Kate Westmoreland, MD, crouched in the dirt of a courtyard at the Malawi hospital. Under the shade of a tree, a mother was holding her son. He was thin, too weak to hold his head up, and had an obvious abdominal tumor. Working through a translator, Westmoreland spoke to the woman, and eventually diagnosed the young boy with Burkitt lymphoma, a cancer that’s common – and can be deadly – in sub-Saharan Africa. Westmoreland soon began treating him with chemotherapy, as well as for malnourishment – an all too common condition in her pediatric patients. In fact, the majority of her patients in Malawi presented to the hospital moderately to severely malnourished.“In Malawi, we routinely saw baseline malnutrition, and then children would have cancer on top of that,” she said.
Westmoreland fed the boy nutritional supplements and a formula provided by the World Health Organization (WHO). She also treated him for tuberculosis, a disease caused by a bacterial infection that can lead to weight loss. The disease has been on the decline in the United States since 1992, but it’s still one of the top 10 causes of death worldwide, according to the WHO. The treatment combination led to weight gain, Westmoreland said, which allowed the boy to continue his cancer treatment.
“This child was really, really sick when he came to the hospital. We thought we were going to lose him several times,” she said. “I didn’t even recognize him the next time I saw him. It was great to see him gain weight, smile and be more interactive.”
Westmoreland is on a mission to improve the survival for children in sub-Saharan Africa who have cancer, which is a dream she’s had since childhood. She was able to work toward that goal with the Malawi Cancer Consortium, a partnership between the University of North Carolina Lineberger Comprehensive Cancer Center, the Institute for Global Health and Infectious Disease, the Malawi Ministry of Health, the University of Malawi College of Medicine and others.
With improvements in the management of infectious diseases in sub-Saharan Africa, treatment for chronic and non-communicable diseases like cancer has gained traction. An estimated 84 percent of children with cancer in the world today live in low-and-middle-income countries, according to a report published in The Lancet in 2013.
“Working in Malawi is my passion, and I believe this is what I was meant to do with my career,” Westmoreland said.
Dreaming Out Loud
Westmoreland became interested in global health in middle school, when a classmate’s parent came in for career day to talk about Operation Smile, an international nonprofit that provides free facial surgery to children with birth abnormalities.
The Winston-Salem, N.C., native is the first in her family to attend medical school. As a medical student, her favorite rotation was her pediatric oncology elective. After completing residency, Westmoreland began living her dream to work abroad when she traveled to the Himalayan Mountains of Nepal. She worked with a non-governmental organization to improve health for mothers and new babies. At high altitudes at the Tibetan border, she lived in a tent, cooked her meals by fire and hiked to remote villages to teach community health volunteers about safe delivery, breastfeeding and general newborn care.
She then moved to Botswana in Africa for two years through a program with the Children’s Hospital of Philadelphia. She not only served as a general pediatrician at a large teaching hospital, but also began to care for patients with cancer.
Journey to Malawi
Westmoreland got word of UNC Project-Malawi while in Botswana. She reached out to Satish Gopal, MD, MPH, cancer program director for the project, and through his mentorship, was awarded a fellowship through the UJMT Fogarty Global Health Fellows program. That gave her the opportunity to spend one year in Malawi researching pediatric Burkitt lymphoma.
To join the team, she strapped canisters full of gasoline to the roof of her car and drove nearly 1,500 miles from Botswana to Lilongwe, the capital of Malawi. It took her a week to drive there, traversing two-lane highways, mostly paved and some dirt. At times, as she drove through remote areas, and passed elephants alongside the road.
Her role in Malawi was two-fold: care for children with cancer and conduct research on pediatric Burkitt lymphoma. Westmoreland learned this work was sorely needed. She and colleagues estimated that the five-year survival rates for pediatric Burkitt lymphoma were as low as 29 percent in Malawi. In the United States, five-year survival rates have been reported to be more than 90 percent.
The Limit of Care
Westmoreland faced limitations in caring for children with cancer in Malawi that she addressed through research.
For example, the intensity of chemotherapy regimens that can be delivered safely differed between the United States and Malawi, Westmoreland said. Limited medication and supplies, an unreliable availability of blood and platelet transfusions, and poor infection control all lead to inadequate supportive care, which is important when patients are on high doses of treatment that can have toxic side effects.
The challenges families faced to access care were great, she said. Some families had limited ability to afford travel costs, which impacted their ability to continue treatment or get follow-up care. The hospital in Lilongwe is the only hospital providing chemotherapy to children in northern and central Malawi. The Malawi Cancer Consortium works to mitigate these issues, providing a transportation reimbursement to help ensure that patients get their follow-up appointment for chemotherapy treatment on time.
“In Malawi, patients sometimes live far away from the hospital,” Westmoreland said. “So if we use a treatment that depletes their immune system, and they get a fever, and they’re four hours away on a minibus, they could die on the way to the hospital,” she said. “So we have to figure out a regimen that balances these risks.”
She has continued her work after returning to the United States. To find a better balance between side effects and appropriate amounts of chemotherapy for her pediatric patients in Malawi, Westmoreland will be leading a dose escalation study of the treatment methotrexate. She has a specific interest in malnutrition, and how it effects chemotherapy metabolism.
While in Malawi, she also led an important study to improve Burkitt lymphoma diagnosis. In the study, she showed that testing for Epstein-Barr virus, a virus linked to Burkitt lymphoma, can be useful in resource-limited settings to help diagnose pediatric disease, predict prognosis and measure the tumor’s response to treatment.
“I was so grateful to have Dr. Gopal as my mentor and to work at UNC Project-Malawi with such a fabulous team,” Westmoreland said. “This experience changed my career and my life.”
Driven to Do More
Westmoreland is now back in Chapel Hill for her fellowship in the UNC Department of Pediatric Hematology Oncology, but she’s continuing her mission to help improve outcomes of children with cancer in Malawi. Throughout her fellowship, she will spend blocks of time in Malawi and will continue to lead research on pediatric Burkitt lymphoma.
She knows firsthand that more needs to be done to improve pediatric cancer care.
“We do have success stories, but I think the patients who stand out are the ones you lose because you spend a lot of time with them, and it impacts you as a physician and as a person if they die,” she said. “For me, it just gave me more incentive to do more research, and try not to lose the next one.”
Westmoreland said she is focused on improving the survival rate for Burkitt lymphoma.
“I hope to see the survival rate of Burkitt lymphoma in Malawi increase from 30 percent to more than 60 percent,” she said. “I know this is possible, and I am determined to make this happen. My pediatric patients in Malawi who are battling cancer and their families are counting on me, and this is my ultimate motivation.”