1. Oncology Ethical Dilemmas in Zimbabwe Dr. A.M. Nyakabau Consultant Oncologist ZiMA Conference 20 August 2015

2. Presentation Outline Background Cancer Information Case Presentation Principles of ethics Ethical Dilemmas facing Cancer doctors – Patient & Disease Factors – Health Professional Factors – Environmental & socioeconomic Factors Conclusion

3. What’s Cancer ? Worldwide, Projected 50% more new cases next 20 yrs Most in developing countries ( Globocan, 2008 )

4. Care for Carers

5. Multi-disciplinary, Multi- sectral Comprehensive, Holistic Approach Quality Ethical Cancer Care

6. Risk factors for cancer Infections Tobacco use Alcohol use Radiation exposure Occupational Risk Genetic: 5-10% of cancers Age: 70% cancers occur in > 65 yrs Socio-economic status Diet /Physical Inactivity

7. Zimbabwe cancer situation ? > 6000 new cancers /yr 1500 cancer deaths /yr 60 % HIV associated 80 % advanced stage presentation Prognosis poor Souce:ZNCR

8. N Cases Years Total Cancer cases in Harare & Zimbabwe, Years 2005-2012 Source : ZNCR

9. CANCER INCIDENCE IN ZIMBABWE: 2012 SOURCE: ZNCR ANNUAL REPORT 2012

10. Multi-disciplinary, Multi- sectral Comprehensive, Holistic Approach Quality Ethical Cancer Care

11. VISION: Towards a cancer-free Zimbabwe MISSION: Increase awareness on all cancer related issues and create an enabling environment for adoption and practice of evidence based cancer prevention, early detection, diagnosis, treatment, palliative care, rehabilitation, surveillance and research OVERALL GOAL: Reduction of cancer morbidity and mortality through implementation of evidence based cost-effective prevention and control interventions and providing palliative care to improve quality of life of people living with cancer and their families by 2017. OVERALL GOAL: Reduction of cancer morbidity and mortality through implementation of evidence based cost-effective prevention and control interventions and providing palliative care to improve quality of life of people living with cancer and their families by 2017. Goal Area 1 Programme Strengthening Goal Area 1 Programme Strengthening Goal Area 2 Primary Prevention Goal Area 2 Primary Prevention Goal Area 3 Early Detection Goal Area 3 Early Detection Goal Area 4 Diagnosis & Treatment Goal Area 4 Diagnosis & Treatment Goal Area 5 Palliative Care & Rehabilitation Goal Area 5 Palliative Care & Rehabilitation Goal Area 6 Surveillance & Research Goal Area 6 Surveillance & Research Guiding Principles: Equity; Effectiveness; Confidentiality; Holistic; Accountability; Dignity; Compassion

12. Principles of ethics Autonomy Beneficence Non-malfeasance Justice Appropriate framework Subject to contextual Interpretation Often Conflict

13. Doc, I wish it was HIV Limited Cancer programs Limited funding Scrounging for services Limited HCW education Upon Cancer Diagnosis

14. Cancer & HIV Double Diagnosis

15. Doctor Prescribed Prayer? 36 yrs female secretary Stage 4 Bilateral BC First seen May 2015 Med Aid July 2015 Money challenge

16. Patient & Disease Factors Consent & Confidentiality Cancer Burden & double diagnosis Cancer prevention Access to screening, early diagnosis & treatment End of life issues – Research – Cancer care challenges

17. Multi-disciplinary, Multi- sectral Comprehensive, Holistic Approach Quality Ethical Cancer Care

18. Radiotherapy Chemotherapy Hormones Biologicals Immune Tx Analgesics Adjuvants Bis- phosphonates Complimentary Cancer Treatment: modalities Emotional Spiritual Psychologic Surgery

19. Cancer prevention Vaccination (HBV,HPV) HIV/ AIDS & STI Bilharzia control Life-style –Tobacco / alcohol Physical Activity/Weight loss/Diet Control Limiting Exposure – Harmful RT/Chemicals

20. Cancer Care Ethical Dilemmas Funding Limited awareness/prevention Skilled staff Shortages Equipment & technology challenges Limited access to early diagnosis, treatment & palliative care

21. Barriers to early diagnosis Health education & awareness Poor; no sources information Little formal education; disempowered Paucity trained local professionals Treated traditionally or spiritually* Myths and misconceptions Incurable; contagious Attributed to witchcraft* Mystical origin: “attack from the enemy” ** Religion Fatalism; beliefs Social Poverty:  out-of-pocket payments Decision-making Fear of treatment Fear loss of breast, husband ***, support Surgery: mutilating Anaesthesia: death * BMC Research Notes 2012, 5: 627 Suh, Atashili, Fuh et al ** Cancer Nurs 2006, 29: 461 – 466 Oluwatosin ***Psycho-oncology 2010, 19: 893 – 897 Odigie, Tanaka et al

22. Health Funders Providing services Autonomy compromised Quality of service (>40 patients/day) Continuity of service interrupted Early diagnosis compromised Cancer early detection measures? Compromising MDT concept

23. End of life Issues in Oncology Life sustaining therapy at the end of life Prescribing placebo treatment Communication issues Euthanasia issues - palliative care failure

24. Ethical Issues in Oncology Knowledge asymmetry in MDT Paltry salaries & bad debtors Preferred service providers/ conditional referrals Pharmaceuticals -gifts /favors Cost of care / Medical Aid rationing of service

25. Summary: Oncology Ethical Issues Competing unorthodox medicine practices Heterogeneity: – Cancer pathology & natural history – Dynamic nature of disease – Multiple complex, Treatment modalities – Management pathways – Cultural & socioeconomic High disease burden Limited prevention, early diagnosis treatment & palliative care Limited reources

27. Primary Care physicians are Indispensable & Key Quality Ethical Cancer Care

28. Presentation-Tip of an iceberg

29. Thank You

30. CONSCIENCE IS VERY PRECIOUS 1 Corinthians 10:25-29a

33. Foreign better than local? Patients Medical Aid Colleagues Health tourism-curse/blessing? Local resources /costs

34. Where do we miss the boat? Some resources Best workforce High literacy Cancer Strategy ? METHODOLOGY