Mar. 12, 2015
By definition, déjà vu indicates:
The feeling of having already experienced something that is actually being experienced for the first time.
An impression of having seen or experienced something before.
Dull familiarity or monotony.
“Already seen,” according to the literal meaning of this term in French.
As I stepped out of the Delhi International Airport, I experienced my first déjà vu moment. The sky was filled with smog, and people and cars were everywhere. I thought, Did the pilot take a wrong turn somewhere, and I am in Los Angeles, California, in the 1970s?
I realized at that moment that stepping into the country of India would be like stepping back in time in many ways. What I did not yet realize is that although many of the buildings are modern and reflect the Western way of life, at its core, India and its people are still true to their roots — roots that were planted within their culture centuries ago and are still prevalent today.
After only a short rest at a nearby hotel, I returned to the Delhi airport to continue my journey to Chandigarh, India. As a member of the “frequent-flyer-for-work club,” I have seen many airports, from the smallest of the small to the largest of the large. The Chandigarh airport was much like one of our smaller regional airports here in the United States. I felt right at home. After almost 30 hours of traveling, I had to remind myself that I was not in Kansas anymore — actually, Tennessee; I am from Nashville — and remember that I was in a foreign country, even though the surroundings appeared to be so familiar. Thankfully, there stood a young man with a sign to welcome me and Shelly Lillé, a fellow mammographer and travel partner, to Chandigarh and to escort us to our hotel. We had traveled to India to participate in Asha Jyoti, a women’s health care mobile outreach program, as part of the global health initiative sponsored by RAD-AID International and the ASRT Foundation.
Chandigarh was alive with cars, motorcycles, buggies, bicycles and people moving quickly through the streets. All moved as they wished, vehicles honking loud, discordant warnings while seeming to break every rule of the road taught in the United States. As we traveled across the city to our hotel, I saw very few traffic accidents, much to my amazement! Upon arrival at our hotel, the culture shock continued, as well as more déjà vu. When I walked into the hotel lobby and scanned the area, I very much felt like I was in a highly rated hotel in the USA. (Once past the lobby area, however, not so much.)
Based on my other international working experiences, I believed that the medical business in India would not necessarily be like the medical business in the United States. My thoughts were both right and wrong. In the United States, medical facilities seem to try to outdo the competition with lavish buildings and interior design. Based on what I saw at the Post Graduate Institute Medical Education and Research (PGIMER), the main concern was not the beauty of the buildings but the beauty of caring for the people of the community.
A little déjà vu crept in when I stepped inside PGIMER and was reminded of some of the very basic medical facilities I have visited in the United States. In my experience, sometimes the more basic the facility, the more personal the medical attention; the focus remains on the patient rather than the surroundings. Once I was introduced to the staff of the PGIMER imaging department, the time had finally come for me to enter the mammography suite. Much like what one would see in the United States, when I walked into the mammography suite at PGIMER, I noticed a digital mammography unit. I thought to myself, Great! They are performing digital imaging for mammography. Again, perception is not always what it seems.
The facility did have a digital mammography unit. However, the way they were using the unit wasn't producing the best images. Through troubleshooting test images and after long and involved discussions, a new way of imaging was introduced to the facility — a change that benefited the patients and the radiologists. Better images mean higher contrast and the ability to identify breast cancer. Not only did the way they obtain the image change, but how they printed the images also changed. Originally the facility was printing breast images that were “out of scale,” or not always on the standard breast imaging scale. A hint of déjà vu returned when I noticed some artifacts that I would have considered to be guide shoe marks. These images were not being developed in a film processor, however, so the artifact actually was coming from the laser printer. The printer settings needed to be adjusted to limit artifacts on the printed images.
As I began to work with the mammography technologists, my sense of déjà vu peaked. Observing how technologists positioned the patients was like watching my staff back in the early 1990s. Because many of the Indian technologists’ skills were based on the positioning skills introduced to mammographers in the United States in the early ’90s, their images reflected these older positioning methods — positioning skills are directly connected to image quality. With some simple updated positioning instructions, I saw their image quality go from what we were seeing and accepting here in the United States in the early 1990s to the quality of images we accept in the United States today, as far as positioning is concerned. Just as I experience here in the United States when I am asked to assist a facility with image quality, suggestions are made, and one can hope that the facility will take action. As always, budget is a concern, whether one is working in India or anywhere else.
As I watched the patients come and go in the mammography department at PGIMER, déjà vu took me back to breast imaging in the United States in the 1970s, 1980s and 1990s. Prior to the Mammography Quality Standards Act and accreditation becoming mandatory in the United States, breast cancer rarely was found in an early stage. As I witnessed the patients in Chandigarh coming in with advanced breast cancers — cancers that have already eroded through the skin — it was like looking into a time machine. Seeing the same type of breast cancers today in Chandigarh that we saw in the United States in the early days of breast imaging was sad, but it was a reality.
Breast cancer in India is considered to be at an epidemic stage. The reason is not fully understood. While preparing for my trip to India, I learned that research has pegged a “Western” lifestyle as one reason, meaning that the urban women of India are waiting until a later age to have children and might be less likely to breastfeed their children, unlike their rural counterparts. These factors could be contributing to this breast cancer epidemic.
So where does breast imaging in India go from 2015 forward? One hopes that through research and development, as well as educational assistance such as the program I was able to participate in with the mammographers of PGIMER, the women of India will survive breast cancer rather than lose their lives to it. It has taken decades of research, development and education for American women to benefit from the early detection of breast cancer. India has only begun its journey in this fight. As a mammographer and as an international mammography consultant and educator, I realize that we have no control regarding who will and who will not develop breast cancer. The best we can offer is for the patient to have the opportunity to survive breast cancer.
I hope that someday the technologists I worked with in Chandigarh will have their own déjà vu moment when passing breast imaging knowledge on to the next generation of mammographers. As mammographers, we have a universal connection: most of us are women, and some of us will develop breast cancer. I am thankful to have been given the opportunity to have an influence, whether it be small or large, on the lives of the women of India. As a mammographer, my goal isn’t to cure breast cancer or to remove it from our gene pool. My goal is to help increase the number of breast cancer survivors, one facility and one technologist at a time.
Linda F. Robertson-Hull, R.T.(R)(M), has been a radiologic technologist since 1978 and has specialized in mammography for more than 30 years. She formed her own mammography consulting and education company, Health Learning Source, in 1998. She provides both stateside and international mammography and breast sonography continuing education seminars, staff development, and on-site consulting with regulation compliance, and she assists facilities and mammography technologists in the United States through the accreditation process. She began her international work in Canada prior to her work in Nigeria in 2010. In 2014, she traveled to India to participate in the R.T. Fellowship global health initiative sponsored by RAD-AID International and the ASRT Foundation.