Breast Cancer in Swaziland

The Kingdom of Swaziland is a landlocked country, roughly the size of the state of New Jersey, situated northeast of South Africa. It's one of the few absolute monarchies still remaining, and as such has two capitals: Lobamba, the royal capital, and Mbabane, the administrative capital. It is here in the Mbabane breast cancer clinic that I've been scoping out a possible project with the Swaziland Breast and Cervical Cancer Network (SBCCN).

Breast cancer is the most common cancer in women in both the developed and developing world. There is a widespread belief that cancer plagues mostly higher-income countries; however, that is not the case. For example, almost 50% of breast cancer cases and 58% of deaths occur in the developing world. Although incidence and survival rates vary greatly worldwide, survival rates are lowest in developing countries, attributable to lack of early detection programs, leading to high proportion of late-stage disease presentation, lack of adequate diagnosis and lack of treatment facilities.

This is the outpatient building of the Mbabane Government Hospital in which the breast clinic runs. Patients occupy every available space in the corridors from early morning waiting to be seen. Babies wailing, children screaming, adults chattering- if I closed my eyes, the sounds would lead me to think I was rather at a busy market. 

There is currently one oncologist in the entire Kingdom of Swaziland...and he's from Cuba. He is a jolly fellow who's been in the country for a little more than a year now. His English is very basic (his conversations are mostly composed of nouns, pronouns, and present tense verbs) and he calls everyone "my friend." I learn that he's 1 of 19 Cuban physicians here. There's a bilateral exchange agreement between the governments of Cuba and Swaziland, in which Swazi doctors go to Cuba to train and Cuban doctors go to Swaziland to provide much needed specialist care. It's mandatory public service; instead of being drafted for military service, you're drafted for medical mission. 

In the course of 4 hours, we saw 39 patients. That's nearly 10 patients per hour! Documentation is a meager process here, as notes are scribbled into the patient's Health Card. This is the equivalent to the medical chart, but instead of staying with the institution, patients carry it with them at all times (and it can get pretty ragged).

Patients come for screening, examination, follow-up, and referrals. The clinic takes place in a very small room containing a desk, chairs, and a room divider that separated the examination table. There were 7-8 people in the room at any given time, with 2-3 different patients, leaving very little patient privacy or confidentiality. This was the epitome of a HIPAA compliance nightmare.

There are not many options for women who are found to have breast cancer here: either surgery or do nothing. There is no availability of radiation, chemotherapy, or targeted therapy. Hormone therapy is available, like tamoxifen, but the tricky part is that testing is not done here to determine whether the tumor is estrogen/progesterone receptor positive and whether therapy is warranted. Patients who can afford it come to South Africa go to seek treatment. The Swaziland government used to have a program to send breast cancer patients to SA, but for unclear reasons, the program no longer functions. Most patients are from rural areas, and they struggle to collect enough money to ride the taxi bus, or kombis, to the clinic (~R5 or $.50). Even when early screening and diagnosis is achieved, it sometimes is fruitless as patients can't afford to come back for follow-up. Until the time Swaziland expands its health care delivery system, most patients who are diagnosed will go untreated.