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(New York Times) As Cancer Tears Through Africa, Drug Makers Draw Up a Battle Plan

Posted by: Biniam Tekle

Date: Monday, 09 October 2017

As Cancer Tears Through Africa,
Drug Makers Draw Up a Battle Plan

In a deal similar to the one that turned the tide against AIDS, manufacturers and
charities will make chemotherapy drugs available in six poor countries at steep discounts.

    By DONALD G. McNEIL Jr. 

NAIROBI, Kenya — In a remarkable initiative modeled 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 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 H.I.V. drugs, many of them thanks to American aid.

“It’s exactly what we went through then,” Dr. 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 450,000 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 tumors.

But here they are often lethal. In the United States, 90 percent of women with breast cancer survive five years. In Uganda, only 46 percent do; in Gambia, a mere 12 percent do.

Cancer wards at Mulago Hospital in Kampala, Uganda. Cancers in most of Africa are more lethal than in the West. In the United States, 90 percent of women with breast cancer survive five years; here, only 46 percent do. CreditCharlie Shoemaker for The New York Times
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Patients receiving chemotherapy at Mulago Hospital. In a breakthrough, two major pharmaceutical companies will work with the American Cancer Society to drastically reduce the price of cancer medicines in six African countries, including Uganda. CreditCharlie Shoemaker for The New York Times

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 organizer of the deal.

“There’s nothing like that in Africa — but I can save a child with leukemia for $300. That’s a disease that has a 90 percent cure rate in America, and a 90 percent death rate in Africa.”

An Ill-Prepared Continent

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. Tumors are often misdiagnosed or even blamed on witchcraft, and 80 percent 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 tumors 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.”

Brenda Nakisuyi, who has Burkitt lymphoma, at Kawempe Home Care in Kampala.CreditCharlie Shoemaker for The New York Times

Many Africans who get cancer assume they are doomed.

“I came here to see if I was condemned to death,” said a wry George Odongo Ogola, 73, a retired high school principal being treated for prostate cancer at the M.P. Shah Hospital in Nairobi.

“But the doctor says they got it in a nascent stage and gave me a 99.9 percent chance that it will be contained,” he added. “I brought all my children and their wives so they could hear this. Here, once you are diagnosed with cancer, they treat you like a dead person.”

Even doctors — especially rural ones — may be slow to recognize the disease.

Paul Mugumya, a lively 7-year-old in the Kawempe hostel, had three hernia operations before surgeons realized that something else was swelling his abdomen, which now has a football-shaped tumor with tangerine-sized blisters on it.

And Flavia Anyesi, 4, who stood in her crib at the Uganda Cancer Institute in pink and white hair beads matching her pink nightgown, was first sent to a dentist to have a tooth pulled, said her mother, Teopista Nafuna.

Only when Flavia’s jaw kept swelling did doctors realize something else was amiss. She, too, has Burkitt lymphoma.

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.

Continue reading the main story
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Flavia Anyesi, 4, at Mulago Hospital in Kampala, Uganda, has Burkitt lymphoma. She was first sent to a dentist to have a tooth pulled, but continued swelling in her jaw indicated to doctors that something else was wrong. CreditCharlie Shoemaker for The New York Times

“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 tumor 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.”

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 Ms. 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.


Photo
At the Cancer Charity Foundation in Kampala, Flavia Nabwire tended to her mother, Proscovia Mutesi, who lost an eye and part of her jaw to a growing tumor she has battled for seven years.CreditCharlie Shoemaker for The New York Times

Counterfeit Drugs

Almost everywhere in Africa, cancer drugs are in scarce supply, and prices remain a huge obstacle.

Small orders mean hospitals pay more per vial and often must settle for whatever brands are available, sometimes even those smuggled in by what is bitterly called “donkey import.”

Currently, the W.H.O. does not certify which brands of cancer drugs are safe and effective, as it does those for AIDS and malaria.

“In terms of quality, you cannot tell for sure, you just trust,” said David E. Wata, an oncology pharmacist at Kenyatta, the country’s top public hospital.

