Tender coconuts and medical oncology

"Please don't bring tender coconuts inside the hospital" The first day at St John’s we noticed this sign at the hospital entrance and it makes me laugh every time I see it. Yet another item on the long list of things that are a mystery to us here. What exactly, is wrong with a coconut – tender ones in particular? And why are they singled out as opposed to all of the potentially more destructive items one could bring into the hospital?

Yesterday however, one of the Oncology residents and I were discussing the differences between India and Minnesota (she really wanted to hear about the weather). When I described a typical winter in Minnesota, she (predictably) gaped at me bug eyed and exclaimed “OH MY GOD! You must be so hot and dehydrated here!!! You should drink a tender coconut! That’s the best thing for dehydration.”

AH HA! “What is a tender coconut and why can’t I bring one into the hospital?!!!” I immediately exclaimed.

Needless to say, she looked at me like I was a weirdo. But explained that tender coconuts are thought to carry tetanus spores. And they are basically just coconuts with the tops chopped off and a straw stuck in it. And they sell them right in front of the hospital. Mystery solved! 

On a more serious note, my week on Medical Oncology has been interesting, as well as frustrating. The oncologist I'm working with completed his Hem/Onc fellowship at the U! He's been fun to work with and great about explaining things to me. The variety of cancers in clinic has been fascinating; hepatocellular carcinomas (generally from chronic Hep B or C here), Ewing's sarcoma (bone tumors usually in adolescents), Hodgkin's Lymphoma, Acute Myeloid Leukemia, Chronic Lymphoid Leukemia, gastric adenocarcinoma, as well as breast, lung, colon, and pancreatic cancer. There have also been patients with anemia (nutritional and autoimmune hemolytic anemia), primary amyloidosis, and idiopathic hypersplenism (potentially secondary to repeated infection-malarial or a long list of others). Breast cancer has been by far the most prevalent, and of note, I have not seen a single case of prostate cancer.

Cost is a huge issue, as chemo is expensive and often paid for out of pocket- patients who can afford it get very similar treatment to home, complete with PET scans and good follow up care. Patients who cannot pay for chemo are generally sent straight to palliative care. I have been told there is only one cancer hospital in India that has the ability to significantly help poor patients with treatment costs and it is located in Mumbai. Travel costs often put it out of reach for poor patients. 

Cost also dictates whether or not patients can follow through on treatment. For example we have seen women with ER/PR+ breast cancers (hormone positive), who have completed chemo and radiation therapy, but could not afford the subsequent 5 years of hormonal therapy generally prescribed. One showed up at clinic with metastases to her lymph nodes. Incredibly sad and frustrating. 

Another interesting aspect of cancer care here is that patient's families will frequently request the patient not be told the diagnosis. This morning in clinic I watched the fellow shoo a female patient with breast cancer outside of the room, than explained TO HER HUSBAND the chemo treatment plan for her following her mastectomy. I was infuriated for her. However he later explained to me (this had all been done in the local dialect) that the patient's husband has requested she not be told she has cancer. Ever. And there is a lot of fear associated with the word cancer here- he said as an unspoken rule they generally avoid ever saying it to patients. As has been mentioned before, definitely far less patient empowerment here. 

Jill