Miriam Mutebi, MD, MSc, FACS, was born and reared in the outskirts of Nairobi, Kenya. “The suburb I grew up in (Langata), has seen a lot of development over the past couple of decades. When I was a child, it was a smaller community, where you would go and play at somebody else’s house and have lunch there and just walk back at the end of the day in a carefree manner. All the moms knew each other, and the kids would all play together. It was a quaint, almost bucolic, existence, sort of an interconnected community where we all looked after each other. I think the growth of urbanization has diluted that somewhat,” she related.

Miriam Mutebi, MD, MSc, FACS

TITLE

Assistant Professor, Department of Surgery, Aga Khan University Hospital, Nairobi, Kenya
President of the African Organization for Research and Training in Cancer (AORTIC)

MEDICAL DEGREES

MMed/MD: Aga Khan University, Nairobi, Kenya
MBChB: University of Nairobi, Kenya
MSc: Weill Cornell University, New York

ON ACCELERATING THE PUBLIC CONVERSATION ABOUT WOMEN WITH CANCER

“In many parts of Africa, women are not the primary determinants of their health-seeking behavior and may require either financial support or at times even permission in order to access care. There’s also a sense of cancer fatalism, where one believes that cancer equals death, so we’re trying to shift narratives around that and bring well-deserved optimism into the public discourse. Knowledge also helps to foster shared decision-making. It is important to have well-informed patients whose wishes have been acknowledged and incorporated into the treatment plan, as it is a journey we help to support alongside our patients.”

Bus Ride and Fatherly Advice

According to Dr. Mutebi, her father’s advice about passing time on her long bus ride to grade school with a book inspired a life-long love of learning and literature. “Our school was about 15 km away, and my dad told me that if I have 25 minutes or so on the bus, I should spend the time reading. So, I did, and that’s when I discovered the school library and began looking forward to the long bus ride because I got to read about The Chronicles of Narnia or whatever interesting book I chose next. Those long bus rides with a book in my hand also sparked my interest in writing, which maintains to this day,” she added.

Asked about any early influences on her decision to become a physician, Dr. Mutebi commented: “The early influences were more external than personal, because I grew up next to an airstrip and that actually housed the AMREF (African Flying Medical Relief Services). They were doctors who did a lot of relief work and had small planes, flying to different parts of both Kenya and East Africa. And then we lived in a place called Langata, which was maybe 2 to 4 km from the airstrip. So, as a child, I thought it would be cool to be a flying doctor.”

Dr. Mutebi continued: “I also should give credit to my high school St. Mary’s School, because we used to have what we call a CAS (creativity, action, service) program. On the creative side, I was a budding thespian. And I did a lot of creative writing. I still feel I have the next great African novel inside coming soon. As for the action section, you needed to do something that was of social responsibility, like either planting trees or becoming aware of the environment. But then the service component was about volunteering to help out in sectors of need.”

Dr. Mutebi’s first volunteering gig as a high school student was in Aga Khan, ironically where she works now. “Obviously, that had a big influence on my career decision. But as a teenager graduating from high school, I wanted to do a bunch of things, such as pharmacy, writing, law, architecture; in the end though, it was between medicine and writing. I remember asking my dad for advice, and he said if I choose to become a doctor, I can still write, but if I choose writing, it might not offer the opportunity to become a doctor as well. So, in a roundabout way, that’s sort of how I decided on medicine as a career.”

At the time, Dr. Mutebi entered medical school in Nairobi in the early 2000s, it was still the tail end of the HIV epidemic. She noted the antiretrovirals that have turned HIV/AIDS into a manageable chronic disease were just then arriving in Africa, and their dissemination to needy populations was inadequate, until the inception of PEPFAR—the U.S. President’s Emergency Plan for AIDS Relief program.

“When we were doing our clinical rotations, there was still a lot of stigma around HIV/AIDS, and patients were being abandoned by their families,” Dr. Mutebi recalled. “If you can imagine the situation, there were about five different wards, and the first two had patients with acute medical concerns. And then the last three wards were filled with patients who had AIDS and who had been unfortunately, largely abandoned by their families. Because there was no access to antiretrovirals then, the patients were at different stages of severe complications or dying. There was a pervasive sense of helplessness among the health-care professionals because we had so many sick patients for whom we had no therapies. As a medical student, filled with passion for the profession, this was very difficult. This was a very different experience to medical students currently, where easy access to medications and reduction in stigma, ensures  that HIV has become like any other chronic illness.

However, the sense of helplessness that was pervasive on the HIV/AIDS wards was reversed by the hands-on, can-do optimism she discovered in the surgical arena. “When I began surgical rotations, I felt like I’d found my calling. As opposed to the other wards, when a patient comes in with trauma, you take him or her into the OR and sort it out; he or she goes home after 4 days perhaps saying, ‘thanks, doc; you made a difference.’ For me, I was entering medicine because I felt it was a career where I could impact the human condition on a patient-by-patient basis; and with surgery, there was a sense of immediacy and actively contributing to patient outcomes,” said Dr. Mutebi.

Becoming a Breast Surgeon and Advocate for Women

After Dr. Mutebi earned her medical degree, she began her surgical residency at Aga Khan University Hospital, not certain on a specialty as she moved through general surgery rotations. “In medical school, we learned that breast cancer is a disease of the sixth and seventh decades, typically in women who had prolonged estrogen exposure, had not had children, and had not breastfed. But one day, I’m sitting there in clinic and seeing patients with breast cancer in their 30s and 40s, all with traditionally protective factors. And I’m like, what is going on? That set off an internal alarm to get to the bottom of this,” she explained.

