Dr Ishak Lawal is the Executive Director of End Cervical Cancer Nigeria Initiative(ECCNI), an NGO with overarching goal of ensuring that Nigeria will be on the path to eliminating cervical cancer come 2030. The NGO was formed as part of Nigeria’s response to the launch of global strategy to accelerate elimination of cervical cancer as a disease of public health significance. EM’s Ileri Obaweya speaks to Dr Ishak about his role in ending cervical cancer in Nigeria to commemorate January being cervical cancer awareness month and World Cancer Day on the 4th of February.
EM: In a time where many healthcare professionals were/are relocating out of the country to practice, you returned to render your services here in Nigeria. Why did you choose to return to the country for practice?
DR: Truth be told, it was not an easy decision, but I am glad I took the path of coming back despite the challenges of medical practice here. Not all doctors that left the country did so for money, a lot relocated for job satisfaction and security for their lives and properties. I have a feeling that I probably wouldn’t have returned back to the country if my oversea training exposure had happened earlier in my career. There are factors pushing doctors out of the country and there are factors pulling doctors into these foreign countries they migrate to. In my situation, neither of these factors was strong enough to overcome my growing desire to help the helpless cancer patients I see regularly in my practice.
I left this country with the singular purpose of getting the skills to perform difficult cancer surgeries that are not routinely performed in Nigeria. It was therefore relatively easy to come back after acquiring the skills despite the good life that practicing medicine abroad could offer. Though I have not been able to achieve even a quarter of my dreams for gynecologic cancer care thereby making me to sometimes doubt if I took the right decision to come back. Overall, I am glad I took the decision.
EM: Having experienced cancer care in Nigeria and outside the country, what would you say are the differences in cancer research, awareness and treatment between Nigeria and other developed countries?
DR: The summary is that cancer is unfortunately still a death sentence in Nigeria. While developed countries have implemented strategies to detect it early enough such that it can be effectively treated with hope of a cure, the Nigeria’s sorry cancer story is due to multiple factors at individual, community and government levels. Arguably, our religious belief of miracle healing might be one of the most important individual factors responsible for poor cancer outcome in Nigeria. Lack of vibrant cancer support groups that cancer patients or their careers can go to for emotional and psychological support is an important community level factor responsible for the poor outcome of cancer care in Nigeria. The weak health system in the country cannot support efficient cancer care at least for the masses. There is no single government owned hospital dedicated to cancer care in Nigeria. What is currently obtainable is having a cancer department within a general purpose hospital. It is therefore not surprising that the inadequate radiotherapy machines in the country are also not adequately maintained. Similarly, we don’t have standalone surgical-oncology departments. They are usually a unit in related “general surgical” departments.
EM: Statistics show that in Nigeria, cervical cancer is the second most frequent malignancy among women. In 2018, West Africa saw 31,955 new cervical cancer cases, with Nigeria accounting for over half of them (14,943). In the same year, there were 10,403 cervical cancer fatalities in the country (28 deaths each day). What factors should Nigerian women be more aware of to prevent and reduce these statistics?
DR: The trend now is to regard the prevention of cervical cancer as human right issue. This is because the world is sufficiently knowledgeable on how it can be prevented that it is contemplating the notion of cervical cancer elimination. Cervical Cancer is triggered (note that I did not say caused) by a virus which the world has the vaccine to prevent; the Human Papillomavirus (HPV), it has a recognizable pre-cancerous stage which can be efficiently treated to prevent progression to cancer. Protection against cervical cancer starts from adolescence, young girls between the ages of 9 to 15 should be vaccinated with the HPV vaccine. Women should be screened for cervical cancer when they are older than 30years and all screened positive cases should be adequately treated.
EM: Was there any influence on your passion or niche for cervical cancer?
