This is an extract from a Facebook discussion between Dr. Robiel Habtemariam (MD) and me[the Author] based on an article I wrote about Cancer in Eritrea. We could not come to terms of agreement on the way I handled the topic. After an intensive exchange, he promised to come back with rebuttal response to flatter my take. I welcomed him.
Initially, he started his comment under my post by writing:
“Tesfe, you are obsessed with cancer. To make matters worse, you speak of it as if it is a deliberately disseminated contagious disease. Clearly, you don’t have the slightest idea of what you are talking about.”
And I responded to this particular post by saying,
Indeed I am obsessed. And the reason is you guys (doctors) are trying to make it normal.
And as a human rights defender and political activist, I am telling you to do something. I don’t want you to live in your comfort hospital zone.
On Tsigereda – like all other PFDJ officials, I don’t have any admiration. Saying that, as human, I feel sorry for her death.
Robel, by now as you can see we are in a different political zone. Be cool, therefore. Otherwise, I have many tools to make you ashamed of yourself for supporting PFDJ policies.
Since after, we engaged seriously on this subject matter.Well, I was curious on his take. I considered it as a big opportunity to see my article being challenged by a professional doctor. What you write must get the attention of readers. Critical responses from experts matters for growth.
As expected, after 4 days, he came with a series of comments posted on Facebook. I found his take irresponsible and non-professional. Initially, I thought to ignore what he wrote. Instead of focusing on the content, he dropped lines that were loaded with bashing words that express his highness on the subject matter. He literally told me I shouldn’t have written the article without consulting experts.
It is self-embarrassing to Dr. Robiel to come with this unprofessional and irresponsible comments that harm his career. If there is anything to learn from his comments is what he stands for.
I found Dr. Robiel H. to be a typical PFDJ cadre. I had the same impression before but I thought it is better to give him a benefit of doubt. It didn’t help either.
A brief introduction about Dr. Robiel Habtemariam
According to information available from his Facebook page, Dr. Robiel is a graduate of Orrotta School of Medicine and Dentistry. He did his high school study in Asmara Hafeshawi. After graduation, he was assigned to Assab, the second port city of Eritrea, as a medical doctor in 2014.
What makes him among those who leverage PFDJ crimes is that he did not hide his pride to express PFDJ’s political correctness. Though it seems that he is living outside Eritrea, his mindset is fully lodged with PFDJ ideology. He is among the very few medical doctors who are defending PFDJ crimes in social media.
Dr. Robiel Habtemariam with his classmates in 2009 (Source: Facebook)
I have no detailed information who he is routside his facebook page and as an active member of Eritreans Scholars Group. He is among those few contributors who do not hide support to PFDJ regime. Reading his inputs, it is quite possible to know what he promotes for.
Why his comments are so important?
Through Dr. Robiel H. comments, we can learn how die-hard PFDJ professionals think about the current situation of Eritrean suffering. It can help us to understand their thinking. It is indeed a valuable material to be studied to challenge servants of PFDJ. Above all, Dr. Robiel is a medical doctor who is supposed to contribute positively to the status of the health sector in Eritrea.
Access to health services is a basic human right issue. Though there is undeniable positive progress in this area, so far, Eritrea lacks some important care services to its citizens. For example, cancer care center is absent. As a result, cancer patients face a challenging moment to look after their health. It is hard to know what mechanism exists to treat cancer. As it was explained in my previous article published on August 04, 2017.
As far as a patient can afford, the only option available is to go abroad for treatment. What makes it extremely painful is that it is not easy to get permission to leave the country. Dr. Robiel confirmed the extreme bureaucracy and vetting process to go abroad.
This material is therefore important to understand how human rights issue is seeing in Eritrea by politically charged professionals.
Dr. Robiel Habtemariam’s Rebuttal comments to my Article
[…] I’m serious about this.
Tesfabirhan Redie, I have already read your article and have been following your posts on cancer in Eritrea(this is the third one I believe). As I said, if you are mature enough to defend your article and your posts, and accept criticism, I can take you seriously and show you why I think you are missing the whole point and how your article and posts are fallacious.
In your first post, I told you that you were just politicizing the issue. Your response (and that of wed Wed Hmrarib) was vehement, full of ad hominem, and suggested that I was defending the ruling party. After a little bit of derailed nonsense, I decided to disengage myself from the topic, because it was fruitless, to say the least. Now, let me make one thing clear: As far as Eritrean politics is concerned, I don’t have a single political party that Impresses me and I don’t have a single figure in mind that I would vote for if elections were to be held. I support ideas, and not people or parties. I argue in favor of what I think is right, and not someone who I think is right. Because, naturally, nobody gets’s everything right. Accordingly, if I think there was something Hitler got right and see you – out of hatred – make a sweeping argument that “since Hitler is evil and hence everything he does is wicked, that particular thing he did was wrongful and ugly,” I will simply tell you that you are wrong. If you tell me that I’m defending Hitler and therefore I’m a Nazist, again I would tell you that you have a fallacious conclusion. That’s really your problem and all I can do is point it out to you and say goodbye. Any further discussion would be pointless. I hope you got my point.
