Asha Javeed

Pa­tient care was used as a pawn in a bid to dis­cred­it the Bri­an Lara Can­cer Treat­ment Cen­tre (BLCTC) says Dr Kong­shiek Achong Low, ex­ec­u­tive chair­man of Med­corp Ltd. Achong Low ad­mit­ted that an "er­ror of judg­ment" was made by BLCTC in the way 223 pa­tients were in­formed of a mis­cal­i­bra­tion of ra­di­a­tion treat­ment over the pe­ri­od Jan­u­ary 2009 to June 2010. He rea­soned that 178 of those treat­ed pa­tients were in a pal­lia­tive con­di­tion and the de­ci­sion was made "pure­ly with con­cern not to cre­ate pan­ic, anx­i­ety or mis­judg­ment" in their pa­tient's minds. But while the board ac­cepts and re­grets there was a mis­cal­i­bra­tion of its linac ma­chine-at least up to a max­i­mum of 13.9 per cent-they re­lied on their chief op­er­at­ing of­fi­cer, clin­i­cal di­rec­tor and clin­i­cal on­col­o­gist Dr Ane­sa Ahamad, who they hired from MD An­der­son in 2005, to en­sure that the Cen­tre was held to first-class stan­dard. While the cen­tre is reel­ing from the me­dia blitz of the past few weeks fol­low­ing the pub­lish­ing of an 11-month-old re­port by the Pan Amer­i­can Health Or­gan­i­sa­tion (PA­HO) by Health Min­is­ter Dr Fuad Khan, it claims there was a cal­cu­lat­ed at­tempt to com­pro­mise the cen­tre. The mys­tery mis­cal­i­bra­tion of a rel­a­tive­ly un­vari­able Var­i­an linac ma­chine is pit­ting two en­ti­ties against each oth­er.

Ahamad against the BLCTC's Board of Di­rec­tors

Ahamad first raised an alert to the MOH about a mis­cal­i­bra­tion of ra­di­a­tion at the cen­tre af­ter she was in­formed by a for­mer co-work­er, Dami­an Rud­der, dur­ing his Qual­i­ty As­sur­ance (QA) tests at the BLCTC in May 2010. Ahamad was sent on va­ca­tion leave from BLCTC on May 12, 2010, un­til her five-year con­tract end­ed in Ju­ly 2010. Ten­sions had steamed dur­ing her tenure-she even took the board to court in Ju­ly 2009-but it boiled over from May 4 to 12, af­ter Ahamad, in an e-mail to the board, said the cen­tre was op­er­at­ing un­der un­safe cir­cum­stances. Ac­cord­ing to Achong Low, Ahamad took an unan­nounced day off on May 11, which pro­hib­it­ed ac­cess to pa­tient files by her re­place­ment clin­i­cal on­col­o­gist. "We put up with a lot from Dr Ahamad but it nev­er com­pro­mised our pa­tient care. When I felt that pa­tient care was be­ing com­pro­mised, I im­me­di­ate­ly act­ed on that," he told the Sun­day Guardian.

Ahamad's ex­it let­ter, dat­ed May 12 stat­ed: "It is ap­par­ent that the stressed work­ing re­la­tion­ship has led to your re­cent ac­tions that fre­quent­ly in­ter­rupt the day-to-day run­ning of the Can­cer Cen­tre." The let­ter al­so ex­pressed alarm at Ahamad's re­quest to her per­son­al as­sis­tant to delete da­ta files com­plete­ly from the com­put­er sys­tem. "Your as­sis­tant has in­di­cat­ed that you asked her to re­move the da­ta files from the net­work and/or com­put­er sys­tem. This is un­ac­cept­able be­hav­iour that in­ter­rupt­ed the func­tion­ing of the Can­cer Cen­tre," the let­ter stat­ed. Ahamad's re­sponse was in­cred­u­lous: "Pa­tients were over­dosed and the BLCTC wants to talk to about let­ters and in­ter­nal ad­min­is­tra­tive is­sues? As be­fore, none of this has any bear­ing on the ra­di­a­tion in­ci­dent and is be­ing brought up pure­ly to mud­dle the wa­ters and cast doubt on my cred­i­bil­i­ty. I used let­ters from tem­plates for my physi­cian com­mu­ni­ca­tion with oth­er physi­cians. These let­ters had my sig­na­ture."

