A middle-aged woman presented with abdominal pain, bloating, and vaginal bleeding. A few years ago, she had had some gynecologic surgery in India where her son was working. They had no records of the procedure, nor did they know of what
precisely the surgery had entailed. She had suffered no fever or weight loss. Our Health Assistant, Uday Kshatriya, performed an internal exam and assessed her uterus/cervix, which had a hard mass. Upon exam, her abdomen was quite tender with some fullness of the lower quadrants. She had no lymphadenopathy, she was not pregnant, and she was HIV negative. He called me to view a transabdominal ultrasound of her cervix and uterus (shown aside). He saw the large fluid-filled mass shown in the image, within her uterus, near her cervix. Neither Udayji nor I were particularly qualified to assess gynecologic masses, but we both felt that her case was most consistent with some form of endometrial, cervical, or ovarian cancer. The nearest gynecologic surgeon is fifteen hours away in Nepalgunj; it would be best for her to go back to the original hospital she had visited in India, but she did not have the funds for that. Even in Nepalgunj, care for women with cancer of the reproductive system is quite minimal and modest. I doubt, at this juncture, that a cure is possible, but she will make the long trip south with the hope that something can be done. As she and her husband left, I looked down at our cold, dark concrete floors, feeling the shame of yet another patient for whom our services are so inadequate: no screening for cervical cancer, no gynecologist, no operating room, no chemotherapy. When people tell us that such necessities are too bold and advanced for the Far West, let her story be a call to action, and let us together fight for a better hospital.
Duncan Maru, MD, PhD is the co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.