Robel, now you seem to be serious.
Ok to start with.
1. Understand the objective of my article.
My objective is to increase public awareness on the increasing number of cancer victims in Eritrea. It is all for political awareness. I am not politicizing the issue but calling for people, including the Ministry of Health and the international community to act. At least, for the time, being, Eritreans need a place of treatment. Sudan is too expensive and impractical.
It is sad to ignore this and see you jumping on what I listed as the possible cause.
To be frank, I was totally disappointed by you when you try to argue on the political dimension. This is the reason I wanted to react. Otherwise, I want your genuine professional input.
2. I am not blaming PFDJ as someone who caused cancer. What I am saying is PFDJ is simply watching. Check the title, please.
Academically, I am not an expert in cancer. And I think you are not. However, you are much better equipped to say something about cancer. I am sure you know many secrets about health in Eritrea. Say something if you are in safe place without violating your professional oath.
I am not campaigning to be elected. I am just talking about challenges Eritreans are facing.
Remark: I am very serious on this issue and be serious.
I have good friends who graduate from Orrotta. They deserve respect. By respecting you, I am respecting them. Please be away from the PFDJ thing here as you are expected to be professional in this special topic. If you act politically, I will be too.
Am I the only one here who thinks the main purpose of the post was not the fact that Mrs. Tsgereda died, but the fact that she died from cancer? Anyways, I’m back with my criticism of your article, Tasfabrhan, as promised. I’m putting my comments separately so that you can reply to them separately. I will try to point out the pitfalls of your article from a medical and a statistical point of view. Besides, I will briefly highlight why I think it is biased and intentionally distorted and manipulated to serve a political motive, instead of attempting to analyze the issue with intellectual honesty so that the article can provide a platform for a constructive discussion and give an insight as to how further research can be taken from there.
Please don’t try to defend your article, as you’ve already hinted, by claiming that cancer is not your area of expertize. In that case, you should have left the issue to experts, or consulted experts in writing it after contracting adequate literature review, research and coverage of background information on cancer before rushing into writing your article just to enrich your website. Real writers go through a painstakingly lengthy study of their subject of concern before starting to scribble, even for fiction meant to entertain.
My impression is that you went through the following sequence of events to end up writing the article: you were inspired by the desperate plights of Eritrean cancer victims shared on Facebook from inside and outside the country (usually Sudan), and being a political activist, you went out of your way to find real health data, mingled it with graphic pictures of individual cases, and manipulated it in a way that portrayed the problem as alarmingly the heaviest health burden in the country which has never been addressed in any way whatsoever. I’m absolutely dazzled that you recklessly asserted that nothing is done to prevent and treat cancer in Eritrea. The truth is that any health professional in Eritrea can write you an entire book on just what is actually done to prevent and treat cancer in Eritrea. You should have known better, or if you had known, you shouldn’t have swept facts under the carpet, if you are to be in a position where you can claim that you are intellectually honest and not driven by a political motive.
Good. I actually agree with the idea that Sudan is not the best place for Eritrean cancer patients and that something should be done about it. The other strong point you made was the fact that you pointed out the bureaucratic delay patients face in the ministry of health in the process of letting them leave the country legally.
I know that there is a group of people in Khartoum who are devoted to helping Eritrean cancer patients professionally, logistically, and economically to those who end up there. I liked the part where you mentioned that group and their Facebook page in order to make people aware of their activities so that any interested party can lend a hand. I wish the entire article was about that.
I will comment on the weaknesses and fallacies of your article. I expect you to defend it with reason and evidence. I will see you sooner or later.
Robel, remember this is not an academic paper. It is a political article. Therefore, don’t expect me to be academically correct.
Within this scope, I am more than capable to defend every line I wrote.
I am well equipped with that.
On this positive compliments, thank you.
What I can be OK with it if you don’t try to come from the so called Government of Eritrea point of view. I am a die hard opponent of all Eritrean policies – 100%. Be aware therefore when you build your argument.
One last point – don’t expect me to, write what it will make you happy. Take those strong sides, argue with those that you feel need proper attention and dump for dump lines. Be systematic.
