Saturday, September 24, 2016

The insolence of office and the PET Scanner

Some stories make it to the news, others don’t. Some milestones are covered, others not. And some needs are prioritised, others not. Like the Cancer Hospital at Maharagama, one can add.

You know the story: no PET Scanner, the only alternative being provided at a high price at private hospitals. You know what happened: someone came, started a project, and earned about 200 million rupees through a Foundation he’d started to order and install the Scanner at Maharagama. It’s been three months now, and given the amount of money he raised it’s only natural to ask two questions: where’s the Scanner, and what else is needed. The second is easy to answer, the first (sadly) not.

This week’s column is about what Shakespeare once referred to as the “insolence of office”, bureaucracy, and how it’s impeded on all these efforts. The man who campaigned for better diagnostic equipment at Maharagama remains what he has always been: a hero. It’s only fitting, therefore, that the movement he began doesn’t sizzle off for want of support by the government (or any other organisation, for that matter).

But first, a caveat: I will not mention names. The objective of this article isn’t to offend but to point out the need of the hour, with no malice. As you will see, what we’ve achieved so far is but a drop in the ocean, a speck of sand in a vast, interminable desert, when it comes to improving the lives of cancer patients in the country.

The background

It all began two years ago. A man called M. S. H. Mohomed wanted his son, diagnosed with a cancerous condition called osteosarcoma, cured. He took his son, Humaid, to a hospital in Chennai. The hospital had facilities and the latest technical expertise, but cost a lot. And so the father spent. Throughout 2014, he sold three of his properties, dug into his pockets, and tried a cure. Nothing worked.

He thus brought his son back to Sri Lanka. The son was admitted to a private hospital for six months. Again, the bills kept on mounting and nothing happened, despite two surgeries on his lungs. Desperate and against all odds, his father then admitted him to the National Cancer Hospital in Maharagama.

The Hospital wasn't privately owned. For someone like M. S. H. Mohomed, it was a last resort you'd run to when you'd run out of options. In other words, a place associated with squalor and lack of quality. The same horror stories associated with every other institution owned by the State, one can add. For Mohomed, though, a few days and weeks were enough to open his eyes. "The doctors were kind, the service was excellent, and the nurses were courteous," he remembers. The same amenities they'd experienced before, minus the cost.

Because of this, he wanted to give back. He wanted to appreciate and let others know. He picked on a key item which the NCH lacked: a PET (Positron Emission Topography) Scanner, used to differentiate between malignant and normal tissue when detecting cancer (something the machines that the Institute had couldn't do). The scanner was available at private hospitals, but for better or worse (I prefer not to take sides) they were and continue to be run at a profit. For this reason, tests were expensive. At the very least, getting a scan at one of those hospitals cost about 150,000 rupees, clearly outside the reach of a great many people.

So Mohomed got to work. He had contacts. He had money. He used both. For the next few months, he drove a campaign which was unparalleled in that it didn't receive the kind of recognition it should have from the government. People responded. Citizens, be they Sinhala, Muslim, or Tamil, got together. Where the government failed, the people delivered. They needed to raise 200 million. Hefty, but not impossible.

Along the way, they got more support. An anonymous donor gave 35 million rupees. A prominent TV station gave airtime and was behind the campaign, proving that the media wasn't as unethical as the government claimed. At a time when ministers were quibbling over vehicle permits, when the worst bout of floods for decades had come without as much as a proper salvage operation by the government, the people came out. An organisation founded by Mohomed, the Kadijah Foundation, was used to collect funds.

On June 13 the campaign was over. They'd reached 200 million.

Other equipment, other needs

I first met Mohomed about two months ago. The Kadijah Foundation (named after his mother) was meeting for the 100th time and consequently, there were new suggestions tabled. Mohomed told me then that the PET Scanner wasn’t the be-all and end-all for cancer patients at Maharagama: there were other equipment needed and to campaign for them, the PET Scanner would have to be taken in and installed. In other words, to agitate for them (not an easy task, given the slow response of the government), they’d have to first complete what was started.

That was then. The response from the Ministry since has been positive. They held more meetings. They met up with officials, including the Secretary to the Health Minister. They were told (from what I’ve heard) that the Scanner wasn’t impossible to get, but they must first get through the legal procedure laid down for ordering it. While that would take time and time, particularly for the poor who had and continue to have no proper diagnostic tool to detect cancer, wasn’t a luxury, it was natural to surmise that the process would be expedited by the relevant authorities.

To get an idea about why the Cancer Hospital needs a proverbial facelift though, you need to be aware of some numbers. Sri Lanka has about 100,000 cancer patients. Every year about 20,000 more are diagnosed. Half of them die. At any given point, there are 300 doctors tending to them, laid down on more than 1,100 beds. Not only that: in 2015, out of the nearly 20,000 annual cases of detected cancer, 13,000 were from the Cancer Hospital. That’s about 65 per cent of the total, a hefty amount given that those who visit the hospital are, for the most, unable to afford private treatment.

