Coping with cancer in Somalia

With mortality rates from cancer in sub-Saharan Africa approaching those in developed countries, there is clearly a need for improved methods of diagnosis and treatment, especially chemotherapy and radiation therapy. But there are many obstacles in the way, ranging from the fatalistic belief that all cancer is incurable (Lama daawayn karo) to critical shortages of trained personnel, facilities, and drugs.

About decades ago, it was widely believed that malignant neoplastic diseases were rare among Africans. However, the introduction of cancer registries in some centres and the progressive documentation of cases have shown this belief to be wrong. For instance, data from Kenya indicate, cancer deaths in Kenya account for as much as 20% of all deaths.

Malignancy as seen in Africa, generally strikes younger age groups than in western countries and kills rapidly. This has far reaching implications for the economically productive population of Africa and their economies in general. However, these facts are understood neither by the lay population nor by the health planners who thus do not take them into account in their health budgets. Inadequate finance magnifies the considerable problems already confronting cancer workers in Sub-Saharan Africa especially Somalia, and makes the measurement of the extent and nature of the cancer problem a matter of priority.

Cancer in Somalia

The Nature of the problem:

Somalia’s health care collapsed with the collapse of the state of Somalia in 1991. Inefficient, un-regulated, and an ethical private practice replaced Somalia’s state controlled health care system. During the civil war, Somali doctors were not interested in dealing with cancer. There was not a single cancer clinic in Somalia since the start of the war in Somalia. Because of the lack of understanding of the impact of cancer in Somalia, and shortage of resources, Somalia never had professional oncologists. A rational approach to cancer therapy is only now beginning to be possible in Somalia. Until now, the sole treatment was surgery. Radiotherapy, which has been in use for over 50 years in Europe, is only available in few countries in Africa.

In Somalia most of the patients present themselves late for treatment. On presenting themselves for treatment, the majority of patients already have advanced disease with large tumor burdens. These will obviously have a relatively high proportion of drug-resistant tumor cells which are a source of tumor recurrence when the susceptible cells are killed. Even when patients are seen at an early stage at peripheral hospitals, diagnostic services are often not available. Most of the times, confirmation of the diagnosis is delayed.

Actually most of the diagnosis is made outside Somalia in countries where Somalis go for medical care such as China, India, Malaysia, Thailand, Turkey, and neighboring countries. At present, Mogadishu is the only city in Somalia that has a diagnostic center that can diagnose certain number of cancers. Another problem is that, owing to inadequate facilities staging procedures are of limited scope; this leads to understaging of the disease in most cases, which in turn affects decisions about the type of treatment and the eventual prognosis. The chemotherapist thus finds himself consulted only as a last resort.

The primary physician’s lack of interest in chemotherapy, compounded by a fatalistic view that cancer is incurable, commonly leads to inappropriate channeling of patients, causing further delay. This negative attitude is enhanced by uncertainty about the rational and principles of cancer management and denies the patient of the benefits of treatment. There is a lack of oncologists and chemotherapy-oriented physicians in Somalia. We already know, in Africa, western developed chemotherapy protocols are ineffective. Increased dosages and more vigorous regimens are needed to obtain comparable levels of remission. Apart from scattered data on cancer in Africans in general, there is hardly any information on the biological evolution of the majority of cancers in Somalia. For example, such tumor characteristics as cell kinetics, doubling times, and the presence of cell markers. Since the available data on the effectiveness of drugs, which were collected in studies on Caucasians, do not necessarily apply to African patients, therefore, chemotherapy in our patients will be a question of trial and error.

Turning to logistical problems, chemotherapy is more difficult to handle in Somalia than in any other country because of the difficulty of moving patients from place to place, lack of means of transportation and lack of a support network. By the time the patients come for medical care, their tumor will be too advanced to benefit from treatment, and if they achieve remission; follow-up and maintenance of therapy will be a major challenge. Another problem is cancer is new to the Somali concept of disease and most of the patients seek medical attention only when they are totally incapacitated. The Somali public is totally unaware of the importance of cancer screening and early detection of cancer. Most of the patients rely on quack doctors and only turn up for medical attention at a hospital when the tumor is too advanced for any aggressive treatment. This lack of understanding makes patients resist surgical procedures that could cure their disease in the early stages. Most of the patients stop taking oral medications when they feel better, thus making intravenous therapy mandatory. Patients and their families don’t understand the need for continued attendance of the clinic for treatment. Another problem is the lack of interest in cancer treatment on the part of Somali doctors.

Newly diagnosed cancer patients need surgery, chemotherapy and/or radiation therapy.

The number of oncologists needed is based on the number of patients requiring pathology, surgery, chemotherapy and radiation services. This number is estimated from the percentage of patients requiring surgery, chemotherapy and/or radiation therapy for the top ten cancers in both men and women. For developing countries, the International Atomic Energy Agency (IAEA) recommends training radiation/ clinical oncologists who can prescribe both radiation and chemotherapy for the common solid cancers, instead of separate medical and radiation oncologists. Hematological malignancies are treated primarily by hematologist-on- cologists.

Summary and Recommendations:

Currently, like many other essential services, cancer care services do not exist in Somalia except that the only oncologist Somalia has, (Dr. Hussein Abshir.) has started chemotherapy services at Uniso Hospital of Somali University in Mogadishu, Somalia. At present, this is the only referral center that accepts cancer patients in Somalia. There is a golden opportunity to build on this embryonic cancer service in Somalia. It is now or never, yes, we can do it and we will do it insha-allah and will succeed.

N.B A new cancer organization has been established recently in Mogadishu called Somali Cancer Society thanks to the generosity of the International bank of Somalia that played a pivotal role in the funding of this society which aims to deal with cancer issues in Somalia. Founders of this society intend to invite all concerned Somalis and non-Somalis to become members and contribute to the advancement of the cause for which this society was founded.

This article was contributed by:
1. Dr. Meymuun Geelle of Digfeer hospital in Mogadishu/Somalia. Dr. Meymun is a founding member of Somali Cancer Society.

2. Dr. Hussein Abshir Hassan, an oncologist in Somalia, he currently works at Uniso hospital of Somali university, also, lectures among other universities at Somali university and Somali National university.

He is also, a founding member and the chairman of Somali cancer Society.
MD, Msc, MCCQE, Medical Oncologist.
Tel: 00252 61707 0007

Dr. Meymuun Geelle
Digfeer hospital in Mogadishu/Somalia
Dr. Hussein Abshir Hassan
MD, Msc, MCCQE, Medical Oncologist.

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