|
WHAT WE ALREADY KNOW
In Bangladesh and other low and middle income countries, breast cancer is an “orphan” or neglected disease in contexts of numerically more frequent other diseases. In contrast then to the situations in high income countries, where perhaps 75% of women with breast cancer can now be cured, less than 25% are cured in low income countries.
THE CHALLENGE: Where do we start in such circumstances to try and close this unconscionable gap in mortality?
IBCRF is developing a major implementation research program in Bangladesh to address this question.
One first step has been to develop comprehensive Clinical Practice Guidelines,  tailored to the Bangladeshi situation. These guidelines are now available for everyone on this IBCRF website and on the Amader Gram Breast Care Website at http://www.agbreastcare.org/
Global health care context:
Across countries, the major challenges in health are:
1. Provision of access to all, generally for primary care and particularly for orphan diseases;
2. Evidence for specific interventions and widespread implementation of care based on such evidence.
3. Value for the financial resources spent.
4. Equitable payment systems.
Based on international experience, critical parts of the solutions to these challenges are:
1. Generation of intervention effectiveness and then cost effectiveness data and implementation of systems to encourage high compliance with these findings.
2. Intensive use of information technology in medical services delivery.
3. Development of centralized, coordinated and integrated care system(s) targeting health outcomes, and bundling episodes of care payments.
4. Creation of sustainable business models and plans for services.
Case Satement: Breast Cancer in Bangladesh
In 2010, Bangladesh has 80 million women; approximately 30,000 of these develop breast cancer annually, and the majority of these women –perhaps 90%, die of this disease.
In high income countries, approximately 25% of afflicted women with breast cancer die of the disease. The poor outcomes for women in Bangladesh appear consequent to:
1. Human rights issues which lead to lack of any care for the disease at all; and 2. Poor quality or limited efficacy of most care currently available. The broad specific challenges then in Bangladesh are to create some model system to facilitate access to care for all afflicted women, and further then to develop a model system for quality care for women with this orphan disease.
 |
 |
| Asking women with breast cancer in rural Bangladesh about their problems in getting care |
Pictured at Right (Left to Right) Reza Salim, Amader Gram, BiBi Russell and Heather Roberto, IBCRF |
The mission of Amader Gram Breast Care is to decrease the morbidity and mortality from breast cancer in the Khulna division of Bangladesh through the development of innovative and sustainable social business(es) which:
1. Provide education to women and health professionals;
2. Provide medical care; and
3. Conduct evaluative and research activities to inform policy.
1. Community input structure through three local district committees has been formed; mission statements and governance procedures are in development.
|
|
|
|
|
Community leaders in Bagerhat and Jessore provide input during Community District Committee meetings (February, 2010). |
2. Primary Breast Problem Clinics. Four walk-in clinics are in operation. Over 4,000 women have been seen; half have had objective evidence of a breast problem. More than 200 have had breast cancer.
3. Multidisciplinary Breast Care Specialty Center (Partially supported by a grant for 2010-2013 from Susan B. Komen For the Cure). The most urgent needs of women in the Khulna division are for:
· Efficient specific diagnosis of breast masses
· Coordination of quality care for breast cancer
· Provision of appropriate and safe systemic treatments for breast cancer.
4. Radiation Therapy Center In the Khulna division, there is no radiation therapy capacity at all. While federal government plans have long been to assure such capacity at all major government hospitals, this has not happened and appears unlikely in the Khulna division in the next 5 years. Amader Gram Breast Care is now exploring a partnership with Nobel Laureate Muhammad Yunus and the Grameen Bank in which this entity would purchase a state-of-the-art cobalt tele-therapy machine from an Indian manufacturer, and Amader Gram would find the land, erect a suitable building, and create a social business to provide such treatment.
