among health care providers (physicians, nurses,
psychologists, nutritionists, social workers), institutions
(hospital directors, university deans) and non-governmental
foundation members (community and patient advocates).
These individuals must understand the needs of children with
cancer including physical, emotional, economic, social and
spiritual as integral components of the chain of care and
twinning relationships are not established unless or until all
pieces are in place. Moreover, these activities have to take
into account social and cultural values, required needs and
available resources. Treatment plans must be based on
medical evidence and integrated with other programmes
existent in the health care system. The vision is that by
implementing a paediatric cancer unit within a hospital, not
only will children with cancer benefit but so will other sick
children and the hospital itself. The goals include improving
cure rates and access to care for children with cancer,
producing generalizable knowledge that has global benefits,
and demonstrating to the local community that progress in
paediatric cancer care is both necessary and feasible.
Although the benefits of twinning are almost always
bidirectional, twinning programmes must be distinguished
from contractual or commercial partnerships for mutual gain
and from research collaborations that focus on a specific
project. The St Jude twinning model emphasizes a horizontal
distribution of resources dedicated to improving survival
rates in childhood cancer overall and developing local support
for children undergoing therapy. It also assists in the creation
of fund-raising efforts (e.g., parents' associations) and the
building of relationships with local foundations willing to
provide financial support that ensures the sustainability of
each project in the long term, rather than restricting the
activities to single diseases that answer specific questions
within a defined time-frame. St Jude staff integrate outreach
activities into their daily schedules and maintain close
contact with their peers through e-mails, phone calls and online meetings. Each country has assigned directors within the
IOP and make site visits every one or two years - sometimes
in association with educational meetings.
Our twinning programmes have been fully established in
Amman, Beijing, Shanghai, Beirut, Casablanca, Rabat,
Caracas, Maracaibo, Culiacán, Guadalajara, Tijuana, Davao,
Guatemala City, Quito, Recife, San Jose, San Salvador,
Santiago and Tegucigalpa. The St Jude IOP also enters into
agreements with institutions in developed countries that
have specific training needs or wish to actively participate in
the development of twinning sites. These include the Hospital
Infantil Manuel de Jesus Rivera in Managua, the Russian
Children's Clinical Hospital in Moscow, the National
University Hospital in Singapore, the Ospedale Nuovo S
Gerardo and Universita` di Milano-Bicocca in Monza, Italy,
and Rady Children's Hospital in San Diego, United States. We
have also facilitated other medical organizations to form
their own twinning programmes. These include the Keira
Grace Foundation with the Hospital Infantil, Dr Robert Reid
Cabral (Santo Domingo, Dominican Republic); the American
Society of Hematology International Consortium on Acute
Promyelocytic Leukemia with institutions in Brazil, Mexico,
Uruguay and Chile; and the Dana Farber Cancer Institute
with the National Cancer Institute in Bogotá, Colombia. The
latter project is supported by a grant from the World Child
Cancer Foundation. Finally, the St Jude IOP has worked in
collaboration with global health agencies such the
International Agency for Atomic Energy to develop specific
paediatric cancer control projects in member states and has
collaborated with the Union for International Cancer Control
(UICC) and the Sanofi-Espoir Foundation to develop the My
Child Matters programme, which funds specific paediatric
cancer programmes in low- and middle-income countries.
Optimally, patients are cared for in a dedicated paediatric
cancer unit that combines the necessary professionals,
expertise and infrastructure. Agreements are only made
when senior medical staff are able to devote themselves to
the project on a full-time basis and to accept the St Jude
philosophy of integrating the programme into the community
and to provide holistic, multidisciplinary care to the children
regardless of the ability of the family to pay for treatment.
We found that medical competence in conjunction with
compassionate care is the most crucial programmatic
component. Ideally, the paediatric cancer unit becomes the
focus of intense education for direct caregivers, including
paediatric haematologists/oncologists, nurses, surgeons,
pathologists, radiotherapists, infectious disease specialists,
acute care physicians, family members and communities.
In many low- and middle-income countries, the paediatric
cancer units must also be the focus of intense educational
efforts to reduce death from infection and abandonment of
therapy. Death from infection is a greater risk in low- and
middle-income countries, partly because of a delay in starting
antibiotics and other supportive measures.
We adopt a stepwise approach to implementing
interventions. This takes into consideration local resources
and needs. At most of the partner sites, acute lymphoblastic
leukemia (ALL) is the initial disease to be addressed, as it is a
common childhood malignancy and is highly curable with
relatively accessible drugs and evidence-based treatment
guidelines. However, successful management of ALL requires
the integration of several components of care, including
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