When
the sickness persisted, Genet Ashenafi became alarmed.
At the regional hospital, in Ethiopia's southern rift valley
city of Awasa, the 34 year old single mother's worst fears
were confirmed.
Four months after she had first noticed vaginal bleeding
and a discharge she was diagnosed with invasive cervical
cancer.
Genet felt her life collapse: the probability was that
in less than two years she would be dead and the fate of
her two sons left to chance. She prayed and she wept.
In Ethiopia and most of sub-Saharan Africa, cancer of the
cervix -- the mouth at the entrance of the womb -- is among
the most prevalent forms of cancer in women. It is usually
fatal because of late detection and the dearth of treatment
facilities.
The consequences of the death in Ethiopia of a mother,
still rearing her children, are catastrophic. Without her
the family usually disintegrates and the significant economic
contribution that her labour provides is lost.
Cervical cancer mostly affects women in Ethiopia over 30
years old and peaks in the 40 -45 year old age group according
to local statistics. Estimates put the number of women in
developing countries who die from the disease each year at
200,000.
The rate at which it strikes is more than four times the
average incidence in affluent developed countries where routine
monitoring, providing early detection, leads to usually simple
and effective treatment.
In the last half of July, 2001, as showers from an unusually
active rainy season continued falling across central Ethiopia,
Genet boarded a bus in Awasa, with her teenaged son, and
made the journey of about 300 km. north to the nation's capital,
Addis Ababa.
She had been referred by the Awasa hospital to Dr. Bogale
Solomon, director of the Black Lion Hospital radiotherapy
department.
The centre opened in 1997, a joint project between the
government of Ethiopia and the United Nations International
Atomic Energy Agency (IAEA). Ethiopia is the poorest country
in the world to introduce radiotherapy. In four years the
department has treated 1300 patients and the number of patients
being treated is growing all the time.
Today is the seventh day of treatment in a 30 day course
Genet is receiving. She has joined a group of patients, mostly
other women, who attend the clinic daily as outpatients.
Patients are exposed to small doses of radiation, lasting
one to two minutes, a process known as fractionation, that
best spares healthy cells.
The treatment entails directing multiple beams of radiation
from outside the body at the tumour in Genet's pelvic region.
The radiotherapy machine being used is Chinese made and its
radioactive source is Cobalt-60, first used therapeutically
50 years ago.
Already the bleeding and the discharge that alerted doctors
in Awasa to Genet's condition has stopped.
Yes, she says through Bogale -- who translates her Amharic,
the predominant language of Ethiopia, into English -- she
has an upset stomach and her appetite has decreased.
But she’s relieved that the symptoms are improving: she’s
feeling more confident, less desperate. Her husband left
her and her two sons, now 16 and 20, never to return, to
join the army of Mengistu Haile Mariam.
Mengistu waged a campaign of terror, at the head of a junta
known as the Derg, after toppling the former Emperor Haile
Selassie in 1974. He was head of the country during a series
of devastating famines and was in turn overthrown in 1991.
Genet was married when she was 12 years old, the convention
in Ethiopia, where girls may marry even younger. She had
her first child when she was 14 years old.
Her chances of being cured are good, says Bogale, an internist
and Ethiopia's sole radiation oncologist. "Although her disease
was too advanced to be operated on, she’s an early case," the
physician said. "The cancer hadn't spread (out of the pelvis)."
Yet many of the patients referred to his department are
not diagnosed until the disease is far advanced, he said.
Nevertheless 50 per cent of patients treated at the Black
Lion radiotherapy department are still alive four years after
it began delivering treatment, Bogale said.
"Some patients, when they arrive, can't control their bladder,
can't walk, and suffer extreme pain," he said. "We will then
give them a short treatment (of radiation) that is only enough
to control the bleeding and relieve the pain.
"No, we don't expect a cure and the life expectancy of
the patient wouldn't be very long but we can improve the
quality of their life, and if you can control the pain, that
is our objective".
Genet says that the treatment has been painless and she
doesn't feel it's doing her harm. She would encourage other
women to receive it, she said.
Statistics reveal that the Black Lion radiotherapy department
is a small beacon of light in a large and troubled sea.
Ethiopia has only one radiotherapy machine to serve a population
of more than 60 million people. The European standard, by
contrast, is one machine for every 250,000 people. Addis
Ababa alone has a population of about 3.5 million.
There is increasing recognition of cancer in developing
countries, says Vic Levin, head of the IAEA section of Applied
Radiation Biology and Radiotherapy.
