Until very recently, international health bodies such as the World Health Organisation (WHO) concentrated their efforts on the prevention of contagious disease, while chronic non-contagious conditions such as cancer, cardiovascular disease, diabetes, and respiratory diseases have been side-lined. Yet cancer accounts for almost 13% of all deaths worldwide, more than those caused by human immunodeficiency virus/ acquired immunodeficiency syndrome, tuberculosis, and malaria combined, and the largest mortality burden occurs in low- and middle-income countries (IARC globocan).
Even among oncologists, cancer may not be the first disease that comes to mind when thinking about the major causes of morbidity and mortality in Africa. However, it is responsible for over 715 000[1] deaths per year on that continent, and WHO has recently estimated that by 2020 there will be a million new cancer cases a year in sub-Saharan Africa alone [2]. This is a huge social and economic burden in a part of the world that has very little in the way of facilities for cancer patients, let alone the provision of the effective screening and public education programmes that could aid in cancer prevention and control.
It would be easy to be pessimistic and say that the parlous political and economic state of so many African nations means that there is little that can be done about this situation. But we only have to look at the stunning success of advocacy campaigns in high-income countries to see that big changes can be brought about via relatively simple means—organised public pressure delivering the right messages to the right people. In some African countries, advocacy campaigns have already been successful in improving cancer health education and hence prevention, and in the provision of hitherto unavailable facilities for cancer patients and their doctors. This is why four organisations—the Africa Oxford Cancer Foundation (AfrOx), the African Organisation for Research and Training in Cancer (AORTIC), the European Society for Medical Oncology (ESMO), and the Union for International Cancer Control (UICC)—have launched a ‘toolkit’ to provide an advocacy roadmap so that many more individuals and organisations can become involved in cancer advocacy in Africa.
The Non-Communicable Disease (NCD) Alliance has identified five priority actions to provide an effective response to the preventable morbidity and mortality of NCDs, including cancer [3]. These are leadership, prevention, treatment, international co-operation, and monitoring and accountability. They also call for the delivery of five priority interventions—tobacco control, salt reduction, improved diets and physical activity, a reduction in high levels of alcohol intake, and essential drugs and technologies. These interventions are not just important for their health effects, but they were also chosen because of their cost-effectiveness and low cost of implementation. They are also politically feasible to a large extent in almost every country in the world. If implemented globally, it is estimated that they would reduce NCD death rates by 2% across the world and avoid tens of millions of premature deaths in this decade alone. The WHO has called for just such a reduction [4].
While these five interventions can help with cancer control in the future, it is important to support those already suffering from chronic diseases in countries where healthcare systems are under-resourced. A particular problem of these diseases is that they require care to be given over long periods, often over the whole lifetime of the patient. This requires a completely different organisation, both from the point of view of the healthcare provider and from the patient, than that which is required for acute interventions. Well-organised, effective primary care is essential, but how often is this available in low-income countries?
This is where advocacy comes in; in addition to planning and implementing prevention programmes to change risky health behaviours, for example, community action can also appeal for primary healthcare programmes that correspond to the needs of those with chronic diseases. Many of the interventions mentioned in the toolkit are not complicated, expensive, or high-tech. In order to undertake them, all that is needed are motivated people who have done their research in order to get the right message to the right place. For example, some African advocates have worked with the media to bring about changes in national cancer policy, and developed public information campaigns on nutrition or childhood cancers. Yet others have lobbied governments for national cancer registries, or for palliative care programmes—particularly important in countries where early detection is rare and the chances of curative treatment severely restricted.
When Kenya was slow to ratify the Framework Convention on Tobacco Control, one of the members of the African Tobacco Control Consortium (ATCC) knew who to talk to in order to get things moving and the convention ratified within days. Following ratification, the next step was to pass legislation, so the ATCC set out to identify those members of parliament (MPs) most likely to vote for it. When they found that the taxation of tobacco was not included in the legislation because it was the responsibility of the Finance Ministry, they prepared an economic case for the introduction of a 10% tobacco tax.
Of course there is still plenty to be done, but what has already happened is heartening and shows what can be achieved to those who may still be wondering whether it is worth getting involved. To the question: ‘Can we really make a difference?’ the answer must be a resounding ‘Yes’!
The days when oncologists were almost solely concentrated on treatment are long past. The prevention of cancer is a global issue, and despite being a European organisation, ESMO's commitment to it is not just limited to Europe. By launching this toolkit with its partners, ESMO's Developing Countries Task Force and its Cancer Prevention Faculty are underlining yet further its duty to promote prevention [5] by trying to bring about a reduction in the incidence of cancer caused by lifestyle factors, and by identifying those likely to be at risk and screening them.
A further important step along the road of underlining the importance of NCDs was taken in September 2011, with the adoption by the General Assembly of the United Nations of a declaration on their prevention and control [6]. The declaration underlines the huge health and economic burdens caused by NCDs, most particularly in low- and middle-income countries.
A crucial next step for us is the implementation of the cancer advocacy training toolkit throughout Africa. AORTIC will lead the promotion and implementation of the toolkit continent-wide beginning in 2013 through several initiatives: (i) As a first step, AORTIC's African Cancer Advocates Consortium (ACAC) will organise advocacy campaigns based on the toolkit. There are currently over 50 active ACAC members from diverse countries in Africa. Armed with the mission to ‘Make Cancer a Top Priority in Africa’, ACAC members will effectively promote and disseminate the toolkit to advocates in Africa; (ii) AORTIC will organise a master trainer cancer advocacy workshop during AORTIC's 2013 conference in South Africa. The master trainer programme will prepare at least 25 cancer advocates as trainers who will transfer knowledge about cancer advocacy throughout Africa using the toolkit; and (iii) the toolkit will be used as the curriculum for the biennial International Workshop on Cancer Advocacy for African Countries during 2013 AORTIC conference and provided to all workshop participants. Of note is the fact that AORTIC has just completed a survey to identify other unique cancer advocacy case studies in Africa. These case studies will be published as a supplement for the toolkit and will provide a comprehensive synopsis of innovative cancer advocacy programmes throughout Africa. The toolkit supplement will be published electronically on AORTIC, ESMO, UICC, and AfrOx websites, showcasing diverse cancer advocacy activities by different organisations in Africa.
The tide is turning, but we must not lose sight of the fact that words alone are not enough—we need to ensure that African cancer advocates receive practical support for their attempts to save lives through their campaigns. Now four organisations committed to prevention have come together to aid all those who are concerned about cancer to get their voices heard in order to try to stop the runaway train of cancer in Africa. We must continue our efforts until they have achieved their goal. African cancer advocates need our help, and as oncologists, we are duty-bound to give it to them.
A copy of the Cancer Advocacy Training Toolkit for Africa can be downloaded from the following Web sites:
(ii) http://www.aortic-africa.org/images/uploads/AdvocacyToolkit(Web).pdf
disclosure
The authors have declared no conflicts of interest.