Africans with the means usually seek treatment in India or South Africa. Those with political connections sometimes go at government expense, draining national treasuries.

The poor must fend for themselves. If the shelves of public hospital pharmacies are bare, patients and their families seek out private ones, which may carry low-quality drugs or counterfeits.

“There’s nothing more tragic than seeing a family spend everything they have and get nothing,” Dr. O’Brien said. “Sometimes the first sign that it’s not working is that they don’t lose their hair.”

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 percent of our current oncology budget. So we are really, really grateful for a chance to get better quality at a better price.”

Continue reading the main story
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Medical staff in the solid tumor ward of the Uganda Cancer Institute at Mulago Hospital in Kampala.CreditCharlie Shoemaker for The New York Times
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Medical records archived at the Uganda Cancer Institute. CreditCharlie Shoemaker for The New York Times

Drugmakers’ attitudes toward helping Africa have changed since the late 1990s, when Western companies were pilloried for refusing to lower prices on their AIDS drugs as millions here died.

Now nearly all companies offer a combination of donations and “tiered pricing,” under which they charge poor countries a small fraction of what they charge rich ones — but impose safeguards to prevent smuggling of their products into wealthy markets.

Companies compete to rise higher on the Access to Medicines Index, which ranks them on how well they do at getting their products to the world’s poor.

John Young, president of Pfizer’s essential health group, said the price-cut deal differs from Pfizer’s charitable donations, like the 500 million antibiotics doses it provided to help eliminate the eye disease trachoma.

“The challenge of pure philanthropy is that it’s not infinitely sustainable,” Mr. Young said. “We expect to make no money on this — but we also don’t want to lose money.”

The company will charge enough to cover just its manufacturing and packaging costs, not those related to research, marketing or advertising, he said.

Cipla’s prices, said Dr. Denis Broun, the company’s head of governmental affairs, will be as low as one-eighth of what it charges for generics in the United States. The company hopes to start making cancer drugs soon at its factories in Uganda and South Africa, he added.

A Strategy for Poor Nations

Cipla has a long tradition of serving poor countries. In 2001, its chairman, Yusuf K. Hamied, shocked the global pharmaceutical industry by offering a triple-therapy AIDS cocktail for $350 a year to Doctors Without Borders at a time Western companies were charging $12,000.

That offer set off a price cascade that in turn led to the creation of donor agencies like Pepfar and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

The current deal started taking shape two years ago, when Dr. O’Brien, an epidemiologist and palliative care expert, convinced the leadership of the American Cancer Society to give the Clinton Health Access Initiative a grant to study the market and approach pharmaceutical companies.

The initiative, known as CHAI (pronounced “chy”), is largely independent of the better-known Clinton Foundation, though Mr. Clinton and his daughter, Chelsea, are on its board.

Foreign donations to the foundation while Hillary Clinton was secretary of state raised questions of conflict of interest during her presidential campaign. Had Mrs. Clinton won, the family and former White House staffers would have resigned from CHAI’s board, and it would have dropped the Clinton name.

For several years, Dr. O’Brien was chief of H.I.V. mathematical modeling at CHAI.

Continue reading the main story
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A view of Kampala from inside the Uganda Cancer Institute at Mulago Hospital. The country has only 16 oncologists, and its only radiotherapy machine has been broken for more than a year.CreditCharlie Shoemaker for The New York Times
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Patients in the solid tumor ward of the Uganda Cancer Institute. Oncologists are so scarce in most of Africa that they cannot specialize and must learn to treat every type of cancer. CreditCharlie Shoemaker for The New York Times

CHAI has not previously worked in cancer, but the organization has long experience negotiating low prices for drugs and vaccines for poor countries, finding donors to pay for them, and overcoming obstacles like red tape, corruption and shortages of refrigerated trucks to ensure delivery.

Other drug makers will eventually be asked to consider selling other chemotherapy drugs, the initiative’s chief executive, Ira C. Magaziner, said in an interview. The first 16 to be made available now are those most urgently needed.

