Beryl Thyer

Memorial Africa Trust

Burkitt's Lymphoma: Follow up


It is not always easy to reach BL cases at their remote villages	Peter and Prof Hesseling on a tour to visit BL cases at home

We have already presented an outline of our work in the investigation and treatment of children suffering from Burkitt's Lymphoma, at two major centres in the N W Province. There is more to the successful management of this highly malignant yet potentially curable disease, than blood tests and chemotherapy. First you must get your patient; secondly you must retrieve him for subsequent courses of chemo. There follows here the salutary account of our Research Assistant at Banso Baptist Hospital, who was commissioned to retrieve a patient for her overdue chemotherapy.


There comes a time and place at which vehicles can go no further	We always rapidly acquired an inquisitive young audience

Burkitt's and the motorbike

Having travelled to the Foumban area on a previous occasion, I thought that the present trip to the same locality might be fairly simple. Taking local advice however, I was warned that it might not be so; indeed it might not even be possible to go and return the same day.

After my shift at the hospital on July 10th 2003 I left Banso in the N W Province, for Foumban in the W Province - about 80 kilometres distant to the south east of Kumbo. It was necessary to spend the night there. Early next morning at 6.00 am I started the journey from Foumban to Malantouen - about 30 kilometres to the east. Early morning wetness made the shortcourse route hazardous, so we took the longer road and arrived at Malantouen Mancet Square at 10.00 am. On locating the relatives of our patient I was told that the child and her parents were all at their distant farm. It was then necessary to take a car from there to Mapuh village, followed by a motorcycle lift to the farm some 2 km further on again. A ten year old boy was pressed into service to lead us to the farm - both of us astride the motorbike. At the farmhouse we were told everyone was actually on the land another 200 metres away. I therefore pressed another local man to accompany us to the right place, and to plead with the motorcyclist to accompany us also, since the return journey without him and his machine would create a serious problem.

As we approached the farm, the track was so overgrown that the driver could not see the track beneath his wheels. The poor fellow rather wished he had never met me! As for me I was astonished at the sheer distance over inhospitable terrain, that these rural folk had to walk on a regular basis in order to make a living.

After brief greetings from the astonished father of our case, we returned to the farmhouse, where it was necessary for the child and her people to bathe. The father said that he would like to send me on back to Banso immediately, and follow himself the next day. I resisted that suggestion, since the child was already one week late for her vital chemotherapy. Happily my argument prevailed!

So it was that the four of us - the child in front, then the longsuffering driver, then myself, and at the back the father of the child - set off on the bike to Malantouen, a three hour ride, and then on to Foumban. From Foumban to Banso was a taxi ride for the three of us. The epic journey was completed at 10.00 pm on July 11th - a very full and a very important journey for the sake of the child.

My normal nursing job was resumed next morning. It was only later that a friend made two observations; firstly that my pullover was full of grasses picked up during the bike ride in the bush, and secondly that part of the heel of one sandal had been sheared off by some moving part of the motorbike. I didn't even know that that had happened.

The cost of this journey was a little short of 20,000fr CFA [£20], and this by the way, is more than the chemo costs, and is payable by the sponsors of the Trial. The whole trip was at once exciting, strenuous, and essential. I was tired but proud to be part of a project to rescue children with this awful disease'.

Nurse Vera Samba

Research Assistant, SIOP Burkitt's Lymphoma Trial

Banso Baptist Hospital, Cameroon, Central Africa

July 2003

Burkitt's In Bamenda

Nurse Vivian with child O and family, at their home

Child O is a very special little boy for me. He had Burkitt's Lymphoma, and was admitted to my hospital for treatment almost a year ago. The investigations and aspects of treatment were free of charge, through the assistance given by the English organisation called Child Advocacy International. the child has received all six doses of his chemotherapy, and it appears that he is saved from the disease, which appeared as a tumour of his left jaw.

The family village is called Massangan, and is actually not in the North West Province where we work, but around 150 km away - in the Western Province. It is near the towns of Foumban and Foumbot; places we have come to recognise as having many cases of this disease. Why such a lot of our children come from this area is still a mystery; but surely it will be a good research project for the future.

