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IAEA General Conference
45th Regular Session

Biting the fly
Saving a mother's life
Counting every drop
Finding safe waters below

Serving Human Needs

Saving a mother's life

Radiotherapy offers new hope for women of child rearing age suffering cervical cancer in developing countries
by Peter Rickwood, IAEA Division of Public Information

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.

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