Let me start with your choice of words
“Cancer is killing everyone in Eritrea.”
Whaaaaaat!!? That was the overstatement of the year(perhaps globally). እሞ ኣብ ኤርትራ ደኣ ዝተረፈ ሰብ የለን ዘይትብለኒ:: እንታይ ደኣ እዘን ማዔከናት ዜና ከምዚ ኣብ ግዜ ለበዳ ኢቦላ ወይ ሸሮኽ ዝገብረኦ ዋጭዋጭ ዘይበላ? ኣብ ኤርትራ ዝተረፈ ሰብ ይህሉ’ዶ ይኸዉን ኢልካ ተሌፎን ደዊልካ ከተረጋግጽ ቅሩብ ይተርፈካ::
Tasfabrhan, did you even consider the kind of audience you were trying to reach out to? It looks like you either failed to consider your audience, or underestimated them, or even deliberately ignored those who can clearly read between your lines to mislead and alarm the naive who don’t have an idea of what’s really going on so that you can align them on your political assembly.
Anyways, what is the point that you are trying to make by telling us that Mrs. Tsgereda died from blood cancer?
Who is to blame?
Do you know what type of blood cancer (leukemia) it was?
Was she treated for it?
Do you have any idea what her chance of survival was with and without treatment?
The other thing is your manipulation of statistics. You gave us a number ( 9,482 laboratories confirmed cases in a decade) which means nothing if broken down into individual types of cancers, indicating their respective percentages and rates and compared to other causes of morbidity and mortality in the country as well as to similar cancers elsewhere around the world. Without such a comparison, a plain number means nothing, even to an expert.
While you devoted paragraphs in unnecessary and irrelevant details, you did not attempt to put the cancer burden into context by highlighting its relative significance in the list of the top causes of morbidity and mortality and the immense health burden they pose to the country’s struggling economy. Accordingly, you failed to mention if it is appropriately prioritized as per its rank as a health burden in light of the budget allocated to and within the health sector. Instead, surprisingly enough, you made a flimsy attempt to discredit the achievement of 6 out of 8-millennium development goals within the assigned timeframe, something many third world countries fell short of achieving.
Here is a simple example of how prioritization works and how you conveniently avoided it: You are a father of a poor family with 8 children. You work hard to make ends meet and earn way less than what your family needs to lead a “normal” life.Your wife returns from the hospital and tells you that she has breast cancer and that the doctor told her she needs the amount of money you can hardly make in a lifetime.
Your eldest son is in the hospital ward getting treated for AIDS and its complications. Another one is in the same ward getting treated for TB. A third has malaria. Your oldest daughter is unmarried, pregnant and has anemia. Two of your young kids have malnutrition with all sorts of complications that go with it. Your youngest daughter has severe pneumonia and is dying in the emergency room. That kid older than her has had persistent diarrhea for more than a week. You went to the hospital to follow-up your chronic heart disease three days ago, only this time your doctor tells you that you may have a prostate cancer. Now imagine your sleepless nights trying to figure out a way to divide your savings between feeding the family and paying the medical bills. Which child or disease would you prioritize? Obviously, the most down-to-earth thing to do about it is to pay for kids who have cheaper, life-threatening but easily treatable conditions first, wouldn’t you? You can take care of your wife’s breast cancer and your prostate cancer – which is costly, and usually fatal anyway – only when you have the simpler issues addressed, and provided that you have managed to collect enough money one way or the other.
Now imagine one of your sons which you have asked to get a job and put all his income on the table except for the little bit of pocket money you allowed him. He not only had a nasty fight with you and absconded from home, but also was going around the neighborhood proclaiming how his mother (your wife) is dying of cancer, asking for financial assistance on Facebook, while his father (you) is not doing anything because he doesn’t care!
I think that is exactly what you did, Tasfabrhan. You want to raise peoples awareness? You are particularly interested in cancer? Here is what you could have done:
Have an in-depth look at the epidemiology of cancer in Eritrea. Study the prevalence, incidence, and demographics (distribution by age, sex, ethnic group, geographical area… etc) of the commonest cancers in the country. Calculate their rates per unit population and time and compare them with the data of the same cancers in other countries. Point out which specific cancer types are significantly more prevalent in Eritrea than their counterparts in other countries. Try to identify a correlation between a certain unusually prevalent cancer and a specific fraction of people who seem to be affected by it. At that point, you would be in a position where you are supposed to be able to isolate some known (or unknown) risk factors which presumably contribute to the specific type of cancer you identified. That is evidence-based practice. Only then will you be able to conclude, assert, recommend and blame.
WHAT LEAD TO THE “GROWING” RATE?
