Conversation with Dr. Dayalan Clarke, visiting breast surgeon from the U.K. and president of Friends of Vellore U.K., the mission hospital where he trained. We talk about his connection to Kijabe through Dr. Peter Bird, similarities between Vellore and Kijabe, Christianity in the non-European world, and breast cancer incidence and treatment.
Dayalan: I'm Dayalan Clarke. I'm a breast surgeon from the UK. I came out to Kijabe mainly to help because Beryl [Akinyi] has been on maternity leave. Beryl is the surgeon who does most of the breast work here, and Peter Bird, who we have known for many, many years, asked if we could if I could come and help. Peter grew up in India as a missionary child with his father being a surgeon and a missionary hospital, at a mission hospital in India in a place called Mysore. And it so happened that my wife's father was also a surgeon in the same hospital, and they grew up together across a wall as neighbors growing up in India. And that was my connection with Peter Bird. I think my wife and Peter lost connection, though our respective parents kept in touch. And then when we were visiting Nairobi for a safari in 2006, we heard that Peter was here. So we were going for a safari with my wife's parents. It was their 50th wedding anniversary and they loved wildlife. So that was our treat for them for their 50th wedding anniversary. And they said, “Oh, Peter is in Kijabe, let's try and meet up with Peter.”
So we came and visited Kijabe had lunch with Peter. In 2006 I took an early retirement from my work in the NHS in the UK with the express purpose to go and help mission hospitals in need. And then in 2019 I came out to Nairobi with a group of breast surgeons from the UK to train to do a training course and a teaching course in Nairobi, and who was on the local faculty to spread the word. So we met up again and I was telling Peter how I had taken an early retirement with the express view of going in and helping mission hospitals in need. And then he turned around said, Oh, would you be able to help in Kijabe if we needed us at all? I'd love to come to catch up if he needed me. And then of course, Peter was leaving last year and Beryl was going on maternity leave. So he contacted me and said, Can you come and help us while on maternity leave? And so I'm here. That's how I'm here.
David: That's amazing. Did you and your wife meet? How did you meet?
Dayalan: I went to medical school in India, which is a Christian medical school called CMC Christian Medical College Vellore. And we were classmates in Vellore and we met there and got married after we finished our house jobs and then did some mission service, which is part of our obligation in India, then did our respective postgraduate training and in Vellore again, myself in general surgery and my wife in pediatrics. And then it worked again in mission hospitals in India and then went out to the UK in 1991, never intending to settle in the UK. But God, God's wills are strange and we never thought that's going to be the plan. But that's what happened. And I was very conscious that because we've trained in Vellore, I've always grown with the feeling that I consider myself very fortunate, coming from a very average background in India. My father was a minister in the church and retired as the Bishop of Madras. So very ordinary background, but consider ourselves very fortunate to have been able to have gone to the UK and to made a career there, to become consultants there and always felt as soon as my children were on their own feet, I'm going to stop working, retire and try to give back to people who been less fortunate than myself.
David: Wow. That brings up so many interesting questions. I'm not super familiar with India, but one of my dreams is - this is why I was so excited to meet you is I heard from from Dr. Nthumba when we were starting Friends of Kijabe - he said, "you need to learn about Vellore, you need to learn about this place." And so, I'd love to hear about that. But then also I'm curious just what. . .you said your father is a minister and then became a bishop? Most people in America associate India with Hinduism, Jainism, Sikhism. Is Christianity regional?
Dayalan: Christianity is much more common in South India than in North India. Where I come from, which is South India, but the population of India is huge. As you know, 1.3 billion people and 2% are Christians. So, 80% Hindus, about 10% are Muslims. And then, like you said, the other communities like Sikhs, Jains and such like from the rest of it with Christianity being 2%. So even Clark, which is my surname, is a very Indian name, but the background to that is one of my forefathers must have been converted. And when you convert it from Hinduism to Christianity, the way you denounced your previous religion was either you took on a biblical name or you took on a very western sounding name, often a missionary who converted you. I presume one of my forefathers was probably converted by someone called Clarke or decided to take on a Western sounding name. And that's how Clarke has come down the generations.
David: Wow. So, there's a tradition that the Apostle Thomas went to India, right?
Dayalan: It's historic. Legend is that he came down to this west coast of India, which is Kerala, and then traveled down and then actually came through Tamil Nadu where I'm from, near Chennai. It's called Saint Thomas Mount. And they say that that's where he probably last either left India or died there. We don't know. But I don't think there's enough factual evidence but that's what they think happened. Yeah.
