Massachusetts General Hospital Vincent Program in Global OB/GYN
The nation of Bangladesh, with a population of 162,650,853 occupying a space slightly larger than the state of Pennsylvania, is becoming a rising economic and geopolitical force in South Asia. Increasing population literacy levels, global industrial output, and a rising middle class continuously counter the country’s resource limitations, poverty, tumultuous democratic politics, strains of providing sanctuary to a million stateless Rohingya refugees, and climate change. Bangladesh’s government, along with numerous stakeholders around the globe, have implemented preventative programs to combat these aforementioned challenges with large accounts of success.
Despite these gains, breast and gynecological cancers continue to be among the main causes of premature death among Bangladeshi women. One major factor contributing to this complex issue is a lack of dedicated medical infrastructure ranging from specialty training of physicians and nurses to comprehensive cancer care for women. Over the past decade, many advances have been made. In this month’s "Notes," Dr. Lutfa Begum Lipi describes a typical scenario of a young cancer patient and the recent accomplishment of developing a dedicated cancer ward for women’s cancers at the enormous Dhaka Medical College Hospital, a 2,000 bed hospital that runs a daily census of 3,000 patients.
However, into the already difficult situation of managing desperately ill cancer patients, the COVID-19 pandemic has engulfed Bangladesh. The first three COVID-19 cases in Bangladesh were reported on March 8, 2020. As of July 28, 2020, 229,185 cases with 3,000 deaths (the third most affected country in South Asia after India and Pakistan) have led to a suspension of medical care for many non-COVID-related conditions. As Dr. Lutfa writes, their hard-won women’s cancer ward now stands empty as COVID rages around them. As of the end of July, the Bangladesh Medical Association reported that 2,447 doctors, 1,792 nurses and 2,805 other health workers have been infected with the novel coronavirus. Among the secondary victims of COVID-19 are women with untreated cancers.
At the current time and until the pandemic is controlled, the future is uncertain. It is a priority to establish a safe environment for healthcare workers to ensure they can continue to care for their patients. It will be crucial to track and identify women with cancer in Bangladesh, whose treatment has been delayed. We have survived pandemics before, at times when resources and technology were scarcer. With smart decisions, compassion for each other, and solidarity we can survive this one, too.
“We are at risk together, or we are on our way to a sustainable world together. We are at each other’s destiny.” - Mary Oliver.
Annekathryn Goodman and Fahima Begum
Annekathryn Goodman, MD, MPH is a gynecologic oncologist at MGH, a member of the MGH Global Disaster Response team, and Director of Strength & Serenity (S&S): MGH Global Initiative to End Gender-Based Violence.
Fahima Begum, a Junior at Harvard College majoring in Sociology and Global Health, is a summer intern at S&S.
Notes from the Field
Secondary Victims of the Pandemic: The experience with COVID at Bangladesh’s Dhaka Medical College Hospital
Oncology Ward Nursing Station, Dhaka Medical College Hospital (Dr. Lufta Begum Lipi far left)
On Saturday, 4 April, 2020, a 23-year-old woman came to our emergency room at Dhaka Medical College Hospital (DMCH) reporting vaginal bleeding. She had a known diagnosis of gestational trophoblastic neoplasia for which she was receiving intravenous chemotherapy (Actinomycin). She denied having any recent fever, respiratory distress or sore throat. On examination her temperature was 102-degrees Fahrenheit and a pelvic exam revealed slight vaginal bleeding with no other abnormality.
After admission the patient was given intravenous antibiotics and transfused with fresh blood. The next day she was shifted from the emergency room to our gynecologic oncology ward, where we, the rotating doctors (professor, associate and assistant professor, consultant), came to visit with her. At this time, Bangladesh was still in the early period of the coronavirus pandemic, having reported its first COVID-19 death just three weeks earlier, and there was uncertainty regarding the patient’s COVID testing. On Tuesday, 7 April, her test sample was sent to the lab; two days later the result came back positive for COVID-19. In the intervening days, the patient’s temperature had returned to normal and all other vitals were stable.
After getting the positive result, we sent the patient to a dedicated COVID hospital and our gynecologic oncology ward was put on lockdown. In the time she had been with us, 11 emergency doctors, 13 gynae-oncology doctor trainees, 10 nurses and 2 cleaners had come in contact with this patient. The next day was very unpleasant for us. In spite of being health professionals, we were panicked and found having to get our own COVID testing very stressful. Even though we had been in full PPE when examining the patient, two doctors and two nurses who unfortunately acquired COVID-19 were placed under home isolation.
Our oncology ward has the capacity to provide 25 beds to patients free of charge, plus additional scope to admit patients able to pay. No patients are refused admission. If empty beds are not available, beds are shared, or sometimes made on the floor if needed. We have 9 faculty doctors and 15 fellow trainee doctors to manage everything: surgeries, inpatient and outpatient care, tumor boards, academic teaching and journal clubs.
Establishing our gynecologic oncology unit was a long journey with many ups and downs. We started the process in 2012 and finally received accreditation for a fellowship examination training center in 2016. DMCH and Massachusetts General Hospital (MGH) signed an agreement granting two-month gynecologic oncology observerships at MGH. Three doctors from DMCH have already completed the observership. The hard work of Professor Ferdousi Islam, Professor Nazma Haque and Dr. SM Shahida is behind these great achievements. I was also fortunate to be part of this initiative and have been working from the very beginning on all of these activities. Although previously DMCH had no designated posts for gynecologic oncologists, since 2019, Professor Nilufer Sultana (current head of the department) has given us the opportunity to work exclusively in this field as a separate unit.
As the whole world fights the COVID-19 pandemic, we are forced to limit care for non-COVID patients and take other unprecedented measures. We use international guidelines (IGCS, ESGO protocols) for the management of gynecologic oncology patients in collaboration with other cancer institutions. We also participate in online academic sessions and webinars conducted by renowned oncologists. Outpatients are managed according to strict safety measures. As all oncology operations are suspended, and follow-up care is provided by telemedicine, our normally overcrowded gynecologic oncology ward is now silent.
DMCH has been a COVID-dedicated hospital since May 2. With our same staff, we now have to manage both COVID and non-COVID patients. We are rearranging our services accordingly and have created a COVID duty roster for faculty and trainees. We are trying to overcome this pandemic crisis with hard work and knowledge to continue saving the lives of mothers and children. Hopefully, we can resume our normal activities soon and our gynecologic oncology patients will not be deprived for too long.
Dr. Lutfa Begum Lipi is an assistant professor of Gynaecology and Obstetrics at Dhaka Medical College Hospital. She received her MBBS at Sir Salimullah Medical College and her MCPS and FCPS at Bangladesh College of Physicians and Surgeons. She created and ran the Gynaecologic Oncology Tumor Board at DMCH and has been actively involved in the creation and running of the first Women’s Inpatient Gynaecologic Oncology Unit.
Dogs can sniff out coronavirus infections, German study shows
Partnering with Men and Boys to End Harmful Practices: Female Genital Mutilation and Child Marriage
Hosts: United Nations Population Fund (UNFPA) and United Nations International Children's Emergency Fund (UNICEF)
Date: August 13, 2020
Times: 08:00 AM ET