Africanizing Oncology

Creativity, Crisis, and Cancer in Uganda

Marissa Mika

• Editorial: Ohio University Press
• Año: 2022
• ISBN:
  9780821447512
• Categoría: Ciencias sociales
• Categoría: Antropología cultural y social

An innovative contemporary history that blends insights from a variety of disciplines to highlight how a storied African cancer institute has shaped lives and identities in postcolonial Uganda.

Over the past decade, an increasingly visible crisis of cancer in Uganda has made local and international headlines. Based on transcontinental research and public engagement with the Uganda Cancer Institute that began in 2010, Africanizing Oncology frames the cancer hospital as a microcosm of the Ugandan state, as a space where one can trace the lived experiences of Ugandans in the twentieth century. Ongoing ethnographic fieldwork, patient records, oral histories, private papers from US oncologists, American National Cancer Institute records, British colonial office reports, and even the architecture of the institute itself show how Ugandans understood and continue to shape ideas about national identity, political violence, epidemics, and economic life.

Africanizing Oncology describes the political, social, technological, and biomedical dimensions of how Ugandans created, sustained, and transformed this institute over the past half century. With insights from science and technology studies and contemporary African history, Marissa Mika's work joins a new wave of contemporary histories of the political, technological, moral, and intellectual aspirations and actions of Africans after independence. It contributes to a growing body of work on chronic disease and situates the contemporary urgency of the mounting cancer crisis on the continent in a longer history of global cancer research and care. With its creative integration of African studies, science and technology studies, and medical anthropology, Africanizing Oncology speaks to multiple scholarly communities.

1

The African Lymphoma

IN 1957 the physician Dr. Hugh Trowell asked Dr. Denis Burkitt to examine a pediatric patient for a surgical consultation. The boy was a five-year-old with massive swellings in all four quadrants of his jaw. Jaw swellings were not uncommon, and children often came to Mulago Hospital with this sort of complaint, their jaw swelling either from infections or single tumors. But a swelling distributed in all four quadrants of the jaw simultaneously was, Burkitt and Trowell agreed, quite rare. A few weeks later, Burkitt visited Jinja District Hospital and saw another young boy with jaw swellings in all four quadrants. Burkitt and colleagues convinced the patient’s family to come to Mulago Hospital. At Mulago, Burkitt examined the boy and found similar tumors in all four jaw quadrants. Going back through old case records, Burkitt found that patients with this distinct jaw tumor often had other tumor deposits throughout their bodies, suggesting that this was a multicentric tumor. Burkitt thought that perhaps this was a new discovery, an East African oddity he had uncovered.¹

Burkitt took his notes, photographs, and tissue samples of these patients to Dr. J. N. P. Davies in the pathology department. Davies looked through the materials. Lymphosarcomas were, according to Davies, known “to be common in both children and adults since 1948.”² Davies informed Burkitt that he and his colleagues were well aware of the tumor and researching unusual pediatric and adult jaw tumors. These colleagues included Dr. Pritham Sing, Dr. J. Cook, Dr. A. G. Davies, and Dr. Gillian Jacobs. Working in concert, the cancer registrar, the pathology laboratory, and the radiography department conducted research on the tumor and published a report on jaw tumors for the East African Medical Journal a year before Burkitt’s consultation.³ In 1956, Jacobs, a pathologist, identified the childhood tumor as a lymphosarcoma. The Makerere-based Cancer Research Committee presented its collective research efforts on jaw tumors to the Colonial Medical Research Council and International Cancer Congress in London in the 1950s.⁴ In 1951 Davies had invited Burkitt to be on the newly formed Cancer Research Committee at Makerere Medical School. At the time, Burkitt was dismissive of the whole enterprise. As Davies would later recall, “Mr. Burkitt, who had been a school friend of mine, promised all the assistance he could give but thought I was wasting time, as he could assure me as a surgeon that there was not enough cancer in Kampala to make it worth investigating. So he did not become a member of the committee.”⁵ Burkitt was “rather crestfallen” when he found that Davies and colleagues were already working on this tumor.⁶ Cancer was, it turned out, worth investigating.