You have discussed some factors which you thought could have contributed to the apparently increasing trend of incidence of cancers in the country. For the most part, I disagree with your evidently superficial and unfounded analysis of the possible “causes” of cancer in Eritrea for several reasons. I will give you my opinion on the individual factors in subsequent comments. For now, let me give you a general overview as to why your suggestion was unconvincing.
- You talk of the factors as causes. The issue is not as straightforward as that (I wish it was). Turns out that cancers don’t have clear cut causes per se but risk factors which may or may not lead to them in the long run. There is no cause and effect relationship. You can not pin point to one factor and say that it is an inevitably definite cause of cancer.
- I don’t believe that there was a significant change in the factors mentioned between the years 2000 and 2010 parallel to the rate of growth of cancer. These variables have more or less remained the same before, during and after the decade considered.
- There is no empirical evidence whatsoever that suggests the factors you mentioned were behind the “growing” rate of incidence of cancer in Eritrea. In the article, these factors were not only put as tangible facts but also were used accusingly. Eg. There was a point silly enough to suggest that people from the highlands who go to Sawa were at an increased risk of skin cancer.
As far as I am concerned, you have failed to point out three important reasons which may explain the growing trend of cancer.
- Enhanced health seeking behavior of the people. 3, 4, or 5 decades ago, the incidence rate of all types of cancers as obtained from reports from health institutions was next to zero. Why? Because people tended to not only believe in traditional healers but also used to be skeptical on modern medical practice as it was presumed to in fact worsen cancers. With increased awareness, people gradually started to come out to hospitals, instead of dying helplessly at home or at the hands of traditional healers.
- Enhanced detection rate due to improved diagnostic capability. A lot changes in 10 years. Before the year 2000, the distribution of health facilities and availability of health professionals and diagnostic tools was considerably limited. Back in the days, there was a lack of diagnostic imaging techniques including CT scan, MRI, and ultrasound as well as pathologic investigation of tissue biopsies. In such a scenario, you would, of course, have cancer in the society but you keep missing them because you are not equipped enough to see them.
- Population growth. While not necessarily affecting the incidence RATE, population growth gives you an increasing NUMBER of cases every year.
CANCER AND GENETICS: The other central issue which was deprived of attention in the article perhaps to avoid weakening its accusing tone.
Heredity plays a decisive role in the development of cancer. Simply put, in general, cancers develop in the context of specific genetic aberration continually provoked by various environmental factors over a long period of time (years to decades).
Countless studies show that different ethnic groups or races genetically have different rates of predisposition to different cancers. Although evidence is lacking currently, it is not impossible that Eritreans (or specific ethnic groups) may be genetically more prone to the types of cancers commonly seen in the country.
In this screenshot from your article, you’ve tried to emphasize on what appears to be abnormal. That’s just a superficial layman’s perspective.
It is actually completely normal. Cancer can affect both sexes and all age groups. It all depends on the cancer type. Some cancers are exclusively seen in older males. Eg. Prostate cancer. In fact, 1 in 15 males in their 60s have it and the rate increases with age. Other cancers like lung cancer and colorectal cancer are more common in males. You also need to know that some cancers like nephroblastoma( kidney cancer), brain cancers, lymphoma, leukemia, Ewings sarcoma… etc are predominantly seen in children.
**, By the way, there is a little bit of error you need to correct: You have mentioned prostate cancer as both the first and second common cancer type in males.
As a medical doctor, all diseases are not abnormal to you.
For ordinary people like me, who witnessed only one person as a victim of cancer in their entire life, is abnormal to read such alarming statistical data.
I know you were working in a hospital. Every day, you were watching death, suffering, and pain of hundreds of people. Hence, 1 in 15 is normal for you. For me, I want it gives me a heart break.
SPECIFIC REASONS YOU DISCUSSED AS MAIN CAUSES OF CANCER IN ERITREA
Cancer and Nutrition:
When one talks about nutrition as a predisposing factor to cancer, it doesn’t imply that you enjoy a life time of protection from what you consume during your honeymoon or a few days after child birth; rather, it is about the cumulative long-term predisposing effect of consumption of foods containing carcinogenic ingredients (especially processed foods) on one hand, and the protective effect of certain ingredients when taken consistently for a lifetime on the other.
Malnutrition is a huge problem in Eritrea, especially in children. Impaired immunity due to malnutrition leads to all kinds of complications many of which are fatal. Associating malnutrition to cancer is a little far fetched.
I didn’t rule out malnutrition is a cause. What I am saying is, it is a possible cause for some types of cancer.
