Community-based cancer treatment at the grassroots level

By Rita A. Widiadana

The government has just launched a five-year program to develop a national cancer control strategy which actively involves the community. A number of non-government organizations, however, have been applying a community-based cancer treatment program at the grassroots level since l980s. The Kusuma Buana Foundation in Jakarta is one example. The Jakarta Post recently visited the foundation's family clinics to look at its activities in the early detection and prevention of cervical cancer. The endeavor involves thousands of women from middle and low-income groups in Jakarta.

JAKARTA (JP): Better late than never, a doctor at a health foundation commented on the implementation of the government's five-year cancer control program.

"The rapid growth of various cardiovascular and non-infective diseases, including cancer, can actually be halted by implementing a series of preventive actions rather than resorting to curative treatment," explained Adi Sasongko, chairman of the Kusuma Buana Foundation, a non-profit organization dealing with mother-and-child health care.

Cancer can inflict the rich and the poor as well as the young and the old, he said, but "so far, the government seems to focus more on hospital-based programs, which turn out to be too costly and ineffective in controlling the diseases."

Efforts directed towards cancer control in all parts of the world encompass a wide range of areas, from fundamental research to preventive epidemiology, from public education to the development of professional expertise, and from skills for early diagnosis to creation of infrastructure for sophisticated therapeutic technology. The problems in developing nations are compounded by over population, poor education and socio-economic constraints.

The development of sophisticated hospitals or cancer treatment centers, Sasongko said, is indeed very important in curing cancer.

"But, there are only a small number of cancer patients who can afford such costly medical treatment while at the same time the number of cancer sufferers is increasing very rapidly," Sasongko said.

In l989, one in every 1,000 Indonesians had cancer. The number is rapidly increasing because of changing patterns in diet and lifestyle. Official data from the Ministry of Health reveals that each year Indonesia sees an additional 190,000 cancer sufferers. At least a fifth of them are terminal.

Soejoga, the Director General of Medical Services at the Ministry of Health, said earlier that more than 80 percent of cancer patients in Indonesia are incurable because they seek medical treatment too late.

Sasongko explained that the number of Indonesians suffering from cancer can be reduced by actively educating the public about its dangers.

"Indonesia can learn from other developing nations, including India, to deal with cancer," he said.

India's experience in applying the rural model developed by the Tata Memorial hospital in New Delhi indicates the benefit of such efforts when dealing with cancer.

The problem of cancer in India is mainly solved at the grass- roots level, in the rural areas where the majority of the country's population reside. Educating the public about the symptoms and augmenting professional education helps in earlier diagnosis and promotes simple treatment methods that can be applied on the national level rather than at large-scale metropolitan cancer centers. The establishment of simpler cancer centers can effectively serve the needs of low-income patients who will be spared the cost and time of traveling to major cities.

"We can encourage people, for instance, to change their diets and their lifestyles. We can also ask them to undergo medical check-ups for early detection of any related cancer disease," Sasongko added.

Impressive program

Cervical cancer is the biggest killer of Indonesian women.

Poor education, excessive menstrual bleeding, early sexual intercourse, repeated pregnancies and two or more marital partners allow the disease to develop in Indonesia. Smoking and the low educational level of husbands are also crucial risk factors.

To increase the public's awareness of the cervical cancer, the foundation set up an community-based program in 1987.

The foundation has been very active in promoting pap-smears among adult and married women in Jakarta's most densely- populated areas, including in Pisangan, Jatinegara (East Jakarta), Pal Batu (South Jakarta), and Kebon Jeruk (West Jakarta).

"Pap-smears have long been known as a very simple medical method to detect any cervical or uterine cancer symptoms," he maintained.

Sasongko went on to say that the main targets of the program are housewives, female teachers, workers and traders living nearby the foundation's clinics.

"However, most targeted women come from low-income families, they have little spare time to join the counseling program in the clinics as they spend most of their time earning a living or taking care of their children," midwife Murdiati, a team member, added.

Every married woman is advised to have a Pap smear at least once in a year.

To have such a test, Murdiati said, a woman should go to a large clinics or a gynecologist. Each examination will cost between Rp 50,000 (US$25) and Rp 100,000 ($50). The foundation sets a lower rate of Rp 15,000 per examination.

Misleading information on pap-smears has also prevented people from taking this important test.

"Many women are afraid to have such an examination because they receive the wrong information from friends and relatives. They often associate Pap smear examinations with other serious uterine observations which use hi-tech medical equipment," she explained.

Murdiati added that many women are also reluctant to have male doctors or health workers carry out pap-smears for them. "Most women prefer to go to midwives or female doctors to have the pap- smears," she added.

Volunteers

To make the program more effective, the foundation established a special team involving three doctors, midwives, trained paramedics and volunteers to work in its six family clinics.

The team provides counseling and education on the importance of pap-smears, medical treatment and laboratory tests.

Midwife Murdiati, said the foundation has trained prominent members of the community family welfare organization as volunteers.

"These volunteers play significant roles in disseminating information. They include the program in their daily activities to reach a wider audience. Their efforts have been quite successful," Murdiati explained.

The program also involves other community groups including elementary school teachers and members of Koran reciting societies in the targeted areas.

Since the program started eight years ago, the foundation has drawn 6,666 women to have pap-smears. About 140 women were found to have pre-cervical cancer.

"We have to send these patients to hospitals for further treatment as we don't have adequate medical facilities to cure them," said Sasongko.

He admitted that the foundation's program still has many shortcomings. Lack of funds and medical staff have hampered the foundation from expanding the program to other slum areas in the capital.

"I only expect that the government pays serious attention to this grassroots cancer treatment program," he said.

Nigel Gray, the president of the International Union Against Cancer, warned on the eve of the International Cancer Conference last week, that a screening program to treat cancer, now available through developments in medical science, would not be successful unless a simultaneous effort was made at making treatment accessible to everyone.