Good morning, Hank, it's Tuesday.

So your video last week about your life with Hodgkin lymphoma reminded me of when you were first diagnosed. As you pointed out, cancer is not really a disease but a category of diseases and for about a week, we knew you had something in the category of cancer but not actually which cancer you had. Was it another kind of lymphoma? Or a metastatic cancer that had spread to your lymph nodes? We didn't know. And when you finally found out it was Hodgkin lymphoma, it was a tremendous encouragement, like, of all of the bad news we could have gotten, that was about the best bad news. And when you called me to tell me the news, one of the first things you said was 5-year survival rate is 93% with treatment and about 6% without treatment. You were already thinking of the people who can't get access to treatment, which as it turns out, is a lot of people.

So there's inequitable access to cancer care everywhere, but most people who get cancer live in low and middle-income countries where it can be really difficult to access appropriate care. Like, just in Sierra Leone, a relatively small country, over 200 people get Hodgkin lymphoma every year and I think a lot about one of them, a child named Mondeh Mansare. Mondeh lived in Sierra Leone's rural Kono district and his parents first noticed a lump on the side of his neck when he was about 6 years old and about the same time, he started to become much more lethargic. At first, as often happens, he was incorrectly diagnosed with tuberculosis because the clinics that Mondeh visited didn't have the super fast super accurate GeneXpert tests. Instead, TB was still diagnosed via symptoms. And tuberculosis often causes swollen or even ruptured lymph nodes and so that's what it appeared to be, but treatment for TB didn't work for Mondeh. And so, his parents kept taking him to healthcare centers and hospitals but because there was no capacity for imaging, no MRI machines, no CT scanners, in 2015, not even X-ray machines, Mondeh couldn't get a diagnosis and this lump just kept growing.

Eventually it was so big it made it difficult for him to swallow and so he was losing weight and this went on for 4 years. Finally, when he was 10, Mondeh was examined by a doctor with Partners in Health who suspected lymphoma and Mondeh traveled to the capital city to get a biopsy where it was found that indeed he had Hodgkin lymphoma. Mondeh was able to get pill-based chemotherapy in Freetown, Sierra Leone, which shrunk his tumor but to get into remission, he needed IV chemotherapy, which for him meant traveling thousands of miles to Rwanda's Butaro Cancer Hospital.

And now, Hank, like you, Mondeh is in remission. He's a great young artist. When I visited him in 2019, I got to see his sketch of my favorite football player, Mohamad Salah. But think of all that had to go right for him to survive. He needed to be correctly diagnosed. We often hear that early diagnosis is really important in cancer care, but in these circumstances, early diagnosis is basically impossible. And then Mondeh needed to be able to access treatment, which meant not just enough money for the treatment itself, but also to spend months in a hotel in the capital city and have transportation from that hotel to the hospital when he was too sick to walk. But even that wasn't enough to truly enter remission. He needed to travel thousands of miles to a dedicated cancer center. All of this would have been impossible for Mondeh's family to afford without support from Partners in Health and so one thing that you often hear is that cancer care in poor countries isn't cost-effective. But one, Hank, nobody ever questioned whether your cancer care was cost-effective because you're you and you live where you live. And two, Hodgkin lymphoma is actually relatively inexpensive to treat, provided you have the systems and structures in place to do appropriate diagnostics and treatment.

And in the years since Mondeh was treated, that's starting to happen in Sierra Leone. Better imaging machines, better access to chemotherapy, soon, hopefully, the first radiotherapy available for cancer patients in the country. But it's only starting to happen, and the devastating truth is that most people with Hodgkin lymphoma in a country like Sierra Leone will die even though they could have lived. What you made clear to me in that very first phone call, Hank, is that the same cancer affecting two different people in different circumstances is not really the same cancer. If the standard of care available to those two people is different, the outcomes will be different as well.

Hank, I'll see you on Friday.