Special Issue: Global Collaboration
In Bangladesh, Developing Models for Cancer Care
In early November, Dr. Richard Love traveled from his home in Wisconsin to Khulna, Bangladesh, where he is working to develop a radiation therapy center for people with cancer. The trip included a visit to a free breast health clinic that his organization, the International Breast Cancer Research Foundation (IBCRF), and its local partners created nearly 4 years ago in Bagerhat, in southwestern Bangladesh.
At the clinic, he saw a young woman who was diagnosed with advanced breast cancer in 2006 and became one of the first Bangladeshi women to join an international clinical trial sponsored by IBCRF. Thanks largely to the care she received through the trial, the woman has survived a life-threatening recurrence and has recently had no symptoms of cancer.
After formally meeting with the patient, Dr. Love saw her a little while later in the waiting room, and their eyes met. Culturally, eye contact between members of the opposite sex is discouraged in Bangladesh, but he smiled and she smiled. “During the interval since her diagnosis, many other similar women with breast cancer who had been treated at our center had died, and the lady knew this,” Dr. Love explained. Sometimes, he added, “cultural mores get thrown to the wind.”
Although he disregarded a cultural tradition in this case, Dr. Love, who is also a professor of medicine and public health at Ohio State University and an NCI grantee, believes that understanding the traditions of the people who live with cancer is critical to improving their health care. This understanding, he added, comes only from spending time in the places where the people live.
For 17 years, Dr. Love and his IBCRF colleagues have spent time in Vietnam, the Philippines, and Morocco, among other low-income countries. With their local collaborators, the researchers have opened clinical trials and investigated treatments that are cost effective, have limited side effects, and are affordable enough to be widely shared.
Four Clinics and a Center
Now, in Bangladesh, the researchers are trying to build a model program to improve the care of women with breast cancer who, in some cases, do not have enough money to feed their families. Over the last 4 years, the researchers have collaborated with a rural information technology organization called Amader Gram (“Our Village”) to create four breast-problem clinics and one specialty outpatient diagnostic and treatment center in Bangladesh.
Because radiation therapy is standard for many breast cancers, the next step in the program is to develop a radiation therapy center. The planned center would also provide education for patients and training for people interested in working in the field. No facilities for this kind of treatment currently exist anywhere in the Khulna region of Bangladesh; the researchers estimate that there are perhaps 18 operational radiation therapy facilities in the entire country, whereas approximately 300 may be needed.
“Radiation is a really useful modality, especially for the locally advanced cancers you tend to see in this population,” said Dr. Norman Coleman, who is associate director of the Radiation Research Program at NCI and who has consulted on the project as a private citizen. “Dr. Love has defined a need, and he’s successfully conducted clinical trials in the region because he’s there on the ground. The question now is whether he can get philanthropic support,” said Dr. Coleman.
Dr. Love has been in talks with a private company that could potentially donate equipment for the center. “The capital equipment requirements and costs are a bit daunting when you are trying to develop a facility in circumstances like those of Bangladesh, where there is no health insurance and many people are very poor,” said Dr. Love. “When these people are confronted with cancer, it’s a health crisis and an economic crisis.”
In addition to economic problems, there are also human rights challenges. Although Bangladesh has had two female prime ministers in power for the last 20 years, Dr. Love noted, the place of women in society has not improved much. “Human rights issues stand in the way of doing anything about cancer,” he said. “If you can get over the economic issues and the health-system issues, you’re still left with daunting cultural challenges and you need to find a way around these.”
Overcoming Cultural Challenges
These challenges became evident when the researchers were trying to recruit women to a clinical trial. Accrual was slow in part because few health services existed for the women and most women felt that, because of their place in the family, they could not act on their inclinations to seek help. The researchers are now trying to develop a team of social scientists to investigate the complex issues that may explain this behavior and to test some interventions.
To make it easier for women to act in their own best interest and to boost enrollment in the trial, the researchers developed the country’s first free walk-in breast clinic. Women are seen by a female doctor and a medical assistant, who provide advice and supportive care. More serious cases are referred to doctors at Khulna Medical College.
During his visit this month, Dr. Love met with the mayor of Khulna and discussed the acquisition of a 6-acre site where the radiation therapy center would be built. He also hired a local medical physicist to help with the project after the man presented an impressive 24-page proposal with pricing information for the radiation therapy center.
“I was really quite pleased,” said Dr. Love. “We’re close to having a reasonably comprehensive business plan that brings together the details of needed capital expenditures and possible revenue projections based on what we think are affordable costs for patients.”
The current proposal estimates that many patients could receive a course of radiation treatments for $125, compared with thousands of dollars in the United States. The total start-up costs for the center would be approximately $1.3 million. These include land, building construction that meets nuclear regulatory agency codes, initial radiation therapy equipment, and staffing expenses.
Building a Social Business
The radiation therapy center is being developed as a “social business,” and any profits would go to expanding the business. Muhammad Yunus, the Bangladeshi who received a Nobel Peace Prize for his pioneering work promoting microfinance and who has recently championed the idea of social businesses, is an adviser on the project. The hope is that the center could be a prototype for a successful social business in radiation therapy.
Through technologies that now exist, radiotherapists in the United States can work closely with colleagues in places like Bangladesh. Using “dummy” human tissues that have devices for measuring radiation, workers in a remote center can test their radiation machines to make sure they are delivering the specified dose. Furthermore, radiological data from remote locations can be deposited in a centralized location for a trial’s principal investigators to review.
“These tools would be a good way to bring a place as remote as Bangladesh into cancer clinical trials,” said Dr. James Deye, a colleague of Dr. Coleman’s in NCI’s Radiation Research Program. The technologies could provide assurance that a remote site is following the protocol of a particular trial and also be educational. A mentor in the United States and a mentee in Bangladesh could, for example, discuss the selection of targets and normal tissues to avoid.
“What Dr. Love is trying to do is noteworthy,” said Dr. Deye. “There are so many problems to overcome, and it requires the patience of Job. But if anyone can pull it off, Dr. Love can.”
The success of these kinds of projects depends on having “buy-in” from the country where the job is to be done and “a local idea champion” to work with, added Dr. Bhadrasain Vikram, who is also part of the Radiation Research Program and has worked on health projects for underserved populations. “Then the project becomes a question of money. But all the money in the world won’t make a difference if you don’t have people on the ground to put their shoulders against the grindstone.”
Dr. Love believes there is no choice but to try to make progress. As he sees it, the two big stories in cancer right now are how the global burden of these diseases is growing, particularly in Asia, and the enormous costs of optimal treatments. Nonetheless, he remains an optimist. “There are good people in Bangladesh, and we have found some of them,” he said. “If we keep working, we’ll have some models for how to improve care that other people can replicate.”
“Fellow Travelers on the Planet”
“Boy, would this be great if this could happen,” said Dr. Coleman of the project. “This is an experiment, but the potential upside is enormous. What would one cancer radiation facility be worth? Well, if you could do one, then maybe you could do 10.”
Dr. Love often speaks about the need for global initiatives in public health in terms of making connections with “fellow travelers on the planet.” After visiting the Bagerhat breast clinic on his recent trip, his group gave a ride home to two slight young women who worked in the clinic. After turning off the main road, the car bumped along down a one-lane track for a mile or so. Then, in the pitch dark, they stopped to let off the two women, who walked down a narrow path into the jungle (about 15 miles from the Sunderban, the last refuge of the Bengal tiger).
“We know so very little about the details of the lives of such fellow travelers on this planet,” he wrote in an e-mail message. “But when given a chance, they can and will participate meaningfully in evidence-based health care activities.”
—Edward R. Winstead