David: Interesting. It's not until really spending time in this part of the world that realize Christianity developed very differently than I perceived. Southeast Asia, Africa, a lot of the early church fathers were in those places. It was not a European thing until much later on, which I think is fascinating.
Dayalan: Yes. Considering Christianity arose, Christ lived in Jerusalem in the Middle East, I think proximity-wise you can see why it happened that way. Egypt is not far from where it was and you have flight to Egypt when Christ was born. But it doesn't surprise me. Definitely there was quite a lot of Christianity around this region and moving both east to us [in India].
David: Wow. I think my understanding of our previous conversation - tell me if this is accurate - that Vellore is probably a picture of what Kijabe could be like in, I don't know, what you would say, maybe 20 or 30 years?
Dayalan: Quite possibly so. I mean, the first thing that struck me when I came to Kijabe, I saw the community spirit, the closeness, and how well people got on together. And the first thing that struck me, especially with a lot of missionaries here, the first thing that struck me was this is below in the fifties or sixties because Vellore was very similar. There's a Christ-centered Mission Hospital, which was largely supported by Americans and some British missionaries, both in terms of the day-to-day running of the hospital and in personnel, which I see exactly what is happening here. And Vellore has then gone on to become one of the leading institutions in India, both in teaching and in terms of health delivery. And my only prayer is that hopefully 30, 40 years Kijabe is going to get there. One of the things that Vellore has, which probably is an advantage for them, having developed so quickly and so well, is a medical school, which I think we don't have yet in Kijabe. But I think if we have Christ at the center, everything else will follow. And I can see great things happening in Kijabe, just in the services that I've seen, in breast cancer care itself, I can see there's huge scope because we've just had a mammogram machine installed. Oh, yes, which is fantastic. And then I've helped in helping the radiographers from here, going to Aga Khan and MP Shah to get some training and of course, we're going to have a breast radiologist coming from America, starting in August. So, with this mammogram machine, we have a state-of-the-art absolutely fantastic machine, and then if we have a breast radiologist to actually drive that forward. I can see Kijabe being a fantastic breast unit going forward.
David: That's amazing. So you went from Vellore, you went from a very faith-based medical system to the NHS, which I assume was not the same. What was that like?
Dayalan: The NHS as a health provider is absolutely fantastic. You have, which I think most developed countries should aspire for, a health delivery system that is free at the point of delivery irrespective of your social status, your economic status, or who you are. Absolutely fantastic health delivery system. But one of the issues with that is that it's very secular, even though the British consider themselves a Christian country. I think that's far from what's practically happening there. So, it wasn't an issue for me. I am still involved in my church. I sing in the church choir. I'm actively involved in church activities. They've been very supportive of me coming here and by their prayers. So that balanced it out. And yes, it was different. But I think the professional satisfaction that I got from treating my patients, knowing that irrespective of whatever treatment they needed, they got it, irrespective of their economic status. And I think that is something most countries should aspire for. Any developed country that doesn't do that I think is really failing their people. And so I think Britain and the NHS is a fantastic health delivery system. It's huge and any huge system like that will have flaws, will have deficiencies. But as a principle where they can deliver good quality care which is completely free at the point of delivery, I think the NHS is fantastic.
David: What does India's delivery system look like? Because you're doing a lot of fundraising for the people who are not able to pay, correct?
Dayalan: Yes. So now in the UK, we have a group very much like Friends of Kijabe called the Friends of Vellore UK. And because Vellore has been training medical students for about 80 years, they have people in various countries. We have friends of Vellore in the US and the UK and Australia and in different parts. And the original role of these organizations, are charities that were set up by mission. Those who went from the UK to the Vellore worked there, came back, and raised funds from their local churches. Equipment that was not being used by discarded by the NHS was being shipped back to Vellore. So, Vellore depended a lot on these Friends of Vellore in the different countries. But Vellore has now got grown so big and it's completely self-sufficient for their day-to-day running for their equipment. So they don't need the Friends of the Vellore UK anymore for that. So, we've turned our focus towards paying poor patients' bills. And one of the things that often used to worry me is that, yes, the law is a fantastic institution. They give brilliant care, tertiary care for people. But what about the poor man living on the street outside or just two miles away from Vellore? Where does he go? I mean, he doesn't have a chance of paying those bills. Vellore has now moved on in that 15% of their income, which is a large amount, is completely for charity.
