In Africanizing Oncology: Creativity, Crisis, and Cancer in Uganda, Marissa Mika presents a vivid historical exploration of vacillations in the history of the social and political (in)visibility of cancer as a public health concern in East Africa. Mika draws on historical and ethnographic data on the establishment of the Uganda Cancer Institute (UCI) and a cancer unit at Mulago National Referral Hospital to analyze the issues in cancer management in Uganda. The study considers the historical context for the apparently low priority African governments — both colonial and postcolonial — gave cancer care across the continent, and describes in detail the creativity of Ugandan cancer specialists who utilized collaborative research with the Global North — particularly with the National Cancer Institute in the United States — as a resource for mobilizing and providing care to cancer patients and their families. Mika's main argument is that, by emphasizing taking advantage of local opportunities and Northern resources, Ugandans contributed to the Africanization of oncology from the 1950s through the present.
Mika highlights the fact that international partnerships that commenced with the British Empire Campaign and the UCI, focused on the study and treatment of cancers in the 1950s, were hardly sustained for long. In spite of this precariousness of cancer control work, patriotic Ugandans have kept the UCI, which has served as the main source of knowledge on cancer in sub-Saharan Africa, operational for over 50 years. Ugandan physicians took advantage of the infrastructure for chemotherapy clinical trials on cancers that were common in East Africa and rare in the United States, especially Burkitt's lymphoma and Kaposis sarcoma in the late 1960s. In addition to the expiration of research partnerships in the 1950s and 1960s, the dictatorial regime of Idi Amin further interrupted research and treatment initiatives at UCI in the 1970s. American staff were forced to leave Uganda after the 1971 military coup. Mika stresses the dedication of an Ugandan oncologist who took charge of running clinical trials, buoyed by international research collaborations. Ugandan physicians and other staff kept the UCI operational under the directorship of a sole Ugandan during the 1980s and 1990s after his predecessor fled Uganda for personal safety reasons in the 1980s. Yet even while they ‘Africanized oncology’, structural imbalances and power dynamics resulted in the scope and practices of cancer care in Uganda being shaped by the research and experimental infrastructure created in the Global North in 1960s. The infrastructure focused on generating knowledge to enhance the efficacy of cancer diagnosis and treatment technologies by validating them through clinical trials in sub-Saharan Africa.
The history of knowledge production is a vital element of Mika's story. Her study demonstrates that the knowledge generated at UCI dispelled a prevalent discourse that held that cancer was a disease of the rich. Cancer was already recorded in the mortality patterns in Africa from the 1900s through the 1940s, yet understudied, given that colonial commonsense held that it was not a significant problem in Africa and, therefore, priority was to be directed to ‘diseases of the tropics’ (30). Current research indicates that the most prevalent cancers in East Africa today are esophageal and cervical cancer.Footnote 1 However, the burden of cancer in the region and the rest of Africa remains underreported due to the historical low priority given to the disease and a shortage of medical equipment, research resources, epidemiological expertise, and comprehensive cancer prevalence registries. Whether authorities wanted to admit it or not, cancer was prevalent in Uganda, and Mika demonstrates the resourcefulness of the research at UCI. The institute provided the essential human and financial capital for cancer care and treatment in Uganda, especially for pediatric patients and their families, from the late 1960s through the early 1980s. Mika takes cognizance of the status of UCI as Africa's living laboratory of knowledge production about cancer in sub-Saharan Africa (7), providing pertinent knowledge about the disease in East Africa, the African Great Lakes region, and Southern Africa until the 1990s. The knowledge was hitherto not available from the research centers that existed in Africa and the Global North. The creativity demonstrated by Ugandan medical technicians, researchers, physicians, social workers, and their research partners amplified the visibility of cancer as public health crisis worthy of increased priority in (East) Africa.
