Breast cancer survival in Ethiopia: a cohort study of 1,070 women.

There is little information on breast cancer (BC) survival in Ethiopia and other parts of sub-Saharan Africa. Our study estimated cumulative probabilities of distant metastasis-free survival (MFS) in patients at Addis Ababa (AA) University Radiotherapy Center, the only public oncologic institution in Ethiopia. We analyzed 1,070 females with BC stage 1-3 seen in 2005-2010. Patients underwent regular follow-up; estrogen receptor-positive and -unknown patients received free endocrine treatment (an independent project funded by AstraZeneca Ltd. and facilitated by the Axios Foundation). The primary endpoint was distant metastasis. Sensitivity analysis (worst-case scenario) assumed that patients with incomplete follow-up had events 3 months after the last appointment. The median age was 43.0 (20-88) years. The median tumor size was 4.96 cm [standard deviation (SD) 2.81 cm; n = 709 information available]. Stages 1, 2 and 3 represented 4, 25 and 71%, respectively (n = 644). Ductal carcinoma predominated (79.2%, n = 1,070) as well as grade 2 tumors (57%, n = 509). Median follow-up was 23.1 (0-65.6) months, during which 285 women developed metastases. MFS after 2 years was 74% (69-79%), declining to 59% (53-64%) in the worst-case scenario. Patients with early stage (1-2) showed better MFS than patients with stage 3 (85 and 66%, respectively). The 5-year MFS was 72% for stages 1 and 2 and 33% for stage 3. We present a first overview on MFS in a large cohort of female BC patients (1,070 patients) from sub-Saharan Africa. Young age and advanced stage were associated with poor outcome.

Overcoming challenges of cancer treatment programmes in developing countries: a sustainable breast cancer initiative in Ethiopia.

The incidence of breast cancer is rising in many developing countries. Here we describe a programme to improve the support infrastructure for the management of patients with breast cancer in Addis Ababa, Ethiopia. Tamoxifen, a cheap, oral, yet effective, anti-cancer agent was made available freely to encourage staff and patients to follow well-defined, but achievable, protocols of care. Mammography, improved histopathological review, tissue hormone receptor assays, agreed treatment algorithms with a cycle of continuous audit of over 250 patients and cross-departmental patient management groups led to a considerable improvement in the management of breast cancer patients in a single institution. Aspects of this programme are now being extended to other regional hospitals in Ethiopia. Fairly limited investments in programmes for cancer can stimulate considerable improvements in the overall approach to malignant disease by encouraging a positive approach, even in very low resource environments.

Injections: a fatal attraction?

The abuse of injections in the developing world has reached alarming proportions in recent years. Formal as well as informal health providers administer far too many injections to clients who perceive this form of treatment as superior to all other forms of medicine administration. Often sterilization procedures are less than adequate or non-existent, thereby increasing the risk of spreading HIV and infectious diseases to all segments of the population. Very little is at present known about why injections are so popular or the extent to which they are administered in the various health care sectors in developing countries. This article gives an overview of the present state of knowledge and highlights the need for further information in order to address the problem appropriately. It is suggested that the quest for injections may be seen as part of some general trends of change in the developing world. The article also indicates some of the important areas for further research.

Pathways to psychiatric care in Harare, Zimbabwe.

A study was carried out on the pathways to psychiatric care in Harare, Zimbabwe. Encounter forms were completed on 48 patients admitted to psychiatric beds. Analysis indicated that there was a by-pass of primary care facilities, with a significant number presenting directly to tertiary care facilities, here were lengthy delays before seeking care, but delays while receiving care were moderate. The sample as a whole was composed of major disorders, displaying severe symptoms, and there was a suggestion that some patients become more disturbed along the pathway. As a whole, the sample is very different to samples screened from primary care settings, and the consequences of this are discussed.

A preliminary investigation into psychological disorders among Mozambican refugees: prevalence and clinical features.

Psychological disorders are common in refugee samples, with several studies showing high rates of Post Traumatic Stress Disorder. The present study examined the prevalence and factors associated with psychological disorders in Mozambican refugees in Zimbabwe. The findings indicated a very high prevalence rate (62 pc), which is considerably higher than that obtained from other settings within Zimbabwe. The demographic characteristics were similar in most respects to other Zimbabwean samples, but there was a trend towards greater social adversity (more relationship difficulties, less schooling and higher employment). Clinically, refugees were severe, with high scores on the SRQ-20, a presenting picture of multiple somatic complaints, and a high rate of rated suicidal risk. There were a significant number of refugees who had had an experience with violence in their recent past, as well as there having been frequent life events in the past six months. The implications of these findings are discussed with reference to Post Traumatic Stress Disorder, and the management of psychological disorders generally.

