Faces

Sometimes in crowds in Nepal I just lifted the camera up and panned around the crowd and and took pictures. 




Sometimes I was too far away, sometimes too close.  Most of the time people couldn't tell, sometimes I think they suspected but tolerated the intrusive.curious.techno-laden American.






I only wish I'd lifted the darn camera more often.

And pretty soon there were faces everywhere......

Dr. Robin Gives A Talk

After many glitches in the plans to go back to Chitwan, several fizzled-out strike threats, several sets of arrangements for the kids to be tended while I was gone for a day, several back-and-forth emails around several periods when there was no electricity, finally, finally, finally with the incredible help and determination of Jeny, I was able to promise one of the Radiation Oncology doctors that we would be returning to his hospital a few days later and that I could help in the clinic for a morning and give a lecture. 

So that is how it came to pass that at 8:45 am on Sunday, January 3, 2010 -- after a four hour frozen ride in the back of a taxi -- we walked into the lecture hall at the BP Koirala Memoria Cancer Center in Bharatpur, Nepal, and found this sign on the front door.

Next post:  The "talk" and the ad hoc visiting professorship

The most ghastly thing I saw in Nepal

Seen below is a consent form for a patient receiving treatment for cervical cancer.

The document is signed with two fingerprints, indicating that the signature is by someone who is illiterate.

Why was this a ghastly document to see?

It was a grim reminder of how common cervical cancer is in "third world" countries, including Nepal, where the incidence is estimated to be 19 cases per 100,000 adult women (vs 8 in the US). 
Plus when Nepalese women get cervical cancer, they are much more likely to die of it --
it's fatal more than half of the time --
and it's a terrible, terrible way to die.
(Cervical cancer is usually caused by a sexually transmitted virus.  Widespread use of PAP smears and better STD education (and hopefully the cervical cancer vaccine) has greatly decreased the incidence and death rate of cervical cancer in developed countries.)


And it's a grim reminder of the horrifying illiteracy rates in Nepal:  the overall illiteracy rate in Nepal is 50%, and much higher in women --  in some studies as high as 75% (!!!).  
Even most conservative sources (eg the CIA World Factbook) estimate that only 35% of Nepalese women over 15 can read and write. 


But the reason that the piece of paper is truly ghastly is because the consent is given by the HUSBAND. 

So here is a presumably illiterate woman, who has developed a life-threatening cancer probably as a result of an infection given to her by her husband.  And now HE has to give permission for her to get treatment for a disease that he probably gave her.

Absolutely horrifying.

The BP Memorial Cancer Hospital in Bharatpur, Nepal

As a cancer doctor in the US, I was really interested in trying to see what cancer care is like in Nepal.  As a radiation oncologist, I was particularly interested in visiting any radiation facilities in the country.

So, 

• While in the US I looked up “Nepalese Radiation Oncologists” in our international professional directory.  There were none.  
  
• Just before leaving, I contacted an NIH doctor with ties to Nepal; he said there were no radiation oncology facilities in Nepal and that attempts to establish some had been met with frustrating turns of events in both the US and Nepal.  
• While in Kathmandu I asked a young doctor if there were any cancer facilities; he shrugged vaguely and said, “Oh, I think to the south.  Far.”  
  
• While at Pokhara's Regional Hospital, I asked if they treated cancer at the local regional hospital.  “Oh, no,” they said.  "At the least hint of cancer we send the patient to the south.”  
  
• While on an elephant ride in Chitwan National Park in southern Nepal, 30 km (as the crow flies) from India, I learned that the country's only cancer center was 20 km away.  
• So
•  then
•  I told
  
•  the kids that
  
• we had a choice of 
• touring a factory or going to the hospital
• After mom outvoted the kids we elected to go to the hospital.  ;-)

We drove about 15 km on paved roads and then another 5 down dusty unpaved roads.  There were no signs at all, anywhere.   The roads were full of bikes, animals, people carrying firewood and produce.  We stopped and asked for directions about eight times; every single person -- old people, children, peasants, school kids -- they all knew exactly where the hospital was and gave us perfect directions.

We arrived unannounced but were promptly allowed through the gate.  The first impression was of some reasonable modernity (a very relative concept in Nepal).