This chapter offers a schematic history of cancer research in Uganda before the founding of the Lymphoma Treatment Center (LTC) at the Uganda Cancer Institute (UCI) in 1967. I focus on the history of two forms of knowledge making about cancer in Uganda in the 1950s and 1960s. One form of knowledge making revolved around cancer pathology, surveillance, and disease registration, which was spearheaded by Davies. Cancer research was made possible by sedimentary layers of cancer case records from Mengo Hospital, the demand for locally specific knowledge about Uganda’s disease patterns (which facilitated medical education at Makerere), and the concentration of patients and expertise circulating through Mulago Hospital. The other form of knowledge making revolved around the jaw tumor that would eventually be named Burkitt’s lymphoma. This was both a field-and hospital-based endeavor that involved describing and documenting the tumor, mapping the tumor across the African continent, and conducting early experiments in chemotherapy with donated drugs from cancer centers in the United States and United Kingdom. Cancer experiments during this period were not conducted as randomized controlled trials. They were clinical and observational studies informed by treatment dose standards from cancer protocols in US and UK metropolitan spaces and then applied to individual cancer patients on the wards of Mulago.

The historical record available in oral histories, personal correspondence, memoirs, and medical publications is largely silent on how colonial medical men such as Burkitt understood and interpreted the ethical, racial, paternalistic, or imperial dimensions of their medical careers and actions in cancer research in Uganda. The record is also largely silent on how pediatric patients and their families understood cancer research and care at Mulago. Instead, the record is brimming with mundane safari adventure stories, clinical discoveries, and the challenges of scaling medical care and education in Uganda.⁷ Today, at the UCI and in international cancer research circles alike, Burkitt is framed as a powerfully observant surgeon who changed the course of cancer care by showing that some forms of cancer could be treated with chemotherapy alone.⁸ But there is ambivalence as well as admiration. Reflecting on Burkitt’s lymphoma research conducted in Uganda in the 1950s and 1960s, a Ugandan colleague commented to me that this was the sort of “heroic medicine” that just simply would not be approved by Mulago Hospital’s institutional review board in the twenty-first century.⁹ Nevertheless, I avoid casting a retroactive twenty-first-century bioethical gaze and sensibility onto Burkitt’s lymphoma research and care in Uganda in the 1950s and 1960s.¹⁰ Instead, this account offers a thick description of cancer research and care practices before efforts to Africanize oncology began at the UCI. In particular, it situates Burkitt’s lymphoma research within the broader context of medical education, clinical care, and biomedical research in Uganda between the end of World War II and the 1960s.

MAKING CANCER IN UGANDA VISIBLE

Cancer research at Makerere Medical School began with observations at the pathology lab and on the autopsy table at Mulago Hospital in the 1940s and 1950s, largely under the direction of the pathologist Davies.¹¹ Like many others working at Makerere at the time, Davies came to Uganda through the Colonial Medical Service.¹² Davies recalls that “it was shortly after D-Day that Dilly (my wife) and I heard that we had a chance for going to Uganda” with the British Colonial Medical Service.¹³ During World War II, Davies had taught at the University of Bristol Medical School, and his wife worked as a nurse at the British Royal Infirmary’s operating theater. Both were excited about the opportunity to leave the United Kingdom. But neither knew much about Uganda, having originally expressed a preference for going to Malaya, nor much about tropical medicine. As a remedy, Davies requested that he attend the University of Edinburgh for a diploma in tropical medicine before leaving for East Africa. Arriving in Scotland in early October 1944, the Davieses were greeted by the first snowfall. The courses themselves were very unevenly taught. As he said, “It was wartime, the staff had been over-worked and were tired and I found the teaching generally disappointing. . . . While even in 1944 the ex-Indian Army Officer who taught Tropical Medicine seemed not to have heard of Sulphonamides, treated Dysentery with Bacteriophages and said he did not believe in Statistics.”¹⁴ Upon completion of the course, they returned to the milder rains of Bristol and prepared for the trip to Uganda. Owing to a combination of wartime scarcity in the UK and a general paucity of supplies in Kampala, the Davieses took out a four-hundred-pound loan from Lloyds Bank and did preparatory shopping in London just off of Regent Street at “the famous tropical outfitters, Griffith’s McAlister [sic].”¹⁵ As Davies recalled, “Everything they advised us to purchase turned out to be really needed and served us well. The exception was a large solar topee which I bought, in a metal case, the case was useful for years, the sun helmet I never wore but gave it to an African assistant who found it useful when he rode to work on his bicycle.”¹⁶ The Davieses celebrated one last Christmas in Bristol, and then set off for Uganda via steamer out of Liverpool early in 1945.

