Cervical Cancer Detection in Zimbabwe: A Scalable Solution
It always inspires us to talk with people like Dr. Lowell Schnipper, an oncologist who is running a cervical cancer detection initiative out of St. Albert's Mission Hospital in Zimbabwe. The work of this team emphasizes prevention, ultra low-cost methods and an emphasis on building local capacity. Cervical cancer hits women of childbearing age and puts families at risk of losing their mothers. We interview Dr. Schnipper here:
## Can you set the stage for us? What was the standard of care for cervical cancer treatment and detection?
Until recently there has been very little cervical cancer screening in Zimbabwe. Fewer than 10% of women have have been in a regular program of cancer screening, and my guess is that most of these are in the private sector. Several years ago the Ministry of Health developed an ambitious plans for screening for cervical cancer throughout the country employing a technique called Visual Inspection with Acetic Acid and Cinematography (VIAC). There have been trainings for medical staff (physicians and nurses) across the country; to my knowledge the program has not been widely disseminated for reasons of lack of funding for appropriate personnel. Thus, one would say that the idealized standard of care in the country is to screen women between the ages of 21-65, but to my knowledge this has not happened except at the largest hospitals.
## How many women do you see in the catchment area? What is the incidence and prevalence of pre-cervical lesions? of cervical cancer?
The St. Albert’s Mission Hospital is an Interim District Hospital that serves a population of approximately 129,000, of whom 23,000 are women of child bearing age. Cervical cancer is the number of killer of women from cancer in this country account for approximately 1300 deaths per year. The prevalence of the disease in Sub-Saharan Africa is 34.8 new cases and 22.5 per deaths per 100,000 women annually from the disease. By contrast in North America there are 6.6 new cases and 2.5 deaths per 100 000 women
## Why did you choose St. Albert's? It has a unique, self sufficient campus-- can you tell us about that?
I learned about St. Albert’s when I was convalescing from a major surgical procedure that was undertaken urgently, within days of my return for Zimbabwe from what was a wonderful holiday. I was in the most remote areas of the country, and it occurred to me that were I to have taken ill while there, the outcome, return to completely normal health, might have been very different. Concurrently, an article appeared in the Sunday NY Times in December 2010 depicting a Zimbabwean woman with a bag of peanut on her head over the headline peanuts for healthcare in Zimbabwe. The inequities in distribution of health care throughout the world (and in the US) were apparent. I resolved to become active in this area and try to have an impact.
Step one was to roll all our end of the year donations to the hospital the woman in the Times article was going to, when my wife suggested we search out another, her reason being that the Times' publicity would likely generate donations for the institution that was publicized. I “Googled” hospitals in Zimbabwe and came upon St. Albert’s Mission Hospital, and selected it because there was a US based contact person heading an NGO that supported the hospital. I contacted Darrell Ward of Better Health Care for Africa, made a donation to a midwifery program, the focus of the hospital’s most urgent need, and asked what the hospital does for cancer patients (I am an oncologist). I was sent a photo of a woman with a large jaw tumor and a baby on her back and was told she was sent home-they were unable to treat her. At that moment, my resolution was predicated on the assumption that if they cannot treat cancer once it has presented the optimal approach is to prevent it. Hence, the development of the cervical cancer screening program that has been developed in conjunction with physicians and nurses at St. Albert’s. To get started I wrote a proposal for funds for an education and screening program. An award was granted by the Sarita Kennedy east Foundation. Thus far we have screened 3300 women over 15 months, have found many pre-cancers that have been treated (and hopefully cancer prevented), and discovered a number of advanced cancers that were sent to the university hospital in Harare for an attempt at treatment. In its second year, the program is now being distributed to outlying rural clinics that St. Albert’s staff oversee as well as at the main institution.
St. Albert’s is a most special institution. It is staffed by four physicians, two of whom are members of the Italian Medical Association, many nurses and practice assistants, and the Director is Dr. Julia Musariri. The hospital is located in Centenary, Zimbabwe in the north of the country. It has a large amount of land under cultivation, all made possible by a dam that has enabled a system of irrigation that is sufficient to grow maize that provides the basis for ZaZa, the food staple in the country. In addition many other vegetables are grown along with raising pigs, chickens, goats and cows. Its commitment to becoming self-sustaining includes the use of solar energy to supply electrical needs, and installation of a bioreactor that will convert waste into usable gas.
## What has your interaction with the Ministry of Health been like?
After conceptualizing the screening project, and before applying for funds, I felt it important to visit with officials at the Ministry of Health to be sure they would be comfortable with the program we were planning at St. Albert’s. We met with the Deputy Director of the Department of non-communicable disease who was very supportive of the effort since it was quite similar to the program being implemented at a national level. We have had subsequent meetings to inform the ministry of our progress to date and again, were well received. In addition, I met with the District Medical Officer of the Ministry of Health for the region covered by St. Albert’s and he too was supportive of our expansion of the program to another hospital were we able to procure funds. Alas, the funds are severely limited in Zimbabwe. In addition to the Ministry of health we have interacted with and received generous assistance from the UN Population Fund (UNFPA) in the form of equipment with which to perform the cryoablation and the digital photography.
## What would it take to scale the VIA screening nationally in Zimbabwe?
The goal of an effort such as ours is to coordinate with the Ministry of Health and assist where possible in extending this life saving activity. VIA is a very inexpensive procedure and one that has shown positive results in under-resourced nations. This screening procedure does not require a physician, nurses, and in some nations, health workers have been trained to do it. A very positive innovation that Zimbabwe has implemented is the use of cinematography, i.e.,photographing the suspected lesion using a digital camera. This enables the lead physician at St. Albert’s to review the areas that are observed to be abnormal by nurses performing the test, and give the “go ahead” or not to proceed with treatment using liquid nitrogen (cryoablation).