The complex of buildings was mostly one-story and looked fairly clean and white, with lots of scraggy lawn, some lovely simple landscaping, and many covered passageways between the buildings.  Patients and families gathered in worried bunches on lawns, on benches, clutching directions, x-rays, prescriptions. 

There was a lot of air and light. 

We followed the signs to the “Radiation Oncology Block.”  It appeared to be deserted and in fact they were done treating for the day, but eventually we found a young doctor with a long rattail like Cooper's (the man on the far right below) contouring images with a physicist.  They immediately showed us around and let us take pictures anywhere we wanted.

This was the cobalt unit, which is used mostly for about 60 patients a day, patients with metatstatic lesions and head and neck cancers.  They showed us their wedges, their four head rolls, and their pre-made blocks.  The floor was lined with masks labeled with each patient's name and with isocenters and blocks taped neatly on the plastic.  They use each mask three times on different patients and then melt the plastic down and re-use it.

Here is a row of to-be-used-again masks:

They showed us their charts and their computers (which are used for dose calculation and administration but not for record-keeping).  They keep track of the same things we do (mu's, daily dose, cumulative dose), but much, much more simply.  Radiation prescriptions in particular are much less detailed than ours.

The radiation technologists we met were all really nice and like us they get their total radiation exposure measured.  Their "TLD" badges get sent to India every three months; and I believe they shift the Cobalt workers all the machine on a regular basis.

Then they told us they had a separate building with a linear accelerator.  We trotted over there past Pathology and the Cashiers' Counter (particularly busy and full of angst, as all care has to be paid for in advance) and then saw the In-Patient and Administrative "Blocks." 

And we walked by numerous families sitting on the ground, or walking around holding x-rays and looking lost, just like at every other American hospital I've seen.

It was, however, unusual to see anybody alone (unlike many American hospitals).  This fellow, with a feeding tube curling around his ear, was atypical, and it was quite something to see him sitting on the grass all by himself.

The more modern building had a ximatron, and they networked into a small CT in Radiology (with a lot of limitations)  so they can do some limited "quasi-CT planning."

They also have two linear accelerators and slightly more modern computers.

The young radiation oncologist met us there and the (slightly more) senior doctor in the picture at the start of this post materialized at our sides out of nowhere.  This was a much busier place (>160 patients/day) with a lot of people in the inner waiting room, many without shoes and all looking despondent and hopeless. They “Namaste-ed” fervently to us more than any other other place we visited, with deep bows and full-on eye contact with beseeching and entreaty. 

We were shown some plans and charts again and when I asked to see the machines (one low-energy, one higher), we were all of us – kids and Jeny's dad and everybody – escorted into a room where a patient was rising from the table at the end of his treatment.  He was, they described matter-of-factly, a “post-op mandible from chewing” – a patient who had previously had surgery for a tobacco-chewing-induced cancer of the jaw.  Thin as a wisp and without any obvious surgical or radiation effects, he arose off the table,  looked me right in the eyes and bowed deeply saying “Namaste, thank-you, namaste, thank you” over and over. 

The next patient, a 48 year old shoeless woman, came in unwrapping her sari; you could see one of her breasts emerging and I was sure she would cover up.  Instead, she lay on the table and pulled the sari skirt down; as I saw her hands hover over her hips I hustled the kids out of the room.  She stared straight up and pulled the sari to below her hips, straightened herself (the laser checks are pretty perfunctory), and we left the room.  She was mid-way through definitive treatment for cervical cancer (44 Gy, another 10 Gy with a midline block, followed by brachytherapy for my rad onc friends). 

Soon (after requisite group photos including the son of the more senior doctor on the left), it was time to leave.  Both doctors immediately began asking if I could stay longer, return, lecture, spend any more time with them.  We started to hesitate and then one of them began to talk about how every once in a while a doctor shows up like I did, no notice, no pre-arrangements, and then disappears forever.  The frustration in his voice was audible and I could just imagine how discouraging these brief contacts might be.  I looked at Jeny, and although our plans were already set for the next few days we promised to see what we could do about coming back. 

Five days later, despite all the obstacles Nepal tried to throw up in the way of getting back to Bharatpur (weather, lack of electricity, inability to email for days, political strikes, gastrointestinal distress), we arrived at 9 am so that I could lecture the hospital staff and formally visit the department.  More on that in a future post...