The Result Names A Drug I Cannot Reach

There is a particular silence in the room when a molecular report comes back. The test has worked. The target is there. Somewhere in the world this is the moment the pathway opens, and the conversation turns to scheduling.

In my clinic it is often the moment I must start doing arithmetic that has nothing to do with medicine.

By the time a result like that arrives, a family has usually already spent what it had. Diagnosis in this region is not a single event; it is a sequence of costs. Imaging. A biopsy. The pathology. The immunohistochemistry. Then, if there is anything left, the molecular panel — which is frequently the point at which the money runs out, and always the point at which it matters most that it has not. Patients arrive at the treatment decision having already been financially exhausted by the process of establishing what they have.

And then the recommended therapy carries a price often exceeding available monthly resources, before importation, and often with insurance already applied.

I know what the standard of care is. I can read the same guidance on the same day as a colleague anywhere else in the world, and I do. That is not where the difficulty lies. The difficulty is that knowing the right answer and being able to deliver it have become two separate problems, and only one of them is mine to solve.

The Loop

Standard of care, in many regional markets, puts the physician into a loop that has no clean exit. I am expected to stay current, and I am expected to advocate for the patient, and I am expected to deliver the best therapy available. The first two obligations reliably produce a recommendation the third cannot fulfil. I became an oncologist because I believe it is a higher calling, a discipline in medicine requiring a level of effort, curiosity, empathy and advocacy for patients I wanted to commit to in my life. After 20 years, I often counsel young physicians through these realities.

This is where the burden falls in ways that do not appear in any budget or any audit. Across the region, oncologists absorb the gap privately — in time, in advocacy, in negotiation with suppliers and insurers and foundations, and in decisions about what a family will be asked to pay to keep a door open at all. None of that is a clinical decision. None of it is recorded anywhere. And it is not sustainable as a substitute for a system.

What We Are Missing Is Not Only the Drug

Patients elsewhere have a route I cannot offer mine: the clinical trial. In other regions, a trial is a legitimate line of therapy — access to an agent, with monitoring attached, at a cost the patient does not carry. My patients do not have that avenue, and I am conscious of why. Our volumes are small. I understand what a sponsor is weighing when it looks at a site like mine and calculates recruitment.

But I would like that conversation to at least be had. Regional collaboration, multi-island recruitment, and consortium arrangements exist elsewhere precisely because individual sites were too small alone. The absence of trials here is treated as a settled fact rather than a design problem, and I am not persuaded it must be.

Why This Matters Beyond My Clinic

I want to be plain about something. This is one of the reasons oncologists leave.

Not pay, and not workload, though those matter. It is the accumulated experience of being trained to a standard, keeping yourself at that standard at real personal cost, and then being structurally prevented from practising to it. That is a specific kind of attrition, and it wears differently from ordinary fatigue.

It would be convenient if oncology in the Caribbean were simply a matter of following the guidelines. It is not. Every guideline here meets exceptions, and the exceptions are ours to work out. We have no choice but to be well-read — more so, I would argue, than colleagues in settings where the pathway is already built — because we are constantly having to reason from the evidence rather than follow it: asserting, advocating, calling colleagues, picking brains, and arriving at a management plan that is defensible when the recommended one is not available. That is a heavy responsibility to carry, and it is carried largely in private.

Restrained resources do not just limit what we can prescribe. Over time they unwind the education itself — the training, the reading, the continuing effort to stay current — by making it repeatedly impossible to act on. That is the loss I would ask the region to take seriously.

About the Author

Dr. Merisa Grant-Tate is a Consultant Oncologist at the Joseph N France General Hospital in St. Kitts and Nevis and Founder/CEO of WellPoint Medical & Oncology Center. Dr. Grant-Tate’s brings two decades in medicine, caring for patients in multiple countries across the region and mentoring young physicians across the region.