Cancer: Cost and causes of a killer ailment

By NIYI ODEBODE

Until 2007 when she was admitted to the Lagos University Teaching Hospital, Idi-Araba, Comfort Adio was hale and hearty. Before December that year, the 46-year-old woman had never been hospitalised. But what she thought was an ordinary sore on her right breast later became fatal. She was forced to consult a doctor, when the sore did not heal after two months of self-medication.
Her husband, Martin, said, ”We did not suspect that it was a serious illness. We thought that it was a sore that we could treat with an antibiotic.”
The woman was diagnosed with breast cancer at LUTH. According to her husband, the cancerous cells had spread to other organs. In September 2007, she decided to go to India for treatment. The 46-year-old teacher required N4m for surgery and other treatments in India. She died early 2008, while her husband and other relations were making efforts to raise the fund.
While Comfort lost the battle of her life to breast cancer, another patient, Adeola, has been bed-ridden by the ailment. She was diagnosed with it in 2008. Adeola initially took a lump in her left breast for granted because it was painless. When the lump persisted, she strolled to a hospital, where she was diagnosed with the cancer. She has been living in pain since 2009, when she began cancer treatment.
The women‘s cases typify the problems associated with cancer in Nigeria. Besides the two, the ailment, which was hitherto thought to be foreign, had claimed lives of prominent Nigerians. Such people included a Lagos-based lawyer, Chief Gani Fawehinmi; a broadcaster, Mr. Yinka Craig; a popular musician, Mr. Sunny Okosuns and recently, the wife of a former military president, Mrs. Mariam Babangida, who died of ovarian cancer in a United States hospital.
These eminent Nigerians died abroad after unsuccessful treatments. Some of them, particularly, Fawehinmi, were forced to seek foreign treatments, when their conditions were misdiagnosed in the country.
Cancer patients are a pitiful sight to watch when they are in agony. A consultant oncologist at LUTH, Dr. Remi Ajekigbe, said, ”There is no pain as worse as cancer pain. It is the worst pain anybody can have.”
The World Health Organisation estimated that 7.6 million people died of cancer in 2005 globally. It stated that there were 100,000 new cases annually. The world body predicted that the figure would increase to 500,000 as from 2015.
Currently, Nigeria does not have a national cancer registry. There are no reliable data on the prevalent rate of the ailment. What the country relies on are hospital-based statistics. There are, however, indications that hospitals are seeing more cases of different types of cancer.
Ajekigbe, who confirmed this, said, ”There are increasing cases of cancer all over the world. As Nigeria is also part of the world, there is increase in the country. Here in LUTH, if we compare what we are seeing now to what we used to see in 1980s, there has been a 25 per cent increase.”
Also, studies in Ibadan showed that there had been an annual incidence of 10,000 cervical cancer cases in the South-Western part of the country.
What are the reasons for the increasing cases of cancer? One of the reasons is the increase in the level of awareness. More Nigerians, particularly, the educated, now go to hospitals for treatment rather than dying at home.
Medical experts, including Ajekigbe, said that there had been an increase in the level of awareness. Ajekigbe also said, ”We are getting more westernised. We are doing everything the Western way. We are changing our diet and importing virtually everything, including foreign diseases.”
In spite of the increase, cases in hospital may be a tip of the iceberg as cancer screening centres are not in many parts of the country.
While the Federal Government in 2009 directed its tertiary hospitals to set up screening services for breast, cervix and prostate cancers, these are not available in many secondary and primary health facilities. Where facilities are available, only a few Nigeria go for check-ups.
The Coordinator of the National Cervical Control Prevention Programme, Dr. Kin Egwunomwu, at the inauguration of the organisation in Lagos, said that some groups that were offered opportunities of screening rejected them.
Narrating his experience, he said that a church did not allow its members to undergo free cervical cancer screening, when his organisation went there. ”What we often hear from such organisations is ‘God forbid. It is not our portion,” said Egwunonwu, who is also a reverend.
Corroborating the cleric, Ajekigbe said that most cases of cancer in Nigeria were presented late. He said, ”Cancer of the inner parts of the body may not be detected early because it affects parts that are not seen. But the cancer of the outer part can be detected early. Our people report late. They say they are bewitched. They go to native doctors and pastors. They come to hospitals as a last resort.”
Also, the Coordinator of Cancer Control Programme of the Federal Ministry, Dr. Patience Osinubi, stated, ”30 per cent of cancer cases are preventable and 40 per cent are easily detectable in the pre -malignant stages.”
She, however, noted, ”Many cases of cancer are presented to hospitals at advanced stages when effective intervention is not possible. This has been one of the major reasons for the high mortality rate.”
Even when cases are diagnosed, does Nigeria have enough facilities to treat the ailment. Investigations show that currently, Nigeria has five radiography machines to serve a population of 140 million people. A radiotherapy machine is a major instrument for the treatment of cancer. A linear accelerator, an advanced form of radiography, costs N1bn, including the funds for the building and accessories.
The hospitals that have functioning radiotherapy machines include, LUTH; the University College Hospital, Ibadan; Eko Hospital, Lagos; Ahmadu Bello University Teaching Hospital, Zaria and the National Hospital, Abuja.
The five radiotherapy machines are not evenly spread in all the six s zones of the country. Three are in the South West, while one each is in the Federal Capital Territory and North Central.
Osinubi, ”In Nigeria, an average of one linear accelerator per 20 million is available when compared to 3.4 and 8.2 radiotherapy machines per million population in the United Kingdom and the United States of America respectively.
Besides radiotherapy, other treatment options available for cancer patients in Nigeria include, surgery, chemotherapy, and hormone therapy.
Management of cancer is multi-disciplinary. This, a consultant radiation oncologist at the UCH, Dr. Atara Ntekim, in an interview in Lagos, said was one of the reasons why the treatment was expensive.
Explaining treatment options in Nigeria, Ajekigbe said, ”Before anybody can be said to have cancer, the growth in any part of the body is taken by a surgeon and passed to a pathologist, who examines it under a microscope and give a written conclusion on the type of cancer the person has.” He added that the surgeon could remove the growth after diagnosis.
Other method of treatment is chemotherapy, which involves the use of chemicals that kills cells. ”They kill both cancer and non-cancer cells,” stated Ajekigbe.
