A case study in best practices, Rwanda’s commitment to cancer treatment demonstrates how a state can utilize private resources while safeguarding national ownership.
by Darja Djordjevic
Darja Djordjevic, now a postdoctoral fellow in the Weatherhead Scholars Program, worked as a MD/PhD student in the Burera district of Rwanda and in Kigali during 2010–2015 when she was a Graduate Student Associate at the Weatherhead Center. As a medical volunteer, she worked directly on the pilot cervical/breast cancer prevention program in Burera, which was developed through a transnational partnership between the Rwandan government and Partners In Health, an NGO based in Boston. Her ethnographic fieldwork contributes to the yet nascent anthropology of cancer in contemporary Africa.
Last summer, two major pharmaceutical companies, Pfizer and Cipla, reached an agreement to sell sixteen standard chemotherapy drugs at very low cost (purportedly only slightly higher than the manufacturing cost) to six African countries: Rwanda, Uganda, Ethiopia, Kenya, Tanzania, and Nigeria.1 This negotiated deal also included a plan for top American oncologists to simplify cancer treatment protocols, which an IBM team would then make available through an online, open-access tool.
This development signaled an important moment in the politics of global health, one of growing awareness and advocacy around cancer in Africa and the Global South. While this particular deal was a positive and overdue development in the battle long-fought by care providers across the world who look after poor people with cancer, we have to wonder for how long such a deal will last, alongside other pressing concerns. Further, how does this initiative fit into the broader political economy of a profit-driven pharmaceutical industry always in search of new markets, with Africa being a potentially massive one?
Although there are more deaths in Africa from infectious diseases than noncommunicable diseases (NCDs) such as cancer, cardiovascular diseases, or diabetes, the prevalence of NCDs overall is quickly rising. It is projected that NCDs will cause nearly three-quarters as many deaths as communicable, maternal, perinatal, and nutritional diseases by 2020, and surpass them as the most common causes of death by 2030. Furthermore, current projections suggest that by 2020 the largest increases in NCD mortality will occur in Africa, in addition to other regions of low- and middle-income countries.2
It is not just NCDs in general that are becoming more prevalent. More specifically, cancer incidence rates are rising too, and predominantly in low- and middle-income countries. The World Health Organization (WHO) has stated that without swift action, the global number of cancer deaths will increase by approximately 80 percent by 2030, with most occurring in low- and middle-income countries. More than half of new cancer cases and about two-thirds of cancer deaths occur in low- and middle-income countries, while only 5 percent of global cancer resources are spent there.3 The Centers for Disease Control and Prevention (CDC) has noted that about 95 percent of the North American population is covered by cancer registries compared to about 2 percent of the African population.4
My doctoral research, and now my work as a postdoctoral fellow in the Weatherhead Scholars Program, examines how Rwanda has been building a national public oncology infrastructure, and with what effects. I initially visited Rwanda following the completion of my first year of medical school, in the summer of 2010. During that first stint, I witnessed and participated in the nascent delivery of public oncological care. This took the form of a breast and cervical cancer prevention campaign, launched by the Ministry of Health in collaboration with Partners In Health (PIH), a Boston-based NGO already substantially engaged with public health sector infrastructure and care delivery in Rwanda. In 2012, these partners and others inaugurated the Butaro Cancer Center of Excellence, Rwanda’s first public cancer center, nestled in the hills of northern Rwanda near the border with Uganda. Since then, thousands of patients have received treatment and palliation there; clinicians at the center treat about 1,700 patients every year.5
From the beginning, the center has been the product of significant transnational private-public partnerships and collaboration. Notably, it is both Rwandan physicians and American clinicians—some of them fresh out of residency at Harvard’s hospitals—who deliver care there and manage both the inpatient ward and outpatient clinic. The Ministry of Health continues to work closely with its transnational partners to develop specialty training programs for Rwandan physicians in all the clinical fields that cancer care demands. To date at Butaro, chemotherapy has been paid for by PIH, and on a monthly basis the organization selects a panel of approximately twenty patients whom they send to Mulago Hospital/Uganda Cancer Institute for radiation therapy. Recently, the old machines there ceased to function and patients have been sent to a center in Kenya.
What policy insights can be gleaned from Rwanda’s public oncology program? Certainly we need to pay close attention to how the private and public are defined on the ground given the widespread prevalence of private-public partnerships for oncology in low- and middle-income countries. In Rwanda, where the central government's power is firmly consolidated, the public and the private bleed into one another. The Rwandan Patriotic Front (the ruling party, led by Paul Kagame) owns numerous private-sector companies and is a shareholder in many businesses.
