Kampala — Agnes Atiang was in line for a breast operation at the Uganda Cancer Institute in Kampala when we spoke. Her story should have been one of double tragedy. Instead, it was one of hope.
An X-ray at Mbale Regional Referral Hospital had revealed that the 31-year old had tumors in her right breast. Medically, her cancer is stage 2; meaning it is growing but is still contained in the breast or growth has only extended to the nearby lymph nodes. But that was half the story.
The other was that this was the second time fate was bringing Atiang to the Uganda Cancer Institute - in two years. In 2015, she was at the institute; nursing an uncle who was battling cancer of the rectum.
She recalls that instead of her uncle being treated, she was many times advised to take him back home to die because the treatment he required at the time was unavailable.
"He needed radiotherapy. There was nothing," she said in a brittle voice, "We chose to stay but they were telling us to go back home and die."
That December, her uncle collapsed in pain and died while she was away searching for painkillers from nearby private pharmacies.
Then just three months after her uncle's death, the Cancer Institute was plunged into a major public relations crisis as news spread that its only cobalt 60 radiotherapy machine - the only radiotherapy machine in the country - had broken down beyond repair. The country was in panic mode. Many other patients died. Some were referred abroad. The institute was seen by many as a death trap.
But today, instead of dwelling on that grim past, Atiang is optimistic.
"Our hope is down there," she said, pointing at an aging house fenced off with a wire mesh with a banner that reads, 'Restricted Area' at the entrance.
The old house is where a new radiotherapy machine acquired by the government for about 630,000 euros is housed. Though only physicians and patients are allowed beyond the entrance because exposure to radiation can be dangerous to humans, we gained special access.
We were first ushered into the IT room where several computer screens and wires are fixed to operate and monitor whatever happens in the next room where the new cobalt machine is fixed. It is a huge blue and white colored machine in two parts. The main visible part is a huge wall-hang neck on whose head is a huge lighting assembly that beams down a tiny bed on a pneumatic base, the second part, on which a patient lies. The third part is hidden behind the wall.
"We put a false wall not to scare patients," says Dr. Daniel Kanyike, the Head of Radiotherapy.
He explains that the machine has two cameras; one for monitoring the patient and the other the environment around the patient during treatment.
There was no patient being treated, but Kanyike said the 7000kg machine that works 24/7 from Monday to Friday can handle 80 patients per day. Just like Atiang, Kanyike also sounded excited about the new machine, describing it fondly as "a machine that has everything modern and almost comparable to the linear accelerator, the most advanced radiotherapy machine in terms of treatment time".
"There are special laser beams to treat the patient precisely," he said as he tilted it to various corners making the red lines of radiation markers to beam neatly on various parts of the neat white walls. "It can rotate everywhere. It will tell you when you enter something wrong or inconsistent with the patients details entered initially. It's electronically controlled."
Dr. Ausi Kavuma, a senior physicist who has worked at the department for the last 23 years and has used the new machine says it quickens work.
"With the old one we used 260 seconds to treat one grade but with this we use 46 seconds to treat the same."
Despite being ordered in 2013, the machine only arrived in the country in December and was commissioned on Jan.19 at an event attended by Prime Minister Ruhakana Rugunda and the Director General of International Atomic Energy Agency, Yukiya Amano.
Dr. Jackson Orem, the Institute's Executive Director tells The Independent that it could have arrived earlier considering the need but they had to go through a lot of certifications and checks for safety and effectiveness before the machine that cost the country about 630,000 euros could be ferried in.
He said they also needed a lot of technical support from the agency even though they got a warranty from the manufacturer to train and build capacity of staff.
"It's new. It's not like people have been saying it's an old thing. It's not about just the machine it's about a system; including staff, facility and the safety features we have for utilisation".
For instance, he says, they had to build the walls to about 1.3meter thickness to ensure that the radiation emitted is absorbed within the walls. But initial efforts at finding a competent company in the country to design it were unsuccessful and the process of designing alone took them close to two years.
They also had to do several tests to ensure that likely radiation leakages are at almost zero and after that they would periodically send samples to the Vienna based Atomic Agency headquarters for inter-comparison.
"Now Ugandans don't need to worry," says Orem, referring to the March 2016 scenario when the only machine got in 1995 as a donation from the Atomic Agency broke down. He says once a new bunker currently under construction is complete, more similar machines will be procured so that the up to 75% of the over 200,000 patients who report to UCI requiring radiotherapy will have options and will no longer need to stay weeks or months waiting for a chance of treatment.
When she spoke to journalists ahead of World Cancer Day celebrations on Feb.04, Health Minister Jane Ruth Aceng said construction of the modern bunkers with six chambers which will house a radiotherapy machine each was 90% complete.
Challenges and hope
However experts like Dr. Ian Clarke, the proprietor of the Private International Hospital Kampala, hold reservations about the said radiotherapy machines. In an earlier interview with the Independent, Clarke, for instance, said the new one is just a newer version of the old machine they had. He explains that the challenge with that type of machine is that it's not as specific as the Linear Accelerator would be in terms of where the radiation goes. He advises that the government should consider procuring a Linear Accelerator estimated to cost at least $5million, approximately the price of six of the new machine.
Clarke, a cancer survivor who is an advocate of health insurance says, to afford top-notch cancer care, public and private health providers need to cooperate. He says this has failed to happen because the public facilities such as the Uganda Cancer Institute feel that they have the major prerogative in treating cancer, yet there are hospitals coming up which can also offer such treatment.
He says the private facilities cannot easily invest in a Linear Accelerator, especially if one knows that patients will not be able to afford the treatment, while the rich people will still go out of the country. He says it would be best if the government allocates a subsidy, either to the setting up of the equipment or by subsidising the bills for the patients.
Clarke says with advancements in technology, however, treatment has become more complex and very soon Uganda will require more than just a radiotherapy machine. Already elsewhere, techniques such as positron emission tomography and computed tomography (PET/CT) in one machine and Positron emission tomography-magnetic resonance imaging (PET-MRI) scans are being used in treatment. He says these machines require a radioactive material with a short half-life which must be manufactured in the country or at the very least in the region, since the short half-life means that it will break down and be useless within six hours. The manufacture of this radioactive material requires a machine called a Cyclotron which has not yet been installed in Uganda and the East African region.
For now, however, patients at the Uganda Cancer Institute are happy that they can at least get treatment. When we spoke, Atiang had been undergoing chemotherapy, another form of treatment involving use of drugs to shrink the cancer tumor. But her doctor had already briefed her about what to expect after the surgery, including radiotherapy; a form of cancer treatment that involves hitting cancer cells with a beam of radiation to kill off cancerous cells.
"After surgery the doctor said I might be here for more three to four weeks," she said, "You know these days they put you on the list for the machine quickly."