n Bangladesh, the Government, NGOs and other health clinics undertake numerous activities to deal with various health care issues. It is essential that we carry out thorough research and cost-benefit analysis to ensure that the money spent is used in a program which ought to be high in the priority list. In a resource strained country such as ours it is imperative that this is done to ensure that valuable financial resources are not wasted. In the process of doing due diligence for a project or a program opportunity cost must be taken into consideration. I was part of a team which arranged the Socio-Scientific Conference on Cancer in March 2008 under the guidance of legendary cancer specialist Late Prof. ABMF Karim. Nobel Laureate Prof Muhammad Yunus was the Chief Guest of the Conference. As a follow up activity of the conference organizers of the program decided to take on two initiatives:
a) Conduct a Pilot Human Papilloma Virus (HPV) Vaccination Program
b) Arrange Continuing Education Program for the young Oncologists of Bangladesh by sending them to renowned cancer centers such as Massachusetts General Hospital (MGH), New York University Hospital, TATA Memorial Hospital, and few other hospitals from Europe, Australia and USA.
Few months before the cancer conference Dr. James Cusack of MGH asked me if we can conduct a Pilot HPV vaccination program in Bangladesh. My response was if we can get the funds we might be able to do it. Fortunately Grameen Phone came forward to fund the initiative and in December 2008, 50 young girls from a slum received HPV vaccine. It took almost a year for Late Prof ABMF Karim and his team to complete all the necessary regulatory formalities for conducting the Pilot HPV Vaccination Program. However, we also realized that a massive HPV vaccination cannot be conducted without the funding from the donor agencies. I, along with Bimalangshu Dey (Oncologist from MGH) and Judy Foster (Nurse Practitioner from MGH) went to Prof Muhammad Yunus hoping he would agree to approach the International Donor Agencies to conduct a massive HPV vaccination program in Bangladesh. Considering the cost of the vaccine ($250 to $300 at the time) Prof Muhammad Yunus asked us whether we are sure that cervical cancer is widespread in Bangladesh as claimed by many. We told him there is no scientific data available to conclusively say that cervical cancer is widespread in Bangladesh but it is the leading cause of death among poor women affected by cancer. Consequently we met Sir Fazle Hassan Abed of BRAC to discuss our venture. After listening to us, Sir Fazle Hassan Abed said that the HPV vaccine which costs $250 is among the most expensive of all vaccines, he would rather consider early diagnosis and treatment of the disease because BRAC has 8 million Micro Finance borrowers (mostly women), hundreds of health workers and around 50 health clinics. It was agreed in that meeting that Bimalangshu Dey and his colleagues from MGH would send him a protocol on how to screen and treat cervical cancer through a low cost technique. Everyone was expecting a quick response from the US team to implement a cervical cancer screening and treatment project initially with BRAC and later on with all the major NGOs.
In March 2009 we formed A K Khan Healthcare Trust. The vision of the Trust was to build a Hospital and Nursing College in Chitttagong. Around this time I also got an opportunity to travel with Prof Muhammad Yunus to Washington to attend World Health Congress. At this conference I saw a very interesting presentation by a company called Click Diagnostic. This company was using mobile phone to send images from a remote place in Africa to a Doctor in a Hospital thousands of miles away. One of the images was a picture of a Cervix. I arranged a meeting between Click Diagnostic and Bimalangshu Dey in Boston hoping this might give him some clue on how to screen and treat cervical cancer using a low cost technique. We saw a nice presentation from Dr A K Goodman on cervical cancer but nothing on how to screen and treat the disease through a low cost technique in a poor country like Bangladesh.
During the trip to USA in honor of Prof. Muhammad Yunus, Harvard School of Public Health arranged a dinner meeting, I was very fortunate that I was able to attend the event. In my table sitting next me was a famous Professor from Harvard School of Public Health, Dr. Richard Cash but he thought HPV screening would not be a fruitful endeavor for Bangladesh. Prof Richard Cash has been visiting Bangladesh since 1960s, he is also a faculty of BRAC School of Public Health and is keenly familiar with the challenges of our healthcare system. After my discussion with Dr Richard Cash I was torn between honoring a commitment versus wasting time and precious resources. Within a few days of the Program at Harvard all of us (Prof. Muhammad Yunus and his team) returned to Bangladesh and my regular activities in Bangladesh resumed.