Dayalan: And they're moving towards no patient will ever be turned away from the law because of lack of funds. So that's where we come in and we have said no more capital investment from us. We are going to concentrate on paying for poor patients' bills and they have a very good system which was set up in the seventies called person to person. So, a person in the UK donates money for a person in the Vellore. So that money is then raised and sent to Vellore. Vellore administers that. Every penny that that person in the UK donates goes directly to paying that poor patient's bill. And the person who in Vellore UK who donates that money gets a report of the patient that they treated and whose bill they helped to pay. That was set up in the seventies and is a very popular way of helping poor patients because the donors love it. They know exactly what's happened, the social standard, how much the bill cost, and what either the patient or their parents earn. So that was that's a very popular program and Friends of Vellore the UK that is our main contribution.
David: I just had to pause. In 1970. So that meant you had to send a letter for every single patient that was helped?
Dayalan: That's right. It was snail mail in those days. I remember as interns and as house officers actually filling in the form for a PCP form. Whenever the consultant knew that this patient is is not going to affect, they'll turn round to the junior, which was us. Can you please fill in a PDP form? We would then go into the patient's history, the economic background, where they live, what they earn, how many meals they have, how big their house is, and then all that details are then put together. Then the money is sent from PCP and then a sort of report is compiled by the administrator and by Vellore, and then sent by mail to the people in the UK.
David: I'm just absolutely floored because I associate this with organizations like Compassion International. This is normal now. This was not normal in 1970 by any stretch of the imagination. For somebody working in the charity space, it's just mind-bogglingly cutting edge. That's so cool.
Dayalan: I think Vellore has been just miles ahead of everybody else in India and even abroad. One of the other things, just to give you an example was the medical admissions when we got into medical college. So, you did an entrance exam where you qualified and then you were called for an interview and the interview took three days and the interview was hardly anything on the subject material. But it's basically to understand what is the aptitude of this individual person. Does the CMC think that this person is someone who has the aptitude to go back and serve? That was the main crux of the interview. We had personal interviews, we had group tasks, we had individual tasks, we had psychometric tasks. This is going back 50 years when it wasn't even envisaged. In the UK we now started bringing this in for our medical admission. And I was saying, “Guys, we've been doing this for 50 years at Vellore.” I think Vellore was really miles ahead of everybody else in lots of their programs and lots of their thinking and a lot of their projects.
David: Yeah, that's just amazing. Wow. Is there anything you see at KJB that reminds you of what that's like? Like what are common threads?
Dayalan: Well, I think the common thread is the Christ-centered attitude of what you're doing for your patients. Nobody is interested in personal gain or personal glory. All you are interested in is that God's name be praised and that patient getting well. And I think that's probably the first thing that struck me when I came here. That's it, I think the most important thing in health delivery system within a Christian ethos. So that was the first thing that struck me. The second thing that struck me is the training system is so similar. Vellore was started by an American missionary, Ida Scudder. The training system where residents do what they were doing here, like the PAACS (Pan African Academy of Christian Surgeons) training system, the residents take personal responsibility for the patient they're looking after. They present in rounds. They know everything about that patient. And the training system was very similar. And I think what I appreciate with PAACS, even more than what we had in Vellore is ours was mainly service-oriented. Here you've introduced some teaching into it. Also, you have, at least in surgery, regular teaching sessions which we didn't have in the Vellore. The onus was on the individual to go read up. And whereas here [in Kijabe] you have a structured training program with structured teaching from starting from the basic sciences, going right up to the operating skills, which is fantastic.
David: How do how does the skill level of our [Kijabe] trainees match up to other places you've been?
Dayalan: I think the training here, the skill level is fantastic, and I think what I like about the system is it's actually geared towards the African setting in that they have a general training which we don't have in the UK. We've moved away completely, but the UK can afford to do it because it's a developed country and they have the NHS which will look after everyone, whatever they need is, whereas here it's not the case. And so, I think the training is very broad here, very good here. And having seen the final-year residents, I know they're going to be doing the exams shortly and they will go out and I'm confident they would be able to manage most surgical conditions. And when I say surgical, not in the narrow sense of the UK, but in the broad sense of what Africa needs. So I think the skill levels are absolutely fantastic for this residency.
David: For some of the non-medical people listening. What are the biggest surgical needs for Africa?
Dayalan: I think the surgical need for Africa is to be a generalist where you can actually have a basic understanding of surgical diseases, know what the pathology is, and be able to quite rightly identify the problem and treat it adequately. One of the things I've noticed here is I've seen lots of patients being referred from elsewhere who actually have no knowledge of how that disease should have been treated but are willing to have a go because of either bravado or there's a financial incentive because if they did something surgical, they're going to get paid for it. And I think that's where PAACS really stands out in that they've grown them quite well and by the end of their training they know exactly what to do.
David: Do we know why breast cancer is so common? I know we're a referral center, so I have a skewed sense because that's so much of what we see in Kijabe. Why is it so prevalent? Why is it affecting young people? Do we have answers to those questions?
