Arbeitsgruppe Frauengesundheit in der Entwicklungszusammenarbeit – FIDE e.V., Vorsitzende: Dr. med. Eva Kantelhardt Zentrum für Frauenheilkunde und Geburtshilfe Universitätsklinik und Poliklinik für Gynäkologie Ernst-Grube-Str. 40, 06120 Halle/Saale, Germany Tel. +49 345 557-1847, Fax -1504 eva.kantelhardt@medizin.uni-halle.de
Developmental Work - the German Perspective
When talking about international developmental work, HIV, malaria, and tuberculosis are the main topics - but there is more: for 15 years the FIDE (Frauengesundheit in der Entwicklungszusammenarbeit (www.ag-fide.de) - Women's Health in Developent Aid) working group has been focusing on topics concerning international women's health. The FIDE working group as a scientific organization in Germany wants to be a platform to discuss gynecologic topics in an international context, collaborate with colleagues from other countries, advise German organizations working abroad and encourage existing scientific organizations, clinical study groups, and experts to become involved in improving international women's health. Indeed, there is a broad spectrum of activities making it interesting and newsworthy to look further than the end of one's own nose!
Clinical medicine was the main subject when modern medicine was introduced in many developing countries centuries ago. Public health and prevention have improved greatly, e.g. immunization in children. Looking at the situation in the 21st century, clinical medicine is becoming more and more important again.
In the year 2000 an important referendum was published by the United Nations proclaimed in Kairo: the Millennium Development Goals (www.un.org/millenniumgoals). For the first time clear parameters and indicators to measure the outcome were put into such a political statement:
1. End extreme poverty and hunger (halve, between 1990 and 2015, the proportion of people whose income is less than $ 1 a day).
2. Achieve universal education: ensure that, by 2015, children everywhere, boys and girls alike, will be able to complete a full course of primary schooling.
3. Promote gender equality and empower women: eliminate gender disparity in primary and secondary education, preferably by 2005, and in all levels of education no later than 2015.
4. Child health: reduce by two thirds, between 1990 and 2015, the under-five mortality rate (has been 180/1000 in sub-Saharan Africa in 2000).
5. Improve maternal health: reduce by three quarters the maternal mortality ratio (has been 920/100,000 in sub-Saharan Africa in 2000).
6. Combat HIV/AIDS, malaria and other diseases: have halted by 2015 and begun to reverse the spread of HIV/AIDS (has been 40 million people infected in 2000) and the incidence of malaria and other major diseases.
7. Ensure environmental sustainability: halve, by 2015, the proportion of the population without sustainable access to safe drinking water and basic sanitation.
8. Develop a global partnership for development: economic support of disadvantaged regions.
Seeing that 4 out of 8 goals are directly connected to women's health will give new seriousness and insistence to the engagement of our profession in the international context. There has been some change in the 9 years since the goals have been proclaimed - e.g. a huge progress is seen in poverty reduction. However, in other aspects, e.g. maternal health, much effort is still needed.
A Shift from Communicable to Non-Communicable Diseases
Due to improvement of living conditions, better nutrition, and higher life-expectancy, the WHO predicts an increase in so-called prosperity associated diseases: not only diabetes and hypertension but also the number of cancer patients will increase. The ratio of communicable to non-communicable diseases will soon change from 3.8:1 to 0.5:1! Of 1.5 million expected new cases of breast cancer in the world in 2010, around 50% will occur in countries with limited resources. Most of the expected 500,000 deaths will take place where few therapeutic options are available. This number will outrun the number of maternal deaths in the world. While European and North-American patients are offered an ever increasing variety of treatments, there are only few options for patients in other parts of the world. Breast cancer will be the number one cancer killer of women in their age as head of the family - even before cervical cancer.
Currently the scientific community and especially oncologic clinical trials are focused on the Northern parts of this world despite these truly international developments. This under-representation of developing countries leads to a considerable imbalance not only in patient care but also of the scientific results. Of course patient care can only be provided by physicians onsite in the developing countries. Organizations like the United Nations are prioritizing international women's health on the highest level - should that not implicate broad collaboration when facing the challenges of limited resources? Developing countries may benefit from past experiences in Europe. Guidelines for management of breast cancer adjusted to the level of available resources published by the Breast Health Global Initiative (BHGI) are an excellent example. Further involvement of German experience would be desirable.
Current Activities of the FIDE Working Group
The international working group FIDE has made ‘Oncology Worldwide’ a major topic at the annual conference ‘Sharing Experience’, held November 12–14, 2009 in Jena (www.conventus.de/isse2009). At the joint meeting of the German Society of Tropical Surgery and FIDE speakers will present and reflect key clinical problems in worldwide medicine in accordance with current scientific development, considering the political and cultural context. Participants and speakers from developing countries will be able to present their most important clinical problems and their various solutions.
The University of Halle has started a collaboration with the University of Addis Abeba to improve education and conduct scientific research of mutual interest. Combined workshops improving evidence based clinical standards, summer schools, development of clinical trials, epidemiologic and laboratory research programs, as well as exchange of lecturers and specialists are planned in the field of Gynecologic Oncology. Breast cancer will be a major focus of this program since it is the most common malignant disease in university hospitals here and there. The interest of both sides in this heterogeneous disease will be to examine the striking differences in ethiopathology seen between Africa and Europe (e.g. early onset, rapid course of the disease, low incidence in Africa, fig. 1) important findings are expected. A balance for collaboration has to be found combining bilateral scientific and pharmaceutical interests (e.g. tissue banking) to the benefit of our patients.
Fig. 1.
Typical breast cancer patient in rural Ethiopia. Patients are of young age and often present with advanced disease (35-year-old patient, 5 children, cT2 cN1, mastectomy - pathology could not be obtained for logistic and financial reasons).
Eva J. Kantelhardt, Anke Mothes, Chistoph Elsen, Gerhard Keil, Christoph Zerm, Jürgen Wacker