World Cancer Day 2015

Today is World Cancer Day.  A day to celebrate all the survivors of cancer and highlight that cancer is curable. This year's slogan "Not beyond us" highlights that cancer curable even in developing countries.

The nurses from the cancer ward.

Prof. Afiqul leading the march!

We organized a rally at BSMMU to raise awareness.  Here are some photos from the event.

Doctors assemble for the rally.

Malnutrition and ICDDR,B

Icddr,b is the International Centre for Diarrheal Diseases Research, Bangladesh.  It is a research hospital funded by Canadian Development funding as well as funding other countries, including Australia, the UK and Sweden.  The hospital has a clinical component where they treat people with diarrhea using a low cost, low tech approach, which has proven to be extremely effective.  They also treat children with malnutrition using a similar approach.  The hospital also does a lot of research about diarrhea, it's treatment and more. Check out their website for more details. http://www.icddrb.org/

Mari, Debbie and I visited icddr,b last week to learn more about how they treat malnutrition since the rate of moderate to severe malnutrition on the children's cancer ward is around 40%.  We talked with several physicians and the head nutritionist.  The mainstay of treatment is giving high energy foods to the children, but to keep costs down, they make these themselves in the hospital kitchen.

Specifically they prepare a milk powder-based formula which is nutritionally complete and can be used when children arrive at the hospital with severe malnutrition. We tasted the formula, and I can honestly say that it's quite tasty!  Basically it tastes like sugary milk, yum! They shared the recipe for this milk with us and we've started to provide it for kids on the cancer ward who are severely malnourished.

The cost per litre is around 30 taka (50 cents Canadian), so it's very affordable, much more so than the commercial formulas which are typically used.

Secondly, icddr,b teaches the mothers to prepare a healthy dish called Khichuri which can be prepared at home and has appropriate amounts of fat, protein and carbohydrates to ensure that the child gets all the nutrients that he or she needs.

Khichuri is a common food in Bangladesh, so it's something that all the mothers are familiar with already.  It's basically rice, lentils, oil and some veggies all cooked together.

Yummy khichuri.

The key is that at icddr,b they've improved the recipe so that it contains more oil and more lentils, making it much healthier.  Again the cost per kilogram is around 50 cents Canadian, so very affordable.  The mothers are encouraged to make this and feed it to all of their children, not just the one who was malnourished, to prevent the other kids in the family from becoming malnourished.

We also tasted the khichuri from icddr,b's kitchen and I really liked it.  Mari has been busy preparing this at our house and then teaching some of the mothers on the cancer ward how to prepare it.

There are lots of barriers for us on the cancer ward, as the is no way to get the hospital kitchen at BSMMU to make something new.  And it wouldn't be clean enough even if they did make it!  So we're stuck trying to figure out how to make it on the ward.  Right now we're teaching each mother individually to make the khichuri or milk formula in her rice cooker.  All of the mothers have a rice cooker at the bedside which they use to prepare food for their child.  The food that the hospital provides is not very good and is perceived as not clean enough to feed to a child with cancer.

The kitchens at ICDDR,B.

More of the kitchens.

Parents determined to see their child cured.

Many of the families at BSMMU come from extremely limited financial circumstances.  These are families who struggle to afford food and shelter at the best of times.  Having a child with cancer is very expensive for them; according to research done in our department, by the time that their child is diagnosed with cancer, they've already visited an average of 3-4 doctors, paid for many tests, and they've travelled from their village to get seen in Dhaka, often full day's journey.  Additionally there's the loss of wages if the father (generally the family wage earner) accompanies the mother and child to Dhaka and cost of food and accommodation.  In spite of all of this they preservere and somehow find a way to pay for their child's treatments.

Making music in the playroom! 

Debbie has spent time each day on the ward bringing happiness to kids admitted to the ward.

Watching the Meena videos on tablets donated by symphony 

This little guy is doing much better and he's much bigger than the last time I saw him 6 months ago!

Another little girl who's looking a lot better than the last time I saw her!

This mom is very dedicated to her son's treatment, she doesn't have much money but she's determined to get him the treatment he needs.  She works in a garment factory.

Pictograms for medication administration

How do you explain to someone who is illiterate when they need to take medications?  How about if there are 5 medications that they have to take?

I have joined with the pharmacy team from the Children's Hospital in Ottawa (CHEO) to develop and test pictograms to help patients understand how to take their medications.

Take 2 pills twice per day.

