Cancer screening and preventable illness

   Sorry to follow up my upbeat post with something sad, but the hardest part of being here is witnessing preventable illness, and in some cases, death. One of the most glaring discrepancies between the US and here is the ability to provide preventative care. While I know that many Americans also have limited access to these services, it is not to the same extent. Although many people lack access to health insurance and don't have the benefit of having a primary care physician who sees them on a regular basis, many communities have free clinics or income based clinics that provide basic screening and care for patients without insurance. Here, this is much more rare, and in addition, many patients here are unable to miss a day of work without risking losing employment, which is much less common in the US. Others simply can't find reliable transportation to the few centers that may be able to provide them care until they are seriously ill.
    I hate to use the word perfect in relation to this topic at all, but cervical cancer is a perfect example. Since the introduction of the pap smear in 1946, there has been a dramatic decrease in the number of cervical cancer cases and deaths. For example, in Iceland, there has been a decrease in cancer deaths of 80% since introduction of pap screening guidelines. Decreases have been similar in the US and other developed countries, however, cervical cancer still remains a huge public health issue. According to WHO, in 2008, there were more than 530 000 new cases worldwide and 275,000 deaths from cervical cancer. And, as you might expect, the majority of these were in developing countries.
    While they have a reproductive health clinic at KCMC which offers breast and cervical cancer screening every Tuesday and Thursday, these are few and far between. In addition, because they do not have pathologists on site who are able to interpret pap smears. Instead they perform VIA exams, or visual inspection with acetic acid, which is essentially a colposcopy. They also perform breast exams and have the capability of doing cryotherapy or LEEP procedures if the exam is abnormal. Patients sign in the morning of the clinic, in a first come, first serve manner, sometimes waiting from 8 AM till 3 or 4 PM to have their screening exams. I often hear from patients that in the US that the wait is too long, or the parking is inconvenient, or even that they live too far away and it's inconvenient... so you can imagine how surprised I was to see a waiting room full of women, sometimes from towns that are hours away, who are spending their whole day waiting to be screened. (I didn't take a picture of the line, I felt like it was too much of an invasion of privacy).
    Despite limited resources, the clinic runs relatively smoothly. Cotton swabs used to apply acetic acid in the US are expensive, so one of the nurses who runs the clinic cuts dried grass and uses a large bale of cotton to wrap the swabs herself. Patients bring their own sheets (usually Kangas) to sit on to reduce laundry costs. They keep paper records of results and treatments in large books, but they also take pictures of the cervix to keep on file to compare on subsequent exams and plan for procedures, if necessary. Since they wouldn't be able to get biopsy results (at least in a timely fashion), they have to assess whether the lesion is concerning for cancer, and whether or not treatment is necessary, just by looking at it.

The Reproductive Health clinic exam room, complete with a patient's wrap placed
to sit on. (You can also see a cervix on the TV screen)

  While they're able to catch a lot of things, they often find cervical cancers which are advanced, as well as breast cancer (I found a large breast mass on one of my exams, and she already had palpable lymph nodes and symptoms of bone metastases). They're starting a study at KCMC soon to look at the utility of HPV testing as a screening method, which I think would be ideal. Cervical cancer (at least squamous type) and dysplasia are virtually impossible in patients who screen negative for HPV, and no pathologists are needed to complete the tests of interpret the results. It's unclear how this will change screening in developing countries in general, or if it will reduce cervical cancer mortality and morbidity, but I guess it at least makes me (and the physicians here), hopeful.

One of the residents, Timi and Jackie, a nurse practioner, update
the record book with screening results.