Dr. Nixon Niyonzima decided to be a physician when he was 8 years old, the year his mother died of cancer. He’d been too young to go with her when she left Kisoro, their home town in southwestern Uganda, to travel hundreds of miles north to a hospital in Gulu district. But the desire to help—to do something—was planted.
Niyonzima stuck to his dream, earning a medical degree at the prestigious Makerere University in Kampala. Joining the Uganda Cancer Institute, however, was another story.
While in medical school, Niyonzima did a stint at UCI. It was—in a word—“overwhelming,” he said. The sole cancer treatment center in a country of 36 million people, it was staffed by a single oncologist. Add an aging and poorly equipped facility, too few drugs, a shortage of supplies as basic as gloves and very sick patients who sought care too late and it seemed that there was no more hope for cancer than when his mother died 20 year earlier.
“Ultimately, your goal is to make the patient better,” he said. “But the vast majority—you’re not able to treat them as you’d like. It is very depressing.”
Today, conditions at UCI are getting better, thanks in large part to an alliance between it and Fred Hutchinson Cancer Research Center that trains Ugandan physicians to become cancer specialists. As part of the partnership, which began as a pilot program in 2004 and was formalized in 2008, doctors come to the United States to study at the Hutch and the University of Washington with the goal of returning to Uganda to treat patients and do research. While there was once only one oncologist at UCI, now there are about a dozen.
Better staffing and other changes underway inspired Niyonzima to sign up. He is two years into a five-year doctoral program in molecular and cellular biology at Fred Hutch, and returns to UCI between semesters. While once he couldn’t imagine a career in cancer care, he now plans to work at UCI full time when he finishes his doctorate.
The chance to combine clinical care with research is a big part of the draw.
“Being at the cutting edge of research is very exciting in its own right,” he said during a recent interview on the Hutch campus. “It opens people to new opportunities and ideas. It’s exciting to be able to discover something. Also to offer hope to your patients—research does that.”
The global scourge of cancer
Cancer in the developing world is a growing, yet largely unrecognized, global health problem, a “neglected disease on the global stage,” said Dr. Corey Casper, Director of the Hutch’s Program in Global Oncology. More people die in low- and middle-income countries of cancer than of HIV, malaria and tuberculosis combined. The World Health Organization projects that by 2020, two-thirds of all new cancer cases will occur in developing countries.
Worldwide, about a quarter of all cancers are believed to be caused by infections. In Uganda, six of the 10 most common cancers are due to infectious disease, including cervical cancer, caused by the human papillomavirus, and the lesser-known Burkitt’s lymphoma, caused by the Epstein-Barr virus. In many parts of sub-Saharan Africa, only 10 percent of patients with Burkitt’s lymphoma live. In the U.S., it’s curable.
The Hutch, which has expertise in both cancer and infectious diseases, is an ideal partner for UCI.
“Seventy percent of people harbor at least one infection that could cause cancer, but only 1 percent will develop it,” said Casper. “Why? That’s what we hope to find out.”
Research is one goal of the alliance. The four-pronged approach also includes providing tools and medicines to improve clinical care, building a state-of-the-art clinic and training center and preparing cancer care specialists and infectious disease researchers.
“Chemotherapy drugs are not a barrier [to treatment]—they’re available,” said Casper. “The barriers are facilities, personnel and knowledge.”
One of the most basic components of a healthcare system is people. Many extremely poor countries face a severe shortage of health care workers. The World Health Organization described the shortage as “one of the most critical constraints to the achievement of health and development goals.”
Developing countries also risk losing the trained health providers they do have due to extremely high workloads, low salaries, limited equipment and a lack of training and research opportunities. According to WHO, doctors and nurses alike often seek work in wealthier countries.
At UCI, for example, a single doctor can see as many as 50 patients a day. In Seattle, where Niyonzima did a rotation at the Seattle Cancer Care Alliance, he saw five to six.
“Here, there’s more time. You have 45 minutes with a patient, time to read their charts,” he said. “In Uganda, you don’t have that luxury. You give each patient much less time, much less attention.”
In Seattle, cutting-edge diagnostic technology allows for an earlier and more accurate diagnosis and earlier treatment. One of Niyonzima’s goals is to bring such tools to Uganda.
Building capacity in Africa
Such challenges were among the reasons why Niyonzima did not intend to specialize in cancer care. Then he came to the United States to earn a master’s degree in global health at North Carolina’s Duke University, and his mentor at Duke turned out to be a friend of both Corey and Dr. Jackson Orem, the head of UCI and co-director of the UCI-Hutch partnership. Those connections led him to the Hutch.
The Hutch—and the changes already underway at UCI, including more support from Uganda’s government—led him full circle to cancer care.
Since 2005, the UCI-Hutch alliance has not only increased the number of oncologists practicing in Uganda but trained other Ugandans as nurses, lab technicians, pharmacists, data specialists and regulatory and fiscal managers.
The Hutch recently was one of just 15 U.S. cancer centers nationwide to receive a contract from the National Cancer Institute to promote research collaborations with institutions in low- and mid-income countries. The $200,000 contract will support genomic research on a human herpes virus that causes Kaposi’s sarcoma, a prevalent cancer in untreated HIV-positive adults worldwide and a common childhood cancer in Uganda, and on multicentric Castleman disease, which is similar to and can develop into lymphoma. The contract includes funding for a new internship to train a Ugandan physician-scientist to lead the research.
“Things have improved since when I was a student to now,” Niyonzima said. “The Hutch has helped keep people at the UCI.”
Still, as a medical doctor with a master’s in global health and soon a doctoral degree, he could go anywhere. Why back to Uganda?
A big reason is family: Homesickness for his extended family, friends and Uganda’s reliable sunshine pulls Niyonzima, the youngest of seven, back home.
But so does something else.
“I think ‘How much closer can I bring Uganda to something like this?’” he asked, waving a hand to take in the Hutch campus. “It’s still my overriding goal to improve health care in Africa.”
Mary Engel is a former staff writer at Fred Hutchinson Cancer Research Center. Previously, she covered medicine and health policy for the Los Angeles Times, where she was part of a team that won a Pulitzer Prize for Public Service. She was also a fellow at the Knight Science Journalism Program at MIT. Follow her on Twitter @Engel140.