Global helse og onkologi

Av Elisabeth Darj, gynekolog, spesialist på fødselshjelp og kvinnesykdommer, professor i global helse, NTNU.

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Elisabeth Darj was recruited from Uppsala University in Sweden, as the first professor in Global Health at NTNU in Trondheim.

Work experiences

Since graduating from the Medical School at Umeå University in Sweden I have always worked clinically and I am an obstetrician/gynecologist. I have worked at all positions at the hospital, including being the Head of the Department of Ob&Gyn at the large University Hospital in Uppsala. Besides Ob&Gyn I have worked in radiology, anesthesiology, surgery and also in gynecological oncology. I have met many women going through radiotherapy and/or chemotherapy and I have been following them for controls or to the end.  I’m happy to say that we, in the Nordic countries, provide very good care for the cancer patients. Simultaneously with the clinical work, I have performed research in reproductive health in obstetrics and gynecology, and my focus has transferred more into women’s health in low-income settings. I defended my PhD-thesis at Uppsala University 1994, became associate professor at the university 1999 and senior lecturer at the Department of International Health. I have been teaching at the Medical School and in Midwifery and appointed as opponent at various universities. I supervise PhD- and Master students, mainly from low-income countries. Tanzania is the country I know best and I coordinate a large bilateral program in reproductive health between Tanzania and Sweden. I’m very pleased to have the opportunity to work 100% with global health now.

What is global health?

Global health is defined, as health issues that transcend national boundaries and call for research and actions to improve health for all, irrespective where we live.  Collaborative international research and action for promoting health for all. As health is influenced by politics, the society, culture and environment, solutions to health problems may be not only be within the health systems, but also elsewhere. I have already met a lot of people in Trondheim, with a strong interest of global health and engaged in different research projects at various faculties. It is important that Norway, a high-income country, contributes to this agenda. Kofi Annan, the former general secretary of UN said: In addition to the responsibilities to our own societies, we have a collective responsibility to uphold principles of human dignity and equality at the global level, especially for the vulnerable. The Millennium Development Goals have raised the awareness of the unequal and huge burden of diseases specifically in low income countries. People in poverty, less educated and with low social status are more likely to have poor health. Gender imbalance makes women less able to make own decisions regarding their health and gender based violence is prevalent in all societies. Globalization also means that communicable diseases are traveling fast around the globe, as people are traveling more frequent. Immigrants will come to hospitals with previously seldom seen diseases and people from the Nordic countries may catch diseases abroad, while working or travelling, and the health systems have to be prepared for this.

The Medical Faculty at NTNU in Trondheim has pronounced strategic objectives, such as promoting high-quality research, strengthen international focus and global perspective, and NTNU has focused on a few countries where capacity building is on-going, within education and research. I recently lectured for a large group of medical students and almost all of them had been travelling outside Europe. They showed knowledge and a great interest of global health and for solutions of the challenging issues. A new two-year international Master program in global health is being developed, and we hope to start the international program in September 2015. When I worked in Uppsala there were around 700 applicants for 25 positions to a similar program. My job at NTNU is to start this Master program, to facilitate international research, and to teach global health for medical students and others. Furthermore, I would like to build a research group called Global Health at NTNU, as I can see there is relevant and good research going on, in different departments.

