Background

In sub-Saharan Africa (SSA), surging numbers of cancer incidences and mortalities need urgent attention. Without any intervention, data estimates show a major increase in cancer mortality from 520 348 in 2020 to about 1 million deaths per year by 2030.1 While upscaling cancer care delivery in Africa has garnered significant attention in recent years,2 specific populations within the continent are more severely disadvantaged in accessing currently available cancer diagnosis and treatment services. Among them are the nomadic populations.

Nomadism is defined as the periodic migration of people with their herds of animals searching for pasture and water, dispersed over time (seasons) and space.3 Nomads are generally classified as hunters, gatherers and pastoralists.4 Hunters and gatherers, such as the Kalahari Bushmen, predominantly live in the equatorial rainforests. Pastoralists are subdivided into transhumans, who regularly migrate between two grazing areas along well-defined routes, and those whose economy is based purely on migration and livestock keeping.5 6 Our paper focuses on pastoralist nomads in Africa, whose trajectories largely rely on grazing grounds for livestock.

There are an estimated 50 million nomadic pastoralists in SSA with little data on healthcare access and utilisation, especially on cancer care.7–9 The Intergovernmental Authority on Development in Eastern Africa block has attempted to map data on numbers and tribes identifying as pastoralists (table 1). They include Afar in Djibouti, Tigre in Eretria, Bodi in Ethiopia, Borana and Gabra in Kenya, Somali in Somalia, Dinka in South Sudan, Ahmada in Sudan and Bahima in Uganda.10

The WHO11 states that there are four key components to cancer control: cancer prevention, early detection, diagnosis and treatment, and palliative care. Most Low-and-middle-income counteries (LMICs) face major challenges in each of these four areas. There is a paucity of data on cancer prevention, early detection, diagnosis and treatment, and palliative care among nomadic communities. Most data are based on specific, often small-scale studies, each providing a small part of the overall picture.3 6 Globally, cancer control and continuum of care protocols are well established, however, due to the migratory lifestyle of nomadic communities, such algorithms might not address the unique cancer care needs among nomadic populations. Population health data are a crucial social determinant of healthcare and is lacking in nomadic communities in SSA. We, therefore, attempted to summarise the fragmentary evidence from the literature on the state of cancer care, the scant cancer epidemiology data of the nomadic communities, and their unique challenges and needs for cancer care. We also attempt to provide real-world proffered solutions to the neglected modern cancer care needs among nomadic communities in SSA (table 2).

Cancer prevention among nomadic populations

While there is a paucity of data on cancer prevention strategies among nomadic populations, their ambulatory lifestyle, less exposure to urbanisation, and Western diet and industrial carcinogens might decrease their risk for certain cancers. However, their mobility means undetected exposures to infection-related cancers such as cervical and liver cancers, and poor uptakes of vaccines, leading to late presentation, and resultant poor outcomes.

The integrated human and animal vaccination campaign has effectively reached the unvaccinated children from nomadic and pastoralist communities of Somalia.12 A similar approach can be used in Human Papillomavirus (HPV) and hepatitis vaccines, a key strategy in cancer prevention strategy against cancers among nomads in SSA. However, gender roles should be considered. For example, girls in nomadic communities are often not sent to schools or taken early out of school; therefore, school-based HPV vaccination is often not feasible for these communities, hence, the provision of mobile health is key.13

Therefore, a systematic global approach to cancer care delivery among nomadic populations is urgently needed to ensure equity in care delivery. Such interventions may include conducting global studies to investigate and understand epidemiological cancer patterns among nomads to ensure equity in care delivery and deploying mobile cancer screening services along the migration routes of nomads. Culturally appropriate education on cancer-preventative measures can also be explored among nomadic communities.