The use of hormone therapy is common in cancer that is hormone -dependent. According to Ajekigbe, ”When we are treating any cancer that is hormone -dependent, we attack the hormone which the cancer feeds on. In breast cancer treatment, we give anti-estrogen hormone.”
With only five radiotherapy centres available in the county, it is obvious that the treatment of cancer is not accessible to Nigerians. Ajekigbe said that a cancer patients needed about N10m a year complete his or her treatment in Nigeria.
With 70 per cent of Nigerians living below $1 (N146) a day, most people cannot pay for the treatment from their incomes. This is compounded by the fact that the National Health Insurance Scheme, which currently covers about three million Nigeria, does not fund cancer treatment. It only covers cancer screening as well as mastectomies and prostatectomy for breast and prostate cancers.
The coordinator of the cancer control programme acknowledged this in an email sent to our correspondent. Osinubi said, ”Cancer treatment is expensive to treat any where in the world. In Nigeria, the challenge facing patients is the inability of the National Health Insurance Scheme to fund cancer treatment.”
A mammogram (an X-ray of breast cancer) goes for N3,000 - N5,000 in public hospitals in Nigeria, where the minimum wage still remains N9,500 a month.
Cancer patients normally undergo CT scan or a magnetic resonance imaging to detect organs that have been affected by the ailment. A CT scan costs between N30,000 and N40,000. An MRI, an advanced form of a CT scan, costs about N80,000 for just a part (chest for example). A patients may be required to do an MRI of three parts (the head, chest and abdomen).
Ajekigbe disclosed that a patient would require between N500,000 and N12m for chemotherapy ;and N2.5m for hormone therapy in a period of five years.
Cancer drugs are expensive considering the income an average Nigerian. For example Adriamycin, a breast cancer drug is N2,000 per bottle. Another breast cancer drug, Eprirubicin, meant for breast cancer patients with heart problem, costs N10,000 per bottle.
Investigations show that a mastectomy, which is the removal of a cancerous breast through surgery, costs about N50,000 in the country. A breast cancer patient that requires radiotherapy through a linear accelerator should be prepared to pay N100,000. A cervical cancer patient would pay N50,00 more. Chemotherapy costs an average of N100,000 per course of treatment.
The high cost of treatment is compounded by dearth of manpower. Treatment of cancer requires a multidisciplinary approach. Experts needed for treatment include surgeons, pathologists, physiotherapists, oncologists.
In the country, total number of oncologists is less than 100. A consultant oncologists, Ajekgbe, who conformed this, said, ”There are 20 consultant oncologists and 40 others that are at different levels of training.”
Also, the coordinator of government cancer control programme, stated, ”For a country of 140 million population, there is a shortage of trained personnel like radiation oncologists, therapy radiographers, medical physicists and oncology and palliative care nurses. As at the last count, three years ago, there were about 27 qualified radiation oncologists, eight medical physicists and 14 oncology nurses.”
With the high cost of treatment, does cancer afflicts the rich alone? Experts, including Ajekigbe and Ntekim, said that it was common in both the rich and the poor.
According to Ajekigbe, ”There are some cancers associated with being poor. An example is cancer of the cervix. If a girl is pretty, but comes from a poor home, she may use her beauty to get what she wants. This may lead to her being loose or promiscuous, thus exposing herself to cancer of the cervix.
”Also, a rich person, who can afford certain things like food that is rich in high cholesterol may expose himself to cancer. He may shun local foods which can protect him against cancer of the colon..”
Besides these, some habits such as smoking and drinking alcohol may also predispose people to cancer.
Explaining further, Ajekigbe said, ”You cannot place your finger on a cause when you are talking about cancer, but there are factors that predispose one to it. For example, if your parent has certain cancer, you have a higher chance of having it than a person, whose parent does not have it.”
Experts said that Nigeria had facilities for the treatment of cancer. The major hindrance, however, is that they are few. Also, there are late presentation of cases, uneven spread and the high cost of treatment.
Ajekigbe explained why some Nigerians travelled abroad to treat cancer. He said, ”We normally do not refer patients abroad. But if a patient says we should refer him abroad, we do that. But we do not on our own refer patients abroad.”
On referrals, Osinubi said, ”The advantage of going abroad is the availability of several choices of cancer treatment centers. But Nigerian patients still have to pay a lot of funds except they have dual citizenship making them eligible for national health schemes.
”Only the rich, as has been observed in Nigeria, can go abroad for treatment. The outcome of their treatment will be the same unless the cancer is detected early.”
Explaining reasons for misdiagnosis of cancer, she said that it was not peculiar to the ailment. She said, ”Several diseases have similar presenting symptoms. A patient‘s diagnosis also depends on the level of competence of the medical facility he visits.”
With more Nigerians coming down with cancer, the Federal Government has intensified efforts to combat it. The government is partnering with organisations such International Atomic Energy Agency, Vienna to fight cancer.
Osinubi said, ”The partnership with the IAEA is called Programme of Action on Cancer Therapy. Within the next eight years, nuclear medicine equipment, which can diagnose cancer efficiently ,and linear accelerators, will be available in federal tertiary hospitals in all the six geopolitical zones.” The government has already paid the first $2m to the IAEA as part of the counterpart fund for the programme.
Government‘s efforts as laudable as they may be, experts and non-governmental groups said preventive measures should be intensified. The Executive Director of the African Tobacco Control Regional Initiative, Mr. Olufemi Akinbode, disclosed that only Osun State and the Federal Capital Territory had passed bill on smoking.
According to him, the bill is still in the second reading in the National Assembly. Akinbode said that tobacco-related cancer accounted for 30 per cent of cancer deaths globally.
Chronic Human Papilloma Virus can cause cervical cancer. It can be prevented through the administration of HPV vaccines. The National Cervical Cancer Control Policy states that girls from the age nine-years should be eligible for the vaccine. Adults can also get it.
The implementation of the programme is yet to start fully. But, Osinubi said, ”The Federal Ministry of Health is trying to get Global Alliance for Vaccines and Immunisation‘s assistance to procure the vaccines at an affordable cost to sustain its inclusion in the National Programme on Immunisation.”
While Nigerians await the full implementation and success of government‘s anti-cancer measures, who will tame the rampaging monster?