Cancer in a global perspective

The global burden of cancer continues to increase largely because of the aging and growth of the world population. Estimation is that 14 million people were diagnosed with cancer 2012 and more than half of them live in the developing countries. The four most common cancers occurring worldwide are lung, breast, bowel and prostate cancer. These four accounts for around 40% of all cancers diagnosed. In the Millennium Development Goals, much has been focused on poverty, education, women’s empowerment, maternal and child health and communicable diseases. This has been good. With measurable and specific targets, it is possible to see progress and improvements. There has, however, been less focus on chronic, non-communicable diseases (NCD) or cancer.  In Norway the most common death cause is cardiovascular diseases, followed by cancer, due to the Folkhelseinstituttet. In low-income countries the major death causes are still mainly infections, and when cancer is diagnosed radiotherapy and chemotherapy may not available in the public health systems. As an example from Tanzania, Ocean Road Cancer Institute (ORCI) in Dar es Salaam, is the only cancer clinic in Tanzania with 44 million inhabitants. The majority of the cases are diagnosed with advanced cancer, mostly due to delayed seeking care or due to delayed diagnosis. Patients who need surgery are operated in the referral hospitals and most of biopsies and material are sent to ORCI. There are 14 pathologists in the country and 9 of them are working in Dar es Salaam. If radiotherapy or chemotherapy is needed, the patients are referred to ORCI. Since 2008 the clinic is a full member of Union for International Cancer Control and joined into their programs, such as ‘Global access to pain relief initiative’, and with palliative care.  A problem is frequent out-stock of drugs for cancer due to costs. Morphine for pain relief should be accessible in hospitals, but in case of unavailability, Pethidine and other pain relieving drugs are used. Morphine is not readily available for patients receiving palliative care at home. However, there are large socio-economical differences within many countries and those with financial possibilities go for treatment abroad, where they can get high technology treatment and good quality of care in private clinics, as ORCI is overwhelmed by the number of patients. The situation is similar in many low income countries around the world. WHO provides mortality data of NCDs and estimates cancer as the cause of death/100000 living people. The lowest numbers 59 men and 57 women of 100000, in Costa Rica and the highest numbers, 234 men and 108 women out of 100000 in Latvia estimates to die of cancer. This shows large variation between countries (WHO 2012). The variation may reflect knowledge or lack of knowledge that something is wrong, delay in seeking care, the possibility for poor people to get a health facility from remote areas, the possibility to diagnose the condition and the quality of laboratories, the efficiency of the health system and the life expectancy in the country. WHO states alcohol, elevated blood glucose, high blood pressure, high cholesterol, physical inactivity, obesity and smoking general risk factors of NCDs. Some of them are known to contribute to the development of cancer. However other factors, the environment, pollution, occupational hazards, and virus infections, such as, human papilloma virus (HPV) adds the risk of developing cancer.

Cervical cancer a largely preventable disease

Around 500000 women are affected annually by cervical cancer, 85% of them in developing countries, and 250000 die of this disease, the same figure as the maternal deaths. Both diseases hit women in mid-life, many of them with children. A concurrent HIV infection is associated with a rapid progression of invasive cervical cancer. A study in northern Tanzania included nurses, midwives, doctors, lab technicians and students and revealed inadequate knowledge regarding cervical cancer, transmission of HPV, HPV vaccine and screening intervals. Most female health workers had never had a Pap smear examination (Urasa, Darj 2011). Morbidity and mortality of cervical cancer can effectively be reduced by screening and conisation of pre-invasive dysplasia, though inaccessible for many women, who are left to die in agony, with no or insufficient pain relief. In these countries, visual inspection with acetic acid (VIA) of the cervix has been found useful, to a low cost and with similar sensitivity as a Pap smear. WHO advocate for developing and integrating cervical cancer screening and HPV vaccination into health systems. However, priority may be given to infectious diseases such as malaria, tuberculosis, HIV, leprosy, and diarrheal diseases, which have established control programs. HPV vaccination has been introduced in many high-income countries, and recommendable efforts are now made to reduce the prize of HPV vaccination in low- and middle income countries, in order to support vaccination of girls.

What can we do? 

60% of world’s total new annual cases occur in Africa, Asia and Central and South America and 70% of the world’s cancer deaths. 30% of cancers could be prevented (WHO 2012). The aim of developing cancer control programs are to promote national policies. Norms, plans for surveillance, evidence based prevention, early detection, treatment and palliative care should be prepared for the different socioeconomic settings. We from the Nordic countries can contribute to this, by supporting transferring our knowledge, support capacity building, education and research. To collaborate with targeted universities is a way to focus and build alliances, get to know researchers in the country and work together bilaterally to improve health systems in order to facilitate for people to access high quality care and treatment in due time.

NTNUs’ vision «Knowledge for a better world» and the Medical Faculty’s vision «Health for a better world» is comprehensive for the global world we live in.

References

Urasa M, Darj E. Knowledge of cervical cancer and screening practices of nurses at a regional hospital in Tanzania. Afr Health Sci; 2011: 11(1): 48-57
WHO 2012. Available [20140405] at http://www.who.int/mediacentre/factsheets/fs297/en/
ACRN African Cancer Registry Network, Tanzania Cancer registry Available [20140407] at http://afcrn.org/membership/members/114-tanzania