I had been a practicing surgeon for several years before I returned to graduate school to study epidemiology. As one of the few Africans in my class, most people assumed that my area of study interest was HIV/AIDS given its high prevalence in Africa, controversy in the public health world about the best approach to treatment and prevention in low-resource environments, and whether pharmaceutical companies can or should provide drug treatments at low or no-cost. I therefore frequently get questions about the epidemiology, clinical, and social aspects of the epidemic. Responding that my interest was cancer was sometimes met with blank stares, but some of my questioners recover quickly enough to ask quizzically whether cancer is a problem in Africa. So, I find that I occasionally have to defend my chosen path.
 

In fact, cancer is not a rare disease in Africa. An urbanized African woman’s risk of developing breast cancer, for example, is only marginally lower than that of a Western woman of similar age while her risk of cervical cancer is much higher. In my clinical practice, over 70% of patients present with advanced cancer for which there is no curative treatment. Many of these patients were young — in their thirties and forties — at the early stages of their professional careers and development of their families, looking towards a future full of life and promise. Into their idyllic world comes a diagnosis and prognosis that would be devastating at any age but is particularly so among this age group. Their illness is usually complicated by social, psychological, and economic factors that health care professionals are poorly equipped to appreciate and respond to in the course of treatment planning dominated by talk of chemotherapy regimens and options in surgical treatments.
 

Observing these women as they cope with a complex disease like cancer in a poorly resourced, pay-as-you-go health care system that is equipped to provide only acute short-term care is a testament to the strength and fortitude of human spirit. One is therefore often drawn to questions about how to reduce the pain and suffering of cancer at a population level. While this hardly negates the value of taking care of the individual patient, one cannot but wonder whether such activities are no more than trickles in the proverbial ocean. Questions about risk factors for cancer, methods of promoting early detection, and prevention naturally arise, so it was only a matter of time before I became more involved in the public health aspects of cancer.

And now, if I were to meet those old graduate school friends again, I will have an even fuller answer to their questions, and their responses would be less quizzical. Because with increased provision of anti-retroviral treatment in Africa, AIDS-associated malignancies have collectively become the most prevalent category of cancer. Given the large number of people living with HIV, this is likely to be the oncology challenge for Africa in the next few years, and I look forward to working with colleagues to respond to this challenge.