Psychiatrist on safari

In the United States, it’s easy to think about all the deficits we have in health care. … Being somewhere like Africa really makes it apparent how fortunate we are.

–Dr. Scott Nichols

Dr. Scott Nichols knows of what he speaks, having recently returned to Chico from South Africa, where he participated in a late-November conference hosted by the African Organization for Research & Training in Cancer (AORTIC).

Nichols, medical director of Enloe Behavioral Health, is a psychiatrist who also practices psycho-oncology (aka cancer psychiatry) at the Enloe Regional Cancer Center. His mentor, Dr. Jimmie Holland of Memorial Sloan-Kettering Cancer Center in New York City, invited him to the AORTIC conference “Cancer in Africa: Bridging Science and Humanity.” He accepted and contributed his expertise during a daylong program titled “Treating the Whole Patient: Moving Psycho-Oncology Forward.”

Including time for travel and a safari, Nichols and his wife, Sharon, spent two weeks in South Africa. “It was an amazing experience,” he said, one that left him with an enhanced perspective of the country and the African continent, as well as an appreciation of home. Americans may complain about the health-care system, but elsewhere, Nichols said, “it’s really on an entirely different scale.”

Take Botswana, for example: a nation in southern Africa with a population of around 2 million that lacks even a single native-born doctor with training in cancer care. Health officials there must recruit oncologists from China, India and Cuba who work rotations in which they face linguistic and cultural barriers.

“In other countries,” Nichols said, “they don’t have any radiation oncologists or radiation-oncology facilities. One of the people we talked to said they don’t have regular access to morphine.”

When it comes to cancer treatment, Africa has “huge gaps in infrastructure but some incredibly talented people working there.” Nichols has pledged to help. He and Sharon intend to work with specialists they met at the conference to develop a new group: the African Association for Psycho-Oncology.

Nichols’ talk during the AORTIC conference focused on delays in diagnosis and treatment, which is common among cancer patients in Africa. He said cancer carries a social stigma; many Africans associate cancer with HIV. As a result, patients may be shunned by their neighbors, lose custody of their children or have their marriages crumble.

Culture, then, plays a big role.

“An American or European, when something starts to happen to them physically, would ask what’s happening and why,” Nichols explained. “What the Africans uncovered in their research was that the typical African response is ‘What’s happening and who—who is causing this?’ They, particularly in times of stress, will revert to their traditional belief systems.”

If an African cancer patient believes his or her condition is a curse rather than an illness, that patient is likely to consult a spiritual leader or healer instead of a doctor, a choice that carries the potential to delay treatment, Nichols said.

Nichols has studied instances in which Western medicine has been introduced to other cultures, and pinpointed a key factor: whether traditional healers were included or excluded from treatment.

“The general thought at the conference was that we need to try to work together with traditional healers,” he said. “The stories and evidence that I brought from an outside perspective really supported that: that things generally go better when one tries to reinforce and support existing social structures rather than compete with them or discredit them.”

One example he shared came from Afghanistan, where U.S. nurse-midwives taught prenatal care and delivery classes to religious leaders rather than to the expectant mothers and fathers. The imams then taught the classes in their communities.

When the nurse-midwives checked back, they heard a common story. A husband would see his wife experiencing difficulties with the delivery. The husband’s father would believe the woman’s survival was up to divine providence, Nichols said: “If God wills, she will live; if He wills, she will die.” But since the imam’s classes had taught that complications in childbirth require medical attention, the husband would take his wife to a clinic, thereby saving the lives of both mother and baby.

Nichols related similar instances from other locations abroad, including a physician who went to South America in the 1960s and helped bridge a gap between Western doctors and local healers. In addition, Nichols explained the benefits in American hospitals of having chaplains available to tend to patients’ spiritual needs.

“I think what came of that [discussion] was a chance to make … African oncologists more willing to include traditional healers in their discussions with patients, even train traditional healers to recognize signs of cancer and know who should be referred,” he said.

“The worst thing you can do is [force] someone to make the choice: abandon my culture and spiritual heritage, or accept modern medical care. It works better when it’s both, and people don’t have to make that choice.”

Nichols came away from the conference encouraged about potential ripple effects, even beyond the push for psycho-oncology. Among the attendees was Dr. Andreas Ullrich, a top official with the World Health Organization, with whom Nichols had several discussions.

“I really got the indication that the things that were presented at this conference are going to modify World Health Organization strategy for controlling and treating cancer in Africa,” Nichols said. “That alone was a huge step forward.”

Nichols and his wife plan on returning to Africa to continue their work with the African Association for Psycho-Oncology and attend the next AORTIC conference, which will be held in Morocco in 2015.