There are also various forms of branding at play in Rwandan governance which impact both the private and public entities of any collaboration. Despite major private contributions from abroad (including those from academic medical centers) and heavy financial dependence on them, Rwanda produces and exercises national ownership over the oncology program in a variety of ways—to their credit. Thus, this is an essential case study for understanding how the development of oncology might proceed in similar postcolonial contexts, and it reveals how innovation and experimentation are built into any private-public partnership. The Ministry of Health determines physician staffing at Butaro and at the few other hospitals that comprise the national cancer care infrastructure. Rwandan civil servants and clinicians also regularly take the lead at multilateral meetings featuring various international partners and are unequivocal about national agendas being homegrown. There is also a regular reference to the specificities of cancer epidemiology in Rwanda, and to the aspiration of becoming a clinical oncology hub for the East Africa region.
In certain respects, the program serves as a model for oncology in low- and middle-income countries, but a critical eye helps us understand the limitations and strengths of various aspects of the model, and how to apply these approaches beyond Rwanda. To offer one example: it is strategic and bold to implement oncological care in an incremental fashion as certain technologies and treatments become available. At the same time, imperfect conditions and lack of material resources mean that the application of standard treatment protocols is limited. Often care is palliative and not curative, and there are toxic exposures to things like chemotherapy, for both patients and clinicians, on a still-evolving cancer ward.
Oncology holds particular power for the Rwandan national imagination, given the technologically demanding treatments and modalities the disease (in all its iterations) warrants. Having received care at Butaro, many patients described major adjustments to how they thought about malignancy, and furthermore, a desire to educate their family and community members toward a rejection of belief in occult forces as relevant for the development of cancer. At the same time, advanced tumors often mean that treatment efficacy is quite limited, and I witnessed many patients holding on to thoughts of malicious acts of sorcery and deep currents of mistrust among neighbors and within society at large. Broad public education campaigns around cancer are as crucial as ever, but so is an enduring commitment to ambitiously expand infrastructure for timely and comprehensive oncological diagnosis and treatment. Rwanda is an African nation constructing a certain modernity through the embrace of new technologies, and this emerges from a political structure that unites private resources, nationhood, and sovereignty. This telos of “techno-modernity” is meant to pull Rwanda onto the “Enlightenment” side of an old division between those nations that embrace reason and empiricism and those that do not. The ‘techno’ in techno-modernity is reflected in various iterations of Rwanda’s agenda to become “the Singapore of East Africa.” For example, the country has renewed its effort to ramp up the quality and breadth of internet services, and develop young citizens as part of a new knowledge-based economy. It also aims to host the world’s first “drone-port” to deliver medical supplies.6
My research on the national development of public oncology in Rwanda sheds light on the challenges and opportunities of building up public oncology essentially from ground zero. My investigation has revealed pragmatic, ethical, and political issues arising from the training of oncology specialists on the ground, patient care and impact on kin, negotiation of national program agendas, and the Rwandan-American research enterprise. Finally, this project has remained faithful to an anthropological analysis of healthcare delivery within the context of Rwandan culture—attention to societal attitudes and belief systems needs to accompany all global oncology policy efforts.
—Darja Djordjevic, Postdoctoral Fellow, Weatherhead Center for International Affairs
Darja Djordjevic is a postdoctoral fellow in the Weatherhead Scholars Program at the Weatherhead Center for International Affairs. She was a Weatherhead Center Graduate Student Associate when she earned a PhD in anthropology from Harvard University and a MD from Harvard Medical School. Her research interests include global oncology; global mental health; the noncommunicable disease movement; ethics of care; history of chronic disease in Africa; transnational public-private partnerships; health equity; application of social science research to health care and systems; medical and Africanist anthropology; and the history of science, psychiatry, and medicine.
- "As Cancer Tears Through Africa, Drug Makers Draw Up a Battle Plan," The New York Times, last modified October 7, 2017, accessed February 16, 2018.
- Chapter 1: “Burden: mortality, morbidity and risk factors,” Global Status Report on Noncommunicable Diseases, World Health Organization, accessed February 16, 2018.
- “The Global Burden of Cancer,” Centers for Disease Control and Prevention, accessed February 5, 2017. See also The Globocan Project and the Cancer Mortality Database, World Health Organization, accessed February 16, 2018.
- "Doctors See Daily Success at Butaro Cancer Center," Partners In Health, accessed February 16, 2018.
- "Rwanda Chosen for World's First 'Drone-Port' to Deliver Medical Supplies," The Guardian, last modified September 30, 2015, accessed February 18, 2018; and "Star Architect Designs the World's First 'Airport for Drones," CNN, last modified October 5, 2015, accessed February 18, 2018.
- Burera district, Rwanda. Credit: Darja Djordjevic
- Most frequently diagnosed cancers worldwide, by country and sex, 2008. Credit: World Health Organization
- Outpatient oncology clinic, Butaro Cancer Center of Excellence. Credit: Darja Djordjevic
- A family member naps near the chemotherapy preparation area on Butaro’s inpatient oncology ward. Credit: Darja Djordjevic
- A man walks through Rusumo (administrative cell) near Butaro Hospital, in the Burera district. Credit: Darja Djordjevic