A Responsibility and a Gift: Dr. Lawrence Shulman on Improving Cancer Care in Low-Resource Countries

Dec 15, 2015

Lawrence N. Shulman, MD, has practiced in some of the best medical centers in the world and has also seen compassionate care delivered by devoted physicians in settings where resources are most constrained. With a longstanding interest in global health, he is deeply committed to improving cancer care in Rwanda and Haiti through his partnership with Partners in Health, and in Botswana through his leadership at the Abramson Cancer Center at the University of Pennsylvania.

AC: How did your involvement with Partners in Health and your work in Rwanda begin?

LS: I met Paul Farmer and Jim Kim, two of the cofounders of Partners in Health, in the early 1990s at Brigham and Women’s Hospital. They were both my interns while I was an attending on the oncology service. I became good friends with both of them. Paul and I stayed in touch throughout the 1990s when he was working primarily in Haiti, and he would call me when he had a patient with cancer to discuss what could be done to help that person.

In 2008, Paul and Jim asked me if I would consider building cancer-care delivery infrastructure at two Partners in Health sites: at the Butaro Hospital in rural northern Rwanda and in Cange, Haiti. In the years since, we’ve worked hard to develop cancer programs in both countries. Our program in Rwanda is now at the Butaro Cancer Center of Excellence, which is the first cancer referral hospital in Rwanda and cares for the majority of patients with cancer A Responsibility and a Gift Dr. Lawrence Shulman on improving cancer care in low-resource countries in the country. Our program in Haiti is now at Mirebalais Hospital.

Paul convinced me over the years that it is our responsibility, as physicians living in what is an increasingly small world, to do our part in bringing care to those who don’t have access.

AC: What did you experience on your first visit to Rwanda?

LS: The first time I went to Rwanda, in 2011, I visited the main ministry hospital in Kigali, which was staffed by a group of very skilled, very devoted physicians—none of whom were cancer physicians—working in an extraordinarily resource-constrained setting. There was no functioning pathology lab and really no capacity to diagnose or treat cancer.

We made rounds first through the pediatric ward, where child after child had tumors in different parts of their bodies. They had no options for treatment and remained in the hospital for months until they died. These were largely potentially curable diseases, if only they had the tools. In Boston or Philadelphia, 80% to 90% of these children would be cured, whereas in Rwanda at that time, 100% of them died. We had a similar experience going through the adult wards—patients with slow-growing, progressive cancers who succumbed to the disease without ever having a biopsy for diagnosis or options for treatment.

It was such a contrast to my day job at the time, a leadership position at the Dana-Farber Cancer Institute, one of the most resource-rich medical areas of the world.

AC: What kind of work do you typically focus on during site visits?

LS: Helping to bring any type of medical care to places that are resourceconstrained involves many different aspects of support. Training physicians, nurses, and laboratory technicians is key, but training alone is insufficient to bring the level of care to their patients that we all believe they deserve. We accompany our Rwandan and Haitian colleagues in developing an infrastructure that allows them to safely and effectively treat their patients with cancer.

While I only visit Rwanda and Haiti periodically, my colleagues and I spend several hours every day helping to manage the cancer programs in those two countries. We’ve made an ongoing commitment to provide support in these settings.

AC: What has been the greatest success of the program?

LS: If you look at Rwanda, where we have a longer experience and have been able to move the program further, there are lots and lots of patients who are living when previously they would have faced certain death. In diseases such as Wilms tumor, the most common pediatric tumor we see in Rwanda, more than half of our patients are still living. The greatest accomplishment I can point to is that we see these kids in clinic or at home visits and they are alive as long-term survivors.

Patients with chronic myeloid leukemia also faced certain rapid death in these settings. Now, three-quarters of our patients have their disease under control and are living healthy lives with good quality of life. This is thanks to the generosity of The Max Foundation and their partnership with Novartis, which supplies imatinib to these patients at no charge. It’s an expensive drug, and these patients need to be on the drug for the rest of their lives.

AC: What are some of the major ongoing barriers?

LS: There are lots of challenges. For one, many patients come in with cancer that is already very advanced, to the point that there is little we can do. Poverty plays a key role here—for a woman who has a growing breast mass but is struggling every day to put food on the table for her children, it is very hard to travel to a medical center to get care.

AC: Can cancer care challenges in low-resource settings inform issues of health disparities in the United States?

LS: There are certainly analogies in the U.S. In Boston, women in poverty often present with advanced disease because their first concern is providing for their families. Some of the interventions we’re using in Rwanda to heighten awareness and help people understand the importance of early detection could be applied to sections of the U.S. Also, providing affordable transportation and accompaniment to patients in their cancer journey is something we can improve in both the U.S. and in low-resource countries.

AC: What would you say to an ASCO member who is interested in doing medical volunteer work overseas but feels nervous at the prospect?

LS: The reality is that it’s not for everybody. You need to understand what it will be like to practice without all the resources you would usually have on hand. But the people who go often describe it as the most gratifying experience of their career. You give life and hope to people who had no other options, in a way that is more pronounced than in the U.S. It’s a great gift we can give to people who are geographically remote and culturally different, but who are warm and wonderful human beings.

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