By Donald G. Mcneil Jr, International New York Times , Oct 10 2017
In a deal similar to the one that turned the tide against AIDS, Pfizer and Cipla will make chemotherapy drugs available in six poor countries at steep
Ratibu Asiligwa, 10, takes morphine to alleviate the pain from a cancer of skeletal muscle cells, at Kawempe Home Care in Kampala, Uganda. Cancer now kills about 4,50,000 Africans a year. By 2030, it will kill almost 1 million annually, the WHO predicts.
In a remarkable initiative modelled on the campaign against AIDS in Africa, two major pharmaceutical companies, working with the American Cancer Society, will steeply discount the prices of cancer medicines in Africa.
Under the new agreement, the companies — Pfizer, based in New York, and Cipla, based in Mumbai — have promised to charge rock-bottom prices for 16 common chemotherapy drugs. The deal, initially offered to a half-dozen countries, is expected to bring lifesaving treatment to tens of thousands who would otherwise die.
Pfizer said its prices would be just above its own manufacturing costs. Cipla said it would sell some pills for around 50 cents and some infusions for $10, a fraction of what they cost in wealthy countries.
The price-cut agreement comes with a bonus: top American oncologists will simplify complex cancer-treatment guidelines for underequipped African hospitals, and a corps of IBM programmers will build those guidelines into an online tool available to any oncologist with an internet connection.
“Reading this gave me goose bumps,” Dr Anthony S Fauci, director of the National Institute of Allergy and Infectious Diseases, said after seeing an outline of the deal. “I think this is a phenomenal idea, and I think it has a good chance of working,”
It reminded him, he said, of his work in 2002 helping design the President’s Emergency Plan for AIDS Relief. PEPFAR, as it is known, has been a success: over 14 million Africans are now on HIV drugs, many of them thanks to American aid. “It’s exactly what we went through then,” Fauci said. “Finding the countries with the highest burden, figuring out how to approach treatment differently in each one, and getting the prices down.”
Cancer now kills about 4,50,000 Africans a year. By 2030, it will kill almost 1 million annually, the World Health Organization predicts. The most common African cancers are the most treatable, including breast, cervical and prostate tumours. But here they are often lethal. In the United States, 90% of women with breast cancer survive five years. In Uganda, only 46% do; in Gambia, a mere 12% do.
The complicated deal was struck by the cancer society, along with the Clinton Health Access Initiative, founded in 2002 by former President Bill Clinton; IBM; the National Comprehensive Cancer Network, an alliance of top American cancer hospitals; and the African Cancer Coalition, a network of 32 oncologists in 11 African countries.
“I have a friend back home whose daughter has cancer, and I can’t believe the outpouring of support she got, like special lacrosse games and T-shirts,” said Megan O’Brien, the cancer society’s director of global cancer treatment and the chief organiser of the deal.
“There’s nothing like that in Africa — but I can save a child with leukaemia for $300. That’s a disease that has a 90% cure rate in America, and a 90% death rate in Africa.”
As more Africans survive into middle or old age, cancer rates are climbing rapidly. But most countries here are ill-equipped for the fight.
There are few oncologists, radiotherapy machines or advanced surgical suites. Tumours are often misdiagnosed or even blamed on witchcraft, and 80% go undetected until they have spread to lymph nodes or distant organs.
Doctors often see cases far worse than Western doctors ever do: babies with growths half as big as their heads, women with breast tumours the size of softballs that have broken the skin, putrid and weeping blood.
On a recent day in July, Brenda Nakisuyi, 17, sat silent and despondent in a darkened room at Kawempe Home Care, a cancer hostel for children in Kampala, Uganda. Burkitt lymphoma had torn open her left cheek, leaving a crater that looked as if a cherry bomb had exploded in her mouth. “In our village, they know malaria, they know HIV, they know typhoid — but they don’t know cancer,” said her mother, Florence Namwase, 48. “People said Brenda was bewitched, and they began to shun her.”
Even when in agony, victims may be too poor to travel for treatment. Patients who find the money to reach urban hospitals often sleep on mats on the verandas or in parks between their daily infusions, or while waiting for biopsy results, which can take weeks.
“When you are not well and you are sleeping under trees, can you really rest in peace?” asked Proscovia Mutesi, 50, a former school secretary who has lost an eye and part of her jaw to cancer.
Sitting on the bed she recently found at the Cancer Charity Foundation, a Kampala adult hostel, she recounted a seven-year battle to slow down the tumour gnawing away her face. “I have struggled,” she said. In some years, she was able to raise $110 for a course of chemo or $85 for radiation. “But in some, I did not have a coin. And then the radiation machine collapsed.”
In a shambles
If there is little treatment, it is partly because there are so few cancer specialists. Ethiopia, one of the six countries covered by the new agreement, has only four oncologists for its 100 million citizens. Nigeria has about 40 for its population of 186 million.
Uganda’s national hospital campus boasts a cancer institute that was founded in 1967, and it has a spotless new clinical trial building erected by the Fred Hutchinson Cancer Research Center. But the country has only 16 oncologists, and its only radiotherapy machine — the one that Mutesi relied on — has been broken for over a year. Before its 21-year-old gears gave out, the machine’s cobalt source had become so weak that irradiation sessions meant to last minutes took an hour.
The 16 drugs that Pfizer and Cipla will sell have unfamiliar names like vinblastine, bleomycin and fluorouracil. They are old standbys of chemotherapy and now available as generics. “These 16 won’t be enough — they’re about half the range we need,” said Moses Kamabare, general manager of Uganda’s National Medical Stores, the health ministry’s purchasing arm.
“But in terms of value, they are about 75% of our current oncology budget. So we are really, really grateful for a chance to get better quality at a better price.”
A novel aspect of the deal is its attempt to overcome the severe shortage of oncologists. Oncologists in Africa cannot specialise; each must treat bone cancer, cervical cancer, leukaemia, and so on. But every treatment protocol is many pages long — together they are far more than any doctor can memorise.
So O’Brien also recruited the National Comprehensive Cancer Network, which brings together specialists from 27 top American cancer hospitals to write guidelines and post them on the web for use by oncologists everywhere.
In breast cancer, for example, “if you can’t do a mastectomy or use tamoxifen, you probably shouldn’t even try to treat,” he said. The next level would include tissue-sparing surgery, radiation and basic chemotherapy; a third would include reconstruction with implants and chemotherapy with monoclonal antibodies like Herceptin.
When she first looked at treatment in Africa, O’Brien said, “I was just blown away because so little attention was being paid.” “In America, since the 1960s, we’ve turned cancer from this frightening, inevitably deadly disease into something very fightable,” she added. “That human triumph has not crossed the border into Africa yet.”