On my last visit in September, I met Vicente Barrios. Last year he had a husky voice with a weak cough, and after a laryngoscopy and biopsy, he was diagnosed with an early stage carcinoma of the larynx. I had also heard that he was known in Zamboanga for an event two years before, and I was determined to ask him about this.

As often happens in third-world countries (or “disadvantaged” countries, as some prefer to call them), we arranged to meet, not in a Jolibee restaurant, but in a local hotel, the Lantaka, in the coffee bar. I had already suggested that he be reviewed for radiotherapy (which is curative in the early stage), and he had been to Cebu to see a radiation specialist but had seemingly been put off by the list of side-effects from radiation. He was still equivocating.

In Zamboanga there is a Cobalt-60 machine but the cobalt source is 12 years old. There is no effective radiotherapy on this side of the island of Mindanao, an island of 38 million people.

Vicente was a fit looking man of 62 with a proud, intelligent face. He came in with his son, a local pediatrician. “I have stopped the smoking, doct-awr, and I improve my diet with my son’s advice. Do you think that will stop this cancer?”

I shrugged. We sat back in the squared seating booth for four and ordered tea: “I hear you were kidnapped by the Abu Sayyaf a while ago. Tell me about that.”

He looked around and his son nodded. “It was perhaps a case of mistaken identity,” said his son. “He looks like the owner of the fish-processing plant. But he is only the manager.”

His father was non-committal: “Who knows? In the afternoon at the dock by the ponds, I was overseeing work when a fast boat came to the dock. Five men jump out and go for me. I carry a rifle at work and the first man to come at me – I hit him on the side of the head with my rifle butt.” He punched his clenched fist reliving the hit.

“Then I was hit on the head. They blind-fold me and take me in the boat over to Basilan. We go a long way inland by motor bike and walking. When the blind-fold is removed I am in a valley with mountains on each side.”

“How did they treat you?” I asked.

“Well enough. I eat the same food as them. But I lie awake every night and doze during the day. They sleep with their guns beside them. I know how to use a gun. I could have shot them all while they sleep. But what then? I did not know where I was – the whole island is under Abu Sayyaf.”

His son interrupted: “All the time he is there, I negotiate with them for ransom. They want two million pesos (about $48,000). We do not have that. So we bargain for price.”

His father continued: "After two months I know something is happening because it is soon Ramadan and they say to me: ‘We must be preparing to purify ourselves." Mr. Barrios curled his lip with a sardonic smile at the memory.

With upcoming Ramadan, the deal was struck, his son carried the money over, the mayor of Basilan acting as go-between, Vicente was handed over, and on return to Zamboanga, the local politicians, like politicians everywhere, crowded into the photographs, looking as though they had been the cause of the settlement. “They did nothing to help,” said his son.

Security has improved over the last 15 years but these kidnappings go on sporadically. It is the main reason we have not recommended medical student or even resident electives – although the learning and experience would be invaluable.

I have mentioned before (Alberta Doctors’ Digest May/June 2010) that these students and residents can knock spots off our students on infectious diseases, village sanitation, hygiene and water purification – although they’re not so well versed as ours in mechanisms of action of third-generation calcium channel blockers…

So the clinical teaching has gone well, but now we are entering a different phase. The economy of Mindanao is growing, a few more cars are on the roads and it’s time to look at helping with training residents and upgrading the facilities for the treatment of patients in the Zamboanga City Medical Centre.

A 15-year-old girl had earlier that day been presented to me: a miserable muco-cutaneous rash, fever and a painless mass in the neck. A chest X-ray showed a large mediastinalmass. A CT scan had even been done and a fine needle biopsy had shown “probably malignant lymphoma, large cell type.” Now the family was running out of money. A biopsy costs 5,000 pesos ($120) – much more than a fine needle aspiration, so there was no biopsy.