Dayalan: Interestingly, the statistics we have shown that breast cancer is a disease of the developing country. When I was in India, working in rural India and Assam in the last few years, I didn't see very much breast cancer, rural India, villages, not so much. You go to the urban cities in India, it's more common. And similarly, Kijabe seems to get a track because of the reputation we have of having treated breast cancer for a long time. With Peters reputation, we are a referral center for lots of people around the area and so I think Kijabe and Kenya are also going in the direction of the other developing countries where breast cancer is getting more common. And I have a simplistic view to this and I've discussed this with you before in that the things that increase your risk for breast cancer, even though each of them is small, are much more common in the developed countries. Things like the oral contraceptive pill, and hormone replacement treatment, all of these are extraneous estrogens which your body is not used to and taking them increases your risk. Things related to childbirth. Not having children increases your risk. Having children and the number of children you have is protective. If you have more children, you are more protected against breast cancer. The same way breastfeeding. In the West, there was a huge fad against breastfeeding and using artificial milk. Breastfeeding is protective in developing countries like India and Kenya. It's a necessity. If you don't breastfeed, it's economically not possible to actually buy powdered milk. And so, it's because of necessity, you have to do it. Everyone breastfed. Each of these is a small risk, but if you add them cumulatively, they become a higher risk. And I think as more countries, the developing countries are getting more developed and getting more Westernized, all of them are following the same trend that we have in the West, and this is increasing the risk. And so, breast cancer is getting more common in developing countries, unlike it was 20 or 30 years ago.
David: Wow. This just sounds both sad and scary.
Dayalan: It is. Because statistics in the cities in India show that they're almost catching up with the West in terms of prevalence of breast cancer. And it's probably this whole modernization shaping the West and doing all the things that they think the West is doing, which is good.
David: I was having a conversation with Rich Davis today about research. The thing that comes to mind is autism. How rare it is for for it to be seen here? Yet in Nairobi, it's much more common each year that goes by. I don't know if your wife has had this experience in anywhere else you travel. Each year that goes by, Arianna sees a few more children [with autism]. And it's I wonder if there are similar factors. I wonder what the correlations are and where it comes from?
Dayalan: I think definitely you can. My wife's in the same field, she's a pediatrician also. And there's no doubt that that incidence is increasing. But also, I think we're more aware of conditions that we didn't know 20 years ago. So 20 years ago, autism was just about coming, making it very similar to screening for breast cancer, pre-invasive breast cancer like DCIS, we didn't know these conditions before, but slowly we're getting more. Research helps with that. We've got good screening programs both in the US and in the UK, fantastic breast screening programs, and so we're learning much more as we go along with each intervention that comes about like screening. So I think we're going to see more of it. And the more you see of it, the more you get to know of it and the more you get to know of it, the better it gets for patients and health benefits.
David: What would have happened in Kijabe, if you did have breast cancer 20 years ago? There were probably very few chemotherapy options? I guess you could have done a mastectomy, but there was no reconstruction. I mean, was it a death sentence?
Dayalan: Almost. One of the problems we have in Kijabe and in Kenya and the whole I think is patients present much later, as a result of which the prognosis is not going to be as good as countries like yours and mine, where we have good screening programs, we pick it up early. If you take breast cancer in the UK now, two-thirds of the patients are going to be alive and well in 20 years' time. In Kijabe it's going to be a complete opposite statistic, roughly just off the top of my head, where two-thirds would be dead after 20 years. But that's because they present so late. So, yes. We've got much better in the treatment everywhere.
And the problem we have is a lot of the new treatments in breast cancer, i.e., chemotherapy. Monoclonal antibodies unfortunately are very expensive. So while in the UK where you have the NHS, where [cost] doesn't matter, in Kijabe and in Kenya, it's much more difficult to access all of these. But saying that, in the three months that I've been here, patients are being given the same chemotherapy regime that we use in the UK. Thanks to NHIF, thanks to patients' awareness, they're able to access monoclonal antibodies, not to the extent we would in the UK, but definitely, it's available and now we give our patients that treatment, and of course reconstructive surgery has moved on miles.
Dayalan: In terms of the treatment options we have, it's increased phenomenally. When I started in the UK 30 years ago, we had one chemotherapy regime for breast cancer. Now we have 20, maybe 30 regimes that we can use - different chemotherapeutic agents and if one fails, you go on to the next and so on and so forth, which we didn't have 20 years ago. I think treatment for breast cancer is really looking up. And with the new mammogram machine, I think one of the big things that we should be looking at is setting up a screening program for the local people because the mammogram machine is not going to be busy with the amount of breast cancer work that we do. So really what we need to be doing is developing a screening program, going out into the community and telling them, come, let's have a look, get some mammograms. Let's pick this up early. If you have a cancer, we'll sort it out for you.