For many Colonial Medical Service officers, going to East Africa during and after World War II was not just an opportunity for what they saw as a grand adventure or a chance to do God’s work, as individuals such as Burkitt and others reiterated so often in their accounts.¹⁷ Given the level of wartime scarcity and material deprivation in the United Kingdom, colonial medical work offered an opportunity to have a relatively high standard of living with house help and a garden.¹⁸ There was a social life at the club for the colonial medical officer and his wife to enjoy strong drinks, banter, and tennis. The surgical theater itself was often downright dramatic, with extreme injuries to repair and scrotums filled with liters of fluid to drain.¹⁹ In other words, the combination of perks usually only afforded to proper gentlemen of the English countryside, puzzling medical maladies, and the rush of the wartime hospital without the war was a fulfilling prospect for these colonial medical officers. Indeed, it was a welcome alternative to staying on a damp island and eating yet another can of beans in dingy, bombed-out 1940s London.²⁰

Davies arrived in Kampala later that year over land and sea to assume his post on Mulago Hill. Kampala was a cosmopolitan city where lifestyles, habits of dress, patterns of cultivation, and power were visibly written into the landscape. And hospitals themselves were an important cosmopolitan zone within Kampala. Davies wrote in 1958:

The hospitals deal with all local cases of serious disease, but are also besieged by hordes of patients, whose complaints vary from the trivial to the rapidly lethal. While most of these patients are local, others may come vast distances, from ocean to ocean and from the Sahara Desert to South Africa. Hausa, Zulu, and Somali figure in the hospital records, and notable linguistic difficulties may be encountered in dealing with far-travelled patients. Pressure on beds is extreme; there are no radiotherapeutic services of any sort, and patients beyond hope of cure or relief have to be discharged to their own homes or to the care of friends.²¹

This cosmopolitan concentration of patients at Mulago created an “abundance of clinical material” that Davies and many others at the teaching hospital worked with as they engaged in research projects on diseases common in East Africa.²² Much of the research conducted at Mulago from the 1940s onward was characterized by the desire to articulate the specific disease ecology of East Africa and also to consider the ways rapid urbanization and changing patterns of food and material goods consumption reshape patterns of illness. This agenda had a political edge. In describing the style of medical research at Makerere in the 1960s, historian John Iliffe argues that these individuals belonged to a “generation of researchers [who] set out to demonstrate that in so far as East Africa’s disease patterns differed from those elsewhere, the reasons were generally economic or environmental rather than ethnic or cultural.”²³

When Davies arrived at Mulago, his supervisor gave him the task of developing the pathology education program at Makerere Medical School. The attitudes of British colonial medical officers varied widely toward the African medical students they were charged to teach and train. Some teaching staff embraced the task, finding their students to be impressively smart, keenly attentive, and genuinely excited about biomedicine. Other teaching staff members were decidedly disparaging of their students and the task of educating East Africans, including Davies’s supervisor.²⁴ Davies himself was enthusiastic about both the students and the practical challenges of tailoring medical education in the Ugandan context.²⁵ That the laboratory space and autopsy room were rather bare bones was to be expected. For Davies, the larger issue was an absence of readily available teaching materials. The pathology slides or organ samples you would find in a standard UK pathology teaching museum—with samples preserved in chemicals and stored in ghoulish jars—were simply unavailable. In addition, textbooks and medical journals were in short supply.²⁶ During the war, many of these materials were stolen for their paper and then used in the shops of Wandegeya to hold sugar and other sundries.²⁷ On the other hand, Mulago had an abundance of unusual patient material when compared to Bristol or Liverpool or Edinburgh. For example, one of the first cases Davies and his new group of African medical students collectively examined was a case of pulmonary tuberculosis that had also invaded the heart tissue. Davies assured his students that this was rare and probably the only case they would ever see. They went on to see several more cases of the exact same presentation in the ensuing months.²⁸ Teaching pathology at Makerere required new ways of documenting and disseminating information on the ways diseases presented themselves in East Africa. Given the need for teaching materials in real time, it did not make sense to write and then publish a full textbook that captured the specificity of pathology in greater Kampala. Davies and his students opted instead to write for and develop the East African Medical Journal. They wrote up interesting cases and published them as they went along. Through publishing detailed case histories and conditions, the East African Medical Journal became a key teaching tool.

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Índice

• Cover
• Series Page
• Title Page
• Copyright
• Dedication
• Epigraph
• Contents
• List of Illustrations
• Acknowledgments
• Abbreviations
• Prelude: A Week in the Life of the Uganda Cancer Institute
• Introduction
• Chapter 1: The African Lymphoma
• Chapter 2: A Hospital Built from Scratch
• Chapter 3: Africanizing Oncology in Idi Amin’s Uganda
• Chapter 4: Rocket Launchers and Toxic Drugs
• Chapter 5: When Radiotherapy Travels
• Chapter 6: “Research Is Our Resource”
• Epilogue: In Memoriam
• Notes
• Bibliography
• Index