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Parallel Patients

As alluded to in my earlier post, we have shifted our location to the Nizam Institute of Medical Sciences, or NIMS, which occupies a strange quasi-public hospital position in the health care system ecology of Hyderabad. This seems to spring historically from its foundation by the charitable trust of the Nizam’s, the prior ruling family of Andhra Pradesh, who remain active around the state to the present day (after being ousted in 1948 by the Indian government).

NIMS is an impressive facility with learned faculty, active (and selective) residency programs, and ample access to quality diagnostics and therapeutics – by way of example, they have CT scanners, an excellent microbiology lab (that we’ll see tomorrow!), regularly obtain BCR-Abl activity to monitor the impact of imatinib in CML patients, and are performing stem cell transplants (albeit only relatively recently) for a range of indications. I will spend more time discussing them over the next few posts, I am sure.

Our first day there was spent in the oncology clinic during the morning, evidently during a CML-focused clinic (based on the daunting number of CML patients we saw). One of the patients we saw was a ~22 year old woman who had been diagnosed a few months prior with osteosarcoma of her right leg. She is now status post above the knee amputation of her limb, and is receiving chemotherapy for disease metastatic to her lungs.

The sight of this vibrant young woman brought back vivid memories of a patient I had in Haiti, also a young women in her early twenties. My patient presented to St Boniface Hospital with a complaint of leg swelling over the last several months, recently painful to the point of having trouble walking:

1 - SS legs

patient provided permission for use of her photograph

The large mass below her knee was slightly warm, but lacked fluctuance, and she denied fevers or night sweats. Hoping that there might be an infectious component, I attempted aspiration, but was not able to get anything out. Subsequent radiography revealed this:

3 - SS leg film 2

mass with subtle lifting of the osteum, a not-quite-classic “sunburst” pattern

This pleasant and cheerful woman, at the hospital with a worried husband and with a 1 year old child at home, almost certainly had osteosarcoma. Her CXR was negative for obvious metastasis; I emailed some orthopedists I know, who told me that her only option (absent neoadjuvant therapy to shrink this mass to a resectable size) was amputation. As St Boniface lacks surgical capacity, this meant referring her onwards – and as she lacked significant money, this meant finding her charity care.

Dr Blaise, the internist of the hospital, and I discussed this with the patient, who was understandably reluctant to face the loss of a limb – especially as she had no particular concept of cancer as a disease. Her pain controlled adequately with acetaminophen, she left, with an intent from our part that she return the following week for follow-up.

I contacted my friend Michelle Morse, who works with Zamni Lasante/Partners in Health (and also runs the NGO Physicians for Haiti that I work with!), and through her was able to contact the ZL oncology coordinator. With their help, we made preliminary plans for how we might get my patient a CT scan and an operation.

But she never came back.

I have thought of her often since, trying to live life with a slowly worsening pain in her leg, likely visiting other hospitals or traditional healers in an attempt to have this dealt with. Perhaps her disease was not metastatic at first; it seems likely that by now, 9 months later, it may well be.

Perhaps she is already dead.

The number of factors that enter into the care of these two patients are vast, and it cannot be boiled down to a simple contrast between healthcare systems or availability of support from the government (or availability of a government to speak of, for that matter). Madam S did not believe us, or did not want to believe us – her Indian double was convinced to undergo therapy, and I do not know how hard a process that was. Too, this Indian counterpart has access to government funding for her healthcare as a poverty-level citizen – evidently up to 200,000 rupees ($4,000, which goes a long way in this setting) per our colleagues here – enough money to have her amputation and to pay for a CT scan and chemotherapy for the metastases found. She is also plugged into a system of care that involves documents summarizing her care that can be carried from hospital to hospital, ready access to the interventions and diagnostics above, and a rational system of referral upwards – all lacking from her Haitian parallel.

GDP per capita is $725.63 for Haiti, $1,508.54 for India (World Bank, 2011), and while this is a crude metric of the monies available for individual patients, it certainly speaks to some degree as to the differences between these countries, and explains some of the gap between these two patients’ experiences.

gapminder slide

adjusted GDP/capita vs life expectancy

The path for Haiti to obtain quality oncology will be a long one (thankfully, some are already beginning to blaze paths that will eventually lead there, such as the Global Oncology and some programs of Partners in Health, among others) – for the moment, I find some solace in the excellent quality of care being delivered to the Indian poor at NIMS.

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