Dayalan: I'm Dayalan Clarke. I'm a breast surgeon from the UK. I came out to Kijabe mainly to help because Beryl [Akinyi] has been on maternity leave. Beryl is the surgeon who does most of the breast work here, and Peter Bird, who we have known for many, many years, asked if we could if I could come and help. Peter grew up in India as a missionary child with his father being a surgeon and a missionary hospital, at a mission hospital in India in a place called Mysore. And it so happened that my wife's father was also a surgeon in the same hospital, and they grew up together across a wall as neighbors growing up in India. And that was my connection with Peter Bird. I think my wife and Peter lost connection, though our respective parents kept in touch. And then when we were visiting Nairobi for a safari in 2006, we heard that Peter was here. So we were going for a safari with my wife's parents. It was their 50th wedding anniversary and they loved wildlife. So that was our treat for them for their 50th wedding anniversary. And they said, “Oh, Peter is in Kijabe, let's try and meet up with Peter.”
So we came and visited Kijabe had lunch with Peter. In 2006 I took an early retirement from my work in the NHS in the UK with the express purpose to go and help mission hospitals in need. And then in 2019 I came out to Nairobi with a group of breast surgeons from the UK to train to do a training course and a teaching course in Nairobi, and who was on the local faculty to spread the word. So we met up again and I was telling Peter how I had taken an early retirement with the express view of going in and helping mission hospitals in need. And then he turned around said, "Oh, would you be able to help in Kijabe if we needed us at all?" I'd love to come to catch up if he needed me. And then, of course, Peter was leaving last year and Beryl was going on maternity leave. So he contacted me and said, Can you come and help us while on maternity leave? And so I'm here. That's how I'm here.
David: That's amazing. Did you and your wife meet? How did you meet?
Dayalan: I went to medical school in India, which is a Christian medical school called CMC Christian Medical College Vellore. And we were classmates in Vellore and we met there and got married after we finished our house jobs and then did some mission service, which is part of our obligation in India, then did our respective postgraduate training and in Vellore again, myself in general surgery and my wife in pediatrics. And then I worked again in mission hospitals in India and then went out to the UK in 1991, never intending to settle in the UK. But God, God's wills are strange and we never thought that's going to be the plan. But that's what happened. And I was very conscious that because we've trained in Vellore, I've always grown with the feeling that I consider myself very fortunate, coming from a very average background in India. My father was a minister in the church and retired as the Bishop of Madras. So very ordinary background, but consider ourselves very fortunate to have been able to have gone to the UK and to made a career there, to become consultants there and always felt as soon as my children were on their own feet, I'm going to stop working, retire and try to give back to people who been less fortunate than myself.
David: Wow. That brings up so many interesting questions. I'm not super familiar with India, but one of my dreams is - this is why I was so excited to meet you is I heard from from Dr. Nthumba when we were starting Friends of Kijabe - he said, "you need to learn about Vellore, you need to learn about this place." And so, I'd love to hear about that. But then also I'm curious just what. . .you said your father is a minister and then became a bishop. Most people in America associate India with Hinduism, Jainism, Sikhism. Is Christianity regional?
Dayalan: Christianity is much more common in South India than in North India. Where I come from, which is South India, but the population of India is huge. As you know, 1.3 billion people and 2% are Christians. So, 80% Hindus, about 10% are Muslims. And then, like you said, the other communities like Sikhs, Jains and such like from the rest of it with Christianity being 2%. So even Clarke, which is my surname, is a very Indian name, but the background to that is one of my forefathers must have been converted. And when you convert it from Hinduism to Christianity, the way you denounced your previous religion was either you took on a biblical name or you took on a very western-sounding name, often a missionary who converted you. I presume one of my forefathers was probably converted by someone called Clark or decided to take on a western-sounding name. And that's how Clarke has come down the generations.
David: Wow. So, there's a tradition that the Apostle Thomas went to India, right?
Dayalan: It's historic. Legend is that he came down to this west coast of India, which is Kerala, and then traveled down and then actually came through Tamil Nadu where I'm from, near Chennai. It's called Saint Thomas Mount. And they say that that's where he probably last either left India or died there. We don't know. But I don't think there's enough factual evidence but that's what they think happened.
David: Interesting. It was not until really spending time in this part of the world that realize Christianity developed very differently than I perceived. Southeast Asia, Africa, a lot of the early church fathers were in those places. It was not a European thing until much later on, which I think is fascinating.