Psychopathology in primary care patients: a four year study in rural and urban settings in Zimbabwe.

It has been argued that prevalence rates for psychopathology in Africa are stable over time and setting. There are, however, few longitudinal studies, and these conclusions are mainly based upon point prevalence studies. It has also been observed that African patients present with somatic symptoms, a feature argued to impede detection. Furthermore, it has been argued that such multiple somatic symptoms (three or more) are diagnostic of psychopathology. The present study examined these questions in the context of a longitudinal design. Prescriptive screenings of both rural and urban primary care patients were undertaken, and repeated the following year. The measures indicate that there is no significant difference in the rates in urban and rural settings, nor any difference in the rates over time. There were few differences between cases and non-cases in demographic characteristics, but there were differences in the clinical characteristics of the two groups. Cases tended to present with more symptoms than non-cases, thus corroborating earlier findings. In addition, the symptoms of cases tended to implicate more physiological systems than non-cases.

PIP: In Zimbabwe, medical students screened 1263 adults, 16-65 years old, attending general medical clinics at Howard Hospital in Chiweshe in 1986-87 and at the Parirenyatwa Primary Care Clinic in Harare in 1988-1989 for psychological disorders. 26% had a score of at least 7 on the self-reporting questionnaire (SRQ) 20, suggesting a psychological disorder. The prevalence of psychological disorder was somewhat higher among urban patients than rural patients, but the difference was not significant (28% vs. 24%; p = .09). Prevalence did not increase with time. The mean SRQ-20 score among cases fluctuated between 9.3 and 10.6 in 1986-1989. SRQ-20 scores for anxiety, depression, and suicidal ideation among cases were basically the same through out the study period. People with some degree of psychological disorder (cases) were more likely to be unemployed (p = 0.05). Cases had a higher number of complaints or symptoms than controls (p .001). They also had more psychological symptoms implicated by the complaints than did controls (p .001). Patient complaints may steer clinicians from examining patients for psychological disorders so that they just focus on physical illness. The researchers have identified a need to develop valid and reliable instruments for good descriptive studies, for longitudinal studies examining prevalence rates of psychopathology over time, and studies comparing psychopathology in different settings.

Teaching Zimbabwean medical students an awareness of hidden psychological disorder in an urban outpatient setting.

A one-week attachment to an urban primary health care clinic was introduced into the eight-week psychiatric teaching block for fourth (penultimate) year medical students at the University of Zimbabwe. Its objective was to alert students to underlying psychological disorder in patients presenting, at primary health care level, with physical symptomatology. Students were required to screen patients using a 20-item questionnaire, take a psychosocial history of all high-scoring patients, and make one home visit. The attachment proved both popular and valuable, and it is anticipated that this will now become an integral part of the psychiatric teaching block.

Anthropological perspectives on injections: a review.

Qualitative studies from developing countries have pointed to the widespread popularity of injections. In addition to their use by formal and informal providers and traditional healers, there is now increasing evidence of the use of injections and injection equipment by lay people. Epidemiological research links the large number of unsafe injections to serious bloodborne infections such as viral hepatitis B and C and acquired immunodeficiency syndrome (AIDS). The present article examines the reasons behind the demand for injections by consumers and the administration of unnecessary or unsafe injections by different types of provider. Interventions aimed at reducing the risk of unsafe injections are discussed in relation to cultural and social factors as well as those factors associated with health systems. Suggestions are made for approaches to the design of such interventions.

PIP: This paper reviews the anthropological perspectives on injections. Qualitative studies from developing countries have pointed out the widespread popularity of injections, which varies according to the culture concerned. Injections are seen as an outstanding symbol of biomedicine and have often been portrayed as such in health and vaccination campaigns. There is now increasing evidence of the use of injections and injection equipment by lay people. Epidemiological research links a large number of unsafe injections to serious bloodborne infections such as viral hepatitis B and C and AIDS. This article examines the reasons for the increasing demand of injections by consumers and the administration of unnecessary or unsafe injections by different types of provider. Furthermore, interventions to reduce the number of unnecessary injections are discussed in relation to cultural and social factors, as well as those associated with health systems. Suggested approaches useful in the design of such interventions are outlined.