Cooperation on an equal footing
Ethiopia is considered a prime example of advancements in public health. The health of many people has improved significantly since the second half of the 20th century. According to the United Nations, infant mortality has fallen from 335 cases per one thousand births to 49 in 2022, and average life expectancy has almost doubled to 65.4 years in the same period.
The positive trends in life expectancy are mainly due to large-scale campaigns against malaria, tuberculosis and HIV as well as other prevention programmes, such as measles vaccinations and improved maternity care. However, this development brings with it new challenges: “An older population increases the chances that people will experience cancer or other chronic diseases,” explains Dr Eva Kantelhardt, a professor of comparative public health at MLU. She conducts research at the Institute for Medical Epidemiology, Biometry and Informatics in the Faculty of Medicine and is also a physician at the Clinic for Gynaecology and Obstetrics at University Hospital.
The healthcare system in Ethiopia, her area of expertise, is underprepared for the developments currently happening in the country, which has a population of more than 120 million. In relation to its area (Ethiopia is about three times the size of Germany) and population, the country has too few medical personnel, most of whom work in the few larger clinics in the country. However, the majority of people live in smaller villages. “It would take more than three times as many healthcare workers to meet the minimum number recommended by the World Health Organisation and ensure adequate basic healthcare.”
Kantelhardt is particularly concerned about one development: “Women account for around two thirds of all new cancer patients in Africa.” Breast and cervical cancer make up one third of these cases, which represents an enormous burden of disease for women.
“Now, more women die from breast or cervical cancer than from childbirth. The latter was the biggest problem a few decades ago,” says Kantelhardt, who lived in Ethiopia for eight months and in South Africa for half a year during her studies. Around 90 per cent of new cervical cancer cases and deaths occur in low-income countries. “There are effective prevention, diagnosis and treatment options for both diseases,” says Kantelhardt. However, in many places, there is a lack of knowledge and implementation.
Kantelhardt decided to become more scientifically involved in Ethiopia in 2007, when a friend there was diagnosed with breast cancer. “I realised that there was only one oncologist in the whole country at the time who could treat her.” Kantelhardt looked for ways to provide support. In the beginning, it was difficult to obtain funding for her international projects. The situation has since changed considerably: For example, the “Else Kröner Cancer Centre” was established in Ethiopia in 2020, which is headed by the Faculty of Medicine in Halle, in close cooperation with Addis Ababa University. The centre receives 2.5 million euros in funding from the “Else Kröner-Fresenius Foundation”. In spring, the Federal Ministry of Education and Research provided 6.5 million euros to fund an international research network led by Kantelhardt. Starting this year, the Wellcome Trust, a British research foundation, is also providing a total of 4.3 million euros in funding for another project. “In the second funded project, responsibility for and management of the project lie with my colleagues in Addis Ababa,” explains Kantelhardt, who adds: “We work with them on an equal footing.” This not only includes the joint training of doctoral students and the further training of medical personnel, research is also being conducted on a joint basis.
In recent years, Kantelhardt has supervised more than 35 German doctoral students studying Human Medicine. They live in Africa for four to eight months, working and collecting data there. In addition, 14 Ethiopian doctoral students have received fully funded scholarships as part of joint projects with the Faculty of Medicine. They live and conduct research primarily in Ethiopia and come to Halle for three months out of the year.
The projects start at different levels. In addition to producing findings for healthcare research, all of the measures aim to create “capacity building”, i.e., the expansion of local medical structures and medical know-how. “We want to ensure that there is good medical treatment for cancer across the board and not just at the few very good university hospitals.” This includes further training for dozens of Ethiopian researchers and medical professionals in Germany, as well as the establishment of more local training programmes.
In many cases it is not too difficult or expensive to find evidence-based approaches that are adapted to local conditions and which can improve the quality of treatment, says Kantelhardt. The World Health Organisation’s (WHO) cervical cancer prevention programme, for example, stipulates that 90 per cent of all girls should be vaccinated against the disease. Here, the costs amount to four US dollars per vaccine dose. Breast cancer can also be treated very effectively and inexpensively in some cases. “Several studies have shown that breast cancer in Ethiopia often has a hormonal component, and we can achieve very good results here with hormone therapy. The treatment last five years and costs seven US dollars per month.
Another focus is on what Kantelhardt calls “long-term improvements through education.” Women need to be educated about the topic and made more aware of it so that they can identify possible signs earlier. According to Kantelhardt, “A lump in the breast that does not hurt can still be cancer. The sooner it is examined, the better the chances of survival are.” A lot has already been achieved here in recent decades. “Until the 1990s, women sometimes came to the clinic with relatively large tumours because they had ignored or suppressed the disease for so long.” This is rarely the case today.
Kantelhardt’s team of researchers also utilise the network of African cancer registries, which has been around for many years. It collects extensive data on cancer cases in nearly 30 countries, including age, incidence in the population and the absolute number of new cases. Using data from ten countries in sub-Saharan Africa, some of which was more than 50 years old, Kantelhardt worked with medical students to investigate the therapies that women have received for breast cancer and what their chances of survival have been. The results were sobering: about half of the women broke off treatment early or received non-standard care.
“The last group experienced, in the worst case, only the side effects of the medication, but no benefits,” says Kantelhardt. The reasons for this vary widely, as Kantelhardt discovered in another study: Often, the therapy failed because access to medical personnel was difficult, for example, because the women lived too far away or lacked a means of transport. Often, the patients simply felt too ill to continue the therapy, sometimes as a result of the side effects.
The findings of Kantelhardt’s research are resonating widely. The consortia, coordinated in Halle, regularly report on their research in international journals, and information is extensively exchanged with the Ethiopian Ministry of Health and even the WHO. Here, the researchers, led by the gynaecologist from Halle, contribute their expertise to the development of national cancer programmes.
As a researcher from Halle, Kantelhardt feels it’s her duty to get involved at an international level. “The social conditions in the world are so unequal that we will see much stronger migration movements to Europe or the Western world in the future.” She adds, that the industrialised nations play a significant role in this development. Therefore, it should be everybody’s responsibility to increase the resilience of healthcare systems worldwide. “This is not an ethical or theoretical responsibility, but a very tangible one and we cannot ignore it.”
Professor Eva Kantelhardt
Institute for Clinical Epidemiology, Biometry and Computer Science
phone +49 345 55-74166