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Letting Loose From The Law

By Banji Adisa

THE report was not supposed to amuse anybody, but that is what it instinctively did. Osun lawmakers had just passed a bill prohibiting smoking in public places - to protect non-smokers from the dangers of smoking. In fact the idea is not novel, neither is it exclusive to the state government because a similar legislation is gathering dust in the archives elsewhere. Looking at the workability of the Osun law, however, the story was unambiguous that the effectiveness of the law is in doubt as the government had not established a mechanism to ensure compliance. That is the crux of the matter, as well intentioned as the law may be.

Taking a cue from global experiences, local environmental rights activists have long engaged the tobacco companies operating in the country in a serious battle aimed at the firms' taking responsibility for health hazards they may bring to bear, directly or indirectly, on the citizens. That at least shows the great danger smokers expose themselves to, more importantly the risk passive or non-smokers face in an uncontrolled smoking environment. (Remember the case of the late legal icon, Chief Gani Fawehinmi, whose terminal illness was linked to inhaling excessive smoke during his confinement in prison in the heady days of his struggles for justice and social order? He never smoked, but the advocate of the masses had to contend with a fatal lung ailment).

Against this background, the action of the lawmakers was perfectly in order. But who will obey this law, or rather who will enforce it, considering the capacity of the average Nigerian to resist change - someone says it is natural - or to break such laws that seemingly curtail freedom, with impunity. So, who shall we send to bring the intended sanity to our society, not only on smoking but on other equally important social disorders this piece will soon touch.

Nigerians are an enterprising lot, they travel a lot; they can be found in almost every corner of the globe. It is curious that while they disregard such protective laws here, as soon as they step out of the country's shores, they obey without complaints similar legislations in foreign lands.

