hematologic malignancies and stem cell research, which sealed his decision to pursue oncology.

Going Global with Partners in Heath

Since he entered the field of oncology, Dr. Shulman’s career has been based in Boston at the many Harvard-affiliated hospitals. His achievements in the clinic and research have been acknowledged by the cancer community for advancing breast cancer therapies and improving quality of life for patients with all stages of the disease. Moreover, his ongoing work in health information technology at Dana-Farber and at ASCO, where he is on the Health Information Technology Work Group, is helping to reshape the intersection of technology and clinical oncology practice.

However, Dr. Shulman’s work has not been limited to just the Boston area, instead taking on an increasingly global scope. Dr. Shulman has assumed the role of Senior Oncology Advisor for Partners in Health, helping to develop structured cancer programs in resource-limited health-care sites in Rwanda, Malawi, and Haiti. Prior to taking a leadership role with Partners in Health, Dr. Shulman served as a case-by-case oncology advisor to the organization’s cofounder, Paul Farmer, MD, PhD, a onetime intern of Dr. Shulman’s.

Dr. Shulman explained that Rwanda—Africa’s most densely populated country—has been the focus of the organization’s most intensive outreach efforts in sub-Saharan Africa, which began in 2005, when the Rwandan government invited Partners in Health to work in the country’s underserved areas. Dr. Shulman recently led a team of doctors and nurses from Dana-Farber to Rwanda to continue the ongoing mission of building a viable cancer delivery service. “Before we got to Rwanda in 2005, there were essentially no cancer care facilities in the country. There were no oncologists to treat the patients with cancer,” Dr. Shulman said.

Progress Made in Butaro

As an example of the progress made, Dr. Shulman pointed to the new Butaro Hospital in northern Rwanda, which opened its doors in January 2011. “Part of the hospital was planned to house our cancer program, and accordingly it has some very innovative architecture, designed with air circulation safety factors for our many immunosuppressed patients,” said Dr. Shulman. 

Outfitting the Butaro Hospital with skilled oncology staff and medical technology is an ongoing project that requires a great deal of on-the-ground human interaction, in order to build the trust that ultimately becomes the bridge for progress. “During my last trip to Rwanda, we ran the first basic cancer training program for the entire country. We wanted to keep the program focused, so each regional hospital was allowed to send two physicians and two nurses. We ended up with about 35 physicians and 35 nurses,” Dr. Shulman said.

The program, although one small step in a long journey, was a success. “These are bright, capable people who simply have never had any cancer training. It needs to be a partnership; we provide the cancer care expertise, and our Rwandan partners provide the cultural know-how to deliver the care,” Dr. Shulman said.

Visual Power of Quality Care

Cancer is a universal experience, and although doctors across borders share a common language, gaining the trust of patients in areas of the world such as Rwanda is built on a patient-by-patient basis. “Initially we were met with skepticism, but the barriers break down once you treat a couple of people successfully. When people see others who look very ill suddenly get better, they begin lining up at the door for treatment,” Dr. Shulman said.

Dr. Shulman illustrated the visual power of quality cancer care by describing a home visit he made while in Rwanda. “We visited a 40-year-old woman with gastrointestinal stromal tumor (GIST). Her husband told us of going from hospital to hospital seeking help as his wife’s weight dropped from 70 kg to 35 kg. She was close to being comatose. The Max Foundation, in partnership with Novartis, provides free imatinib (Gleevec) to GIST patients. So we biopsied her to prove her diagnosis and got her imatinib. When we saw her again, her weight was up to 68 kg. Her husband said the people in his community who had seen his wife when she was so sick were afraid that she might be contagious. Seeing her healthy again has changed the community’s perception about cancer and its treatment. This patient’s story is an example of what can be accomplished. People believe what they see, especially when it’s positive, ” Dr. Shulman said.

Importance of Sustainability

Dr. Shulman said that the new 150-bed hospital in Butaro is situated on a verdant hillside nestled in a startlingly beautiful area of the world. The structure itself is somewhat beyond what many in the region would take for a hospital. “When the hospital was near completion, people in the surrounding area were convinced it was a resort for foreign tourists. I might return to Rwanda this summer to dedicate the new cancer center in Butaro, perhaps with President Bill Clinton and NASCAR driver Jeff Gordon, who have been great supporters of the initiative,” Dr. Shulman said.

Acknowledging the overarching issues in such a poor country, Dr. Shulman said, “Our goal is not only to help bring cancer care to individual children and adults, but also to work with the Rwandan ministries in developing the policies and infrastructure needed for this work to take place throughout the country, and for it to be sustainable. Why should these people die of cancers that could be cured in Boston?”

Despite being involved in multiple cancer initiatives on the national and international stage, Dr. Shulman still sees patients at Dana-Farber each week. “Treating patients with cancer, no matter where they are, is still the best part of my job. It is a constant reminder of why I decided to become an oncologist in the first place,” Dr. Shulman said. ■

Disclosure: Dr. Shulman reported no potential conflicts of interest.