Dayalan: Yes. Considering Christianity arose, Christ lived in Jerusalem in the Middle East, I think proximity-wise you can see why it happened that way. Egypt is not far from where it was and you have the flight to Egypt when Christ was born. But it doesn't surprise me. Definitely, there was quite a lot of Christianity around this region and moving both east to us [in India].
David: Wow. I think my understanding of our previous conversation - tell me if this is accurate - that Vellore is probably a picture of what Kijabe could be like in, I don't know, what you would say, maybe 20 or 30 years?
Dayalan: Quite possibly so. I mean, the first thing that struck me when I came to Kijabe, I saw the community spirit, the closeness, and how well people got on together. And the first thing that struck me, especially with a lot of missionaries here, the first thing that struck me was this is below in the fifties or sixties because Vellore was very similar. There's a Christ-centered Mission Hospital, which was largely supported by Americans and some British missionaries, both in terms of the day-to-day running of the hospital and in personnel, which I see exactly what is happening here. And Vellore has then gone on to become one of the leading institutions in India, both in teaching and in terms of health delivery. And my only prayer is that hopefully 30, 40 years Kijabe is going to get there. One of the things that Vellore has, which probably is an advantage for them, having developed so quickly and so well, is a medical school, which I think we don't have yet in Kijabe. But I think if we have Christ at the center, everything else will follow. And I can see great things happening in Kijabe, just in the services that I've seen, in breast cancer care itself, I can see there's huge scope because we've just had a mammogram machine installed. Oh, yes, which is fantastic. And then I've helped in helping the radiographers from here, going to Aga Khan and MP Shah to get some training and of course, we're going to have a breast radiologist coming from America, starting in August. So, with this mammogram machine, we have a state-of-the-art absolutely fantastic machine, and then if we have a breast radiologist to actually drive that forward. I can see Kijabe being a fantastic breast unit going forward.
David: That's amazing. So you went from Vellore, you went from a very faith-based medical system to the NHS, which I assume was not the same. No, no. What was that like?
Dayalan: The NHS as a health provider is absolutely fantastic. You have, which I think most developed countries should aspire for, a health delivery system that is free at the point of delivery irrespective of your social status, your economic status, or who you are. Absolutely fantastic health delivery system. But one of the issues with that is that it's very secular, even though the British consider themselves a Christian country. I think that's far from what's practically happening there. So, it wasn't an issue for me. I am still involved in my church. I sing in the church choir. I'm actively involved in church activities. They've been very supportive of me coming here and by their prayers. So that balanced it out. And yes, it was different. But I think the professional satisfaction that I got from treating my patients, knowing that irrespective of whatever treatment they needed, they got it, irrespective of their economic status. And I think that is something most countries should aspire for. Any developed country that doesn't do that I think is really failing their people. And so I think Britain and the NHS is a fantastic health delivery system. It's huge, and any huge system like that will have flaws, will have deficiencies. But as a principle where they can deliver good quality care which is completely free at the point of delivery, I think the NHS is fantastic.
David: What does India's delivery system look like? Because you're doing a lot of fundraising for the people who are not able to pay, correct?
Dayalan: Yes. So now in the UK, we have a group very much like Friends of Kijabe called the Friends of Vellore UK. And because Vellore has been training medical students for about 80 years, they have people in various countries. We have friends of Vellore in the US and the UK and Australia and in different parts. And the original role of these organizations, are charities that were set up by mission. Those who went from the UK to the Vellore worked there, came back, and raised funds from their local churches. Equipment that was not being used by discarded by the NHS was being shipped back to Vellore. So, Vellore depended a lot on these Friends of Vellore in the different countries. But Vellore has now got grown so big and it's completely self-sufficient for their day-to-day running for their equipment. So they don't need the Friends of the Vellore UK anymore for that. So, we've turned our focus towards paying poor patients' bills. And one of the things that often used to worry me is that, yes, Vellore is a fantastic institution. They give brilliant care, tertiary care for people. But what about the poor man living on the street outside or just two miles away from the law? Where does he go? I mean, he doesn't have a chance of paying those bills. Vellore has now moved on in that 15% of their income, which is a large amount, is completely for charity.
And they're moving towards no patient will ever be turned away from the law because of lack of funds. So that's where we come in and we have said no more capital investment from us. We are going to concentrate on paying for poor patients' bills and they have a very good system which was set up in the seventies called person to person. So, a person in the UK donates money for a person in the Vellore. So that money is then raised and sent to Vellore. Vellore administers that. Every penny that that person in the UK donates goes directly to paying that poor patient's bill. And the person who in Vellore UK who donates that money gets a report of the patient that they treated and whose bill they helped to pay. That was set up in the seventies and is a very popular way of helping poor patients because the donors love it. They know exactly what's happened, the social standard, how much the bill cost, and what either the patient or their parents earn. So that was that's a very popular program and Friends of Vellore the UK that is our main contribution.
