Tuesday, September 7, 2010

Women's Health with Some Vinegar on the Side

Cervical cancer is a major problem in Haiti. Of all the countries in the LAC (Latin America and Caribbean) region, Haiti has the largest number of women getting the disease each year, estimated at 84 new cases per 100,000 women (versus 8 in North America). This form of cancer is the primary cause of cancer deaths among women in Haiti (64% of cancer deaths) and is highly preventable. While methods for prevention include reducing the transmission of HPV (human papilloma virus, some strains of which put women at high risk for cervical cancer), another important measure is screening for early signs of cervical cancer.

In the US, this routine screening might happen via a PAP smear. However, PAP tests are not feasible for most of Haiti’s women. One of my colleagues explained the vast resources required: You need a doctor or nurse to do the PAP test. The cells collected during the test must be taken to a laboratory. (Note that (a) the woman must bring her cells to the lab herself and (b) all the labs are in Port-au-Prince.) The lab results must then be interpreted by a specially trained biologist: a cytologist. (In Haiti, there are an estimated 8 cytologists.) After that, the woman needs to find a doctor to provide any needed treatment. (Keep in mind: none of this travel and few of these services come at cheap or low cost.)

So, given limited resources, where do we go for help?

A bottle of vinegar.

There is a fast and low-cost method for identifying early signs of cancer. It is called Visual Inspection with Acetic Acid (VIA). The procedure involves a large q-tip soaked in vinegar solution. The q-tip is applied to the cervix (see refresher on female anatomy) and left there for one minute. Precancerous lesions will turn white (in contrast with the normal pink cells of the rest of the cervix) and can be detected by the trained eye. (Aspiring gynecologists: don’t try this at home.) Once any areas of concern are detected, a biopsy can be done if further information is needed or the lesions can be removed on the spot with a hot wire (LEEP) or by freezing (cryotherapy). 

I was lucky to join a group of clinical staff in rural Haiti for part of a training on the VIA technique. The training included a section on theory as well as much practice. By the third day of practice, word had spread around the hospital and in the community that free vaginal exams were happening. The team saw almost 100 patients that day and was even able to detect and remove some lesions.

Through experiences such as this, I am learning much about the challenges of supporting women’s health in rural Haiti. A few striking ones include:

Access to care:

Many women have never been to the doctor for a vaginal exam. It is difficult to address women’s health from a hospital or clinic if women are not going there on a regular basis – or at all. This speaks to the need both for facilitating access to care and strengthening community-based programs.

Literacy/Numeracy/Collecting basic information:

Sometimes I assist with intakes for patients: I write down the information clinicians want to see before they speak with a patient. When I ask people their names, they often respond with a name I recognize. But, there are some names that I just can’t figure out how to spell. This has prompted a few awkward moments when I ask a woman to spell her name for me, but she doesn’t know how. To get around the name issue, some women hand me a piece of paper with their name and other useful information neatly printed on it.

When I ask people how old they are, it often requires some calculation. Some do not know their age at all. One spunky woman said she had been told she was 80, but when I asked her what age I should write on the paper, she said 60. When I met her, I had not yet learned an oft-used technique to estimate age: ask under which presidency she/he was born. This method can get you within 5 years of the person’s age under the current system of limited presidential terms. But, the methodology is not so precise for people born during Fran├žois Duvalier’s 13-year stint as president (1957 – 1971) or the 14-year gig of his son, Jean-Claude Duvalier (1971 – 1986). But, you do what you can.

Perhaps that is one of the greatest lessons I am learning here: the importance of creativity and finding ways to do what you can with what you have. It sounds trite, but I regularly see the difference it can make: in the absence of a robust health system, a clinician with some vinegar and basic tools could save someone from cancer.

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