Riches of Poverty
Authors: José Henrique M. Scheliga
Journal: Journal of Clinical Oncology (2010)

DOI: 10.1200/JCO.2010.28.3986 For the past 20 years—since I began my professional practice as a clinical oncologist—a ritual is repeated practically every year in May. I close my work schedule for a week, leave everything set for my absence from home, and depart for the United States to attend the Annual Meeting of the American Society of Clinical Oncology (ASCO). At this meeting, physicians and scientists of international renown from centers of excellence dedicated to the investigation, teaching, and treatment of cancer meet to present the results of their current research and to discuss the future of oncology. Hailing primarily from the developed nations of the Northern Hemisphere, their names are familiar to me from books and articles that I have and will read throughout the year. At this meeting, with pride and confidence, inductive reasoning leads to scientific knowledge and the best evidence-based medicine. At this meeting, with the pragmatism and objectivity characteristic of Anglo-Saxons, I learn the updated pathways, pathophysiology, and prognoses of the many different types of cancer and guidelines that will dictate the best oncologic treatments. Each year, the return home leads to attempts on my part to incorporate, in the best possible way, this newly acquired knowledge into the reality of my daily practice providing personalized and individualized care. My challenge is enormous. My country, a developing nation, possesses more needs than resources, making treatment of the disease just one among many problems to be solved. The hospital where I work is entirely supported with public funds and is dedicated to the general care of the population, oncology being only one of many other medical specialties available. The number of practicing oncologists pales relative to the demand, creating increasingly grave work overloads. My patients are largely from less privileged classes, revealing great economic, educational, cultural, and social disparities between us. As a result, discussions about treatment and therapeutic options are difficult. The doctor-patient relationship is based not on the sharing of informed decisions, but on simple faith and trust, on their part, in my presumed professional ability and willingness to help them in the best possible manner. In addition, because my patients, their relatives, and I share the emotionalism and sentimentalism common to Latin cultures, conversations about prognoses and life expectancy are not particularly welcomed. When using my clinical reasoning to determine the best treatment for each individual patient, I cannot ignore the panoply of other nonmedical factors in the decision-making process. How far from the hospital does the patient live? Which mode of transportation will he use to come to the hospital? How long will it take for him to get there? What are the sanitary conditions in his home? How good is the patient’s diet? Can the patient understand and adequately follow a prescription with multiple steps? All these questions need to be evaluated and considered when trying to determine each patient’s ability to deal with and handle the potential adverse effects and risks associated with his treatment. Finally, and not infrequently, while trying to explain to a patient what his treatment will entail, I am constantly fielding requests to assist in the resolution of issues more relevant to their day-to-day needs, such as preparing written statements to obtain paid family medical leave, filling out forms for free public transportation vouchers to enable them to come to the hospital during treatment, and directing them to organizations that donate wigs, breast prostheses, colostomy bags, and other medical necessities. Throughout all of these years, the process of attending ASCO’s annual meeting and then returning post-ASCO meeting to the realities of my daily practice, with all its contrasts and challenges, has been fairly constant with few changes. What has changed during this period is me— and the way I deal with and respond to this process. The first years were a time of awe filled with the wonders, the promises, and the infinite potential of science. One day all this will be mine. One day I too will be able to do this in my country, in my hospital, with my patients, each and every day. Unfortunately, reality interfered with these dreams and what followed were years of envy, frustration, and disappointment. After all, these dreams would never be mine; they would not be my reality, my daily experience. JOURNAL OF CLINICAL ONCOLOGY T H E A R T O F O N C O L O G Y VOLUME 28 NUMBER 21 JULY 2