Although the spectrum of cancers in developing countries
differs from that in the affluent, the perception that there
is less chance of getting cancer in developing countries
is proving increasingly false, Levin says.
Cases have risen from two million in 1985 to five million
in 2000 and are projected to reach 10 million in 2015. Experts
say that the rise in cancer in developing countries is mostly
related to increased life expectancy.
At the Black Lion clinic the waiting list for treatment
is lengthening. The department now remains open until 10pm
and treats 52 people every day. Bogale is the only radiation
oncologist in the department. He's had no holiday in four
years.
Women make up about 70 per cent of the patients, among
whom cancer of the cervix is the most common disease. "Cervical
cancer makes up 35 per cent of the group (of patients treated),
followed by breast cancer at 18 per cent and neck and head
cancer between 13 and 14 per cent," Bogale said.
The incidence of cervical cancer is similar to other sub-Saharan
African countries, where lifestyle is blamed for its proliferation,
he said.
The main factors are trauma from repeated births - birth
control is not practised; promiscuity, and poor hygiene linked
to poverty, said Bogale. The spread of HIV (human immunodeficiency
virus that causes Aids) has also increased the risk of women
getting cervical cancer.
Bekelu Senbeto, 66 years old, the wife of a farmer, who
mothered the last of nine children when she was 48, has just
completed a course of 36 treatments in the Black Lion radiotherapy
department and is on her way home.
Her symptoms have improved, says Bogale and Bekelu says
she will resume work, on her husband's farm 45km south of
the capital, as she gets better.
In a country where 85 per cent of the population is employed
in agriculture Ethiopian women provide much of the muscle
as well as tending the hearth and raising children.
But there is no great value placed on their role, Bogale
said. "In our society women don't control the economy and
that is the problem. Culturally women don't decide their
own fate, someone is deciding for them."
"The woman plays the dominant role in child raising. She
is the mentor, she is absolutely vital," said Bogale. "She
is the determining factor in a family , the woman takes the
central role in a family.
"When the mother dies at a young age it is a disaster.
The father can't take care of the children. If there are
grandparents alive maybe they'll take care of a child, or
the uncle, or other relatives will take a child. But upon
the death of the mother the family disintegrates."
His concern echoes frustration with attempting to raise
the profile of medical care for women in Ethiopia. He advocates
early screening for cervical cancer. "We are trying to sensitize
the public to this problem, but so far we have been unable
to launch a campaign.
"Cervical cancer can be detected early, it is so simple,
the treatment is straightforward and the outcome is extremely
good."
He continues to seek funding to expand the Black Lion radiotherapy
department. It has facilities for brachytherapy, a medical
procedure, that reduces side effects by directing a large
controlled dose of radiation from a device inserted next
to the tumour.
But brachytherapy requires that patients are admitted and
there are no funds to pay nurses to look after the 20 beds
with which the department is fitted out.
Meanwhile patients such as Jenet, who earns 130 birr (about
$US15) a month as a government employee, are expected to
pay a fee for treatment at the Black Lion Hospital.
She can barely afford a hotel room in Addis Ababa where
she stays with her 16 year old son during the treatment.
But other patients referred to the radiotherapy department,
who are less well off, "pass the night on the street or in
a church, or a mosque," Bogale said.
The spread of HIV (human immunodeficiency virus that causes
Aids) has also increased the risk of women getting cervical
cancer, Bogale said.
But Ethiopia has a rich tradition of healing. It impressed
early European visitors who reported the use of anaeshetics
and effective treatment of fractures . More than 50 per cent
of Ethiopia’s population continue to turn to folk healers.
There are plans to instal cobalt machines in regional hospitals,
including the new Mek’ele hospital in the north of Ethiopia
to relieve pressure on the Black Lion radiotherapy department.
The IAEA’s Levin says that the treatment of cervical cancer
with radiation is among the oldest and most resounding success
stories of radiotherapy and has been practised for nearly
a century.
In Africa the number of machines that provide the treatment
nearly tripled in the last decade of the 20th century,
largely due to the succesful transfer of technology by the
IAEA, Levin said.
The capital cost of establishing a radiotherapy department
is "mind boggling" said Levin, but after overcoming the start
up hurdle, the treatment it delivers is very economical.
National cancer control programs, that offer preventive
and early detection, a modest mixture of treatment by surgery,
radiotherapy and chemotherapy, result in the cure of 45 per
cent of all cancers In affluent countries.
It is a target to which a developing country, such as Ethiopia,
also aspires.
The success of the radiotherapy department at the Black
Lion Hospital serves as a model on which future development
can be based.