Take 5ml twice per day

Take morphine 1/2 tablet twice per day, when having pain 

Take 5ml every 4 hours

Tylenol: take for medium pain or fever

Welcome Back!

After almost 5 months in Canada, I'm back in Bangladesh.  Returning to the hospital was great!  The staff were happy to see me, especially the nurses who are keen to show off their improved English skills.  As part of the World Child Cancer funding we are able to give the nurses English lessons.  The lessons are important as many of the resources for pediatric oncology nursing that they need to access are in English.  Many of them have improved dramatically and are no longer shy to speak with me!

I am thrilled to have several visitors from Canada who are going to be working with me for the next few months.  Debbie is a nurse who I worked with in Canada, she brings 27 years of nursing experience to the ward. She'll be working with the nurses to continue to improve their practice.  She'll also be spending some time with the kids in the playroom.

Mari is a nutritionist and Masters in Public Health candidate from the University of Toronto who is doing a 3 month placement on the ward as part of her training.  She's working on nutrition related issues, assisting the doctors and nurses to improve the nutritional status of the children as more than half are moderately or severely malnourished.

The playroom is now open almost everyday as a dedicated team of volunteers comes to play with the children.  

Mari (left) and Debbie exploring the markets of Dhaka!

Cleanliness

Infections are the leading cause of death in children with cancer in Bangladesh.  When children receive chemotherapy, it significantly reduces their ability to fight infections; illnesses which would be mild in a healthy person can be life-threatening.  

Chicken pox is still prevalent in Bangladesh, as there is no universal immunization program, leading to frequent exposure in children with cancer. When a child with cancer develops chicken pox, chemotherapy needs to be stopped, delaying the cancer treatment and increasing the risk of relapse. In these circumstances, I have no choice but to watch, wait, and hope that the child is able to recover. Treatment is limited to support with antibiotics and antiviral medications; we don’t have access to the much more effective (and expensive) treatment which is available in Canada.  (If you needed a reason to get your child vaccinated against chicken pox, hopefully this convinces you!)

Better management and treatment of this vulnerability to infections is a priority for the BSMMU project in Bangladesh, as this could significantly improve survival rates. The good news is that most of the infection prevention interventions are not expensive or technologically complex. Meticulous hand hygiene practices by health care workers, parents and children themselves have the potential to make a big impact. Unfortunately, getting everyone to wash their hands more often is a lot more difficult than it sounds. Even in developed countries, we are still figuring out how to get people to wash their hands when the should. A recent session with the nurses revealed that they know exactly when the SHOULD wash their hands, they just don’t do it! Doctors, it turns out, are even worse.

That is not the only challenge to ensuring hand hygiene is practiced. There have been several times in the past 6 months, when the ward ran out of alcohol based hand sanitizer for weeks!  What is striking is that no one else seemed that concerned; when I asked why this had happened, I was met with ambivalence and shoulder shrugging. I still don’t fully understand what was the reason why we ran out. One of the senior residents tried to convince me that we shouldn’t bother filling up the dispensers more than once per day, as the dispensers will just get empty again quickly because parents will use more cleanser if we refill it more often!

The recent ward cleaning day has been followed up by a program to more closely supervise the activities of the cleaning staff; making sure that they wash the floors several times per day and don’t just sleep all day. We have also undertaken a cockroach eradication program, coupled with much more strict enforcement of rules prohibiting the storage of food on the ward.

Randi, an American volunteer nutritionist, is running a weekly hygiene education session for parents. This session explains the unique risks for children with cancer, emphasizing the importance of hand hygiene, safe food handling practices and avoiding anyone who is sick. We have teamed up with Unilever to provide bars of soap to all parents who attend the session.

Poster explaining the system for where to place different types of waste.  Until recently the cleaners were sorting everything by hand, including  needles!

I recently ordered 100 bottles of this alcohol based hand cleanser.  Every parent will get a bottle when their child is admitted.

The changes are slow and painstaking, but we are making progress.

Playroom Opening Ceremony

The playroom has been up an running for several months.  On Thursday we held a small opening ceremony to officially open the room.  Heather Cruden, Canadian High Commissioner to Bangladesh, attended at the chief guest as well as the Vice Chancellor of BSMMU.

Heather also distributed welcome packs to all the children on the ward.  Thanks to Dr. Loutfi's contribution for sponsoring these!

Here are a few photos from the event as well as a short article which was printed in the Financial Express.


http://www.thefinancialexpress-bd.com/2014/08/08/49309

Handing out welcome packs!

Heather with the medical team from the department.

With the nursing team.

With all of the playroom volunteers!