Like most of Cameroon, the district is richly fertile and wholly agricultural. And like most of rural Cameroon, the population here consists chiefly of poor subsistence farmers. The family of child O would never be able to afford even the simple chemotherapy we give, and the transport to and from the hospital was also more than they could afford.

In fact most of the roads to the village are of moderate quality. I have used public bus services on three occasions to visit and fetch him back to the hospital. The buses are slow though, and do not go until they are well-filled with passengers, and well-loaded on top with all sorts of cargo - chickens, goats, furniture, bags, sacks of rice and plantains etc.. It normally takes six hours to reach Massangan in this way, so it has always been a full day's round trip on each occasion.

It is always a great joy to find our patient happy, healthy and playing with his friends and family in the village. His progress has come to the attention of Cameroon Radio and TV, and he has featured in a half hour documentary produced by the TV people here. We hope one day to get a copy of this film for the people in UK to see.

Now that one year has elapsed, we believe that we can genuinely class child O as cured from his cancer. What more can anyone wish for?!

Vivian Manka'a

Research Assistant Nurse for Burkitt's Lymphoma

Provincial Hospital, Bamenda, Cameroon, Central Africa

February, 2004

Burkitt's Lymphoma ~ Domiciliary Visits

It had not hitherto been my practice to visit surviving BL cases in their homes. I had always been part of the on-call team for acute admissions in the children's ward at Banso Baptist Hospital. To have gone away for a day would have been tantamount to abandoning the post. It has to be admitted however, that the passing of the years has somewhat blunted my enthusiasm for repetitive on-call duties; to be doing at 66 that which was designed for chaps of 26 is not easy. So it is that I have focused in on Burkitt's lymphoma cases - an ever-growing and increasingly gratifying aspect of the paediatrics at BBH - and now give most of my time and energies to their management. My friend and mentor Professor emeritus Peter Hesseling (the overall Director of our BL work), clinched the matter for me. It has always been an integral part of his philosophy to visit these children in their own homes. He declared there was an element of fun in the activity; not to mention the adventure and the unexpected; the 'cor!' and the 'wow!' that often arise.

We therefore asked our admirable BL Research Assistant Nurse, Vera Samba (who herself has experienced remarkable things on her visitations to BL cases in their remote localities) to select a number of BL cases more or less grouped in one of the two areas from which we have noticed clustering, and let Prof H and herself and me hire a taxi for a day, and visit them.

Fifteen thousand francs [about £15], plus the cost of the diesel fuel, plus a small additional gratuity, secured the services of Demas the driver and his taxi. At 7.00 am on Wednesday March 9th we set off in the four-door slightly decrepit Toyota taxi, for the region of Foumbot, about 100 km S E of Kumbo.

Along the way, the sharp-eyed Vera spotted Euphorbia plants growing at a roadside compound. Here we stopped and counted six Euphorbia plants, of at least three different species. Wide-eyed inhabitants and their clutch of small children must have been astonished at our interest in their garden. No child here had BL, and later today would find several children with treated BL - but with no Euphorbia in their immediate localities. All these observations are hardly in keeping with our hypothesis that Euphorbia is an important co-factor in the causation of BL.

Our first enquiry for a patient was at the government Health Centre at Bangourain - about half way to Foumbot. The doctor in charge was Theophile Ninkam, and it was to him and others we showed the photograph of our patient and his carer.

It did not take long for us to pick up the comment - 'Il est mort'. The sadness of this discovery was somewhat offset a little later, when a man gesticulating as he pursued the car caught our attention and stopped us. He had recognized Vera, and he chatted to her with smiles in effusive French. Prof and I did not get the full content of his speech; but this was the father of the dead child, and he was clearly very glad to see us, and very appreciative of all that had been tried by the BL team at BBH to rescue his child.