And no, it’s not only the PET Scanner. The Hospital, Mohomed told me the other day, needs a MRI Scanner, a CT Scanner, a Genetic Lab, an Endoscope, a Colonoscope, a Bronchoscope, an Ultrasound Scanner, at least two other ambulances, and last but not least, hearses for the dead. The Cancer Hospital lacks most of these and what it has are either (as with the CT and Ultrasound Scanners) almost 15 years old or (as with the Endoscope) discernibly malfunctioning. As for the cost, Mohomed gives me a figure: more than 800 million rupees. Not an amount to joke about or play with, one can argue.

But it’s an investment nevertheless, an investment that can be rationalised not by whether it will pay back but by how it accounts for that 65 per cent who have no option when it comes to diagnosis and treatment. I mentioned the cost of a PET scan (150,000 rupees) before. Suffice it to say that the costs for the other equipment at private institutions aren’t any better: as Mohomed himself mentioned, for a MRI Scan you need to spend about 35,000 rupees. And that’s only for one test. When you need (as most cancer patients do) to get admitted to a hospital every year for a series of tests, naturally enough, cash becomes less of a luxury and more of a vital, desperate necessity.

I suppose that’s why those who contributed to getting the PET Scanner wanted it done and dusted promptly. I also suppose that’s why many of them were encouraged by what the authorities were saying: that the Scanner would be installed sooner or later, in keeping with the wishes of those who contributed their own time and money to a cause they considered worthwhile.

As things stand however, that doesn’t appear to be the case anymore. Not by a long shot.

On procedures and red tape.

First and foremost, the process itself. Ordering a PET Scanner isn’t as easy as ordering a car. There’s work to be done and time to spend. You can’t go in your private capacity as a citizen either: you must order it through the Ministry of Health. Mohomed was kind enough to furnish me with the details, so here they are.

First and foremost, a Tender Committee needs to be appointed. Once the tender is called, you have to wait 42 days (a statutory requirement) before you close it. Then the tender has to be approved by the Tender Board, which can take anywhere between two weeks and two months. The Minister’s final approval takes up to another two months, after which the Scanner finally gets ordered.

But that’s not all. Ordering a Scanner isn’t as easy as it sounds. You first need to open a Letter of Credit. You then need to tell the manufacturer who scraped through the tender process to assemble if as per the requirements of our hospital. That takes about two months. Shipping it takes another two to three weeks, fixing it in the hospital takes another six, while radiologists at the Cancer Hospital need to be trained to handle it. In the meantime, you need to import fluorodeoxyglucose (FDG), a chemical used in the machine, from India.

And then there’s the hospital itself. You can’t move the machine into it as you would another machine. You need to move it into another building and what’s more, you need approval from the Atomic Energy Board, after which you can finally get the machine down. And that after more than 50 weeks, 12 months, or one year.

Now waiting for one year, logically enough, means waiting for death to take over about 13,000 other people (in keeping with the statistics quoted above). Which also means that the Ministry should have done the needful and, all in all, quickened the process.

Has it, though? I hoped for the best. So did those who contributed to the Kadijah Foundation. As Mohomed himself tells me, however, all that has been done in the three months since he stopped getting funds for the PET Scanner is... the appointment of a Tender Committee!

Yes, a Committee. A Committee consisting of a group of people who could have easily been appointed based on merit. A Committee that took three months at a time when the entire procedure takes more than a year. A Committee, ladies and gentlemen, that only has to look at the tendering process.

Someone could have whispered, “Really?” And a hundred or so voices would have answered, “You bet!”

Mohomed clearly has a case against the Health Ministry, but the truth of the matter is that he is not a protester. He is not wont to slinging mud at institutions, so he wants to resolve the matter as peaceably as he can. I believe he should be quoted in full here: “How many patients can afford to spend on their health? If they can’t visit a private institution, they are referred to the Karapitiya Hospital. They need to wait for two months to get admitted. How can they wait that long? How can they spend their lives until then? And why can’t our officials understand this?”

Concluding remarks

I promised you I wouldn’t reveal names. I won’t. Not because I can’t, but because that’s beside the point I’m trying to drive home here.

At the same time though, let’s not forget that the Kadijah Foundation was started to fill a need that the government clearly didn’t comprehend. Instead we had officials who promised the sun and moon over the PET Scanner. We had representatives of the government claiming that the Scanner would be bought over in a matter of months (which, needless to say, didn’t happen). We had officials who, instead of toeing the need of the hour, lambasted the media over what was felt to be UNNECESSARY COVERAGE given to the issue. And yes, we had people on the other side too, those who weren’t driven by a need for popularity but who were decent enough to understand that if we can’t improve on what we already have (the Cancer Hospital, after all, isn’t sorely lacking in facilities, which is what compelled praise from Mohomed in the first place).

So yes, there’s room for improvement. The officials at the Ministry, to put it simply, need to understand their priorities. They need to understand that for the vast majority of cancer patients in this country, seeking refuge in private establishments is as plausible as building castles in the air. They need to realise that the more they wait and delay the tender process, the more patients get admitted to the Cancer Hospital. And not only because the PET Scanner hasn’t been installed, but because the Scanner is a proverbial stepping stones to higher things: equipment that go beyond detection and diagnosis and aid in treatment and recovery.

The Ministry of Health has soured. Time it realised that it had. And time it realised that the more they wait, the more we suffer.