Cancer Control through Law: making 'the healthy choice the easier choice'
Ms. Hillary Ataro (A Certified Lawyer and Director for Policy at ACCR) lays out the importance of promoting the prevention and control of cancer using law, policy, and legal frameworks. She says:
Cancer costs people a fortune in expensive treatments and lost wages, forcing millions of families into poverty.
This puts enormous pressure on societies and governments, particularly in countries like Uganda where 80% of cancer patients present with advanced disease and where the majority of cancer deaths occur.
It is predicted that the burden of cancer will continue to grow over the coming decades.
Hence, tackling cancer is an urgent development priority and one that requires concerted effort from all sectors to implement comprehensive and cost-effective strategies to mitigate the escalating cancer burden.
The Law is central to this and is the most cost-effective tool available to the government to protect Ugandans from cancer and promote the health of the people. The law can take any form from Constitutions, Legislation, Acts, Regulations, Policies, Decrees, By-laws, Litigation/decisions of courts and tribunals, judicial rulings and case law; Enforcement practices, Customary law, agency rules and regulations, and policies of public bodies.
Laws establish and delineate the missions of all sectors towards disease control, authorize and delimit public health functions, and appropriate essential funds.
The indispensable role of law is evident across the entire history of public health and in today's innovative law-based approaches to preventing diseases and injuries. For example, the global experience of the COVID-19 pandemic illustrates how law-based interventions (such as the legal-epidemiologic strategy of lockdown and social distancing) were implemented even before scientists elucidated the nature of the threat.
Law also helps address high priorities other than infectious diseases and emergencies, as illustrated by the roles of law and legal strategies in the Tobacco Control Act 2015.
Preventable causes of cancer in Uganda
Infections: In Uganda, about 28.7% of cancers are due to infectious agents. The greatest share of infection-associated cancers is due to human papillomaviruses, the virus that is associated with cervical cancer, the most common cancer in Uganda. HPV is a sexually transmitted infection. It can be prevented through the vaccination of girls and boys and the screening of women.
There is a need to Emphasize public health campaigns that encourage people to self-test, attend screenings for cancer, and seek medical advice for symptoms early on.
We need all sectors to be involved in this fight against cancer: For example, we should have laws that mandate schools (Education sector here) to have HPV vaccine for all girls, and HPV vaccines should be extended to include boys and replicated for other infectious agents associated with cancer.
Unhealthy feeding: Unhealthy diet is the most prevalent lifestyle risk factor (at 88%) for both males and females in Uganda. The government needs to prioritize public health policies on food production, processing, distribution, consumption, and disposal, such as excise taxes on unhealthy products.
Overweight (range of 9% to 24%) is the second risk factor among women in Uganda.
Alcohol use: Harmful use of alcohol is the second lifestyle risk factor among men in Uganda at a range of 14% to 26% and is the second leading cause of death in the world. Recent evidence shows that any levels of alcohol are carcinogenic. We need laws that enact and enforce restrictions on the physical availability of retailed alcohol (for example, through reduced hours of sale).
Tobacco use: The prevalence of Tobacco use ranges from 0.8% to 10% in Uganda. We should build on the smoking ban in public spaces with more policies to reduce the demand for tobacco products both at home and globally.
Physical Inactivity; Physical inactivity ranges from 3.7% to 4.9% in Uganda. Policies that introduce physical activity behaviors in the early years of life.
Examples of the use of law to advance cancer prevention and control
Unhealthy diet: The trade law may prevent the trade of unhealthy foods. Healthy food choices at home, work and schools could be made easier through the continuation of the responsibility deals with food and drink manufacturers, employers, businesses and the education sector. The introduction of a levy on unhealthy products for example, sugary soft drinks is a start in the right direction, or the introduction of other regulations like minimum pricing.
Physical Activity; Road safety and traffic laws that enhance walking and cycling environments; planning and environment laws that provide access to open space for recreation; education laws in schools that provide space and adequate amount of time and quality of lessons for sports and physical education (PE) in schools.
Environmental and Occupational Health: We need laws that set standards for air quality as air pollution can be a risk factor for cancer. Employers are also a key audience in the prevention and early detection agenda. We need policies to ensure healthy workplaces to prevent cancers associated with lifestyle choices for example; workplace physical activity policies to make it easier and more accessible for employees to exercise in different ways. There should also be an emphasis on welfare benefits for cancer caregivers, cancer survivors and people living with cancer. For example, having clear policies which allow employees who are affected to take time off whilst being kept informed and engaged with working life, be granted additional leave and have the option for flexible work schedules tailored to the employee’s needs and regularly assessed and adapted.Bans on the use of asbestos and regulations of asbestos handling, various forms of chemical regulation, mandatory PPE by workers exposed to hazardous materials, regulation of fuel content, vehicle emissions or efficiency standards; regulation of wastage/garbage management including e-waste.
