To learn more about Women’s Global Health and how you can support it, please contact Susie Posner-Jones, Director of Development, Population Health at 802-656-4334 or Susie.Posner-Jones@uvmhealth.org. If you would like to make a gift to the Tanzania project today, please go to www.uvmhealth.org/foundation and click on the “Donate Now” button – in special notes/instructions please indicate Women’s Health- Tanzania.
When friends and colleagues hear that I travel to Tanzania for cervical cancer prevention, they often say: “so you do Pap smears all day?”
If only it was that easy.
Tanzania: A Public Health Crisis
In Tanzania, the number of women diagnosed with cervical cancer is nearly ten times the US rate. Cervical cancer is a leading cause of death. A major reason is the lack of cancer screening programs appropriate for Tanzania and treatment for early stage disease.
Cervical cancer prevention programs like the ones in the US require labs and pathologists and intensive follow-up by patients. Consider this: in Tanzania, there are only 15 pathologists for a country of 44 million people. The Department of Pathology at UVM employs more than 30 pathologists alone.
Every year since 2014, I return to Wasso District Hospital in rural Northern Tanzania. During my OBGYN training cervical cancer was rare. After two years of seeing cases of advanced, untreatable cervical cancer in my makeshift Tanzanian clinic, the hospital staff and I discussed screening.
At that time, many women didn’t know that cervical cancer is preventable. For them cancer equaled death. And if they wanted screening, they took a harrowing 10-hour bus ride to the nearest city. As is true in many low-income countries, screening is a written priority, but there is no funding available. The district in which Wasso Hospital sits is about half the size of Vermont with a population of roughly 175,000. They were never offered screening. Imagine if the entire southern portion of Vermont was denied this type of preventative health care?
Tackling the Problem
In 2016, with this injustice at the forefront of my mind and a shoestring budget, I began work to increase cervical cancer screening in the district.
The idea: to build local capacity to run a screening program, rather than to run it myself. One colleague, an expat working in Tanzania, was skeptical. “They will never come,” he said, referring to the Maasai population, a traditional pastoralist tribe who often come to the hospital at the last moment after all traditional remedies have failed. There is ongoing lack of trust between the local Maasai, the government, and the hospital. Nevertheless, we persisted.
Tanzanian experts in cervical cancer screening visited Wasso Hospital. They set up the clinic as a mirror of what is offered in the city. Through this, we realized the opportunity to also screen for breast cancer and to test for HIV.
How We Set Up the Program
Following World Health Organization (WHO) recommendations, we set up a bare bones screening technique. We applied household vinegar to the cervix and then a trained person identified pre-cancerous areas using the naked eye and a battery-powered head lamp. Women with pre-cancerous areas were treated using cryotherapy, a low-risk technique, right then and there. That saved them hours of walking back and forth to the clinic and lost time in their garden or caring for children.
The “ingredients” for a clinic like this are readily available in low-resource areas and do not require electricity. After years of study, WHO now sanctions the “see and treat” model in low resource areas, such as Ngornogoro District.
If You Build it, They Will Come
In 2016, we borrowed supplies, including carbon dioxide tanks and a cryotherapy device from the urban referral hospital, in order to keep costs down. And the women came!
They started lining up before the clinic entryway and stayed until 11 p.m. We had no idea how successful it would be. It was impactful, too. We treated women for pre-cancer, we made new HIV diagnoses, and we started women on anti-retrovirals. We referred women with suspicious breast lumps for mammogram. Women received education about health prevention, and we trained four hospital staff in the “see and treat” model.
Taking it to the Next Level
In 2017, with the generous support of the Eleanor B. Daniels Fund at the UVM Cancer Center, our team returned to Wasso Hospital with a cryotherapy device and funding to purchase carbon dioxide tanks as well as supplies to mobilize the clinic to two other villages.
We were joined by an incredible trilingual (English-KiSwahili-KiMaasai) interpreter as we traveled to remote areas where only the tribal language, KiMaasai, is spoken. With an innovative portable GYN exam table that folds into a backpack designed by Emily Ryan (UVM LCOM ’19), our team of Tanzanians and UVMers travelled over impossible roads and stream beds, learned how to change a tire without a working jack and that “shortcut” means something different to Americans than it does to Tanzanians.
The real meat, though, was the women who were served by the mobile clinic, the mothers who brought their sisters and their daughters and who waited patiently under shade trees for multiple hours to be seen. Even if they were not eligible for screening because of young or old age, they learned about the importance of cervical cancer screening and health prevention in general. Furthermore, the hospital staff who were trained in 2016, underwent a refresher course. They continue to provide services to the local women between our visits now.
2018 and Beyond
In April 2018, the UVM team returns to Wasso Hospital. Through joint priority-setting, we have agreed to expand the mobile clinic further. We will once again refresh the skills and knowledge of Wasso Hospital staff. With generous funding from the Laurence Coffin, MD Award to Alexandra Miller (UVM LCOM ’18), we will also add a targeted, culturally-appropriate educational component for Maasai men and women on health prevention and CACX specifically.
In 2014, neither I, nor the hospital staff imagined that all of this would blossom out of our partnership and that we would have learned so much through our interaction with each other. It is this type of friendship and collaboration along with the faces of the Tanzanian women that keep me thinking positively these days.
Anne Dougherty, MD, is an obstetrician and gynecologist at the University of Vermont Medical Center. She is director of the UVM Global Health Program. She is also assistant professor at the Larner College of Medicine at the University of Vermont.