DR: I am passionate about prevention of all preventable cancers. The Nigerian Cancer Society (NCS) is the umbrella body for all organizations and individuals involved in cancer care and advocacy in Nigeria. The association was established in the 40s by Prof emeritus Toriola Solanke and colleagues. I was instrumental to reviving the association in 2015 because of my passion for cancer prevention. The story of reviving Nigerian Cancer Society is emotional one for me because I spent my money energy and time to revive the association but ended up being persecuted. Thanks to the current president of the association, Dr. Alhassan Umar Adamu, for steering the ship of the association in the right direction and giving us hope for possibility of collective efforts towards reducing the burden of cancer in Nigeria. I guess I have digressed, back to the question of my passion for cervical cancer, two factors might been responsible for my smilingly bias for cervical cancer; 1- I am a Gynaecologist and cervical cancer is the commonest gynaecologic cancer in Nigeria, 2- Cervical cancer can be prevented through cheap and simple means, hence it causes me some degrees of emotional distress when I see patients suffering needlessly from a completely preventable condition.
EM: What do you think is the biggest misconception Nigerians have about cervical cancer?
DR: In my opinion, meaning not a confirmed fact, the unfounded faith on possibility of miraculous healing or protection from cancer is the biggest misconception about cancer in Nigeria. It is easy to blame religious indoctrinations as the promoting factors for the unfounded faith, I however think the problem goes beyond religion. I think the health system failure is the main factor pushing people to seek hope in religion in the face of hopelessness in the health system.
EM: Statistics show that higher cases of cervical cancer and deaths as a result of cervical cancer occur in developing countries. What steps can these countries take in eradicating cervical cancer, bearing in mind the economic situation of these countries and their citizens?
DR: Luckily the World Health Organization (WHO) has produced a roadmap to guide countries on the path to cervical cancer elimination. In 2020, November 17th to be precise, WHO launched the global strategy to accelerate elimination of cervical cancer as a disease of public health significance. The strategy has a 3 prong approach to cervical cancer prevention; 1- 90% vaccination of girls between 9years to 15 years of age, 2- 70% screening of women using HPV testing and 3- 90% treatment for both pre-invasive and invasive lesions of the cervix. Most developing countries don’t have the resources to achieve these targets, hence there is the need for innovative thinking such as the concept of resource stratified strategy that Kebbi State is currently developing with the support of Medicaid Cancer Foundation (MCF) and Office of the First Lady of the state, Dr. Zainab-Shinkafi Bagudu. The resource stratified strategy to cervical cancer screening has a 2 tiered approach where the state invests in a sustainable lower tier of Visual Inspection with Acetic Acid (VIA) but relies on donor support for the upper tier of HPV screening.
EM: Throughout your career in dealing with cancer, are there any success stories that stick out to you?
DR: Success story in cancer care within the government hospitals in Nigeria?!! That is more like oxymoron. I don’t have what can be called success story in the true sense of successful care of cancer patient. Every patient encounter is a unique story with its “successes” and “failures”. The story of Aisha Yahaya however stands out for me. She was a young woman who presented with advanced stage cervical cancer. I had a frank discussion with the relatives and we agreed on palliative course of action. I used the opportunity to educate the family on importance of screening and early diagnosis in improving prognosis for cervical cancer. Incidentally, the elder sister is the head of women catholic group in Dabai town in Zuru LGA Birnin- Kebbi. She volunteered to mobilize women for cervical cancer screening to prevent them from going through the suffering she witnessed her sister suffered. Over 150 women were mobilized screened and 12 positive cases were treated thereby preventing from progressing to cancer. The catholic hospital in Dabai headed by Rev. Sister Dr. Bridget is has taken up the challenge to start a comprehensive cervical cancer screening program as a pilot for the whole catholic hospitals in Nigeria. I am excited at the prospect of having a nation-wide catholic hospital program on cervical cancer prevention. The potential success story started from the depressing story of late presentation of a patient.
Dr Ishak was recently appointed the technical lead for Kebbi State Cervical Cancer Prevention and Control program. He is working in collaboration with Medicaid Cancer Foundation(MCF) and the Office of the wife of the Kebbi state governor, Her Excellency, Dr. Zainab Shinkafi-Bagudu to implement resource stratified comprehensive state owned organised cervical cancer prevention and control program for Kebbi state. The program will hopefully serve as a pilot for all low resource settings struggling to implement cervical cancer prevention and control program.