I recognize that any adult above 18 years is free in most countries to buy and smoke cigarettes, of course with health warnings clearly marked on the packs. There are also designated spots within cities, outside of one's home environment that is, where smokers are allowed to do their thing. That was my experience in Japan last year. The rule is simple: just move into the cubicle out there and satisfy yourself in the midst of fellow smokers). This is sensible enough, I think.

Here, the norm is that every inch of space in a public place is available to puff the choking smoke even if it is discomforting to other people. But because of non-compliance with set rules, the only option open to non-smokers is to walk away with style even though you have every right to be there like your tormentor. A smoker with a poor orientation hardly takes to correction no matter how polite. You would only be lucky if he doesn't pick a quarrel on account of his correction.

Smoking is not the only area an average Nigerian is guilty of anti-social behaviour. There is a ban on the use of siren in the traffic except by ambulances, security patrols in emergencies and certain categories of public officials. That is as far as it goes; nobody listens. Bullion vans, pilot vehicles of 'big men', private individuals and commercial motorcyclists (okada riders) are unrepentant culprits. Surprisingly, road safety escort vehicles are not exempted as witnessed on the Apapa-Oshodi expressway this Monday evening (the mad rush along that axis is always en route the airport to catch a flight). But then which ordinary law enforcement agent will stop the mad fleet of vehicles in the traffic with armed escorts in tow? This society is sick.

There was a sigh of relief the other day the FRSC banned riding on a motorcycle by the driver or the passenger without a safety helmet. Not only that, it became an offence to carry more than one passenger. My people, oh my people! They needed only a few weeks of compliance with the traffic law. Now, it's back to business with two passengers and without the protective helmets, done even with the encouragement or active connivance of passengers themselves. You then begin to wonder whether the people have any sense of value for their own safety.

Of course it is more money for the okada man and the ubiquitous uniformed men in black (did you get my drift) and certain touts from the local councils who present as law enforcement agents? The longer an okada man stays on the roads after the allowed limit of 10 p.m - for security reasons - the more cash for the uniformed men at the toll points. That is another example of a brazen breach of the law. The okada man is ready to take the risk to breach the law to charge a higher fee, assured that workers would always be stranded for lack of functional transport system. Among other dysfunctions, that is a legacy of men of the past, leaders without vision who cared less about the people they govern. Who shall we send then to effect the change we don't believe in?

It is easier for residents of a city to dump refuse right under a signpost indicating 'don't dump refuse here' and even attack sanitation officials in spite of possible sanctions. Vehicles can be parked illegally against designated points. In Abuja, the Directorate of Road Traffic services arrests an average of 140 vehicles weekly for illegal parking, in spite of road signs indicating otherwise.

For as long as anybody could remember, police Inspectors-General have been mouthing 'no more checkpoints' seen by the public as toll collection centres by officers and men. The IG emphasises motorized patrols. That is not a law in the real sense but the rule has variously been abused over time. Only a fool would think that senior officers at the desks are unaware of the deployment of their men on any particular day?

Our children are supposed to be protected to a great extent under the Child Rights Abuse laws. But this has been so ineffectual in as many states that have passed them, including at the federal level. Whether it's ignorance by parents or guardians, have the laws stopped an army of children hawking on the streets, being offered for prostitution or being subjected to physical abuse by wicked guardians? Has the abuse stopped marrying out children in some parts of the country through some funny cultures?

Prostitution is supposed to be an outlawed trade among women. Are the makers of our laws immune to patronage of the ladies of the night? The women feel so secure paying dues to some law enforcement agents in return for protection. Some officers might even be patrons of the women of easy virtues. Regrettably, the country's prostrate economy has not made matters any better for women, including female students who have been accused by the professionals of taking a good chunk of their means of livelihood.

In public hospitals in Lagos where the government has done a lot to assist patients believed to be resident tax payers, it is against the law to charge illegal fees. But a friend whose wife was in labour at a General Hospital in Isolo area narrated an ugly experience of having to pay for mundane items like detergents, gloves and what have you to get attention from the medical personnel. What a load of rubbish is this? Well, he had no choice in a matter of life and death, where some people think they hold the ace.

A lecturer in the university who charges illegally for handouts or forces students to pay for a book he managed to piece together as a survival instinct is not doing the society and the struggling parents (or students) any good. So it is for a traffic officer who extorts money from offending commercial drivers to escape the law. The list is endless.

Corruption is the bane of this society. It is hard to divorce the habit of breaking laws from corruptive tendencies of law enforcement agencies. The day that is taken care of, there is a likelihood the society would get better. It would require a lot of re-orientation though, preceded by a reordering of societal values. The awareness has to be there. But who shall we send, as we are all guilty one way or the other as law breakers?

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