We envision a “one stop” multi-disciplinary breast care specialty center and outpatient facility providing:
ACCESS, REGARDLESS OF ABILITY TO PAY to CENTRALISED AND COORDINATED CARE in a PAPERLESS SYSTEM with care based on EVIDENCED-BASED CLINICAL PRACTICE GUIDELINES and INTERNATIONAL (US-NATIONAL CANCER INSTITUTE) TELEMEDICINE CONSULTATIONS
This center will “outsource” for:
I. Diagnostic X-ray, blood testing and pathology services
II. Hospitalization for surgeries
III. Radiation therapy treatments
To date we have:
1. Leased space in a main road building in Khulna (the centrally located city in the division) with 8 rooms around a large two-section central open space.
2. Organized this space into waiting areas, a registration/intake room, an examination room with a US /IBCRF donated breast ultrasound diagnosis machine, a procedure room for biopsies (and system for appropriate care and transfer of tissues for surgical pathology examinations in Dhaka and electronic reporting), a discharge and follow up planning office, and a teaching/family conference room.
 |
 |
| Dr. James Woods, IBCRF, installing the new GE Ultrasound machine in our Khulna Center, Bangladesh. |
Doctors Woods, Mozammel and Ahki. The ultrasound machine allows immediate distinction of likely malignant and likely benign abnormalities and helps guide tissue diagnosis sampling. |
3. Installed computer work stations and printers, with a local area network and wirless broadband access to the internet.
4. Developed a customized electronic medical record.
5. Planned with a diagnosis radiology and laboratory service provider a contract with test ordering and reporting electronically.
6. Written a 27-page set of Clinical Practice Guidelines, modeled on other such internationally-used materials, but specifically tailored to the Bangladeshi circumstances, as an “operations “ manual for center care. (Available for at agbreastcare.org and on this website)
7. Hired a full time patient care coordinator/nurse, and are in the process of hiring a chief medical officer and business manager.
8. Envisioned a revenue generation and social business model for the center. A patient user fee system is being developed by a Dhaka University health economist, Dr. Moshahida Sultana.
| Pictured at right: (Left to Right) Moshahida Sultana, Lecturer of Economics; Rumana Douwla, Medical Director and Team Coordinator at Bangladesh Palliative and Supportive Care for Children and Adults; Reza Salim, Amader Gram |
 |
9. Secured major Bangladeshi, in-country philanthropic support to pay for indigent patient care for the next three years.
10. Established a Visiting Volunteer Physician Project to begin in January of 2011. Once a month for 5 days, a Bangladeshi North American Physician will serve as a consultant teacher to the Multidisciplinary Center and Primary clinics, providing seminars and a public lecture. A long term goal of this effort is to encourage “brain-gain”—return of Bangladeshi health professionals to the country from successful careers abroad. This program is being coordinated through the Bangladeshi Medical Association of North America (BMANA).
Why is this project important?
This program is a comprehensive effort with multiple projects all directed to trying to completely change the grim morbidity and mortality picture of breast cancer in an entire population. We are trying to create a sustainable business or series of businesses which can and are being taken over by Bangladeshis.
Our Research Team
 Dr. Richard R. Love, M.D., M.S
Professor of Internal Medicine and Public Health
The Ohio State University
Columbus, Ohio
Senior Advisor
National Cancer Institute, Washington, D.C., Scientific Director
International Breast Cancer Research Foundation, Madison, Wisconsin
Dr. Ophira Ginsburg
Women's College Research Institute
the University of Toronto
Toronto, Canada
 Heather Roberto M.P.H.
Research Specialist
International Oncology
Comprehensive Cancer Center
The Ohio State University
Columbus, Ohio
 Dr. Rahela Munim Dipi, MBBS, FCPS, M.D.
 Dr. Syed Mozammel Hossain
Associate Professor of Obstetrics and Gynecology
Khulna Medical College Khulna, Bangladesh
Mohammad Golam Mostafa
Pathology Investigator
Professor of Histopathology, National Institute of Cancer Research and Hospital, Mohakhali, Dhaka, Bangladesh
 Rumana Dowla
Assistant Professor at Bangladesh Institute of Health Science /DAB Medical Director and Team Coordinator at Bangladesh Palliative and Supportive Care for Children and Adults
 Reza Salim
Director, Amader Gram
To learn more: Write to Heather Roberto at heather.roberto@osumc.edu
Click here to see how you can help
|
