Many Curable illnesses in the world are Incurable in Bangladesh – Dr. Rubayat Rahman,

Not because our doctors are less skilled. Not because our biology is different. But because the Health system that supports the patient in London or Boston does not exist here. And we, the doctors of this country, have never been taught the ethical understanding of what it means to apply those costly treatments to a person who does not know what he will eat after one meal.

Palliative care should be considered a RIGHT: A Doctor’s Confession from Bangladesh by Dr. Rubayat Rahman, MBBS, MSc (Palliative Care), PhD Fellow (Palliative Care)

The Journals and the Reality

I am a doctor and a researcher. Every morning, I open the same journals as my colleagues in Boston, London, or Melbourne. I read about ongoing developments in chemotherapy and immunotherapy. I study data on checkpoint inhibitors, CAR-T cells, and targeted monoclonal antibodies that can achieve permanent remission in non-Hodgkin lymphoma (the example used, as it is relevant to the real story; otherwise, it could be any disease). The results are beautiful, precise, and published in the most reputable places.

These studies have been conducted in developed countries, where the health system is insurance-based, or the state is a welfare state supporting its patients. The money has been provided by the pharmaceutical industry. The infrastructure has been built over decades. And the outcomes are real. People who would have died twenty years ago are alive today.

But every afternoon, I sit across from a different reality in Bangladesh. After years of living in this contradiction, I have arrived at a truth I can no longer ignore. It is a truth that does not appear in any journal. It is a truth that no clinical trial has ever measured. It is simply this: many curable illnesses in the world are incurable in Bangladesh.

Not because our doctors are less skilled. Not because our biology is different. But because the Health system that supports the patient in London or Boston does not exist here. And we, the doctors of this country, have never been taught the ethical understanding of what it means to apply those costly treatments to a person who does not know what he will eat after one meal.

 

The Singer and the Labourer

Let me tell you about two people. One is a famous singer, Sabina Yasmin (real name), whose voice has filled the homes of millions in Bangladesh. When she was diagnosed with non-Hodgkin lymphoma, the government stepped forward. Corporate donors contributed. International organisations offered support. She received the world’s best treatment in both Bangladesh and Singapore, using the same protocols I read about in those journals. She completed every cycle, underwent every scan, and survived. She is alive today, singing again. And she was cured.

The other person was a day labourer, a man who earned perhaps five hundred taka a day (3.5 BGP), barely enough for two meals for his family. He came to me with the same diagnosis, the same histopathology, the same stage of non-Hodgkin lymphoma. I remember the exact moment when I finished explaining the treatment. I told him about the chemotherapy, the scans, the supportive care, and the six months of regular hospital visits. I used the word “curable” because the textbooks told me to. He listened carefully, his face quiet and tired. Then he asked me only one question. He said, “Doctor, how much?”

I did the calculation honestly, and my own hand trembled as I wrote the numbers. The PET-CT alone would cost him nearly six months of his income. The chemotherapy cycles would add several more months. The supportive care, the transport, the lost wages, the days he could not work because he would be too sick from the drugs meant to save him. The total came to roughly eight years of his earnings. He had no savings. He had no insurance. He had no relative in a government job who could sponsor him. He looked at me, and he did not cry. He did not shout. He simply smiled, and that smile broke something inside me that has never fully healed. He said, “Doctor, I am not Sabina Yasmin.”

Those words have not left me. The singer and the day labourer had the same disease. The singer received the cure. The labourer attempted one cycle using borrowed money, sold his tin-roof home, defaulted on the remaining treatment, and died within seven months of his diagnosis. The singer is still alive. The day labourer is gone. And the line that I wrote in my notebook that night has become the thesis of my professional life: many curable diseases in Bangladesh are incurable. That line is not hyperbole. It is justified. It is relevant. And it is a quiet indictment of everything we are doing wrong.

 

The Knowledge Gap No One Talks About

Let me now speak analytically, because emotion alone does not change policy. But let me speak with emotion still present, because policy without emotion is empty.

The new knowledge that guides modern oncology has been generated entirely in rich countries. The clinical trials are funded by pharmaceutical companies. The infrastructure is supported by insurance systems or welfare states. The patient in Germany, Canada, or the United Kingdom does not see the bill. The doctor there does not have to calculate whether the patient can afford the second cycle before prescribing the first. That doctor’s only responsibility is medical. My responsibility in Bangladesh is medical, financial, social, and ethical, all at once. And no one trained me for that.

The same journals that reach London reach Dhaka. The same knowledge that informs the oncologist in Singapore informs me. We read every new invention. We attend the same international conferences. We are capable of learning the newest knowledge. And I believe that if these treatments can be administered, people may achieve better results in some cases. But the question that no medical school in Bangladesh has ever taught me to ask is this: what is the justification for providing these costly treatments to a person who cannot afford a single day’s meal?

 

A Question I Ask Myself Daily

I often ask myself this question. Is it justified to follow all this new knowledge or inventions for these people? Or should there be a separate protocol for developing countries? Should there be an approach to palliative care in an early stage to support these people? Because the alternative is what we have now, and what we have now is a quiet massacre dressed in the language of hope.

The health system in Bangladesh is not like that of the countries where those trials were conducted. Let me draw the contrast clearly, because this is where the ethical fracture lies. In a developed country with insurance-based care, the patient pays a monthly premium, and the insurance company pays the hospital. The risk is pooled across millions. No single patient faces financial ruin from a cancer diagnosis. In a welfare state, the government pays through taxation. The patient may never see a bill. The system carries the patient from diagnosis to cure or to death with dignity, but always without bankruptcy.