In the aggregate it requires investment of resources in the form of training personnel and purchase of modest amounts of equipment to implement the program.
Thus, the program is ready to go were there to be the resources to make that happen.
## Can you set the stage for us? What was the standard of care for cervical cancer treatment and detection?
Until recently there has been very little cervical cancer screening in Zimbabwe. Fewer than 10% of women have have been in a regular program of cancer screening, and my guess is that most of these are in the private sector. Several years ago the Ministry of Health developed an ambitious plans for screening for cervical cancer throughout the country employing a technique called Visual Inspection with Acetic Acid and Cinematography (VIAC). There have been trainings for medical staff (physicians and nurses) across the country; to my knowledge the program has not been widely disseminated for reasons of lack of funding for appropriate personnel. Thus, one would say that the idealized standard of care in the country is to screen women between the ages of 21-65, but to my knowledge this has not happened except at the largest hospitals.
## How many women do you see in the catchment area? What is the incidence and prevalence of pre-cervical lesions? of cervical cancer?
The St. Albert’s Mission Hospital is an Interim District Hospital that serves a population of approximately 129,000, of whom 23,000 are women of child bearing age. Cervical cancer is the number of killer of women from cancer in this country account for approximately 1300 deaths per year. The prevalence of the disease in Sub-Saharan Africa is 34.8 new cases and 22.5 per deaths per 100,000 women annually from the disease. By contrast in North America there are 6.6 new cases and 2.5 deaths per 100 000 women
## Why did you choose St. Albert's? It has a unique, self sufficient campus-- can you tell us about that?
I learned about St. Albert’s when I was convalescing from a major surgical procedure that was undertaken urgently, within days of my return for Zimbabwe from what was a wonderful holiday. I was in the most remote areas of the country, and it occurred to me that were I to have taken ill while there, the outcome, return to completely normal health, might have been very different. Concurrently, an article appeared in the Sunday NY Times in December 2010 depicting a Zimbabwean woman with a bag of peanut on her head over the headline peanuts for healthcare in Zimbabwe. The inequities in distribution of health care throughout the world (and in the US) were apparent. I resolved to become active in this area and try to have an impact.
Step one was to roll all our end of the year donations to the hospital the woman in the Times article was going to, when my wife suggested we search out another, her reason being that the Times' publicity would likely generate donations for the institution that was publicized. I “Googled” hospitals in Zimbabwe and came upon St. Albert’s Mission Hospital, and selected it because there was a US based contact person heading an NGO that supported the hospital. I contacted Darrell Ward of Better Health Care for Africa, made a donation to a midwifery program, the focus of the hospital’s most urgent need, and asked what the hospital does for cancer patients (I am an oncologist). I was sent a photo of a woman with a large jaw tumor and a baby on her back and was told she was sent home-they were unable to treat her. At that moment, my resolution was predicated on the assumption that if they cannot treat cancer once it has presented the optimal approach is to prevent it. Hence, the development of the cervical cancer screening program that has been developed in conjunction with physicians and nurses at St. Albert’s. To get started I wrote a proposal for funds for an education and screening program. An award was granted by the Sarita Kennedy east Foundation. Thus far we have screened 3300 women over 15 months, have found many pre-cancers that have been treated (and hopefully cancer prevented), and discovered a number of advanced cancers that were sent to the university hospital in Harare for an attempt at treatment. In its second year, the program is now being distributed to outlying rural clinics that St. Albert’s staff oversee as well as at the main institution.
St. Albert’s is a most special institution. It is staffed by four physicians, two of whom are members of the Italian Medical Association, many nurses and practice assistants, and the Director is Dr. Julia Musariri. The hospital is located in Centenary, Zimbabwe in the north of the country. It has a large amount of land under cultivation, all made possible by a dam that has enabled a system of irrigation that is sufficient to grow maize that provides the basis for ZaZa, the food staple in the country. In addition many other vegetables are grown along with raising pigs, chickens, goats and cows. Its commitment to becoming self-sustaining includes the use of solar energy to supply electrical needs, and installation of a bioreactor that will convert waste into usable gas.
## What has your interaction with the Ministry of Health been like?
After conceptualizing the screening project, and before applying for funds, I felt it important to visit with officials at the Ministry of Health to be sure they would be comfortable with the program we were planning at St. Albert’s. We met with the Deputy Director of the Department of non-communicable disease who was very supportive of the effort since it was quite similar to the program being implemented at a national level. We have had subsequent meetings to inform the ministry of our progress to date and again, were well received. In addition, I met with the District Medical Officer of the Ministry of Health for the region covered by St. Albert’s and he too was supportive of our expansion of the program to another hospital were we able to procure funds. Alas, the funds are severely limited in Zimbabwe. In addition to the Ministry of health we have interacted with and received generous assistance from the UN Population Fund (UNFPA) in the form of equipment with which to perform the cryoablation and the digital photography.
## What would it take to scale the VIA screening nationally in Zimbabwe?
The goal of an effort such as ours is to coordinate with the Ministry of Health and assist where possible in extending this life saving activity. VIA is a very inexpensive procedure and one that has shown positive results in under-resourced nations. This screening procedure does not require a physician, nurses, and in some nations, health workers have been trained to do it. A very positive innovation that Zimbabwe has implemented is the use of cinematography, i.e.,photographing the suspected lesion using a digital camera. This enables the lead physician at St. Albert’s to review the areas that are observed to be abnormal by nurses performing the test, and give the “go ahead” or not to proceed with treatment using liquid nitrogen (cryoablation).
In the aggregate it requires investment of resources in the form of training personnel and purchase of modest amounts of equipment to implement the program.
Thus, the program is ready to go were there to be the resources to make that happen.
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