Screening, diagnosis and treatment: Regulation of safety, quality, and efficacy of cancer screening, diagnostic and treatment services. Readily avail information on treatment options in Uganda and their implications such as financial and measures to support patient/family decision-making about treatment. New diagnostic and screening techniques in our fight against common cancers such as cervix and breast need to be made more accessible, affordable and accurate for the Ugandan population. Early detection is a key component for secondary and tertiary prevention of cancer. We need to have policies and public health campaigns that reflect that cancer is no longer a death sentence but like other chronic diseases. Health promotion programmes through cancer champions and survivorship that focus on the advances and cure rates from early detection need to be highlighted further, which will encourage people to no longer be afraid. Encouraging people to self-test, to attend screening for cancer and to seek medical advice for cancer-related symptoms is vital and a clear policy imperative. We know countries with organised screening programmes with call-recall systems have the best outcomes. Uganda needs to be supported by a National Cancer Control Programme (NCCP) law to introduce screening programmes and have a centralised programme to make screening tests available and linked to cancer treatment. This should include; educating populations about screening opportunities, leaving no one behind; ensuring people are aware of signs and symptoms of common cancers; having a timely integrated health information system which includes registries and systematically inviting target populations to local services.
Cancer survivor’s laws: We need laws and policies to promote the well-being of people who have been diagnosed with cancer throughout their post-diagnosis lives, and to avoid potential negative consequences of having or having had cancer, including protection against discrimination or stigmatization; income protection; protection against misuse of personal health information; protection in employment, including appropriately flexible working arrangements and support; and access to insurance (including health, life, and travel), pension funds, and loans.
Cancer registries and other collection of health information: Cancer registries are institutions that continuously collect and analyze cancer data to provide a picture of the country’s cancer burden to support the planning and implementation of cancer control services. We only have two functional cancer registries in Uganda (in Kampala and Gulu) that are facing enormous challenges. One of them is that cancer is not a notifiable disease in Uganda and this affects the completeness of the data in these registries. Cancer registration needs to be backed by laws (Act or legislation) that covers the establishment of cancer registries, mandatory reporting of individual cancer cases by all health facilities to national cancer registries and other activities including funding; data access; and training and certification of cancer registrars in Uganda.
ACHIEVEMENTS SO FAR:
Tobacco law in Uganda: According to Nakaganda et al. 2023, trends of tobacco use have been decreasing over time, for both sexes from 25.2% and 3.3% in 2000 to 10.1% and 0.8% in 2016 for males and females respectively. This decrease in tobacco use resonates with the sustained effort towards tobacco control in Uganda that started in 2007, by joining the WHO Framework Convention on Tobacco and later instituting a Tobacco Control Act, in 2015. The Tobacco Control Act led to numerous actions against tobacco use, including creating a smoke-free environment and banning smoking in public places and those with children present; banning tobacco advertising, promotion, and sponsorship; regulating all tobacco product sales, packaging, and labeling; and protection against tobacco industry interference. Hence, the observed decreasing trend of tobacco use indicates some impact of Uganda’s tobacco control efforts. For more information click https://doi.org/10.1186/s12885-023-10621-y
The Uganda Cancer Institute Act-2016: Momentum in addressing cancer in Uganda has increased over the past decade, especially since the Uganda Cancer Institute Act 2016, which established UCI as an autonomous government agency to spearhead the control of cancer in Uganda. The UCI Act 2016 needs to be supported by laws, policies, and legal expertise in the cancer fight. For example, Uganda needs a National Cancer Control Programme law/policy backed by cost-effective policies such as increasing the excise taxes on tobacco, alcohol, and sugar-sweetened beverages and banning tobacco and alcohol advertising.
Harmonized cancer registration guidelines for East Africa: The East African Cancer Registration Guidelines were harmonized under the stewardship of the East African Center of Excellency for Oncology at the Uganda Cancer Institute (UCI) and were approved by the East African Community Sectoral Council of Ministers of Health on 10th December 2021 (EAC/SCHealth/21/Decision 003) and a directive issued to all partner countries to use the approved guidelines (EAC/SCHealth/21/Directive025). These harmonized guidelines are an important tool for enhancing cancer registration in East Africa to produce comparable data across the EAC members’ states to direct the cancer control effort in the regions. For more information click https://doi.org/10.1158/1538-7755.ASGCR23-Abstract-17
A CALL TO EVERYONE
Cancer control is a 'whole Society' challenge and no single ministry or institution can do it alone. Hence, policymakers should take their share of the burden, by putting supportive laws and policies in place and, crucially, reinforcing these with the necessary resources that this area demands. As we wait for more policies to support cancer control, please ensure that your girl is vaccinated against HPV, the virus that is associated with cancer of the cervix, go for cancer screening regularly, check your breasts regularly, do not use tobacco products, do not drink alcohol, do physical exercises for at least 30 minutes daily, eat health foods (avoid sugary foods/drinks, processed foods and too much salt) and avoid excessive body weight.