Once again on smaller tracks and across wooden bridges of questionable integrity, we visited a further 7 homes of our BL children before stopping in Foumbot town for lunch. All those children were alive and well. One child, had a remarkably protuberant belly. We found he had a huge spleen and a moderately enlarged liver. We felt no solid masses within the organs, and no other evidence of recurrence of lymphoma. It is to be hoped the splenic enlargement is due to malaria. An ultrasound examination at his next follow-up will help clarify this.

In all the visits it was a joy for us to see the pleasure on the faces and hear the pleasure in the voices as Vera announced the reason for our visit. The earnest of our intentions; the seriousness of our concern; the depth of our commitment - were all obvious to the parents. Good relationships already forged at BBH were thus consolidated by our visits. This can only be good for the children, and good for the service being freely offered by BBH.

Wherever we called, we urged the people to be on the lookout for other BL children, and to refer them to BBH; all children with swollen jaws or big bellies - such as their own children had had. Indeed we learned that carers had already seen such children and had urged their parents to waste no time in getting to BBH. So it is that with the help of the good people of the bush, the Gospel of BL Treatment is being propagated far and wide; word of mouth; bush telegraph; hugely effective where radio, TV and newspapers are non-existent.

Research Assistant Nurse Edith, Peter, BL survivor and her father. This child had left school early and walked barefoot for 2km to keep the rendezvous with us.

One child was brought out of school to see us. Another was brought to us by motorbike from the family farm, whilst we waited in the welcome shade and coolness of the humble family home.

At every venue we rapidly accumulated an audience of twenty or so people, at least fifty percent of which were small children. We wondered, as we saw a small child being carried by her mother - who was also pregnant - about the availability of family planning in these rural communities.

At the home of one patient we found the child to be well; but his father was in pain with herpes zoster. Vera knew the mother to be dead from HIV/AIDS. We wondered therefore about the underlying cause of the father's shingles. Happily our boy was known to be HIV negative. It looks however as though this little boy is on course to be another African AIDS orphan.

After our belated lunch there remained a further two cases on Vera's list for us to visit. Local advice given to Vera as to the whereabouts of these two children turned out to be inaccurate in time and space; Ten minutes became nearer one hour of rough motoring, and the offered 4km more like 10km. We discovered that one of the children had died, and upon finally reaching the most distant home - taking with us a little girl as guide - we found that our and her parents, were somewhere in the NW Province, from whence we had set out at 7.00 am today! She was however reported by neighbours to be alive, and could be counted as such for our statistical purposes.

So now, at about 5.00 pm, we started the long homeward journey. One of the small bridges we had crossed earlier was partially damaged by our crossing. It was necessary for Prof H and me to re-arrange a few planks in order the more safely to negotiate the bridge.

Then it started to rain. The rainy season was not expected until March 15th; I knew this; Vera knew this, but no-one had told the clouds. The formerly dry red dusty tracks became covered with red slime and the car began to skid. Before reaching Foumbot we came to a standstill on an up-gradient. Two local lads on pushbikes could not be coerced into helping us push the car out of trouble; it fell to the three of us to do the shoving in the gathering gloom.

The road from Foumbot to Foumban is tarred and of good quality. The only hazards on this stretch were at checkpoints manned by Gendarmes demanding to see the driver's documents and the passengers' ID. The first Gendarme was clearly out to make trouble for us. Demas' documents were OK; my own Cameroonian Resident's Card worked like a dream; the problem was with Prof's ID. It was not his habit to carry his passport around the countryside with him; he had photocopied it. The Gendarme demanded to see his visa. 'It is in his passport'. 'Where is the passport?'

'It is in the hospital'. Prof pointed out that for him to be in Cameroon at all he must have a visa. The man was not impressed. Nor was he impressed we were on a medical project for the hospital. 'Could we present the passport at the Kumbo Gendarmerie in the morning?' Not impressed. It was only when Prof pointed out his official flight itinerary; Capetown to Johannesburg; Johannesburg to Nairobi; Nairobi to Douala; with all the dates, that we were grudgingly allowed - after twenty minutes of delay in the darkness at the roadside - to continue. A bribe was clearly expected, and equally clearly was not being offered.. We were lucky; I have experienced worse than this at the hands of naughty Gendarmes in the past. The second checkpoint had a much more affable officer in it, so that we were not delayed at all there.