David: I just had to pause. In 1970. So that meant you had to send a letter for every single patient that was helped.
Dayalan: That's right. It was snail mail in those days. I remember as interns and as house officers actually filling in the form for a PCP form. Whenever the consultant knew that this patient is is not going to affect, they'll turn round to the junior, which was us. Can you please fill in a PDP form? We would then go into the patient's history, the economic background, where they live, what they earn, how many meals they have, how big their house is, and then all that details are then put together. Then the money is sent from PCP and then a sort of report is compiled by the administrator and by Vellore, and then sent by mail to the people in the UK.
David: I'm just absolutely floored because I associate this with organizations like Compassion International. This is normal now. This was not normal in 1970 by any stretch of the imagination. For somebody working in the charity space, it's just mind-bogglingly cutting edge. That's so cool.
Dayalan: I think Vellore has been just miles ahead of everybody else in India and even abroad. One of the other things, just to give you an example was the medical admissions when we got into medical college. So, you did an entrance exam where you qualified and then you were called for an interview, and the interview took three days and the interview was hardly anything on the subject material. But it's basically to understand what is the aptitude of this individual person. Does the CMC think that this person is someone who has the aptitude to go back and serve? That was the main crux of the interview. We had personal interviews, we had group tasks, we had individual tasks, we had psychometric tasks. This is going back 50 years when it wasn't even envisaged. In the UK we now started bringing this in for our medical admission. And I was saying, “Guys, we've been doing this for 50 years at Vellore.” I think Vellore was really miles ahead of everybody else in lots of their programs and lots of their thinking and a lot of their projects.
David: Yeah, that's just amazing. Wow. Is there anything you see at Kijabe that reminds you of what that's like? Like, what are common threads?
Dayalan: Well, I think the common thread is the Christ-centered attitude of what you're doing for your patients. Nobody is interested in personal gain or personal glory. All you are interested in is that God's name be praised and that patient getting well. And I think that's probably the first thing that struck me when I came here. That's it, I think the most important thing in health delivery system within a Christian ethos. So that was the first thing that struck me. The second thing that struck me is the training system is so similar. Vellore was started by an American missionary, Ida Scudder. The training system where residents do what they were doing here, like the PAACS (Pan African Academy of Christian Surgeons) training system, the residents take personal responsibility for the patient they're looking after. They present in rounds. They know everything about that patient. And the training system was very similar. And I think what I appreciate with PAACS, even more than what we had in Vellore is ours was mainly service-oriented. Here you've introduced some teaching into it. Also, you have, at least in surgery, regular teaching sessions which we didn't have in the Vellore. The onus was on the individual to go read up. And whereas here [in Kijabe] you have a structured training program with structured teaching from starting from the basic sciences, going right up to the operating skills, which is fantastic.
David: How do how does the skill level of our [Kijabe] trainees match up to other places you've been?
Dayalan: I think the training here, the skill level is fantastic, and I think it's what I like about the system is it's actually geared towards the African setting in that they have a general training which we don't have in the UK. We've moved away completely, but the UK can afford to do it because it's a developed country and they have the NHS which will look after everyone, whatever they need is, whereas here it's not the case. And so, I think the training is very broad here, very good here. And having seen the final-year residents, I know they're going to be doing the exams shortly and they will go out and I'm confident they would be able to manage most surgical conditions. And when I say surgical, not in the narrow sense of the UK, but in the broad sense of what Africa needs. So I think the skill levels are absolutely fantastic for this residency.
David: For some of the non-medical people listening. What are the biggest surgical needs for Africa?
Dayalan: I think the surgical need for Africa is to be a generalist where you can actually have a basic understanding of surgical diseases, know what the pathology is, and be able to quite rightly identify the problem and treat it adequately. One of the things I've noticed here is I've seen lots of patients being referred from elsewhere who actually have no knowledge of how that disease should have been treated but are willing to have a go because of either bravado or there's a financial incentive because if they did something surgical, they're going to get paid for it. And I think that's where PAACS really stands out in that they've grown them quite well and by the end of their training they know exactly what to do.
David: Do we know why breast cancer is so common? I know we're a referral center, so I have a skewed sense because that's so much of what we see in Kijabe. Why is it so prevalent? Why is it affecting young people? Do we have answers to those questions?