Cancer early detection among nomadic populations

Nomadic-specific cancer screening, early detection and treatment strategies, including an amalgamation of ‘mobile’ services informed by the migratory tendencies of nomads, culturally acceptable services, community-directed interventions (CDIs) and One Health design, have shown promise.14 One Health is an approach calling for ‘the collaborative efforts of multiple disciplines working locally, nationally and globally, to attain optimal health for people, animals and our environment’, as defined by the One Health Initiative Task Force.9 15

Deploying mobile cancer screening/early detection to designated water and pasture points could be explored. Women’s presence at such waterpoints is variable but offering risk-stratified HPV vaccination for girls, on-site clinical breast exams, cervical cancer screening and digital rectal exams for elderly men with urinary symptoms are some of the prevention, screening and early detection modalities that can be explored.

CDIs can reach underserved populations and have been successful in treating diseases such as malaria case management through local community efforts.16 A study from Ethiopia reported the success of a mobile health team that provided nutrition services, vaccinations against measles and acute malnutrition among pastoralist children.17

Similar efforts led by trained community health workers (CHWs) can be attempted in introducing cancer screening, early detection and patient education, among the nomadic communities in designated villages or waterpoints well known to CHWs. Designing such programmes requires political will and leadership to provide sustained and practical support to these marginalised communities

Cancer diagnosis among the nomadic population

Nomadic patients often ignore illnesses that do not cause immediate functional loss and resort to the use of predominantly traditional and alternative medicines due to the low trust in or limited access to modern allopathic medicines.18 Timely cancer diagnosis among nomads can be challenging due to their inherent migratory lifestyles.19 Therefore, effective cancer management among nomads should include a continuity of care model that will not clash with nomadic lifestyle patterns. These interventions may include on-site clinical history taking and physical exams at converging water and grazing points, a form of mobile health. Another feasible approach is adopting the tuberculosis treatment model for nomads, in which Tayler-Smith et al and Keus et al20 21 reported the ‘TB village’ and humanitarian model, respectively. In both studies, the TB village approach to patients (and the main reason for the very low defaulter rate) was the provision of incentives such as free temporary social amenities such as food and housing. Similar interventions could be adopted by implementing a ‘cancer village’ that will bring mobile cancer services closer to hard-to-reach nomadic communities, especially cancer screening, clinical diagnosis, palliative care services and subsequent referrals. Furthermore, it is important to link the cancer diagnosis among these communities to a clear care pathway from diagnosis to treatment, be it curative or palliative by possibly following up these patients in their watering points and other approaches.

Health information from online or in leaflet form can be inaccessible due to low literacy levels, particularly among older adults in nomadic communities; therefore, where possible, local healthcare professionals need to address such patients in a language they understand best or through a translator.

Cancer treatment among the nomadic community

Several factors that impede access to cancer treatment among nomadic populations are outside their community’s control. These include geographical isolation, logistical difficulties, lack of available resources in rural areas and their marginalised status.22 ,23 Health systems are often designed to serve static populations, with services that cater to nomadic lifestyles rarely being prioritised.24 For example, the Bedouin women in Lebanon perceive the health system as being underpinned by institutional discrimination against their ethnic group.25

There is often a lack of representation of nomadic cultures in national governments, therefore, nomadic populations are left out of health policy agendas including those that aim to increase access to modern cancer care services. Another way in which nomads are vulnerable to political factors is through regional political conflict and climate change.26

Decentralisation of access to care remains a challenge due to unpredictable migratory patterns of nomads. A study from Timbuktu, Mali,27 a country with a nomadic community, showed the average distance to the local health centre was 40.94 km. Key barriers to access were transportation options (79.4%), the quality of healthcare services provided (39.2%) and the high-cost health services (35.7%). Additionally, the study reported more than a quarter of the study subjects would not consent to be examined by a healthcare worker of the opposite gender. This unique cultural need for consenting to treatment highlights unspoken barriers to other healthcare needs like cancer treatments which require cultural sensitivity. A study from Somalia, a country with (59%) of its population practising a nomadic lifestyle, found that 90% of nomads were out of the reach of the national health services due to constant mobility coupled with seasonal barriers such as rivers, floods and terrains, making treatment access even more challenging.28

One Health provides healthcare services that are tailored to the nomadic pastoralists that integrate the human and veterinary health services that improve both human and animal health9 ,15 ,29 a potentially effective strategy for cancer care delivery and prevention strategies among nomads.

