Map of life expectancy at birth from Global Education Project.

Wednesday, March 08, 2006

Con la sangre hirviendo

One way I occupy my copious free time is to talk to community groups about health disparities. Disparities in the health care that people receive are only a part of the explanation for why some groups of people suffer worse health, not even the biggest part, but they still matter, and they are offensive to a society premised on equality.

Last night I spoke, as it happens, in my own neighborhood, which has a large Latino population. A woman from the Dominican Republic, who I will call Malena, told us that last June she found a lump in her breast. She went to her primary care physician, who speaks Spanish, and he sent her on to una especialista, who I presume is an oncologist. The specialist conducted a physical examination, and without ordering any imaging or a biopsy, told Malena through an interpreter that she had a benign cyst, and sent her on her way.

Malena told us that she was still very worried, because her sister died of breast cancer, her grandmother died of ovarian cancer, and her mother had breast cancer. As soon as she could get another appointment with her primary care doc, she went back to express her fears. He again sent her to the specialist, who this time ordered a mammogram, and then reported that Malena indeed had a benign cyst. It was now November.

By February, the lump had grown, and was painful. Malena's primary care physician sent her to the same specialist, for the third time. La especialista said, through the interpreter, that there must be liquid in the cyst, and she would draw it out with a needle. But all she got was blood. So she now conducted a more thorough physical exam and found another lump near Malena's armpit. This time she ordered a biopsy. The verdict? Malena has Stage III B breast cancer. She is scheduled for an MRI to look for metastases. While she was telling this story, her 8 year old daughter came into the room and sat quietly, and sadly, beside her.

Now, I haven't spoken to the oncologist, and I didn't witness any of this. I don't know what might be the outcome of a malpractice suit. Perhaps something about the presentation of this lesion on physical examination and imagery was so atypical of cancer that the oncologist's actions are defensible -- although they probably made the difference between life and death. However, I can hypothesize about a few things that may have gone wrong here.

First, communication through the interpreter may have discouraged taking a thorough history. I have to think that if the onocologist had known about Malena's family history, she would have had a very high index of suspicion. Second, for cultural reasons, and perhaps also because of the language barrier, Malena was obviously very unassertive with the oncologist. I doubt that most women of our dominant anglophone European settler culture would have settled for the answers Malena got without insisting on a biopsy. Clearly she was able to express her fears to her primary care physician, with whom she had a trusting relationship, and he took them seriously.

Finally, we have to consider the question of racism. Would the oncologist have been so casually dismissive and careless of a woman with a similar presentation who seemed more like her friends at the country club in Weston? Just a nasty, suspicious thought.

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