Cancer and stress:
Stress can be a precursor to all kinds of diseases. It prevails everywhere and is actually more common in the developed world. I don’t believe it is unusually higher in Eritrea. (research needed). If it is very common, what should be concerning is people suffering from chronic anxiety, major depression, gastritis,.. etc and dying from heart attack, stroke, hypertensive crisis, diabetes… etc.
The association of deprivation with a higher rate of cancer has nothing to do with stress because deprivation and stress are simply two different variables.
Cancer and contraceptives:
Yes, there is an almost negligible risk of developing cancer that doesn’t warrant the drug’s withdrawal from the market. That little risk is in women having additional risk factors and who take it for a relatively long time.In fact, contraceptives, apart from birth control, are useful in the treatment of different gynecological problems.
Anyway, you have shown that its use is too low in the country, which means it is not a problem as far as cancer is concerned.
Consumption of poorly stored grains:
Aflatoxin and liver cancer:
Liver cancer is one of the rare cancers in Eritrea. And when you have a patient with liver cancer, it is commonly due to chronic hepatitis B and C infections, fatty liver, alcoholism, etc. Aflatoxin has been implicated as a possible cause but it is at the bottom of the list. It is a rare cause of a rare cancer type. It is more concerning as a cause of kwashiorkor.
Exposure to UV radiation and cancer:
The only practical way to protect all Eritreans from UV is to build a roof all over the country.
“a Highlander is therefore not able to resist lowland of Eritrea.”
Well, that is purely a psychological issue. There isn’t a significant variation in the skin tones (melanin pigment) of all Eritreans wherever they come from. There are both fair and dark skinned people in both the highlands and in the lowlands.
Your last paragraph associating military conscription to skin cancer is too lame. In general, people spend their entire lives outdoors making a living. Besides, high temperature (35*c) and UV radiation are two different things. You can live in a hot area and not be exposed to UV.
Asbestos exposure and cancer:
Forget it, it is not a problem in Eritrea. Asbestos can lead to lung cancer in industrial workers exposed to it through inhalation on a regular basis.
Benzene and cancer:
Forget this one too. በቲ ሓደ ነዳዲ የለን ትብል, በቲ ሓደ ከኣ ካንሰር ኣብ ኤርትራ ብሰንኪ ነዳዲ ይበዝሕ ኣሎ ትብል:: you are contradicting yourself. Science ተዛረብ:: Obviously, your principal aim here was to emphasize on the scarcity of fuel in the country.
Alcohol and cancer:
Switching between different brands of alcohol has nothing to do with an increased risk of exposure to cancer. It is about the dose. It has to be taken in high doses continually (most days of the week) for years to contribute as a risk factor for cancer. I think few people have that habit in addition to being able to afford it in Eritrea.
Smoke and Cancer:
መጎጎ ኣድሓነት was meant to drastically reduce the use of firewood and animal dung as fuels ad well as reduce the effect of smoke on mothers. As far as I know, it is compulsory in rural areas for every woman to have one. Of course, there are women still exposed to household smoke in different ways.
STDs and cancer:
The apparent correlation of high STD and cancer rates in 2005 in Eritrea is just a matter of coincidence. There isn’t any logical medical explanation to that.
As you have previously mentioned, the commonest cancers in Eritrea are breast, prostate, ovarian, uterine, cervical, connective tissue cancers and leukemia. What you didn’t notice is that not only the cancers associated with HIV/AIDS are different (Kaposi’s sarcoma, non-Hodgkin lymphoma, cervical cancer), but also appears several years after one contracted HIV (typically 10 to 20 years) when AIDS advances to its end stage.
“what happened in 2005?”
Here I was expecting a scientific attempt to explain as to how AIDS and cancer peaked in the same year, creating an impression of correlation. What I read was quite absurd.
Finally, about “the government is doing nothing” part, I will tell you that, despite the obvious shortages in man power and resources, the ministry of health is probably the most well organized and functional ministry in the country. As I said, one can write a book just on what is done to prevent and treat cancer. You should have known better, or if you had known, you shouldn’t have swept facts under the carpet, if you are to be in a position where you can claim that you are intellectually honest and not driven by a political motive.
Why I did not respond to most of his posts?
To be honest, I was fed-up with his shallow response. I prefered to respond by saying, “FUNNY” in most of his take. It did no give me sense at all to respong accordingly. His take didn’t deserve my response.
Although I appreciate him for his time to read my article seriously and respond for major points, it is unwise for him to write from the perspective of PFDJ political book. All that he was trying to do was finally exposed by his own conclusion.
Dr. Robiel Habtemariam is a corrupted medical expert who is working against humanity. I hope he will remember his oath one day and turn his respected profession to fulfill the duty of human dignity.