'BLCT TO THE POINT OF BE­ING HELD HOSTAGE'

But Achong Low told the Sun­day Guardian that BLCTC "bent over back­wards" to ac­com­mo­date Ahamad, to the point of be­ing held hostage to her ser­vices. He said while con­trac­tu­al­ly bound to "de­vote the rea­son­able ma­jor­i­ty of her time" to the Can­cer Cen­tre, Dr Ahamad ne­go­ti­at­ed a three year con­tract with the Min­istry of Health short­ly af­ter it opened in April 2007. The chief ex­ec­u­tive of Med­corp at the time, Shel­don Cyrus, wrote to Dr Ahamad on Ju­ly 2, 2007, on the is­sue seek­ing clar­i­fi­ca­tion of her con­tract with the Min­istry of Health. "We are there­fore con­cerned with your ded­i­ca­tion to, as well as the quan­ti­ty of time al­lo­cat­ed to your func­tions at the Can­cer Cen­tre," he wrote. Achong Low said a com­pro­mise was reached to al­low Dr Ahamad to work with the Min­istry of Health (MOH), pro­vid­ed that the Cen­tre was not com­pro­mised. He ob­served that in her ca­pac­i­ty at the MOH, she re­ferred pa­tients to the cen­tre for care.

It's a point that Ahamad cor­rob­o­rates. While she dis­missed the sug­ges­tion that her MOH con­tract was "not in con­flict" with her em­ploy­ment agree­ment, she said that work helped "cre­ate syn­er­gy" be­tween the BLCTC and the pub­lic sec­tor "that may have oth­er­wise proved dif­fi­cult to im­ple­ment". "For in­stance, I helped lay the ground­work for pub­lic pa­tients to be treat­ed in the pri­vate sec­tor at a dis­count, which turned out to be a sig­nif­i­cant amount of pa­tients. These pa­tients, many of whom could not have af­ford­ed pri­vate health care, could now ac­cess a more mod­ern type of ra­dio­ther­a­py with a bet­ter chance of cure than if they were treat­ed in the pub­lic sec­tor. "My Min­istry of Health con­tract was a not a re­new­able con­tract. None of this has any bear­ing on the ra­di­a­tion in­ci­dent and is be­ing brought up pure­ly to mud­dle the wa­ters and cast doubt on my cred­i­bil­i­ty," she de­fend­ed to the Sun­day Guardian.

Red-flag­ging ra­di­a­tion

Achong Low ob­served that long be­fore the QA be­came an is­sue, a red flag was raised by In­ter­na­tion­al Atom­ic En­er­gy Agency (IAEA) which in­di­cat­ed a pos­si­ble over­dose of 14 per cent in April 2009. He pro­vid­ed the Sun­day Guardian with a no­tarised state­ment by Aman­da Moses, ju­nior med­ical physi­cist at the BLCTC. In her state­ment, Moses said in Oc­to­ber 2009, she re­ceived a re­port from the IAEA re­veal­ing a 12.3 per cent de­vi­a­tion. "I im­me­di­ate­ly print­ed this email and showed to Dr Ahamad (then chief op­er­at­ing of­fi­cer, med­ical di­rec­tor and ra­di­a­tion on­col­o­gist) and Mr Nigel Pe­ters (then man­ag­er at BLCTC, now de­ceased) and ex­pressed my con­cern. Dr Ahamad, Mr Pe­ters and I dis­cussed in de­tail the need for se­nior physi­cist pres­ence with sub­se­quent de­par­ture of Mr Prakasam, and Dr Ahamad said that she would pur­sue this is­sue at the next board meet­ing. I sug­gest­ed to Dr Ahamad and Mr Pe­ters that we should not ac­cept any new pa­tients un­til there was prop­er staff cov­er­age," stat­ed Moses.

Ahamad ex­pressed alarm at this state­ment.

She told the Sun­day Guardian that it rais­es se­ri­ous con­cerns about fab­ri­ca­tion of records. "The mea­sure­ment of dos­es on the lin­ear ac­cel­er­a­tor is done by a physi­cist, and in the case of the 2009 PA­HO TLD, test­ing is sub­mit­ted to physi­cists at PA­HO. I was not aware that the 2009 PA­HO TLD test­ing in­di­cat­ed any­thing out of the or­di­nary. I would have ex­pect­ed that any in­di­ca­tion of dose out­put out­side the ex­pect­ed range, even an un­con­firmed in­di­ca­tion, would have been re­port­ed to me; it was not. I did not have any sus­pi­cion or knowl­edge of in­cor­rect dos­es un­til Rud­der's in­for­mal re­port of his find­ings to me. "I had no knowl­edge of any­one mak­ing changes to the out­put dose of the ma­chine that could cause such an over­dose. As a ra­di­a­tion on­col­o­gist, it goes against every grain of my train­ing to al­low an over­dose to be ad­min­is­tered, and if I had at any point the mer­est hint of a sus­pi­cion that such an over­dose was oc­cur­ring, I would have not treat­ed pa­tients," she told the Sun­day Guardian. She said: "If this meet­ing took place as Moses claims, then it is in­cred­i­bly damn­ing of me and my cred­i­bil­i­ty."

