Aftermath of the AIDS Pandemic: Cancer Care in Botswana  

A Conversation with Bruce A. Chabner, MD

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Dr. Chabner examining a patient on the cancer ward in Gaborone Hospital.

The Republic of Botswana is slightly smaller than the state of Texas and with a population of just over 2 million people it is one of the world’s most sparsely populated countries. Botswana was among Africa’s poorest countries at the time it gained independence from the United Kingdom in 1966. Since then, the small nation has transformed its political and economic structure, becoming a stable democracy, and offering its people a modest standard of living.

The Second Wave of Disease

Like many sub-Saharan nations, Botswana was hit hard by the AIDS pandemic. And although the HIV/AIDS treatment model has emerged as one of the more successful global public health-care initiatives, many sub-Saharan countries including Botswana have experienced a surge in cancers related to immune suppression, the so-called second wave of disease related to AIDS.

Outreach and teaching programs have been developed by many in the global oncology community to address the growing cancer care needs in developing nations. Recently, Bruce A. Chabner, MD, Professor of Medicine at Harvard Medical School, and Director of Clinical Research at Massachusetts General Hospital Cancer Center in Boston, and a team of colleagues traveled to Gaborone, the capital of Botswana, to visit hospitals and clinics responsible for physician training and cancer care. Dr. Chabner shared his experience with The ASCO Post.

The Botswana-Harvard Relationship

Several institutions in Boston, notably Massachusetts General Hospital and other members of Dana-Farber/Harvard Cancer Center, have created valuable cancer-care relationships in sub-Saharan Africa. Would you please discuss the long-standing Botswana-Harvard relationship in studying the AIDS epidemic?

The partnership was established about 10 years ago to help cope with a very high incidence of HIV infection in an adult population. The Botswana-Harvard partnership has expanded over the years. The partnership now has about 300 people, which is based on the campus of the Princess Marina Hospital, one of the largest hospitals in Botswana. The partnership has a rotating and permanent faculty, including a number of people from Harvard. It’s been a very effective program in establishing research projects and ensuring that drugs were made available to people with HIV infections.

New Collaboration

Would you tell us about the new cancer collaboration in Botswana, informally named BOTSOGO (Botswana Oncology Global Outreach)?

About two-thirds of the cancers in Botswana are related to the underlying issues of HIV infection. A whole series of HIV-related tumors are increasing in incidence, including cervical cancer, Kaposi sarcoma, various lymphomas, and squamous carcinomas of the skin, head and neck, cervix, and other squamous-based sites. About 3 years ago, the Department of Radiation Oncology at Massachusetts General Hospital was contacted and asked for help in treating this rapidly rising incidence of HIV-related cancers. Jason Efstathiou, MD, Assistant Professor of Radation Oncology at Massachusetts General Hospital, leads the MGH team that has established the BOTSOGO initiative to link MGH and physicians in Botswana. He specializes in genitourinary oncology. Dr. Efstathiou and his team traveled to Botswana to collaborate and assist the local oncology community in dealing with complex cases of cervical cancer. The group quickly concluded that a brachytherapy facility would best serve the population’s needs, because radioactive seed implantation doesn’t require daily visits to the clinic, sparing patients the burden of multiple, long-distance trips.

Anthony Henryk (Tim) Russell, MD, Director of Gynecologic Oncology Service at Massachusetts General Hospital and an expert in cervical cancer, also made several trips to Botswana and set up a brachytherapy facility at the Gaborone private hospital. A radiation therapist, Memory Nsingo, MD, who directs the local facility in Gaborone, became the partner on site to form the collaboration that made it possible. They now treat about 60 cervical cancer patients a month and have become experts at delivering brachytherapy for cervical cancer. This collaboration proved very successful for cancer patients and their doctors.

Serious Health-Care Issues

Is Botswana making headway in its cancer care system?

In many ways, Botswana is a country of contradictions. For one, it has a very stable government, unlike many of its neighboring countries.  Botswana also has a comprehensive universal health-care system for all its citizens. Comparatively, its per-capita income is also relatively high. It has a rapidly growing economy.

That said, the country has serious health-care issues. Although ­Botswana is building some fine medical facilities, the nation’s biggest challenge is establishing enough training programs for medical subspecialists such as oncologists, radiation oncologists, and surgical oncologists. Other physician specialists, particularly pathologists, are in very short supply. Another obstacle is establishing community outreach programs and training health-care workers in the oncology sector to perform follow-up visits. Patient health records are not digitized, which fragments the long-term continuum of care.

The new medical school at the University of Botswana is graduating its first class of doctors in 2015, so the prospects for improvement are there. But the facilities are simply overwhelmed with cancer patients.  A 400-bed university hospital for tertiary care is also under development, but recruiting the necessary medical faculty to operate an institution of that size is an uphill battle.

The government is very much behind initiatives that will speed up the process of building a better cancer care infrastructure, but they have benefitted from the outside. Besides Massachusetts General Hospital, there are many universities from the United States that are collaborating with the Botswana officials and health-care providers. For instance, the University of Pennsylvania has shared expertise in gynecologic oncology, and Baylor University has a physician on site helping develop a pediatric oncology program.

Equally important, however, is that the government is very engaged in these collaborations. In fact, next year we plan to have a conference in Botswana with many American cancer centers and hospitals in attendance. The goal is to help develop a roadmap toward building a comprehensive cancer care strategy for Botswana.

Is there sufficient access to cancer drugs?

The short answer is no. Public access to oncology drugs is largely confined to generic cytotoxic agents; targeted molecules and biologics are cost-prohibitive, limited to private sources only. Drug shortages for common medicines are a frustrating problem for doctors trying to carry out long-term care. And palliative care medications for nausea and pain are very limited. This is one of the issues to be addressed at the ­conference.

A Rich Experience

How did officials and medical staff receive your team?

We were greeted with open arms by everyone, from government ministers to medical school and hospital officials, to the cancer patients on the wards. As a whole, the people of Botswana are incredibly friendly. Although Botswana faces significant challenges, it is a well-adjusted nation with a bright future ahead, particularly if it can harness the economic wealth of its mineral resources. Our team from Massachusetts General Hosptial had a rich experience. It was rewarding for me to see such enthusiasm among our young oncology fellows as they took part in teaching rounds and patient care.

Is there anything to learn from the Botswana experience that is generalizable to care in the United States?

Yes, of course. There is a lot to be learned in terms of how to best treat various diseases in a low-resource environment. Naturally, doctors in the United States have almost unlimited access to state-of-the-art drugs and therapies, but we also face our own issues with costs, so there is much to be learned from doctors who work in a environment of constant medical triage. Plus, it’s revitalizing for us to work in close collaboration with doctors and specialists from a totally foreign culture.

Treating cancer patients, whether in Boston or Gaborone, is essentially the same. We’re all doctors with the same goal, giving our patients the best care possible. ■

Bruce A. Chabner, MD, is Professor of Medicine at Harvard Medical School, and Director of Clinical Research at Massachusetts General Hospital Cancer Center in Boston.

Disclosure: Dr. Chabner reported no potential conflict of interest.

Editor’s note: For more on experiences in Botswana, see the discussion with Julie Livingston, PhD, MPH.

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Julie Livingston, PhD, MPH, is a Professor of History at Rutgers University. She is also an African historian with interdisciplinary training in public health and anthropology. Among other issues, her work considers the challenges of delivering oncology services in southern Africa, where there is a ...