Cancer in a time of Ebola

Yes, you have breast cancer. The tests clearly show it.

Your chart indicates that after your practitioner discovered the lump, a mammogram and then an ultrasound-guided core biopsy suggested an invasive ductal carcinoma, and surgery was recommended. As best as I can tell, you stopped there.

You are still a young woman, from my perspective. You have a beautiful daughter starting school and older children starting families. I want you to remain healthy. I have heard that your surgeon, radiologist and oncologist have given up on you. Or you have given up on them. You and I, we have a history of fighting illness together. Our routine has been that I play the advisor and you fight for what you believe in.

Ebola has begun to spread in Guinea, Sierra Leone and the Ivory Coast. As fear and panic take hold, people hide in their homes. Médecins Sans Frontières declares an Ebola epidemic and leads an emergency public health response. Within months, thousands of people fall ill with fevers, weakness, muscle pains and headaches. More than half of those admitted to hospital with Ebola will die over the coming months. Western doctors, traditional healers and sorcerers alike desperately seek answers. Trust is in short supply for hotas, strangers that come from away. In the crisis, rural people head home to cope, to the countryside. Most West Africans believe death occurs when an outside source weakens one’s life force.

You decide to treat your curse, the breast lump, your way. You return to your place of birth in upper West Africa. You enter the territory affected by the Ebola outbreak, undeterred. Not a city, but a rural savannah full of colourful fields, rolling hills, green trees and charcoal burners’ huts. Western-style hospital care remains a luxury in these parts. You visit your mother. You seek consultation with your healer. Both are happy to see you after so many years. Your witch doctor, a sowei elder, spends time getting to know you again. In his home he examines your breast inquisitively and later offers you a cutting and cleansing ceremony. The surface of your skin is cut, your blood is let and neat rows of scars are left as flame-shaped tattoos to guard your breast.

Image courtesy of Henrik5000/IStock

You come back to Canada. We sit in my clinic. Over several visits, over several months, I do my best to understand, to learn more about you, your beliefs about disease and your family in West Africa. You tell me about your mother, the plot of land that you are keen to inherit and your long-standing dream to move back to West Africa. You tell me how land is linked to family, and family is linked to traditions. I attempt to ask about the impact of Ebola on your family, but your eyes drop and your head shakes. So, sometimes we sit in silence. Later, you begin talking about how fast your daughter is growing up, and your smile is back and we laugh. You are never afraid to laugh.

I decide to ask you again to see the Canadian surgeon. I explain again how treatable this form of cancer could be, a kind that we can remove and maybe even cure. You listen silently with respect, but then violently shake your head and your body moves with conviction. You do not want anyone to do invasive surgery on your breast. You strongly believe that surgery will weaken you and that the sickness will spread. Bad spirits will get in. Doctor, you say, I will die. In your eyes, I sense fear of impending death.

Back in West Africa, people continue to die of Ebola. Fisticuffs break out between mourning souls and hospital authorities. People ignore the threat of fines and imprisonment, finding it near impossible to give up their traditions. The closest family members shave and then wash the corpses with mud for a week-long ritual of drumming, chanting and dancing that gives strength to a transitioning life force. The ritual also serves to free family members from the corpse’s jealous spirit so they may go on to live and to marry again. We know about these beliefs and the heavy toll for family loyalty, say the African anthropologists, but it is very hard to change customs, even in a time of Ebola.

I reflect on your life trajectory, your struggles during the long civil war and your determination to continue to remain self-reliant. In difficult circumstances, you have held tight to your beliefs, but you have never stopped coming back. Although I continue to believe surgery for your invasive breast cancer is well worth consideration, I respect your choice at this moment in time. I will not take away your autonomy, and you will continue to come for appointments. And under the auspices of these appointments, physical exams and a continuing relationship, I will learn from you and study the origins of your choice to forgo surgery. Within this arrangement, we will continue to work together and I trust there will be opportunities to help.