She ques­tioned why it was not one of the first state­ments made about her to dis­cred­it her. "If any physi­cist had in­formed me of a 12-plus per cent dose dis­crep­an­cy I would have im­me­di­ate­ly ceased pa­tient treat­ment and tak­en ap­pro­pri­ate ac­tion. Any trained ra­di­a­tion on­col­o­gist would have done the same; to do oth­er­wise would be to dam­age pa­tients and my rep­u­ta­tion. I would have had no mo­tive for con­tin­u­ing treat­ment. Her state­ment is be­yond creduli­ty," she said. The con­trary opin­ions does not change the fact that the BLCTC con­tin­ued to treat pa­tients un­til Puer­to-Ri­can based se­nior physi­cist Pe­dro Montes point­ed out that the an­nu­al QA for the linac was over­due. The Sun­day Guardian ob­tained an email thread in which an where an alert was raised by Ahamad on May 4.

The mis­cal­i­bra­tion

Achong Low told the Sun­day Guardian that it was un­der Ahamad's sug­ges­tion, and un­able to se­cure a se­nior physi­cist in a short pe­ri­od of time, that the Cen­tre gave Dami­an Rud­der a con­tract to do the QA.

Ahamad de­nies this. She said she on­ly lob­bied the board on the ur­gency of the QA. Achong Low said it was agreed that the QA would be done over four Sat­ur­days-on May 15, 22 and 29 and June 5. All tests would be con­duct­ed by Rud­der. He was ac­com­pa­nied by ju­nior med­ical physi­cist Bar­ry Jor­dan. All tests were nor­mal. Jor­dan in a no­tarised state­ment said it was agreed on June 5, that no tests would be con­duct­ed be­cause of a pri­or en­gage­ment. "At ap­prox­i­mate­ly 5 pm on Sat­ur­day 5 June, I re­ceived a call from Mr Rud­der in which he in­formed me that he was at the BLCTC do­ing a spot check of the out­put of one of the ma­chine's pho­ton en­er­gies us­ing the BLCTC's mea­sure­ment equip­ment and dis­cov­ered that there was a "twen­ty per cent dis­crep­an­cy in the out­put val­ue", he said.

Jor­dan said he agreed to meet Rud­der the fol­low­ing day at the BLCTC at 3 pm, along with the chief ex­ces­sive and Sue-Jaan Mejias, a se­nior physi­cist. Jor­dan said Rud­der showed them the ma­chine was ex­hibit­ing pho­ton en­er­gies of ap­prox­i­mate­ly 20 per cent. "I sub­se­quent­ly re­trieved the spare ion­i­sa­tion cham­ber and elec­trom­e­ter and Mr Rud­der set up this equip­ment in the same arrange­ment as the oth­er ion­i­sa­tion cham­ber and elec­trom­e­ter and ran the same pho­ton beam en­er­gy at the same dose and the out­put was found to be about two per cent. The beam was run sev­er­al times, and on every oc­ca­sion the out­put was found to have no more than a three per cent dis­crep­an­cy," Jor­dan stat­ed. "Mr Rud­der then de­cid­ed that fur­ther ver­i­fi­ca­tion be need­ed due to two con­trast­ing out­put val­ues us­ing ion­i­sa­tion cham­bers of sim­i­lar mod­el and in­formed us that he will use the ion­i­sa­tion cham­ber and elec­trom­e­ter from his work­place at South­ern Med­ical Cen­tre to car­ry out this ver­i­fi­ca­tion," he said. Achong Low said sub­se­quent­ly both ma­chines read 19 per cent. He said Var­i­an's ma­chines have a mem­o­ry chip, which records out­put by its ma­chine, and the high­est it ever reached was 13.9 per cent. He said, it was this fac­tor which led him to con­clude that the ma­chine had been tam­pered with.

To be con­tin­ued to­mor­row: Ahamad speaks out on al­le­ga­tions of sab­o­tage