Discovery Woes

Many of you may be wondering why I have yet to really write anything about my project. Well in truth, things are going along very slowly. The first week I was here, I spent two mornings at St. Paul’s Hospital observing Pathfinder’s reproductive health clinic for women infected with HIV. Every morning, men and women gather outside of the clinic and receive counseling about opportunistic infections seen in patients with HIV/AIDs, STDs and cervical cancer. Once the women were done with their regularly scheduled primary care visit, those that were recommended for screening headed on over to us. The VIA/cryotherapy clinic is in one room (I posted the picture earlier) run by three nurses. I became friends with two of them—Zewdu and Nisussu—as they walked me through the day-to-day schedule. Both thought I was hysterical because I kept writing things down and were even more amused by the way I hold my pen. Although they routinely laughed at my Farenji-ness, Zewdu was particularly sweet and regularly gave me hugs, telling me to stay in Addis. One thing is for sure, people here are amazingly friendly and welcoming even if they think you are ridiculous. Although the clinic at St. Paul’s has been up and running for two years, they just recently saw their 1000^th patient, which is a very small patient load considering the need. A big reason for this is due to the difficulty in advertising these services and having to rely on word of mouth. 

            The screening process takes about 15-30min per patient and is actually really simple. The whole idea of the project I’m working on is to provide a cost effective and acceptable method of screening for cervical cancer in low resource areas. Cervical cancer remains the second most common type of cancer and the leading cause of cancer related death in Ethiopia even though it is easily preventable and treatable when caught early. The US used to have similar statistics, but when the Pap smear was invented and we could screen for potential precancerous lesions, incidence rates of cervical cancer dramatically dropped. The method that we are implementing here is called VIA or visual inspection with acetic acid. It involves swabbing the cervix with regular table vinegar (read very cheap and easy to get) and to look for precancerous lesions that show up as white spots on the cervix. If lesions are present, you can utilize cryotherapy (what you use to remove a mole or wart on your skin) to freeze the lesion and kill the cells. VIA/cryo has been proven to be just as effective as the Pap smear in a study done by John Hopkins in Thailand and now several international reproductive health organizations, such as Pathfinder, JHPIEGO, and RHO, are doing implementation and feasibility studies around the world in low resource areas including Uganda and Kenya.

            What I am trying to do is facilitate the creation of a similar clinic as St. Paul’s at Black Lion, Addis’ largest public hospital and the main hospital affiliated with AAU (Addis Ababa University).  I am attempting to have this clinic in working shape and fully stocked by the time we try to start training the two OB/GYN physicians in charge of running the clinic in early August. I am confident that I can find the space and staff in that time, but my concerns include the duration of training warranted by JHPIEGO (the organization we are modeling after) and the availability of patients on which to train. The JHPIEGO manual dictates that training should either take place on a 7 or 10-day course with each day involving up to 7hrs of training. In Addis, doctors work maybe 2 hrs in the morning (not including the mandatory macchiato breaks), take a 2hr lunch, and then usually take the afternoon off or work another job, so I’m not sure how amenable they will be to sitting in a classroom for 7 hours. Additionally, we need patients to be regularly coming to the clinic from the start so that the physicians can practice the method and gain competency within a reasonable period of time. However, advertising, as I said before, is a really difficult concept here and takes awhile to really have a significant effect on patient numbers.

            This morning I met with Dr. Hezkiel Petros, one of the OB/GYN physicians that will be in charge of the clinic at Black Lion, to discuss these challenges. Our meeting was scheduled for 10am, but he did not show up until almost noon and had to leave after 20min. The sad thing is that I am not surprised in the least. The problem with the culture here is that punctuality nor accountability exists. No one answers their emails and no one has a voicemail so getting in touch with people is near impossible. I now understand why foreign medical students who come to Emory are the way they are. I used to laugh that my Egyptian medical student on my surgery rotation would take a two hour lunch break (lunch breaks are nonexistent at Emory for the most part), but now that I see surgeons heading for coffee rather than to the OR when they have two emergent cases, it makes a little more sense. The system is also entirely dominated by the idea of paternalism and the patients are seen as little more than cases to fix. Needless to say, we are all getting a little frustrated here. The struggle of working within this system every day is exhausting and wearing on us all. There is so much to be done but every minor advancement is met with such resistance and stonewalling that it can be easy to want to give up. Luckily, we are all in the same boat and can offer support to one another, but overall, the days are getting pretty long here in Addis.