The UCI's research and clinical trials contributed to understanding the puzzle of cancers which were common in Africa and rare in the US, such as Kaposi's sarcoma and African (Burtkitt's) lymphoma. The incidence of Burtkitt's lymphoma was found to be associated with exceptional African geographical and cultural factors besides the matrix of treatment and patient care. Mika carefully delineates how successive eras of political, social, and economic crises in Uganda since independence in the 1960s, punctuated the desire of Ugandan oncologists and other health workers to utilize research collaboration resources not simply for knowledge production but also to meet the moral obligations of their patient care needs. Colonial ‘developmentalism’ in the 1940s and 1950s shaped the low priority assigned to cancer in Uganda and East Africa. Mika underscores this reality by highlighting a health and development agenda of experimentation on African bodies focused on politically and economically visible diseases, such as malaria, typhoid, and sleeping sickness (16). An era of ‘Ugandanization’ and independence in the 1960s marked the beginning of efforts to replace the European personnel at UCI and the associated medical school with Ugandans. This entailed training indigenous Ugandans in oncology and promoting research relevant to the African continent.
Mika points out how the 1970s dictatorship of Idi Amin and the civil war which raged from the early to mid-1980s undermined and marginalized cancer research and treatment at UCI. Idi Amin's regime expedited Africanization of the institute. But political, economic, and infrastructural instability did not foster equitable partnerships between Ugandans and collaborators in the Global North. Mika notes how cancer research and treatment initiatives were among the key casualties of government underfunding of the public health sector. Similarly, implementation of World Bank and IMF structural adjustment policies in the 1980s and 1990s ushered in austerity that further reduced the financial resources allocated to cancer research and treatment. Patients and their caregivers were not adequately endowed to share the cost of expensive cancer drugs and diagnostic services. The advent of the HIV epidemic and the National Resistance Movement government under President Yoweri Museveni further defined the matrix of Mika's concept of the Africanization of oncology in Uganda. Each successive era challenged the UCI cancer professionals to ‘Africanize’ their profession by developing means to match international equipment and practices to the prevailing context of health care.
Mika closely considers how supposedly unusual cancers, such as Kaposi's sarcoma and lymphoma in children, provide an important intersection between ‘global oncology’ and ‘African oncology’. These maladies prompted more interest in new patterns in cancer prevalence and incidence. The discoveries that Mika reports about the little known prevalence of Kaposi's sarcoma among women and lymphoma among African children, for instance, would inform alternative hypotheses about the disease.
The book persuasively contributes to the growing discourse on global biomedicine, global health, and global oncology. It is instructive for grounding theories of responsive health systems in cancer management. Mika's plea for the incorporation of East African expertise in the historiography of biomedicine and cancer patient care is necessary and timely. Mika convincingly presents the social aspects of care, which may be a missing link in the pursuit of quality cancer care in East Africa and beyond; citing, for example, the UCI's relative success in pediatric lymphoma research and care services, even amidst the disruptions of Idi Amin's regime, due to the remarkable consistency and sustained patient follow-up facilitated by the staff's cultural expertise. The implications for institutional policy and decisionmaking when it comes to local practices of oncology are self-evident. Similarly, the book effectively illustrates how linkages of local health systems to global (international) systems, through corporate and state actors defines — and limits — health justice. Mika is correct to note how access to expensive state-of-the-art cancer diagnosis and treatment technology and expertise helps to define the unequal global health system. Mika argues that ‘global oncology’ must be a humanitarian exercise that mitigates economic injustice and inequalities in prevention, treatment, and palliation of cancers (141).
The language and presentation of the book are accessible for diverse audiences interested in medical history, African history, the historiography of biomedicine in Africa, and global health. Mika offers an important contribution to health systems research and the emerging fields of anthropologies of cancer and medical and health humanities, by linking social science research and the history of medicine. Health policy makers, those interested in cancer care in the Global South, and researchers in science technology studies will also find the book informative. It presents the lived experience of suffering due to cancer and coping with the disease with sufficient consideration of cultural norms. It adequately balances ethical neutrality while safeguarding against ethical indifference, and draws on essential clinical knowledge to present a comprehensive description of realities in the emergent cancer epidemic in sub-Saharan Africa and beyond. The book is a captivating resource for interdisciplinary and multidisciplinary researchers and health care providers, and is enlightening reading for anyone interested in the history of medicine and global health justice.