On a mission to uncover the issues driving the poor outcomes in African women with breast cancer, Dr. Mutebi joined support groups to get first-hand knowledge. “Unfortunately, I discovered a lot of stigma attached to reproductive cancers, based around shaming patients. It’s important to note that stigma is a very nuanced concept. For instance, there is the lived experience of the patient with breast cancer, but it’s even anticipatory, where the patient truly believes she will be discriminated against. I recall one patient had the very uncomfortable situation of sitting through a women’s group meeting where they discussed a common friend with breast cancer and determined she was going to die. She stopped going to any subsequent meetings, as she knew what could possibly wait for her if she disclosed her cancer status. I’ve also had patients who have lost their jobs because of their cancer diagnosis, or their employer did not feel it was necessary to allow them time off for therapy,” she related.

Dr. Mutebi continued: “We need to accelerate the public conversation about women with cancer, especially the highly sensitive gynecologic malignancies. For instance, in many parts of Africa, women are not the primary determinants of their health-seeking behavior and may require either financial support or at times, even permission in order to access care. For us Africans, our strength is a sense of community. However, this can be a double-edged sword, when it results in patients lacking agency in their treatment decisions, where a community elder decides what is next. There’s also a sense of cancer fatalism, where one believes cancer equals death, so we’re trying to shift narratives around that and bring well-deserved optimism into the public discourse. Knowledge also helps to foster shared decision-making. It is important to have well-informed patients whose wishes have been acknowledged and incorporated into the treatment plan, as it is a journey we help to support alongside our patients.”

A Pioneer in a Male-Dominated Field

Following her 2-year surgical fellowship, Dr. Mutebi decided to remain at Aga Khan University Hospital, where she became the first female breast surgeon in Kenya’s history. However, this accomplishment was not without its share of challenges in the heavily male-dominated field of surgery.

Asked to share a brief example of her journey, Dr. Mutebi offered these comments: “When I was training, I had a few bizarre interviews among the different local surgical training programs then. And I think there was almost an overwhelming sense of bewilderment at seeing a young female interested in surgery. I remember somebody asked me, ‘What happens when your patient goes to the ICU, and you start to cry?’ You could imagine, seeing your professor peering down his glasses and asking with a straight face, ‘Okay, so what happens when you’re on call and you have to breastfeed?’ I think I truly represented a sense of change that took the male-dominated culture by surprise. I’m glad to say over the past couple of years, just through some of the efforts that we’re doing, and an increase in visibility and advocacy locally, the number of women in the field is now  increasing exponentially.”

An Uphill Battle for Female Surgeons

Dr. Mutebi noted data indicate that in West Africa, less than 1% of the approximately 5,000 surgeons are women. She stressed that the shortage in female surgeons is not for lack of interest, as most medical schools are about 60% female, with the majority of the health workforce being around 80% female (including nurses and other medical professionals).

To foster a more inclusive environment in surgery, Dr. Mutebi co-founded the Pan-African Women’s Association of Surgeons. “It’s not just a numbers game because again, we don’t need to belabor the benefits of having a diverse team,” she explained. “I think women are uniquely placed to actually address some of the sociocultural barriers that exist in our health systems, for instance when a lady comes in and doesn’t want to be examined by somebody of the opposite sex. However, that also needs to go along with leadership and representation,” she stated. “We still have a lot of work ahead in terms of equity in the workforce, but we’re making progress.”

A Leader in African Cancer Care

Dr. Mutebi is currently President of the African Organization for Research & Training in Cancer (AORTIC), the largest and most influential continental organization involved in the promotion of cancer care and control in Africa. In 2021, she was appointed by Kenya’s health secretary to co-chair a government task force to design an effective cancer management structure in the country. Dr. Mutebi is the immediate past President of the Kenya Society of Hematology and Oncology (KESHO) and Chair of the Commonwealth Task force for the elimination of Cervical Cancer. She also sits on the Board of Directors of the Union for International Cancer Control (UICC), where she represents Africa.

As a leader in international oncology, Dr. ­Mutebi offered an optimistic snapshot of the future of cancer care in Africa: “Access to affordable care has been an ongoing challenge, perhaps the greatest impediment to achieving better outcomes on a public basis. But we are making progress. For example, through the National Hospital Insurance Fund in Kenya, over the past 10 years, we actually support some of the costs of chemotherapy, surgery, and radiotherapy. So, more patients are now making it to the finish line. If you look at examples from Kenya, Rwanda, and Ghana, where there’s some social insurance fund, it’s made a huge difference in terms of completion of care and improving outcomes for patients. And, of course, there’s also been the increase in grassroots advocacy from patient civil society organizations. I am incredibly optimistic that if we continue to collaborate, we can definitely create better cancer outcomes across the board for our patients of all socioeconomic backgrounds.”

Decompression Time

What does a super-busy oncology leader do to decompress? “I love to read and cook. In fact, I have a cooking blog called The Indolent Cook; it was first going to be The Lazy Cook, but I got a message from Instagram saying I was The Lazy Cook number 655! And I’m also taking flying lessons, which is very challenging, but I’ve always wanted to follow my dream of being an African flying doctor. I love my work and cannot think of a better, more enriching career than being an oncologist.”