Story: At the End of the Path

Dona Cielo walks up the steep path to the village of El Cua thinking about the women she will visit. She works as a community health promoter, encouraging women from these remote communities to travel for a full day to be screened for cervical cancer using a fast, effective, low resource method. Cielo knows that cervical cancer, while it affects individuals, is a community disease, killing women in the prime of their lives while they are major breadwinners and still raising children,.

El Cua is a small village of xx people in the northern highlands of Nicaragua where some of the world’s best specialty coffee is grown. The cervical cancer screening is being sponsored by the coffee cooperative, and is saving the lives of these individual women and the community, for pennies. Dona Cielo’s first priority is women like Dona Elena, the woman at the end of the dirt path.

When Dona Cielo arrives at Dona Elena’s home, she is busy cooking tortillas for her family. Her oldest daughter is helping her and caring for the little ones who play at her feet. Elena is 35 and the infant strapped to her back is her 7th child. Each of her days is so full of caring for her children that it is hard to imagine leaving to travel five hours for a simple medical test, but Cielo tells her that the community has organized childcare and help with chores. She is healthy though, it is her two year old son who has recently had a high fever. Elena looks around her home, small but tidy, and remembers her friend and neighbor who died of cervical cancer four years ago. Cielo tells her that caring for her own health is one of the most important things she can do for her family and for a moment Elena believes her. Elena agrees to go to the screening, and they set a time and place for her to pick up the bus to the clinic in Matagalpa next week. The bus fare will also be paid for by the coop.

On the day of the campaign and Elena wakes up at three to make the tortillas to leave with her daughter for the family’s breakfast. Before the sun rises, she slips out of the house and joins two of her neighbors as they walk three miles down the path to the main road where the bus will pick them up at six. If Elena hadn’t seen her neighbor die from cervical cancer, she probably wouldn’t be making this five hour journey today, but the memory of her friend propels her forward.

Elena arrives at the clinic at 9 o’clock and finds almost one hundred women queuing up for numbers to register. It’s going to be a long day and she’s glad she packed a few tortillas. She sees Dona Cielo in the crowd. Cielo is helping with the registration, finding women seats, and answering questions.

Finally, just before lunchtime, it’s Elena’s turn to be seen. The clinic courtyard is a noisy place with women talking, children playing or crying in turns and women being called into various exam rooms to be seen. Elena leaves the noise of the courtyard and enters the quiet of the exam room. She has never had a pelvic exam before and she’s nervous. She is greeted warmly by the local doctor, Doctora Paula, who will do her exam and also by the American volunteer Doctora Susana, who is here with the group, Grounds for Health, mentoring Dra. Paula today. Dra. Paula is learning a new, simple, low-cost but effective technique for screening for cervical cancer called Visual Inspection with Acetic Acid, or VIA, that can be done even in the most remote areas. The total cost of the exam is just twenty-three cents, an amount of money that Elena could imagine, an amount that is sustainable for her community. Dra. Paula is happy and excited to share this information with Elena, carefully explaining what she will do and what her results will mean. The simple test, which uses a vinegar wash on the cervix, can reveal the presence of abnormal cells, possible precursors to cancer. If the test is positive, Elena can receive rapid treatment this very day with cryotherapy, or freezing. This simple, yet effective procedure takes only 15 minutes and requires no anesthesia.

Dra. Paula asks Elena if she has any questions and then invites her to undress. After the exam, Dra Paula tells her that her exam was normal and congratulates her for taking good care of her health. Elena is relieved and happy. She is also tired. It’s already been a long day. But as she boards the bus for the 5 hour trip back to her home she feels content and somehow proud. She’s glad she made the effort to come.

January is Cervical Cancer Awareness month, and while we, as Americans, don’t think of cervical cancer as a threat, 95% of the world’s women who don’t have access to the Pap test, part of our regular care, remain in danger of early unnecessary death from this common killer of women. In fact, cervical cancer is the number one cause of cancer death for women in most countries, killing more women than even childbirth in countries like Nicaragua.

The good news is that this is a problem with a solution. Thanks to the efforts over the past two decades by the World Health Organization, with funding by the Gates Foundation, we now have the tools to bring early detection and preventive treatment to even the poorest women in the most remote communities in the world. Dubbed the “Single Visit Approach”, the combination of Visual Inspection with Cryotherapy, has been shown to be as effective as the Pap test in detecting early pre-cancerous changes, and making treatment available on the same day eliminates the major barrier of making that arduous trip more than once, a requirement that often means no treatment for even those women fortunate enough to receive screening.

Grounds for Health, a non-profit organization that partners with coffee cooperatives Grounds for Health has been working for the past 15 years with coffee farming communities to address the high rates of cervical cancer found in these rural populations. Our experience working in partnership with coffee cooperatives is that engagement of the community is an essential element to resolving the barriers to access that women universally face. By establishing a health initiative under the umbrella of the coffee cooperative – a trusted community presence to which the coffee producers already feel allegiance – a critical hurdle is already overcome. When the co-op invests resources in a women’s health issue, especially a silent one like cervical cancer, the impact can be even greater. We currently have program sites in Mexico, Nicaragua and Tanzania where we partner with coffee cooperatives, Ministries of Health (MoH) and other NGOs to develop an effective and sustainable community-based model that significantly improves access to information and care.

Research predicts that if every woman had access to this effective yet low-resource appropriate care, even once in her lifetime, we could reduce the rate of cervical cancer by more than 30%. Seems like a good place to start.