Mr. Magaziner feared that having too many suppliers at first could mean that all would lose money if the initial orders were small.

“It’s very early days, so I don’t want to say we’ve accomplished much yet,” he said. “But we will accomplish things that are significant. It’s going to be at least a 15-year battle to get treatment close to Western standards.”

Dr. Peter Mugyenyi, whose AIDS clinic in Uganda was a model for Pepfar, called the deal “revolutionary.”

In 2001, Dr. Mugyenyi risked arrest under Uganda’s patent laws by importing cheap AIDS drugs from Cipla. Two years later, he stood at Laura Bush’s side during the 2003 State of the Union address as Mr. Bush described his Pepfar plan to Congress.

“I can only compare this to that breakthrough,” Dr. Mugyenyi added.

Overwhelmed Oncologists

A novel aspect of the deal is its attempt to overcome the severe shortage of oncologists.

Oncologists in Africa cannot specialize; each must treat bone cancer, cervical cancer, leukemia, and so on. But every treatment protocol is many pages long — together they are far more than any doctor can memorize.

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After she broke her right arm playing at a school for the blind, doctors realized that Charity Natukunda, 10, had bone cancer and amputated the limb. Staffers at Kawempe Home Care said her father had declined to send money for chemotherapy, saying he needed it for her burial costs. CreditCharlie Shoemaker for The New York Times

So Dr. 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.

Members are now splitting those guidelines into four tiers for hospitals with different capabilities, said Dr. Robert W. Carlson, the network’s chief executive.

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.

Members welcomed the chance to help, he said, because many African doctors do their oncology residencies in the United States or Europe and then stay, depriving their home countries of their skills.

“One big reason for the brain drain is that doctors get burned out and frustrated, because they can’t provide the care they know they should,” he said. “This should improve morale.”

IBM is helping by taking those guidelines and folding them into its Watson supercomputing program.

Like tax-preparation software, it asks questions based on entries like symptoms, lab results, biopsy results and so on, and then generates the best treatment regimen possible with the hospital’s resources. The program also scans medical journals to update itself without human help.

Continue reading the main story
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Ratibu Asiligwa, 10, with his mother Jackline Kabeye, 33, at the Kawempe facility, receives chemotherapy and takes morphine to alleviate the pain from his rhabdomyosarcoma, a cancer of skeletal muscle cells. Even as drug treatments get cheaper and more accessible, experts warn that progress against cancer in Africa will be slow.CreditCharlie Shoemaker for The New York Times

Slow Progress

Even with cheaper drugs, progress against cancer in Africa will be slower than it was against AIDS, all parties to the deal warned.

AIDS is caused by a single pathogen that can be suppressed, albeit not cured, with a daily three-drug pill.

Cancer — out-of-control multiplication of the body’s own cells — comprises an entire family of diseases. Treatment often entails surgery, radiation and chemotherapy involving complex mixes of drugs.

Kenya offers a glimpse at the possibilities.

Its national health insurance plan, which charges annual premiums of $18 to $200 depending on income, began covering cancer only two years ago. Now, about 8 percent of its payouts are for the disease.

Three years ago, patients could wait 18 months for radiotherapy at Kenyatta National Hospital, the only one poor people could afford; many died waiting. Now, with insurance covering radiation in private hospitals, the wait is gone.

In Nairobi Hospital, a private institution that was once the European Hospital, Christine Kimburi, a 42-year-old property manger with 11-year-old twins, rested comfortably in a bed getting an infusion for her choriocarcinoma, a cancer of the uterine lining that erupted after a failed pregnancy.

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A sign outside Nairobi, Kenya, advertising local cancer care from the Aga Khan University Hospital.CreditJoe Van Eeckhout for The New York Times

She had surgery and is on her fifth chemo round. Her national insurance covers four rounds a year, and her husband’s covers four more.

With luck, that is all she will need. Choriocarcinoma is often curable.

“The mass they removed was not cancerous — we thank God for that,” she said. “And I’ve had nil side effects from the chemo.”

But Kenya remains exceptional.

When she first looked at treatment in Africa, Dr. 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.”

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