Before his mother, who had lost her brother to malaria, died in childbirth when Fazlur Rahman was just seven years old, she told him, “Someday you will be a doctor, Fazlur, and help people.” He took her urging to heart. A native of what’s now the South Asian country of Bangladesh, Rahman remembers residents of the small village where he was born dying of epidemics, often without medical care.
After he left home and eventually completed his training in New York City and at Baylor College of Medicine, in Houston, in his early thirties, he had to decide where he would practice. Most of his medical school friends were headed to big cities like Dallas and Phoenix, but advice from a mentor set him on a different path. “Oncology was a new specialty at that time,” Rahman told me. “We’re talking about 1974, ’75. There was no oncologist in the whole of West Texas. My mentor said that, you know, if you go to San Angelo, you will make a difference.”
That was where he went on to practice for 35 years, until his retirement, in 2011. While medicine has advanced considerably during those decades, for rural Texans, like those who live in the areas surrounding San Angelo, the best treatments often remain out of reach. As rural hospitals struggle to stay open, many have shuttered their chemotherapy departments, with recent research finding that 382 medical centers across the U.S. eliminated those services between 2014 and 2022. In Texas, nearly half of the rural hospitals that previously offered chemotherapy have now stopped.
This week, Texas Tech University Press is publishing Rahman’s book, Our Connected Lives: Caring for Cancer Patients in Rural Texas. The book blends discussions of the science with personal narratives from Rahman’s career. The doctor emphasizes the importance of oncologists treating their patients as human beings not defined entirely by their cancers. “That’s why I like medical humanities,” said Rahman, who turns to literature and poetry to help himself understand patients’ experiences. “Simply because science alone cannot take care of you.” The physician and author spoke with Texas Monthly about how he hopes his book will help others understand the experience—both medically and emotionally—of battling cancer in rural West Texas.
Texas Monthly: Can you tell me about your transition to West Texas?
Fazlur Rahman: In the beginning, I had a difficult time. Then I found out that I could do more intimate care with patients and their families, their loved ones. In training, I mean, everybody’s the same way, whether in New York or Houston—you are so busy; you go to one patient, another one; they get blurred. But here, you have more opportunity and more time, in the sense that you know people, get to know them. I’ve always been interested in the inner lives of people, patients especially.
TM: I think of San Angelo as a kind of big little city in terms of medical access, like a small island in the region. Can you tell me about what that landscape meant for your patients?
FR: It was hard on people. Because if you came from Big Bend, it’s 300 miles. They needed care too. Or Midland-Odessa, which is 120 miles. And then a lot of ranches, they’re quite far. They may be 50 miles away but take 1.5 hours to come through the country roads. So when you give them chemotherapy, and they got sick at home, that was very hard on the patients. And difficult for me too, to see them like that. A lot of family doctors, they are not used to taking care of chemotherapy patients, and they didn’t feel very comfortable. So sometimes the patients have to drive all the way to come here, for me to admit them here and take care of them.
Austin is about 220 miles away; San Antonio is about that; Dallas is about 275; Houston, 400 miles. Nothing was close to San Angelo. So that was sometimes difficult for me, because I wanted to have a second opinion. But then I’d tell patients honestly what I know and don’t know, and they said, ‘No, do whatever you can. We don’t want to go to Houston. We’re just small-town people, farm and ranching people.’ And it almost always worked out.
There are multiple oncologists now in the town. Now there are oncologists in Midland, in Odessa, so this becomes a little bit easier.
TM: In the book, there’s a patient you call J.D., who exemplifies a lot of the issues with access that we have in Texas. Can you tell me about your experience with patients facing those kinds of challenges?
FR: Texas has the highest number of uninsured in the country. And we have quite a bit of hostility to the Affordable Care Act. My own feeling is that it doesn’t make any sense, because taxpayers end up paying anyway: People get sicker and end up in the emergency room. That’s more expensive and hard on the people.
Second is that having insurance sometimes is not enough. J.D. is an example. He went into remission with Gleevec, which was a new drug, but it’s so expensive. Then he lost his job, and so J.D. couldn’t afford it. And what happened to J.D.? He quit taking it. Then he developed acute leukemia from chronic leukemia. And that required two years of treatment: protracted treatment, more expensive treatment, more involved treatment. We had good drugs, but what good does it do if patients cannot afford it?
Third is your distance problem. These people tend to have less screening because they have to go a long way, especially in rural areas. A lot of elderly people live there, a lot of uninsured live there. They have high incidence of diabetes, high blood pressure, and other problems that come with it. And so on top of that, when they have cancer or leukemia, that’s an added burden, the cost and everything.
So this is a kind of a multifaceted answer. One is the access, another is the cost, another is that there are multiple problems as people get older, and those things have to be taken into account. Transportation is much better now, the access is a little bit better, but still, distance is distance. And the older we are, the higher number of cancers. Like I wrote in the book, 85-plus years is the fastest-growing population in the country. So those are the people that get more medical problems also. So you have to decide medically, ethically, and then as a society, how we deal with that.
TM: You talk about how much has changed in the years since you started practicing, both in terms of medical advances and also in choices patients now have about their treatment. Can you tell me about that?
FR: I think that the biggest, in my mind, improvements have been in diagnosis, and definitely treatment has improved. And another thing that is very, very pertinent to health care: end-of-life care. End-of-life care, when it started, was kind of like a stepchild of medicine.
We hardly ever talked about it when I was in training, whether in Houston or in New York—like, “If it happens, we’ll worry about it,” something like that—fifty, sixty years ago. So end-of-life care, we talk ahead of time now, that, “Look, these are the options. We can still keep it under control for a while, but if it breaks through, then we have to decide what to do.” And it gives them time to think, time to do wills and trusts.
Before we had hospice care, I had a big oncology ward, 25 beds, because a lot of patients died in the hospital. Our aim was to make people live as long as they can, but the quality of life and end-of-life care were kind of secondary issues. So home health care cannot take care of them, they can’t go to a nursing home, family cannot take care of them. So where did they go? They ended up in the hospital. But once hospice came, it was kind of a lifesaver.
The end-of-life care and the terminal care, those are critical. Even with all the progress we have made—I’m not trying to be negative—still most metastatic cancers are not cured.
TM: Who is the book for, and what do you hope people take from it?
FR: Cancer patients and their loved ones. And also trainees and doctors, because it talks about some of the ethical issues, bedside issues. For example, J.D. had three years of treatment. It’s easy for the doctor to lose empathy, because he had the same complaint all the time: “I have nausea, I have weakness, I can’t sleep, I have aches and pains.” As an oncologist, you have to make sure that you don’t get dulled; you still have to listen. I hope that we don’t forget that we still are taking care of that person.
As a healthy person, sometimes you don’t always understand what the cancer patient goes through. So I think that some people will benefit from it, to understand the cancer patients, what they go through and their families go through. Loved ones suffer as much as the cancer patients sometimes.
And this could be another window of cancer, because remember that when you’re at MD Anderson or Methodist or Baylor College of Medicine or Memorial Sloan Kettering, you’re in a completely different environment. Your view is quite different from the view that is outside that sometimes. So I feel like maybe this will give them some understanding of what goes on in a small town.
This interview has been edited for clarity and length.
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