Be the change you want to see in the world. ~ Ghandi

Wednesday, March 13, 2013

Preventing Cervical Cancer in Kenya


I had the privilege of working in Kenya in January of 2013 with the non-profit organization Prevention International No Cervical Cancer (PINCC). It was my first time to Africa and my second trip with PINCC. We were a small group this time, 6 of us Americans –and our Kenyan colleagues numbered about 30 in total. I was with the PINCC group for two weeks – the first week was in the Kibera area of Nairobi, and the second week was in Kiambu area on the edge of Nairobi. The weeks were very different from each other in many aspects, and yet shared similar aspects too, like the wonderful Kenyan health care practitioners we worked with, and the gracious patients we helped to provide care for.
The health care practitioners we worked with had varied backgrounds and training –they included nurses; clinical officers; midwives; and obstetrician/gynecologists.  They were all, without exception, gracious and professional and a joy to work with. Their experience varied and in very short order we were able to see who needed particular focus on specific areas of instruction. That was the mission of this PINCC trip, to teach the local health care providers how to screen for cervical cancer and treat in the same step whenever possible. This model of teaching how to provide medical care, rather than providing it, is an example of sustainable health care work that has a big impact.
Kibera is an area within Nairobi that is infamous for its poverty and challenging living conditions. I have never experienced anything like it, and although difficult at times, walking through it and working within it will remain one of the most profound experiences of my life. The health care workers who staff the clinic in which we worked most often lived outside of the Kibera slum, and they took public transportation to the edge of the slum, and then walked in to the clinic on foot. This is because the “streets” (dirt paths) of Kibera are not wide enough for cars. There is no car traffic within Kibera.  
The clinic is part of an organization called Shining Hope for Communities or SHOFCO as we called it. It is a wonderful organization that offers healthcare, education and a sustaining community presence within Kibera. It provides a stable base from which to provide services and this is what we helped do! Some of our Kenyan colleagues had exposure to the concept of “see-and-treat” cervical cancer screening, or, visual inspection with acetic acid and cryotherapy, and some did not. Some had experience using speculums and some did not. Every day was different, which of course was wonderful, and so we began wherever the student needed us to begin. The work, therefore, included things like teaching the participants how to use a speculum and find the cervix; inspect the cervix for changes after the application of acetic acid; perform equipment checks on cryotherapy guns and performs the cryotherapy; do biopsies and do LEEPs (loop electrosurgical excision procedure).
Cervical cancer continues to be a leading cause of mortality in developing countries, as compared to more developed countries, where it is not among the leading reasons for female mortality.  The process-intensive screening that is done with pap tests, in more developed countries, is not suitable in developing/low resource areas. In contrast to the U.S., for example, where cervical cancer screening occurs nearly annually, many women in developing countries receive one screening in a lifetime. This is for many reasons, but geography; access to health care; lack of adequate local health system infrastructure – all of this plays a part in contributing to the increased morbidity and mortality of cervical cancer in developing countries. For these reasons, PINCC and other organizations, teach a method that screens and treats (if necessary) in one step. There is no specimen (Pap test) therefore there is no need for a laboratory or the personnel to interpret the specimen. The clinician doing the pelvic exam visualizes the cervix, and, using 5% acetic acid (vinegar) applied to the cervix, is able to determine if the cells of the cervix appear healthy, or, if there are pre-cancerous lesions. This method has been researched well and has been found to be as effective in finding pre-cancerous lesions as pap testing! And the best part is, it is inexpensive to perform, relatively easy to learn, and equipment and supplies needed are minimal.
Our Kenyan colleagues embraced this method of cervical cancer screening, and at the end of the week they were getting the exam themselves – often the first pelvic and cervical exam they had ever had. The most gratifying moments of these weeks included these exams that the students did on each other – they had clearly learned how to do a good pelvic and cervical exam and they trusted each other to do it well. Serving as their educator was an honor and a privilege.  I learned so much on this trip – particularly about how to teach. I have been a clinician for so long, it’s easy to reflexively perform a task, but it is much more difficult to sit back and teach – and allow the student to learn by doing. I also learned a little bit about the ways in which our cultures differ. It seems that our Kenyan colleagues are typically more soft spoken than we are, and a little bit less assertive in terms of learning needs. There was an emphasis on politeness in the Kenyan culture that I have not often experienced within the U.S. culture and I felt compelled to scrutinize myself to make sure I maintained polite manners!
The conditions in which we worked were difficult, e.g. there were a lot of patients, and they often had complex medical and social histories. Many women had been raped, and many were positive for HIV. Many were single and had had multiple pregnancies and miscarriages. All of this made for overwhelming encounters at times – but our students managed this with grace and ease. They work in such difficult conditions, the poverty is mind-numbing and they work within it all day without fancy equipment, running water or electricity. It is inspirational and I hope to remember these hard working clinicians when I catch myself complaining at my work at home.
One of the most memorable moments of this trip came at the end of the Kibera week. We had finished teaching and working in this very challenging environment and PINCC had certified and graduated a number of clinicians in this method. Being witness to their pleasure and satisfaction was awesome. We said our goodbyes and as we left, we went to a classroom of girls (the clinic is next to the Kibera School for Girls) and these young girls sang to us. They were all beautiful songs, but the last one was about self-realization and fulfillment.  When they were done there was not a dry eye amongst us! The fact that this kind of beauty, hope and joy can exist simultaneously alongside extreme poverty and desperate circumstances, gives me hope and sustenance to continue working to help my fellow human beings.
One Nurse At a Time made this trip possible for me and it was a gift I will always have. I hope to participate in a trip such as this on an annual basis – it will keep me fresh, flexible, and young at heart! It seems to me that this is a cycle of giving – ONAAT gives me the opportunity to do these trips, I give of my time and expertise, and the people I encounter give their grace and good will – and in this way, all of us contribute to an accomplishment that could not be achieved alone.    Anne Daly March 2013