“We get overwhelmed as clinicians,” said Dr. Luutu Israel “seeing patients in endless lines.”
Dr. Luutu holds up a large scan in front of a woman sitting in a wheelchair across from him in his little office at the back of the radiotherapy department at Mulago Hospital—Uganda’s National Referral Hospital. In the background, lively African pop music reverberating from a car parked outside the packed clinic, creates a sonic tension with the series of piercing monotonous beeps that burst from the radiotherapy equipment hidden away several rooms over.
Floating his fingers around the sea of sporadic dark splotches scattered across the scan, Dr. Luutu, the acting head of the department, calmly explains this image to his patient as he maps out the results of her ongoing cancer treatment before wheeling her out of his office. His assistant simultaneously ushers in his next appointment.
Cancer is on the rise in Uganda. The UN’s International Agency for Cancer Research reports that as of 2008 there are approximately 27,100 new cancer diagnoses in the country each year. According to a study by the Department of Pathology at Uganda’s Makerere University using data from the Kampala Cancer Registry, incidence rates of prostate and breast cancer rose annually by 3.7 percent and 5.2 percent respectively between 1991 and 2010. Cervical cancer—the most frequent and lethal of all gynecological cancers in the country—is also on an upward trend with a predicted 34.2 percentage point increase in incidence over the same time period.
Like many of the other cases of cancers presenting in the country, it is estimated that 80 percent of all new cervical cancer diagnoses are presented at late stages. This means patients will require aggressive treatments such as chemotherapy and radiotherapy to improve the chances of their survival or quality of life.
As the country’s cancer burden grows, so does the burden on Mulago’s radiotherapy department. With some 2,000 new patients seen at his clinic—staffed by four doctors, only two of which are radiation oncology specialists, four nurses and nine technicians—each year, Dr. Luutu is faced with a consistently tense professional obligation: He is in charge of managing the only radiotherapy machine in all of Uganda.
For many patients who have come to the clinic, the radiotherapy machine symbolizes the final stages of their cancer treatment.
“The last machine, that’s what locally people call it,” Dr. Lutuu said.
Uganda’s sole radiotherapy machine sits in the middle of a cavernous room, lit only by a small table lamp. While the main waiting room outside of Dr. Luutu’s office is filled with benches teeming with people, only three patients at a time sit outside the heavy doors separating them from the dark, L-shaped corridor that leads to the machine. The patients who wait here clutch large translucent-blue plastic bags that they will use as make-shift canopies to lie on once it is their turn with the machine.
Donated to Mulgo Hospital in 1995 by the International Atomic Energy Agency, the weathered Cobalt-60 machine “is of dubious quality.” Cobalt, the machine’s power source, is ideally replaced every five years. However, the amount of cobalt needed to power the machine comes with a price tag of several hundreds of thousands of dollars and its heavy regulation due to its other application in nuclear bombs creates big barriers to its acquisition. Even more pressing to the Mulago clinic, though, is that cobalt is constantly decaying.
“Whether you are treating patients or not it decays,” said Dr. Luutu.
Patients from neighboring countries who travel to Uganda for cancer treatment increase the already weighty burden on the Mulago radiotherapy department. According to Dr. Luutu, his clinic sees patients from countries and regions like western Kenya, South Sudan, the Democratic Republic of Congo and Burundi where the national health systems lack the appropriate equipment. But Dr. Luutu is sympathetic.
“There’s no doubt about that. There is a lot of strain onto the machine because of our neighbors,” he said, “but you can never ever chase away a neighbor, and especially if one is sick, one cannot look at them suffering and say no. It’s ethically unacceptable.”
With one rapidly aging machine subject to frequent breakdowns and a seemingly never-ending patient load, Dr. Luutu had to come up with a simple solution to avoid patients waiting for up to nine months for radiotherapy cancer treatment.
“The way out of that,” he said, “[is] we improvise a means of work: 21 or 22 hours in a day so that our patients, their waiting time, is about two weeks from the time the patient sees the doctor to the time the patient starts treatment and we are very, very proud of that, extremely proud of that. That doesn’t happen in many places [in Africa] even where they’ve got six, seven, eight machines.”
Dr. Luutu says he takes his job as “a calling,” and he believes the way forward for Uganda’s emerging cancer issue is through early detection.
“If we get a new machine that can treat say like ten patients a day that would improve our cure probability,” he said. “But the best way to [approach] either cervical cancer or any cancer is prevention, which our people in the Western world have done very, very well. That would go a very long way in reducing the incidence of cervical cancer and others.”