Single agent chemotherapy had been suggested. One cycle was given with some improvement in the rash and the mass. But money was now low. Her mother was pleading for help. With some shame I made suggestions, knowing that nothing much would happen, that a routine treatment here in the west with CHOP/rituximab might have sorted her out. She would return to her village to die, probably without morphine.

I was also ashamed because that week (September 17, 2012) I read in the papers the following news accompanied by a medical drama photo: “A nurse comforts Peanut, an orangutan from a private zoo, as a group of medical professionals gather over the table for R-CHOP therapy, a combination of drugs used in chemotherapy to treat her aggressive non-Hodgkin lymphoma in Miami.

"Human medical specialists are treading new ground in applying a standard chemotherapy regimen to treat cancer in an orangutan.”

New ground indeed – Peanut and our pets get better attention than our fellow humans. That usually raises an embarrassed nod and shrug here, but on the rounds in the hospital the Filipino residents had also heard of the orangutan’s therapy. R-CHOP (drug cost for six cycles here is $18,000) is available in the Philippines in Manila or Cebu if you can pay for it. But it is beyond the resources of most on the island of Mindanao and on the Muslim islands of the Sulu Sea.

PhilHealth is a government sponsored insurance scheme costing 200 pesos ($5)/person/month, but even that is beyond most of the population in the Southern Philippines. It covers bare services – perhaps the cost of a doctor visit. There’s always more to pay. And there’s no way it will cover R-CHOP for curable lymphomas even if there were facilities to handle the pathology, radiology, lab work and toxicity complications.

In the Eureka restaurant that evening, I met Gregorio (or “Gay” as he likes to be called), the owner of the Eureka, a top restaurant in Zamboanga. He wanted to discuss his metastatic prostate cancer in his bones. He was 62 and had had bone metastases for 12 years. Gay was a man who’d been everywhere and tried everything – all the hormones, lots of chemotherapies.

He’d had zoledronate monthly for years and now had jaw osteonecrosis. He’d even been to Texas to see Bruzinski, a mega-millionaire, and spent a few weeks there receiving injections of “anti-neoplastons” (made from your very own urine with the curious side-effect of loss of hip pocket weight). He was now on one of the latest medications for prostate cancer, cabazitaxel, managed from Manila. I told Gay that he had a biologically indolent bone malignancy and that he may have done quite well with symptom remedies only, but I didn’t want to discourage him and said the medication looked “promising.”

We munched on chicken adobo and bacon garlic rice. Gay had just got off the airplane from Manila after his injection: “I will not feel well tomorrow, but tonight I am fine. This dinner is on me.”

I’d given him the cheapest advice he’d had in his entire illness.

In the Philippines there are many nuances, things you see and things you don’t see, the obvious and the not-so-obvious. The cost of a course of chemotherapy using five-fluorouracil, adriamycin and cyclophosphamide varies. Some surgeons can give this in their private practice, and the company delivering the drugs charges $600. The government hospital pays $1,000, which is the list price. Why no discount for a big buyer? Where does the $400 go?

The Cobalt-60 source needs renewing. This should be done every five years. They are waiting for “approval” for a new source. A Canadian company has agreed to supply the source at cost. The company has been waiting for a year for the contract and price to be approved in the Philippines.

My father spent a year in the Philippines in the early 70s as a mining consultant for the United Nations. In 1963, the UN gave $10 million to the Marcos regime for development of coal mining in the Philippines. My father found a couple of open cast pits on Mindanao, but he never got to the root of where the money had gone. He was offered some interesting propositions by cabinet ministers in the Marcos government, including putting Filipino-produced gin into Gordon’s Gin bottles.

A member of the Calgary Rotary Club contacted me last week.

“We’ve had a request from Harvard – they want to do a telemedicine project in the Southern Philippines. They think the Filipino doctors will benefit from discussing their cases with Harvard.”

“It’s not like here you know,” I said. “It’s not like a patient in the Northwest Territories being discussed in the University of Alberta by “Telehealth.” They can’t afford much that would be suggested. But it may make the Harvard types feel good.”

This one may be a Jellyby Project.