LAUSR

TO THE EDITOR: The recent article by Gulia et al in Journal of Global Oncology proposed a model for chemotherapy delivery in India that effectively uses district health centers, medical colleges, and apex hospitals in hierarchical chemotherapy delivery according to the complexity of treatment and ease of administration. We believe that this model, although ideal, is more of theoretical interest because previously, a three-tier system for rural health miserably failed in India. As reported recently by Sharma et al, in community health centers (ie, the third tier in the rural health system) a huge deficit of physician-surgeons (83%), obstetricians and gynecologists (76%), physicians (83%), and pediatricians (82%) exists. These shocking statistics provoke ire among health professionals but still have not drawn any intervention or immediate actions by the government. Although these authors have proposed involvement of district hospitals, this seems difficult for various reasons. First, district hospitals and community health centers do not deliver the services they are supposed to, and the current quality of care is pathetic, with almost nonexistent services for basic medicine, surgery, gynecology, and pediatrics. In a nationally representative spatial analysis, Dare et al showed that approximately two thirds of deaths from acute abdominal conditions in India could have been averted by improvement in human and physical resources at existing district hospitals. The addition of medical oncology would be a burden too difficult to manage in the absence of basic resources. The lack of trained specialists in district hospitals is not because of the lack of trained professionals but because of the lack of government incentives, as reported recently in a district hospital in Meerut (second-tier city in India) where all specialist positions in the district hospital are vacant. Second, the administration of various modalities in different hospitals (eg, chemotherapy in district hospitals and radiation therapy in higher-volume centers) would be difficult on patients. Third, hardly any chemotherapy regimen in district hospital practice currently meets the criteria specified by Gulia et al becausemost of the regimens for breast cancer, lung cancer, and head and neck cancer cannot be administered in district hospitals for various reasons, such as extravasation and the need for premedication, hydration, and concurrent radiotherapy. Furthermore, patients might also prefer to go to specialized centers with expertise in multimodality treatment. Thus, before embarking on low-quality, erratic services in district hospitals, we believe it better to strengthen the already-crumbling health systemofmedical colleges andapexcenters in India.