 

How the System Fails

In Bangladesh, the system does not carry the patient. The patient carries the system. More than seventy per cent of healthcare spending is out-of-pocket. There is no universal health insurance. There is no safety net for the informal labourer who makes up the majority of our workforce. When a diagnosis of cancer is made, the family does not call an insurance company. They call relatives. They sell land. They withdraw children from school. They borrow from moneylenders at twenty per cent monthly interest. They mortgage their future for a chance at a present that almost never arrives.

The famous singer had support from the government, the nation, and the international community. The day labourer had no one. And that is the truth about the health system in Bangladesh: it works for the visible, the famous, the connected, and the middle class who can afford private care. It does not work for the man who pushes a rickshaw, for the woman who breaks bricks, for the family that eats rice and salt because that is all they have. For them, a curable disease is a death sentence. Not because the medicine does not exist. But because the system to deliver it does not.

 

Scenes from the Daily Mathematics of Cancer Care

I have seen families lose everything. I have seen a father sell his only piece of land, the land his own father had left him, to pay for two cycles of chemotherapy. When the money ran out, he stopped treatment. He died three months later, and his children inherited debt instead of a future.

I have seen a mother stop eating so that her son could have one more week of antibiotics during his neutropenic fever. She became so weak that she collapsed in the hospital corridor. The son died anyway.

I have seen a young woman, barely twenty-five, with a highly curable lymphoma, default after the first cycle because her husband, a day labourer, could not find work that month. She came back six months later with disease everywhere, her eyes hollow, and she asked me, “Doctor, is it too late?” It was. She died within weeks.

These are not anomalies. These are the daily mathematics of cancer care in Bangladesh. And the doctors who practice here, we read the journals, we know the science, we are capable of learning the newest knowledge, but we are not taught the ethical framework for applying that knowledge to poverty. We are taught to pursue a cure.

We are never taught when to stop. We are never taught that the most compassionate word we can say is not “chemotherapy” but “I will not let you die bankrupt and in pain.”

 

A Separate Protocol for Developing Countries

So, I am proposing something that will sound radical to some and obvious to others. I am proposing that we develop a separate protocol for developing countries. I am proposing that we legitimise early palliative care as a primary pathway, not as a failure of medicine.

For the patient who cannot afford a single day’s meal, for the family that has no land left to sell, for the laborer who looks at me with that sad smile and says, “Doctor, I am not Sabina Yasmin,” I want to be able to say, “I hear you. We will not chase a cure that will destroy you. We will focus on keeping you comfortable, on managing your pain, on giving you time with your children that is not spent vomiting in a hospital bed. We will not abandon you. But we will also not lie to you.”

That conversation is brutally honest. It is also the only ethical option available. Because what we are doing now, offering the full curative protocol as if it were possible, watching patients bankrupt themselves for a fraction of the treatment, and then watching them die anyway, is not medicine. It is a slow, polite, institutionally sanctioned form of cruelty. And we have been doing it for decades because no one had the courage to say that the emperor has no clothes.

 

What We Lose When We Chase Unreachable Cures

The truth is that most people in Bangladesh lose their entire life savings getting cancer treatment. They sell their land, their livestock, their jewellery. They borrow from moneylenders at crushing interest. They die in debt. Their children grow up without fathers, without mothers, and without education. And for what? For a one in three chance of completing an incomplete treatment? For a few extra months of toxic, bankrupting misery?

The famous singer survived because the system carried her. The day labourer died because the system asked him to carry himself. Until we change that system, let us at least stop asking the labourer to pay for a cure we know he cannot reach.

I am not asking the world to stop developing expensive cures. I am asking my own country and other low-resource nations to stop pretending that those cures are available to everyone. And I am asking my fellow doctors to learn a new skill: the courage to say, “I will not ruin you for a small chance.”

I am asking medical educators in Bangladesh to teach the ethical understanding of treating a poor patient. I am asking the curriculum to include not just the molecular pathways of the newest immunotherapy, but also the conversation skills for when that immunotherapy costs eight years of a patient’s income.

 

Carrying His Memory

My patient died with a sad smile and a truth I will never forget. He was not Sabina Yasmin. But he was someone’s father, someone’s husband, someone’s only hope. And I, his doctor, carry his memory every time I write a prescription. I carry his voice every time I open a journal and read about a miracle cure that will never reach my poorest patients. I carry his smile every time I sit with a new patient and have to decide whether to offer hope or honesty.

I have made my choice now. I offer honesty. I say, “The treatment that cures this disease in rich countries costs more than you will earn in five years. If we try it, you will become poorer, and you will still likely die. I am recommending that we focus on keeping you free of pain and comfortable, so you can spend your remaining time with your family, not in debt. Is that what you want?”

 

Neither Victory, But One Is Less of a Defeat

Some patients say no. They want to try anyway. I support them, and I watch them default, and I hold their hands when they die. Some patients say yes. They choose dignity over desperation. And I help them die without pain, without debt, without losing their home. Neither outcome is a victory. But one of them is less of a defeat.

The singer lived. The laborer died. The only difference was money. Until that changes, palliative care is not the final chapter for the poor in Bangladesh. It is the only ethical chapter. And it is time we started writing it from page one.

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rubaiyat1260@yahoo.com

 

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