We now took the 'main road' from Foumban to Jakiri in the hope that it would be better than the minor roads we had used in the fair weather of the earlier part of the day. The road is untarred all the way to Jakiri - about a two hour drive. By now it was 7.00pm - (we had been travelling for 12 hours), so that with the final three quarters of an hour from Jakiri to Kumbo we might have expected to be home by 10.00 pm.. There were however two seriously rutted muddy stretches of the road to negotiate, and we came to grief in both of them. Pushing and shoving in the darkness with the aid of local bike lads, got us under way from the first bad patch. The second one was a worse experience. We just could not get the vehicle out of the quagmire; the bottom of the car was sitting on the road. At this point I really thought we were going to be sitting in the car until morning - when visibility and a degree of drying of the road might favour our escape.

Vera had a better idea; she believed that close to the road was a compound, and that we should go there and beg assistance. By the fading light of my medical torch she and I picked our way to first one hut (no answer), and then to a second one. Here we awakened the male occupant and begged him to assist us. Thankfully he was young and powerful, and he agreed. Living beside this bad stretch of road he was used to helping vehicles out of distress. With his directions the car was lifted - back end and then front end - out of the mud and into a comparatively better position. 'Go, go, go!!' With this verbal encouragement Demas urged the Toyota forwards twenty yards or so, to a safe surface.

By now Prof and I were covered in wet mud. Had we each been sixty years younger our mammies would have been very vexed with us owing to the terrible state of our clothes. We had slipped and fallen into the mess more than once. We had been sprayed repeatedly with muddy water from the uselessly spinning wheels. We had been baptized by sprinkling and by immersion. It crossed my mind that probably never before had an emeritus professor of paediatric oncology been so comprehensively doused in nocturnal mud.. Prof, who had been doing his car rescuing manoeuvres barefoot, had sustained a cut to one sole. We linked arms for moral and physical support, and must have resembled drunken ballet dancers. Curiously we seemed to remain cheerful.

The good man of the compound fetched us water to wash away the worst of our dirt. He received a gratuity from us. He told us that this was the very last bad bit of the road between here and Jakiri. 'Waka fine na for Banso!' With this cheerful farewell from him we were at last on our way to Banso.

A rising mist over the now drying road conspired to keep the speed at which Demas could drive, to a lower one than he would have preferred. This was good news for his passengers, for at times he was a trifle reckless, and showed little respect for the old Toyota as he launched the poor vehicle through potholes at speed, rather than circumnavigating them.

It was close to midnight - with 16 hours and 300km of motoring behind us - when we dropped off a muddy Vera Samba and her cargo of gifts from the people of the bush. A lady at the hospital entrance looked at Prof and me in amazement and said simply - 'Ashia doctors!'

By 12.30 am Prof and I had showered and sat down in our lodgings at LAP Centre Bamkika'ai, contented; full of thoughts and experiences. We nibbled on cheese and biscuits and caught up with seriously overdue tots of Old Mull single malt. We reminisced and considered future plans, in happy mood until 2.00 am on Thursday March 10th.

Was it all worth it? Without doubt it was. Scientific medicine; practical paediatrics; affordable treatment; dedicated follow-up; African bush medicine; deep companionship; consolidated friendships; fellowship with the people: such were our thoughts.

Two tired, contented medical colleagues - with aching forearms due to the unwonted lifting up of Toyotas, went to their rooms for 5 hours of sleep, in preparation for this day's next challenges in the care of children with Burkitt's lymphoma.

Peter McCormick

March 2005

MBH driver, surviving BL patient, Dr Doris Mofor, Research Assistant Nurse Irine (holding baby), sister of the patient, Prof Hesseling with gifts of vegetables and live rabbit, father and mother of the patient, at their home.

(Burkitt's: Follow up)

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Beryl Thyer Memorial Africa Trust, a UK registered charity ~ 1112603