Stark Realities in Zambia
An American cancer survivor's visit to a Southern African nation reveals how doctors are adapting cancer care to meet an overwhelming need.
Story and photos by Cynthia Ryan
Zambia has the second highest incidence of cervial cancer in Africa.
On a summer day in Zambia’s capital, Lusaka, I stood by helplessly as a young woman struggled to communicate why she had come to the University Teaching Hospital, the largest medical facility in the country. The intensity of her pain was agonizing to watch, as it rose from her abdomen to her chest, escaping momentarily through a series of whimpers. Lying alone in a sparse, dimly lit room marked simply “side ward,” she was isolated from the other 28 beds outside the door, most occupied by women who had ventured some distance across this Southern African nation to be treated for cancer or who were simply too sick to return home between treatments.
“She is 36 and has two children, but her husband divorced her when she got sick,” Amy Sikazwe whispered to me as we crept out of the room. A breast cancer survivor since 2005, Sikazwe now works as the publicity secretary for Breakthrough Cancer Trust Zambia, founded in 2001 to educate women about early detection and prevention of breast and cervical cancer.
Sikazwe offered to take me, an 18-year survivor of breast cancer from the U.S., on one of her frequent visits to the women’s cancer ward, which Sikazwe’s organization established at the hospital in 2002.
I learned that although the nonprofit had been instrumental in providing a place for female cancer survivors to seek treatment away from home, this particular woman’s story reflected many issues that the hospital couldn’t address—including the late detection of cancer in a culture where many women fear desertion if they seek care, and patients’ poor understanding of their own medical needs or treatment.
The woman before me had cervical cancer and feared that her cancer had metastasized. But as nurses attempted to gather information from her, they realized that she had little knowledge of her medical history. Now close to death, all she could say with certainty was that she had been abandoned by her husband and might never again see her children.
The woman’s plight is a familiar one in Zambia. About 3.2 million women, ages 15 and up, live in this developing nation, where cervical cancer is the most frequently diagnosed and deadly cancer in women. Among every 100,000 Zambian women, about 53 were diagnosed with cervical cancer and 39 died of the disease in 2008. By comparison, in the U.S., cervical cancer ranks 12th in cancer incidence and 13th in cancer mortality. Among every 100,000 American women, eight are diagnosed with cervical cancer and between two and three die of it each year.
But the tide may be beginning to turn, as the severity of the cervical cancer situation has spurred Zambian and American health care professionals to collaborate on innovative ways to address the problem. Today, a multipronged effort—which takes advantage of Zambia’s existing resources and honors its traditions—is aiming to help save lives. It’s a strategy that’s not unlike anti-cancer efforts in other resource-poor countries and in U.S. communities where researchers have learned that the best approaches for one group of people aren’t necessarily the most effective ones for another community.
Cervical Cancer at Home and Abroad
Now home to a population of nearly 13 million people, the Republic of Zambia was established in 1964 when Northern Rhodesia changed its name after gaining independence from the British. Located east of Angola and bordering the Democratic Republic of the Congo to the north and Zimbabwe to the south, Zambia is a diverse country. More than 70 ethnic groups bring their own languages and cultures to the nation’s fabric.
I initially left the Zambian hospital sure that the cancer challenges in Zambia are vastly different from ours at home, with cervical cancer a prime example. The progress made against cervical cancer in the U.S.—where deaths have plummeted by 70 percent since the 1940s—is one of the biggest success stories in American health care. But it’s not a story that is universal.
Since the introduction in 1943 of the Pap test, which can identify precancerous lesions on the cervix, prevention and early detection of the disease have been the norm among American women. According to the U.S. Centers for Disease Control and Prevention (CDC), in 2008, 75 percent of American women 18 and older had a Pap test within the prior three years. And since 2006, availability of the HPV vaccine—which can prevent the viral infections that cause most cervical cancer—has promised to continue to reduce cervical cancer diagnoses and deaths in the U.S. But developing nations like Zambia currently lack the financial means and infrastructure to make Pap tests and HPV vaccination widely available.
In fact, by any measure of health and health care, the differences between Zambia and the U.S. are stark: Zambia is one of many African countries with a high incidence of HIV and AIDS, with an estimated 13.5 percent of the adult population living with the disease, according to the World Health Organization (WHO), compared with the U.S. rate of less than 1 percent. Average life expectancy among Zambians is 48 years, while Americans can expect to live an average of 79 years, according to WHO data. And infant mortality in Zambia is 69 out of every 1,000 births—10 times the U.S. rate.
So it shouldn’t come as any surprise that cancer outcomes in Zambia are poor as well. Even so, when American physician Groesbeck P. Parham, a gynecologic oncologist at the University of Alabama at Birmingham, headed to Lusaka in 2004 to study the prevalence of abnormal Pap smears among HIV-positive women, a project funded by the University of Alabama at Birmingham’s Center for AIDS Research, he and his collaborators were shocked by their findings. Of 150 women seeking or receiving anti-retroviral medications for HIV, 140 exhibited cervical abnormalities. It was one of the highest rates ever reported in a population.
“Women in resource-constrained countries like Zambia were starting to live longer with HIV, thanks to anti-retroviral therapy,” Parham explains, “but they were at risk of dying of a cancer that can be prevented through early detection with a simple Pap test.”
The data were so compelling that Parham teamed up immediately with the Centre for Infectious Disease Research in Zambia, the CDC in the U.S., Zambia’s Ministry of Health and the University Teaching Hospital to establish two cancer prevention clinics in government-run public health facilities in Lusaka in January 2006.
Parham saw it as his calling to go to Zambia and remain there to help develop a comprehensive cervical cancer prevention program. “In 2005, I made a bargain with God,” he says. “I asked him to take me and put me in a place in the world where I could serve the most dispossessed women on the planet, and if he did, I would go and stay until he told me to come home.”