Dayalan: Interestingly, the statistics have shown that breast cancer is a disease of the developed country. When I was in India, working in rural India and Assam in the last few years, I didn't see very much breast cancer, rural India, villages, not so much. You go to the urban cities in India, it's more common. And similarly, Kijabe seems to get a track because of the reputation we have of having treated breast cancer for a long time. With Peters reputation, we are a referral center for lots of people around the area and so I think Kijabe and Kenya are also going in the direction of the other developing countries where breast cancer is getting more common. And I have a simplistic view to this and I've discussed this with you before in that the things that increase your risk for breast cancer, even though each of them is small, are much more common in the developed countries. Things like the oral contraceptive pill, and hormone replacement treatment, all of these are extraneous estrogens which your body is not used to, and taking them increases your risk. Things related to childbirth. Not having children increases your risk. Having children and the number of children you have is protective. If you have more children, you are more protected against breast cancer. The same way breastfeeding. In the West, there was a huge fad against breastfeeding and using artificial milk. Breastfeeding is protective in developing countries like India and Kenya. It's a necessity. If you don't breastfeed, it's economically not possible to actually buy powdered milk. And so, it's because of necessity, you have to do it. Everyone breastfed. Each of these is a small risk, but if you add them cumulatively, they become a higher risk. And I think as the developing countries are getting more developed and getting more Westernized, all of them are following the same trend that we have in the West, and this is increasing the risk. And so, breast cancer is getting more common in developing countries, unlike it was 20 or 30 years ago.
David: Wow. This just sounds both sad and scary.
Dayalan: It is. Because statistics in the cities in India show that they're almost catching up with the West in terms of prevalence of breast cancer. And it's probably this whole modernization shaping the West and doing all the things that they think the West is doing, which is good.
David: I was having a conversation with Rich Davis today about research. The thing that comes to mind is autism. How rare it is for it to be seen here? In Nairobi, it's much more common each year that goes by. I don't know if your wife has had this experience anywhere else you travel. Each year that goes by, Arianna sees a few more children [with autism]. And it's I wonder if there are similar factors. I wonder what the correlations are and where it comes from?
Dayalan: I think definitely you can. My wife's in the same field, she's a pediatrician also. And there's no doubt that that incidence is increasing. But also, I think we're more aware of conditions that we didn't know 20 years ago. So 20 years ago, autism was just about coming, making it very similar to screening for breast cancer, pre-invasive breast cancer like DCIS, we didn't know these conditions before, but slowly we're getting more. Research helps with that. We've got good screening programs both in the US and in the UK, fantastic breast screening programs, and so we're learning much more as we go along with each intervention that comes about like screening. So I think we're going to see more of it. And the more you see of it, the more you get to know of it and the more you get to know of it, the better it gets for patients and health benefits.
David: What would have happened in Kijabe, if you did have breast cancer 20 years ago? There were probably very few chemotherapy options? I guess you could have done a mastectomy, but there was no reconstruction. I mean, was it a death sentence?
Dayalan: Almost. One of the problems we have in Kijabe and in Kenya and on the whole, I think, is patients present much later, as a result of which the prognosis is not going to be as good as countries like yours and mine, where we have good screening programs, we pick it up early. If you take breast cancer in the UK now, two-thirds of the patients are going to be alive and well in 20 years' time. In Kijabe it's going to be a complete opposite statistic, roughly just off the top of my head, where two-thirds would be dead after 20 years. But that's because they present so late. So, yes. We've gotten much better in the treatment everywhere.
And the problem we have is a lot of the new treatments in breast cancer, i.e., chemotherapy, monoclonal antibodies, unfortunately, are very expensive. So while in the UK where you have the NHS, where cost doesn't matter, in Kijabe and in Kenya, it's much more difficult to access all of these. But saying that, in the three months that I've been here, patients are being given the same chemotherapy regime that we use in the UK. Thanks to NHIF, thanks to patients' awareness, they're able to access monoclonal antibodies, not to the extent we would in the UK, but definitely, it's available and now we give our patients that treatment, and of course reconstructive surgery has moved on miles.
Dayalan: In terms of the treatment options we have, it's increased phenomenally. When I started in the UK 30 years ago, we had one chemotherapy regime for breast cancer. Now we have 20, maybe 30 regimes that we can use - different chemotherapeutic agents and if one fails, you go on to the next and so on and so forth, which we didn't have 20 years ago. I think treatment for breast cancer is really looking up.
And with the new mammogram machine, I think one of the big things that we should be looking at is setting up a screening program for the local people because the mammogram machine is not going to be busy with the amount of breast cancer work that we do. So really what we need to be doing is developing a screening program, going out into the community and telling them, come, let's have a look, get some mammograms. Let's pick this up early. If you have a cancer, we'll sort it out for you.