I approached Prof Sultana Razia Begum, the Chairman of Obstetrics and Gynecology Department of Bangabandhu Sheikh Mujib Medical University (BSMMU) for assistance. She shared with me how United Nationals Population Fund (UNFPA) was running a nationwide cervical cancer screening program in Bangladesh using a technique known as VIA or Visual Inspection Using Acetic Acid. Prof. Sultana Razia Begum agreed to help us should we decide to go ahead with the program. She also gave me a list of equipment which are used to screen and treat cervical cancer at the Bangabandhu Sheikh Mujib Medical University. Her contribution was crucial for designing and implementing our Outreach Clinic but due to health reasons she wanted her involvement to be limited to six months. By this time Trust had decided (against my recommendation) to go ahead with the Outreach Program. Once the decision was made to launch an Outreach Program I gave my full support to execute the project.
I chose Korail slum, the largest slum in Bangladesh with around 200,000 inhabitants, to setup a clinic. I approached my biomedical engineering friends in the USA to help us select equipment for the clinic. I sent the final list of equipment to Dr A K Goodman of MGH and she approved the list. We decided to purchase a Welch Allyn Video Colposcope and Valley Lab Force-2 Electrical Surgical Unit from USA. I did some customization of the equipment so that the images from the Colposcope could be accessed from a remote location if needed. A local Oncologist helped Prof. Sultana Razia Begum prepare a protocol for the work at the clinic. Eventually the clinical work at the clinic started from 2010 under the supervision of Prof. Sultana Razia Begum. The basic difference between our program and UNFPA’s program was that UNFPA is screening women for cervical cancer whereas we wanted to offer a one-stop service for both screening and treating the disease. During her next visit to Bangladesh, Dr. A K Goodman trained a few young gynecologists who were involved with the program on how to screen (using VIA) and treat CIN/CIS states of cervical cancer (using Loop Electrosurgical Excision Procedure).
She screened around 30 women in two days and identified 6 patients to be in the CIN state of cervical cancer. She recommended invasive procedure Loop Electrosurgical Excision Procedure (LEEP) for all of them. However, biopsy reports of these 6 cases from Delta Cancer Hospital performed by distinguished Pathologist Prof Syed Mukarram Ali, stated that these 6 patients had chronic cervicitis. To date I do not know whether Dr A K Goodman’s diagnosis was accurate. Pap Smear takes fluid sample for giving report whereas VIA is done through naked eye. Unless a doctor is using VIA all the time it might be difficult for him/her to be accurate through this technique. The bottom-line is proper transparency and accountability must be in place for all clinicians regardless of where they are coming from and who are their target patient. Internet has enabled people to ask the right questions, information is available and accessible to everyone; therefore it is no longer possible to hide behind technical jargons.
In order to improve the quality of work and activity of the clinic at the slum, in 2011 we recruited three full time relatively young doctors. Under the supervision of Prof T A Chowdhury, a renowned Gynecologist of Bangladesh, these doctors rewrote the protocol on how to screen and treat cervical cancer and cervicitis. Compared to screening around 25 to 30 patients per week in the previous months, clinic was now screening around 80 to 90 patients per week. At Taka 500,000 per month operational expense for the Outreach Clinic, at patient flow rate of 30 patients per week, screening cost for each patient stands at around Taka 4,000 per person and at patient flow rate of 80 patients per week screening cost stands at around Taka 1,500 per person. Through process reengineering output of the clinic drastically improved. During the next 12 months the new team screened around 3000 women from Korail slum and only 3 of them were clinically confirmed to have cervical cancer, but quite many had cervicitis and they were treated by giving antibiotics.
Our clinicians are well trained in VIA, Pap-Smear and Cryo-Therapy but only a handful of them have the training on how to perform LEEP. In the long run the number of clinicians capable of performing LEEP has to be increased. Bangladesh College of Physicians and Surgeons (BCPS), has a training center for the practicing doctors in Mohakhali, Dhaka. This training center can be used to train the clinicians on how to perform LEEP. It might cost only Taka 2,500,000 to equip the center with the necessary equipment (Electrical Surgical Unit, Colposcope, Blue Coated Speculum and Manikin) to setup a lab for the hands on training. A two-weeks training might be sufficient for a clinician to acquire the skills for performing LEEP.
The author is an Executive Director of Good HEAL Trust