Blog from El Salvador 2011

Entrance to the clinic

Patients waiting for their exam

Patient waiting with her son

Patients waiting to be seen

Entrance to the clinic

Clinic nurses checking in patients

Patient intake and checking in

Dr. Laura Shiller teaching medical student

Bedside supplies for VIA can easily be carried to remote areas without road access

Dr. Veronica Lerner in exam room

Salvadorian doctors trained in VIA

Salvadorian trainees gather around Carla, salvadorian doctor who works for Basic Health

Basic Health intern Emma Dominguez helps with patient flow and specimen processing

Checking pap smears of patients that could not get VIA

Checking patient records at the end of the day

Trainees taking an end-of-training test

Trainers, Trainees, Basic Health Staff and Suchitoto Clinic Staff

The Trainers

In April 2011, Dr. Veronica Lerner traveled to El Salvador as a part of a Basic Health International team for a week-long delegation to train local providers on a technique of cervical cancer screening called VIA.

This page shares photos and a summary of the trip provided by Dr. Veronica Lerner. You can also read more at the Basic Health Blog.

I guess I could consider myself a BH (Basic Health) "veteran" since I sort of lost track of the number of times I have been there, but I think this is my 4th or 5th time. My first trip was in 2008, shortly after I met Dr. Miriam Cremer (founder of Basic Health) after I started working at NYU School of Medicine.

My first experience with international work was as a fourth year resident at Mt. Sinai, going on a surgical mission to San Pedro Sula in Honduras. It was a large group of surgeons who volunteered their time to perform surgery on patients who would have never gotten it otherwise or had to wait a long time because they could not afford it. Although I love operating more than anything else, and felt good taking care of patients who needed their surgery but could not get it, after starting on my own as an attending I was looking for something different. I felt that sustainability was missing - after we left, many more patients remained with no one to take care of them.

Getting involved with Basic Health hit the spot. It is an amazing organization that started with nothing 10 years ago (well, at that time, Miriam did pap smears in El Salvador and carried them back to US in her luggage so that a pathologist could read it) and now blossomed into a well-run NGO with an office in El Salvador and in the US, incredible support staff, and an immense amount of valuable and pertinent research.

Medical students are often taught that cervical cancer screening is the best success story in the history of medicine, which I find somewhat ironic because I think it brings out one of the greatest examples of social injustice. There are several reasons why pap is so effective. A pap smear can detect HPV, which is a common sexually transmitted virus for which now there is a highly effective vaccine which prevents cancer and pre-cancer (the vaccine by the way, costs $800 in US and $200 in ES, and Salvadorian government pays only $2 per all vaccines its citizens can get). The pre-cancer is very slow growing and can be detected by pap smears, and treated by a simple minor outpatient procedure. Even if cancer develops, it is very slow-growing, and again, pap smear can pick it up and hysterectomy can cure it. Even in more advanced stages, radiation and chemo are effective. Since pap smear was invented over 50 years ago, rates of cervical cancer in developed countries have plummeted. In the rest of the world, however, it is the most common cancer in women and it is on the top of the list as a cause of morbidity and mortality! How could this be?

This is where politics and the issue of social justice butts into medicine. Cervical cancer is a disease of poor women, no matter where you look. In the US, it is lack of access to care (no insurance-no pap smear) or inability to access care even if it is available (fatalistic view that explains why women do not get screened when/if they could). Most women newly diagnosed with cervical cancer in the US have not had a pap smear in the last 5 years. Of course, a lot can be done in the US to improve this situation. And in other countries... Well, in "developing" countries-where does one start?

When Miriam first came to ES (El Salvador), the country was in ruins. It has recently been through an incredibly bloody and ruthless civil war that destroyed most of what little resources it had. One of the women she met in the beautiful little mountain village of Arcatao was in her 30s and dying of cervical cancer. The reality of health care in ES is that there are not enough doctors to do pap smears, there are not enough technicians to read them, there are not enough gynecologists to do evaluation of abnormal paps, and there are not enough surgeons to do hysterectomies. There is a certain stigma to cervical cancer as well, in a conservative catholic society where women's reproductive (or any) rights are not a priority, and in remote rural communities, husbands often prevent their wives from getting a gynecological exam saying that "a doctor might take advantage" while in reality, they just want control, the "barefoot and pregnant phenomenon". This is also a country in which abortion is entirely illegal, including rape cases and cases where the mother would die if pregnancy continues. On top of that, many women cannot get to the doctor because they cannot afford to take a day away from their jobs and families or because do not have money to travel to their clinics; if they do get a pap smear, they never return to find out the results; if they return they cannot afford to follow up on the abnormal result and get proper care. As a result, the cervical cancer rate in ES is one of the highest in Latin America and in the world. And, as a result, this woman with several small children, was dying in her home from metastatic cervical cancer without any pain medication (palliative care does not exist for those patients), bleeding, infected, a death that could have been entirely prevented with a simple pap smear that a third year medical student can do!

The mission of Basic Heath is to train local providers (nurses and primary care doctors) in a simple technique called VIA (visual inspection with acetic acid) which can be done anywhere: clinic, remote area, hospital - and does not require special supplies or surgical skill. Instead of doing a pap (which is a swab of cervical cells that is placed on the slide that a pathologist can then read), it uses a "see and treat" one-visit approach instead of the "screen" then "biopsy" then "treat" approach used in the US (pap, colposcopy biopsy, treatment) which requires multiple steps and multiple providers. VIA is a simple speculum exam during which acetic acid (vinegar) is placed on the cervix, turning abnormal areas white, which then allows for immediate treatment with cryotherapy (which looks like a toy gun connected to the gas tank) right then and there if abnormality is found. Of course, there are limitations to this technique, such as a higher false positive rate and tendency to over-treat low-grade lesions (in other words, some women might get treated that did not need it), but as a result, women who need treatment will get it.

