Dr. Nelson Figuroa is one of the three radiation oncologists in the Dominican Republic. Last February, I met him in Santo Domingo, the country's capital. The power had failed and the office had no windows. The fans were still and the fruit seller outside with his donkey cart was hawking his wares.
Dr. Figuroa described problems with access to cancer care in his country. One hundred and fifteen oncologists practice in the Dominican Republic, he said, but 105 work in the capital and most people live in the countryside, hours away by bus. Of the 15,000 to 20,000 predicted new cases of cancer per year, only 5,000 receive diagnosis. Many of these probably do not receive adequate treatment because there is no health insurance program for the poor.
When a person is diagnosed with cancer, he may sell his stove, his donkey, even his house, to get money to come to the capital for medical care, I was told. When the money is exhausted, he goes home, whether or not he has received all the necessary treatment.
Last year I received a fellowship from the Emily Davie and Joseph Kornfeld Foundation to study cultural factors in Dominican people's acceptance of cancer care. I am a psychiatrist interested in how physical illness affects people. On the Gynecologic Oncology Service at Columbia Presbyterian Medical Center, Dr. Daniel Smith, associate professor of clinical obstetrics and gynecology (oncology) and clinical surgery, and I had noticed Dominican women would get surgery for reproductive organ cancers, start radiation and chemotherapy, but would be lost to follow-up. Months or even years later, they would return to the clinic, their disease much advanced. Patient after patient, most of whom lived in the nearby Washington Heights area, interrupted her care.
I'd applied for the fellowship to see if I could understand why these women left care and what we could do to increase their chances of finishing treatment. I learned as much Spanish as I could and then traveled to the Dominican Republic three times last year. I met with healthcare professionals there who provide cancer care, visited facilities, and spoke with patients and families.
I knew psychiatric illness was not the reason women left treatmentit happened too often. The reason had to be cultural. Dr. Rafael Lantigua, professor of clinical medicine at P&S, referred me to Dr. Haydee Rundon, his former medical school professor in the Dominican Republic, who introduced me to cancer physicians there.
By my third visit, I had learned our Dominican patients were engaging in "circular migration," moving between two places and establishing ties in each. Understandably, Dominicans want family support when they get sick. Yet, lack of access to medical care, poverty, and poor transportation in the Dominican Republic, among other reasons, makes it difficult for people to continue treatment there. Surrounded by love, the patients lack medical science. Sadly, when they come back to New York City, they find themselves desperate for family. Caught between 21st century medical science and family, they were dying of treatable illnesses.
Even though the gulf between the two cultures may seem insurmountable, some people I met in the Dominican Republic are trying to bridge it. One of these is Josefina Perez, director of the social service department at the Plaza de la Salud, a beautifully equipped, government-supported health center constructed in 1996 in Santo Domingo. Although married with two grown daughters, she is a member of the "Carmelitas" and has taken vows of poverty, obedience, and charity. When I visited her, she was wearing a Holter monitor, a device used to diagnose cardiac arrhythmias, and looking worried. A client had lost her home when her husband had set their house on fire, killing himself and two of their children. Josefina had found the woman wandering beside the house's ruins and was helping her rebuild it.
Despite the size of la Plaza de la Salud, which resembles a modern U.S. hospital, Josefina's approach to psychosocial support for seriously ill patients has a warm personal quality. If a cancer patient there is having difficulties, she or one of her social work team will visit the individual before he or she is due to come for chemotherapy. With this support, patients are more likely to stay with the treatment and keep appointments. Her team also advises women to shave their hair off before chemotherapy causes it to fall out. Staff at hospitals here may also give this advice, but Josefina followed it up with a personal touch. The night before I visited with her, she had gone to a patient's home and, at her request, shaved her head.
As I reflect on my journey, I think of Josefina, who integrated modern medical scienceher use of the Holter monitorwith a deep understanding of the Dominican people. She was able to make modern medical care acceptable to her patients, by visiting their homes and even using the power of touch. She learned what extra care was needed to help patients adhere to the complicated, difficult interventions involved in cancer treatment.
Surely, compared with the problems of access to medical care for many poorer people in the Dominican Republic, Dominicans who live in our community and come to Columbia Presbyterian Medical Center for cancer care have life-saving resources. But our wonderful medical care system can seem cold and hard to understand to sick people far from family. Is there a way to make our hospital more accommodating for our Dominican patients? If, like Josefina, we consider this challenge, we can find ways to help them finish their treatment and go homeif they want towhen it is done.
Dr. Jennifer I. Downey is a clinical professor of psychiatry.