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A different view: how medicine changes when you are half a world away
A recent residency graduate enters the doors of his new hospital at 8 a.m. He assembles his team and starts morning rounds. Throughout his ward are some patients who have already been diagnosed with leukemia or lymphoma and are assigned chemotherapy or supportive treatment. Others who have pancytopenia or lymphadenopathy without diagnosis may undergo bone marrow biopsy or other diagnostic procedures to determine the source of their illnesses. At 11 a.m. a multidisciplinary conference convenes, at which hematologists, pathologists and others will discuss diagnostic and treatment possibilities for these patients.
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Somewhere else, another recent residency graduate enters the doors of his new hospital at 8 a.m. He also assembles his team of medical students and residents and starts morning rounds. On his ward as well there are adults with pancytopenia, leukocytosis or massive adenopathy of unclear cause. Some have HIV, and a subset of these have been assigned antiretrovirals.
His residents repeat the pancytopenic patients’ blood counts until they observe a better result or until they give up because they do not know how to make a diagnosis. The patients with massive lymphadenopathy are started empirically on tuberculosis treatment and then discharged to hospice without further attempt at diagnosis because non-Hodgkin’s lymphoma does not qualify for coverage of chemotherapy.
One patient has a headache and a white count of 100,000 with hemoglobin of 5 and platelets of 50. There are no bone marrow biopsy kits available, but the peripheral smear shows many blasts. Because leukemia is a covered diagnosis, the patient is transferred to a hospital many miles away where treatment will hopefully be available.
Different views
For four years, Rob and I were residency colleagues at an institution where Paul Farmer and Partners in Health had been highly influential in helping trainees to think critically about global health equity. We graduated with similar goals; both of us wanted to teach and to provide care to underserved populations.
I am pursuing my goals through an oncology fellowship in which I will focus on adolescents and young adults, cancer survivors and other groups that have unique and underserved needs. Rob is pursuing his goals through a faculty position at Tanzania’s finest university hospital where he helps to direct the residency program and cares for a population representative of an entire continent that is underserved.
Those who are familiar with Tracy Kidder’s book “Mountains Beyond Mountains” will remember the dedication and ingenuity that Paul Farmer and his colleagues have brought to the challenges of delivering HIV and tuberculosis medications to the citizens of the Haitian plateau. The Gates Foundation and others have joined the rapidly growing global health equity movement by lending enormous amounts of wealth and expertise to combating AIDS and malaria in Africa.
What does this have to do with hematology and oncology? A central tenet of Farmer’s work has been that denying life-saving treatments to the world’s poor based on traditional cost-effectiveness arguments leads to a fatalism where nothing is possible because nothing is attempted. It was not long ago that a realistic fight against the HIV/AIDS epidemic in Africa was felt to be impossible for cost-related reasons. Through strategies that have led to cost reductions of formerly expensive medications, a real war against this epidemic has finally begun.
Providing equal care
In a recent article about this topic, respected pediatric cardiologist Dr. Darshak Sanghavi describes the work of Dr. Aldo Castaneda, the former chief of pediatric cardiac surgery at Harvard who has moved to Guatemala and operated on thousands of children there.
In oncology, St. Jude Children’s Research Hospital has devoted itself to the diagnosis and treatment of children with cancer in some of the poorest parts of the world. Their website, www.cure4kids.org, shares information with health professionals worldwide and chronicles the cure of children with acute lymphoblastic leukemia in poor parts of China and Brazil. The Institute of Medicine has recently identified the treatment of child and young adult cancers as an important cancer control opportunity in low and middle income countries.
Recently, adult hematology and oncology has begun to heed this call as well. The American Society of Hematology has partnered with Health Volunteers Overseas, a nonprofit organization dedicated to education. ASH will provide volunteers to HVO to help diagnose and treat a range of benign and malignant hematologic disorders in underserved parts of the world.
The delivery of subspecialty care to the developing world is not as far-fetched as it might initially seem. With time and with concerted efforts, perhaps, the chasm between my experience and Rob’s may no longer be so wide.
Bill Wood, MD, is a second year hematology/oncology fellow at the University of North Carolina Chapel Hill and a member of the HemOnc Today Editorial Board.