Basic Health started out with sending large delegations of US doctors to ES each year to screen and treat hundreds of women, but now the focus is on training local doctors on how to do it and on creating support systems for them in case they run of supplies or resources. There is a ton of behind the scenes work (dealing with the government, making sure women get proper follow up), organizing delegations that goes on year around. What is even more exciting, is that Miriam and her team are working on incorporating rapid HPV test into VIA technique which should improve its accuracy. There is a lot of talk about that on this trip, as well as the new study BH is about to roll out comparing 2 different types of gas (NO-expensive and CO2-cheap) used in cryotherapy. I learned a lot about "resource allocation," conducting research in the developing world, challenges of fundraising and sustainability, expansion, cultural differences and barriers in this process...

Unlike other NGOs that involve this technique of VIA, Basic Health has also made a commitment to take care of women with cancer found during delegations. Since VIA can only treat pre-cancer, women with cancer (who would have been left to the mercy of the system, which in ES would mean no treatment because most women cannot afford to pay for it to travel to the one and only hospital to get their hysterectomy and the one and only cancer institute to get their radiation) are well-cared for and get free housing, transportation and all care because of Basic Health support. This makes me feel better because each delegation finds several women with cervical cancer, although deep down I know that each woman treated means hundreds not screened (the ethics of this are mind-blowing...try coming back to the US after this and discussing end-of-life issues on a terminally ill patient in ICU). This week, we found 3 cancers in 3 days, one of whom was my patient. She was a 45 year old who managed to get her pap smear in a local clinic which came back as "Adenocarcinoma", but was not able to follow up on it because she could not afford to travel to the referral center. Now she will get her care... This is not a typical story because most women with cancer that we find have visible lesions and have never had a pap, not even a gynecologic exam.

I land in the airport, whisk through customs (you have to push a green button that says "go" in order to pass the security guard... I am still wondering about the purpose of that!) and pay a $10 entry fee. A wave of heat and humidity hits me the minute I leave air-conditioned inside... But what is more striking is a ton of people waiting for their loved onces who are arriving... As people trickle through, hugs, kisses and tears are everywhere. Not something you would see back at JFK in New York... A lot of Salvadorians returning today work in the US and send money home, and are not able to come back often... In fact, we meet so many women during screening whose husbands have been in the US for years, sending money home and not able to return because they are undocumented!

We get picked up by an old BH driver who is smiling at us and greets us happily. BH is big on the "security" of the doctors and staff... On my first trip to ES I was surprised to see a security guard with a gun accompany us everywhere, but now I am so used to it... Security at hotels, the airport, the beach with guns....

I immediately changed into flip flops, a tank top and shorts and happily stuff myself with papusas on our way to Suchitoto. Papusas are difficult to describe, but I can tell you they are not low fat or low calorie. They are delicious!

This time, we traveled to Suchitoto, a lovely sleepy colonial town in the hilly mountains of central ES about one hour away from the capital - San Salvador. If it was not for the murals on the walls, bullet holes and portraits of Che here and there, the thought of a bloody civil war would have not crossed anyone's mind. They are silent reminders that this region really suffered during the war, children being killed in front of their mothers... But now the roosters are happily greeting the next day on my morning run through the cobble stone streets of this tiny town sitting on the hill overlooking the lake.

By the time I get to the site, it is already evening, and I meet other BH doctors and staff. There are 3 US doctors and 2 Salvadorians and we all hang out and talk, catch up at dinner. They are lovely people and we have fun with each other. We also meet 3 Salvadorian medical students who come to help, translate, and learn VIA. The government requires them to do 3 months of "social" medicine where they learn skills needed to take care of the underserved when they are done. They are required to work for a year after medical school ("social year") to give back to their communities as primary care docs...

The next 4 days of work are routine. The clinic is set up with 4 exam rooms, one trainer and 2 trainees per each room. Patients are brought in by the "health promoters", amazing community leaders who tell women about our "campaign" and line them up to see us. We start at 9 am, and work until 3-4pm until everyone who came in is seen. My Salvadorian trainees are adorable: a family doctor and a gynecology doctor, and they are a pleasure to work with. One of them needs a little extra help, but he gets up to speed by the end of week. Each day we rotate, so that trainees get exposure to different styles and trainers. It is a very warm working environment: we often consult each other, and if one finds a "lesion", other trainees get to see it so that everyone gets the most out of the training, with the patient's consent, of course. Patients are shy at first, but we start chatting and then it is like everywhere-doctor and patient....They are happy to see us, thank us for coming to help, and give us hugs. Some of them bring things for us to look at as a "second opinion", ultrasound reports stuffed into their bras, questions about their fibroids.... Some women get IUDs which we place for them during the exam. A lot of women are on Depo, but IUDs are gaining popularity as well...

On our first day, we see over 20 patients in my room and do one cryo. This is pretty typical, although the next day we have 2 cryos and one cancer.... The week goes by so fast! At the end of the week, as a group, we screened 380 patients, treated 14, and referred 5 cancers for treatment... It feels like a drop in the bucket given that a total of 2 million women of reproductive age need screening and so far BH has screened a little under 10,000 women. However, we are training local doctors, and hopefully the fire will spread...

The next thing I know I am at the airport again, boarding my plane and trying to catch up on work. But I am coming back in November. The dates for the next delegation are already set. Until then, ES!