Profiled by Nina Niu, HMS ‘13

Surbhi Grover, MD, is a 3rd year resident in radiation oncology at UPENN.  She has participated and led oncology outreach programs in India and Botswana.  Surbhi is currently obtaining an MPH at the Johns Hopkins Bloomberg School of Public Health in preparation for a career in global radiation oncology.

1. How did you first become interested in global health?

Having grown up in India, I was always interested in a career that allowed me to travel and be exposed to new cultures and systems. I got the opportunity to work in western African and Europe in college, and India, Southern Africa and Nepal in medical school. I got extensive exposure to issues of healthcare access in various parts of the world where thousands of people are suffering and dying of diseases that have well-established treatments. These experiences in college and medical school confirmed that international work would be a strong focus of my career.

2. You mentioned that you entered residency with the goal of helping to establish oncology partnerships with developing countries.  What motivated you to devote your global health efforts to the field of radiation oncology?  

Global health to me is not limited to internal medicine and pediatrics. Essentially, any specialty has lot to offer in the global health arena. My decision to do radiation oncology was purely based on the fact that I enjoyed it clinically. I was not deterred by the fact that it was not a traditionally global health focused field. As I started to learn about the state of oncology care, it didn’t take much to find out that low and middle income countries have a rapidly growing burden of cancer and in fact by 2030 close to 70% of cancer cases will be in countries that are least well equipped to deal with them.  I was fortunate to match at UPENN for radiation oncology, where my interests were supported and encouraged and I met colleagues who were also interested in international health, which allowed me to keep working towards my goals during residency.

3. Can you describe your role in some of the global radiation oncology initiatives that you’ve participated in?

In India, I helped implement a cervical cancer screening program using VIA/VILI in rural Gujarat.  I also worked with an NGO that delivers home based palliative care for oncology patients in Delhi.  My role at this NGO involved organizing their research database and using it to answer research questions with the overall goal to improve the program.  I also conducted didactic sessions on palliative radiation for the homecare staff.

In Botswana, I have been involved with helping to organize a gynecological brachytherapy training workshop for the radiation staff and coordinating data management for patients being treated with radiation. With the help of other folks at UPENN, I have been helping with the cancer guidelines initiative in Botswana and oncology education of medical officers and medical students.

4. Can you describe a typical work day in Botswana during your trip?

Botswana has a population of 2 million people with one radiation oncology facility with one Linear Accelerator (LINAC) serving the country.  It has a high prevalence of HIV and most of the health resources have been devoted to providing anti-retroviral therapies.  The Botswana UPENN Partnership (BUP) has played a significant role in the care of HIV patients and now that patients are living longer and the burden of cancer is more palpable, BUP has started to focus on improving oncology care as well.

I usually spend my time between the radiation oncology facility and oncology ward at the public hospital. There is a lot of interest on the ground in developing oncology research, so I have been spending part of my time with the radiation oncologist there developing research projects. I also spend some time going through oncology teaching cases with the medical students. In the future, I hope be more involved with developing cancer guidelines and an oncology education program.

5. What are the challenges of practicing oncology in Botswana?

Botswana has a high burden of HIV, which often complicates the diagnosis and treatment of patients. Lack of adequate human resources in oncology (medical oncologists, surgical oncologist, radiologists, oncology nursing, pathology etc.) further complicates practicing radiation oncology in Botswana. Radiation oncology services are provided in Gaborone at a private center. Although the government funds treatment for any patient that needs treatment, this government guarantee doesn’t cover follow up.  Hence patients are not followed up for any long-term toxicities or recurrences. There are no national cancer screening programs and cancer awareness is limited, therefore patients often present in very advanced stages and treatment is further delayed because of delays in diagnostic tests.

6. What do you see as the biggest challenge in implementing radiation treatments in developing countries?  Are there any specific political challenges?

Human resources are the greatest challenge in Botswana and most of Africa. Botswana, for example, is graduating its first medical school class in 2 years. Before this, students were sent abroad for medical education and there was no guarantee that they would return. Over 80% of the physicians in Botswana are from outside the country.  There is a grave shortage of pathologists, radiologists and oncologists. This makes developing an oncology program a challenge.

In India, the lack of public healthcare infrastructure to serve the large population is a huge limitation. Although there is a growing well-equipped private sector, it cannot be accessed by the majority of the population because of the prohibitive costs. India is a large country with major cultural and political differences in the various states, which makes implementing programs at the national level (screening programs etc.) difficult. Overall national investment in healthcare, especially chronic disease and oncology care, has been very limited. Without the political will to increase investment in healthcare and focus on developing quality care in the public sector, cancer care will continue to pose a huge challenge.

7. What projects are you working on now?

I am working on a project studying the tolerability of chemo-radiation for HIV positive cervical cancer patients in Botswana. It is unknown if patients who are HIV positive are able to complete treatment at the same rate as the patients who are HIV negative. If there are differences in treatment completion rates, could they be associated with drug interaction between HAART and chemotherapy?

Another project that I am working on is organizing gynecological brachytherapy workshop for the radiation oncology team in Botswana (physician, physicists and nurses). Botswana recently acquired a HDR brachytherapy afterloader. Prior to this, all the cervical cancer patients were sent to South Africa for treatment. A radiation oncologist, physicist and gynecological nurse from UPENN will be conducting didactics and hands-on training on various aspects of brachytherapy treatment.  We will conduct a survey at the end of the training to assess the utility of such a workshop.

8. Where do you see your career 10 years from today?

Ideally I would like to build a career that gives me an opportunity to practice gynecological radiation oncology and be involved in public health projects focused on developing sustainable screening and treatment programs in low/middle income countries.

9. You’ve done some amazing work in India and Botswana.  What advice do you have for medical students interested in global oncology?

Be curious and passionate- take advantage of the opportunities that come your way even if they don’t always seem to fit with the traditional pathbe patient- the best projects and most stimulating ventures take the longest to yield any tangible results.