Implementing new health initiatives in low-resource environments

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Published: 4 Jun 2017
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Prof Sana Al Sakhun - Jordanian Oncology Society, Jordan

Prof Sakhun speaks with ecancer at ASCO 2017 about the hurdles to deploying new oncology initiatives in low income and low resource regions.

Highlighting the forecast data on cancer incidence globally, she describes uneven distribution of funding, staff, and infrastructure as barriers to delivering adequate cancer care to a growing patient population.

Prof Sakhun also highlights the changing distribution of patients, noting the burden of refugees on already-strained healthcare systems,  and how tobacco control initiatives have slowed disease incidence in some nations while it increases in others.

Prof Sakhun encourages political and social engagement by all stakeholders in healthcare, including co-operation between social and industry partners, to find international solutions for local problems.


On Friday afternoon my talk was part of the Global Health Initiative session. I discussed the challenges of implementing new evidence in limited resource environments, particularly focussing on countries of low and middle income. You’d be surprised, limited resource environments is actually a term that refers to most of us practising around the world these days but the reason I’m focussing on these countries, you’d be surprised to know that 70% of the total  number of new cancer cases around the world are expected to be diagnosed in these countries by the year 2030. So if we were to make a global impact on patient outcomes all over the world we have to tackle the challenges in these particular environments.

Tackling the challenges is not only limited to the expense of the equipment or medications, it has different elements; it’s more like piecing a puzzle together. In terms of quantity and quality we have to tackle the challenge of having the qualified staff; in terms of quantity that’s quite an issue, particularly in countries of low income, sub-Saharan Africa. Quality is also an issue, even if the quantity is available we need to promote good international standard of education programmes around the world, CME programmes to keep up with the rapid advances in the field. Also the infrastructure is quite important. If you train the personnel, have the skilled physicians and you do not have the proper infrastructure in terms of proper laboratory support, radiology, diagnostic facilities, pharmacy, all these are needed for optimal implementation of the evidence. Even if you have skilled physicians they are not good enough by themselves, you need the infrastructure to support them. That’s quite an issue again in countries of low income, particularly Africa in addition to other countries around the world.

Then comes the challenge of registering the new medications, having the new facilities for radiation therapy available. It takes a long time for new medications to be approved in these countries and once approved it takes an even longer time for the essential medications to be included on the national essential medications list to be provided at reasonable price or free of charge to the population. That’s another challenge. Then, finally, comes the challenge of addressing the patient. The patients pay out of pocket, they need help. Patients need education about the importance of early detection, of getting the proper treatment, of believing treatment makes a difference. Another issue to address is the importance of access to clinical trials in these countries as a means of access to the new, expensive medications. Communities, governments in these countries still are sceptical about the merits of clinical trials. They need proper awareness and education.

The last issue I discussed is the refugee patient. The situation of the refugees in the 21st century, actually the situation is quite complex, long-lasting. You see it in low and middle income countries alike; you see it in camps and out of camps. Particularly I used the situation in Jordan as an example. In Jordan in the year 2012 we had close to 5,400 new cancer cases diagnosed in Jordanians and an extra 500 diagnosed among refugees. Can you imagine that burden to an already burdened health system? This is in 2012; in 2013, according to the accurate statistics, a 300% increase in the number of refugees was recorded in Jordan so you can imagine the situation in 2017. I do not have the accurate numbers but you can extrapolate by the numbers I just used. So this is another challenge for implementing the evidence for already burdened health infrastructures all over, not just in Jordan, all over the world, particularly again in countries of low and middle income.

At the UICC in Paris last year we spoke with Dr Josep Tabernero who was focussing more on tobacco control as a means of preventing disease but he spoke of the success of having scientists lobby to politicians, of taking the argument to them to improve tobacco control, to improve awareness and engagement with people and politicians. Do you see that translating to your positions as well?

Absolutely. Indeed, that is an important step in cancer care, prevention. I agree one third of mortality around the world attributed to cancer is due to smoking but in my discussion I focussed on treatment, multidisciplinary treatment, medical, surgical, radiation, supportive care. The reason is that two-thirds of cancer patients their cancers cannot be prevented. One-third, even if they have the will to prevent their cancer they do not have the means. So we still need to address treatment. But I completely agree with you, part of the problem in developing countries contributing to the rising incidence of cancer is not only the increasing number of the population but the increasing prevalence of the risk factors, including smoking. Smoking is on the rise in these countries, contrary to the more developed world where it is actually decreasing. Again, we are working on that aspect and I believe it makes a huge impact if the political power does support the medical lobbying to try and ban smoking, at least from public areas. That’s not going to be an easy goal to achieve but it is a step forward. Most governments are trying but still the social opposition is quite strong too, you’d be surprised. The governments are trying but still it isn’t an easy enemy to tackle.

Do you think there could be more support from the wider clinical environment, from international associations, from partners here at ASCO or at other conferences, to support doctors who are lobbying for either getting essential drugs approved faster, getting them released cheaper, getting them where they are needed, getting the infrastructure, the education, the support that you’ve mentioned?

Absolutely, that’s the whole point behind putting this session together. Global health initiatives support each other, whether you’re ICC, WHO, national societies, governments. If we all work together towards that goal it makes a huge difference rather than every one of us working from their own limited space with probably limited impact. The only way to achieve a global impact on the outcome for all patients is to work together. Indeed, not only NGOs, not only the WHO or UICC, the pharma industry has a very important role in helping to improve the access for cancer patients everywhere. We all think about them as the source of the problem, yes partially, but indeed they are a very important part of the game to solve the problem. Let’s give them credit at least in some of their contributions through access programmes, through clinical trial support, compassionate use. If we amplify and work more on these missions we could really help achieve our bigger goals.

That covers all the questions I can think of, is there anything else you’d like to add, any final thoughts?

The challenges are international, they’re not local. The problems are global but the solutions are local. We all are practising in limited resource environments in one way or another. We need to work together to find and learn from each other, to try and find solutions for the local problems. Definitely working together can help us succeed.