While there is no existing evidence, we suggest an adjusted approach to providing access to cancer treatment for nomads including providing oral anticancer agents that can be taken while patients are on the move, even though this is not a one-size-fits-all recommendation against all cancers.

Innovative mobile health delivery methods will be needed to manage toxicities and ensure treatment adherence. Another approach is the consideration of de-escalation treatment protocols using shorter courses of chemotherapy or radiotherapy in addition to facilitating temporary housing for patients who present to cancer treatment facilities. De-escalation therapy can be applied to both palliative and curative modalities.

Palliative care among nomadic community

Public health programmes on hospice and PC services may fail to reach nomadic populations. Nomadic patients with cancer need PC services that are designed specifically for them, although the per capita cost is bound to be high because of the scattered population and the need for mobile clinics.30

The most effective and feasible intervention for pain control among nomadic patients with cancer is medication. Tablets-based inexpensive analgesic medicines such as non-opioids and weak opioids can be provided through mobile health access programmes. Therefore, health planners in developing countries with scarce resources and large nomadic populations should consider such adopted approaches.31

Other effective approaches for specific cancer pain indications include palliative radiotherapy and surgery. Again, through mobile health such patients can be transferred to nearby facilities with palliative radiotherapy and surgical services to alleviate pain and suffering. This will call for a well-established ambulatory referral pathway for hard-to-reach nomadic patients with cancer.31 Exploiting emerging telemedicine, digital palliative care services through mobile applications can be explored to establish and support community-based PC for nomadic communities, particularly pain management.32

Cancer survivorship care among nomads

Given their migratory lifestyle, livelihood, geographical inaccessibility, communication barriers, illiteracy and poverty, it is challenging for pastoralists to access lengthy inpatient clinical care and long-term periodic follow-up at the survivorship clinics.33 Therefore, decentralisation of cancer survivorship services through mobile health services and conducting an onsite qualitative survey for cancer treatment-related symptoms, cumulative disease-related burden and pain, clinical evaluation of disease stage or recurrence and then upscaling through mobile referral pathways is essential.

Effect of climate change, conflicts and wars on the cancer care of nomads

Inherent in the dynamism of nomadism reponse to harsh climatic conditions and political instability is the mobility of nomads to safe havens and favourable climatic conditions as a coping mechanism that can be a reference model for other populations in the context of climate change and civil unrest. Large-scale droughts have historically threatened nomads’ livelihoods, causing the loss of their livestock and livelihood and environmental injustice and inequity. Drought, conflicts and displacement have interfered with these communities’ centuries-built resilience and cohesiveness. The Sahelian countries (Niger, Mali) experienced a drought-induced famine in (1968–1973), while Somalia, Ethiopia and Sudan underwent a prolonged drought in 1971–1972, 1982–1984 and 1990–1992, respectively, associated with political wars and civil unrest.34 35

Such perennial droughts, seasonal migration, cattle rustling and political instability affect the implementation of cancer care services in these communities, forcing nomads to settle in shanty towns in urban areas. The disruption of their lifestyle hampers integration into urbanisation, further exacerbating inequities they face within the urban poor population. Such refugee camps are common in northern Kenya under the human resettlement programmes by the United Nations for previously nomadic communities that were affected by climate change and civil unrest. There is currently no established programme on non-commmunicable diseases (NCDs) such as cancer in these camps, and cancer care needs remain neglected in these areas. Therefore, timely resettlement and tailored mobile cancer services are vital in addressing the care gap for this special population.

Addressing environmental injustice should translate into the funding of research and mobilisation of efforts of the international community to address the increasing health inequities these populations face. While these populations caused a tiny fraction of the current global environmental crisis as compared with high-income countries, they continue to bear the brunt of the effect of climate change.