In 1985, Stephen Jay Gould wrote a best seller in the US entitled, The Median Isn't the Message. He was a patient with mesothelioma, a deadly form of cancer. He was also a discerning scientist, and so he looked up mesothelioma and found that it was fatal with a median survival time of about eight months. However he saw that the survival curve for mesothelioma was skewed to the right with a long tail on the graph suggesting that some people lived many years longer than the average time of eight months. Gould however stressed on the unlikely probability of a longer life and even wrote the book because indeed, he went on to survive for 20 more years. Lucky guy.

In a sense, the American medical system especially as regards terminal problems like cancer care, end stage lung/heart disease, has been built around the improbable: the long tail of the graph. This means spending millions of dollars to entertain the notion of hope, that perhaps this particular patient is an exception. Unfortunately even in the US health care budget is limited, and this has lately hit home with the passage of the health care bill. How is all this relevant for a deprived country like Nepal?

Take malignant lung cancer, an increasing form of cancer in Nepal, thanks to smoking and air pollution. The median survival time no matter what you do is generally a year for this cancer. Receiving chemotherapy, radiation, or even surgery for this cancer is possible here, and there may be clear cut indications for doing this in some instances.

But in many cases in Nepal proper control of pain in the patient and promoting 'hospice' like care may be more relevant and acceptable. This would mean that the patient and the family rather than spending lakhs on ineffective treatment would spend more quality time together. In the US the likely scenario is that in the last stages a lung cancer patient will be in intensive care with tubes and catheters. Amazingly even in the US, and especially due to the budget crunch, many people are opting for hospice care for a more satisfying exit. In Nepal we do not seem to have a choice.