My Work in Kenya: Cervical Cancer Screening

I’m working with a pilot cervical cancer screening and prevention (CCSP) program in a rural area of Kenya on the shores of Lake Victoria.

I first became interested in this topic while working in Moshi with Minjeni Women’s Group (some of you may recall the original ‘moshi moments’ stories). During that time, I learned that cervical cancer – one of the few highly preventable cancers with early screening!!! – is the leading cause of cancer death in women in Eastern Africa. And no one knows. So women get diagnosed when the cancer has reached advanced stages and all that can be offered is palliative care. Oftentimes even getting palliative care is a challenge. So women are dying. They are dying painfully. They are dying unnecessarily. They are dying without anyone saying a word. And when you hear a story like that, it’s hard to forget.

I couldn’t forget. Throughout medical school, it kept coming back to me. We had tried to link women in Moshi to screening services, but the screening services were practically non-existent. We failed. But I couldn’t forget. In medical school, I got involved with some research examining provider’s knowledge of the HPV vaccine, I joined forces with a similarly crazy med student to start a women’s clinic offering pap smears to homeless women (and now trying to offer Garadasil, the HPV vaccine), and I kept thinking about the women back in East Africa dying of a preventable cancer.

It only seemed natural that when I started to look at research fellowships back in Africa, that I would hone in on cervical cancer screening projects. And so I found my way into a research project in Kenya run through Family Aids Care and Educations Services (FACES), a partnership between UCSF and the Kenyan Medical Research Institute. I received funding through the Doris Duke Clinical Research Fellowship and launched myself into a year dedicated to improving cervical cancer screening in a little place on the lake.

So that’s how it all started. Now I’ll tell you a bit about what I’m “supposed” to be doing and what I’m actually doing. For the fellowship, I designed a study to look at how we can improve patients’ understanding of cervical cancer screening and thus improve screening uptake. My study design is a randomized control trial of an educational intervention. That’s a fancy way of saying that I am dividing women into two groups – one group gets a short health talk about cervical cancer and the other group doesn’t. Then we compare the two groups by surveying them about their knowledge and attitudes and then checking to see who ultimately goes for screening. It’s a simple idea that I spent months pouring over the details of how to execute. And then I spent several more months waiting for approval to start my project.

See, all clinical research must first be reviewed and approved by an ethical review committee before it can commence. This is generally a good thing. It serves as an important check to ensure that patients are not being put at undue risk for harm and that they are properly consented about any research in which they participate. Unfortunately, it can also be the bane of a researcher’s existence. The waiting game in Africa is notorious and naturally, ethical review is no exception. So I have spent the first three-quarters of my fellowship (yes, 9 months) waiting. Waiting is not so bad when you know you have to wait. What is challenging is the continuous string of “tomorrows”… the anticipation that approval is just around the corner… the frenzies of preparation that are ultimately wasted. As the cycle repeats itself, you finally learn to stop preparing, to stop expecting. And when you finally release your expectations, a subtle calm creeps in and a way forward emerges.

For the last several months, I have been visiting our screening sites. I’ve mainly been learning how to drive on insane 4WD roads and fix my car when it breaks - seriously two of my biggest accomplishments this year. I’ve also been trying to understand what is going on at our screening sites and trying to provide support and ideas for improving screening, but never launching into full-blown program management mode because every other week I thought I’d soon be pulled into full-blown researcher mode. And then a little over a month ago, I gave up. I fully released this idea that my intended study would ever start. And I ramped into program evaluation and improvement mode.  I started thinking more long-term, more big-picture. And I loved it. I don’t regret my first several months here. I think my expectations of starting a study helped keep me in a place where I was able to observe, build relationships, and slowly understand the reality of the barriers to screening. I found myself pulled into the service delivery challenges at the various health facilities – the systemic challenges of inconsistent supplies and staffing shortages that chronically plague the health-care system in Kenya. I stumbled upon the science of program implementation.

So I am now in full-blown program evaluation mode, trying to figure out how a small research-based screening program can be scaled up and ultimately be incorporated into a national screening program. Big dreams. It will take time. But I’ve learned how to wait… until tomorrow. In the meantime, I’ll practice driving through the mud.