Four doctors  and a midwife are gathered around an examination table in the center of a bright pink examination room in the back of a community health center. While one has just finished carefully applying a vinegar-and-distilled water solution to the cervix of the 35-year old woman on the table, the others are waiting to see whether the solution changes the  color of the cervix. Any noticeable, clearly defined white patches could indicate pre-cancerous cells are developing. They wait about a minute and a half before, shining a small flashlight into the cervix, they determine, with some discussion, that there are no visible pre-cancerous lesions. They’ve already explained to the woman what possible results could mean, and now they reassure here that based on this simple test, there are no signs of pre-cervical cancer, and she need only be screened again in a few years to make sure she is still healthy.

This particular woman, out of the 17 total we saw in the course of  the cervical cancer training, was one of the majority who had a normal test result. But there were also a few women with abnormal cervical changes. This doesn’t mean cancer; it doesn’t mean that all these women are gravely ill, or that they will necessarily become so. But it does mean that they need follow up to ensure that any abnormalities that do persist are treated—and without this simple screening, using common household substances under the direction of a trained doctor, midwife or other health worker, the abnormalities could, over time, become cancer.  And in the vast majority of confirmed cases of invasive cervical cancer here in Mali, the woman will die.

Cervical cancer impacts women in developed and developing countries alike, but in developed countries the widespread availability and use of cytologic methods of screening–ie, our good old annual Pap smears–have greatly reduced the impact of the disease. Deaths due to cervical cancer are rare in these countries simply because the disease seldom has the chance to progress that far–it can take ten years or more for true invasive cancer to develop, and most women will have been screened at least once during that time and treated for any pre-cancer. While a basic understanding of cervical cancer and particularly the link between HPV and cervical cancer is still not as widespread as it should be even in the most affluent countries, regular screening has made its distinct mark on rates of cervical cancer. While in the States the disease once accounted for the greatest number of deaths among women of all cancers, today its incidence is less than 8 per 100,000, with a death rate of less than 3 per 100,000, according to the CDC.

But most women in the developing world will never walk into a doctor’s office for the Pap smear that most women in America have access to. Most Malian women will never have heard of the human papillomavirus, and will have no idea that such a common virus with no symptoms slowly and silently kills over 1,000 women in Mali each year. The WHO estimates that about 1491 women in Mali will be diagnosed with invasive cancer annually, and 1010 of these women die. The incidence rate is about 24 per 100,000 women, so about three times that of the rate in the States.

These are all statistics that are interesting to me in and of themselves–because of the link between cervical cancer and HPV infection,  high rates of HPV infection in the general population, as well as the overall preventability of the disease, cervical cancer is one type of cancer that requires a public health, population approach and not merely greater access to complicated  and expensive, and often ineffective, treatment. There’s no magic; we need to screen more women, we need to screen them at regular intervals and treat positive cases early, and we need to increase awareness of HPV at a community level. As a PCV working primarily in preventative health, cervical cancer and HPV seem like problems we should be talking to people about–in much the same way we discuss with women the advantages of screening for STIs and having regular pre-natal checkups. So why aren’t we?

I started asking myself this question after hearing of the work of another volunteer, who had organized a cervical cancer training for health workers in 2010 in the Cercle (District) of Kita, next door to my Cercle of Bafoulabe. I remembered vaguely a discussion about cervical cancer in the developing world that occured my senior year of college in one of my public health courses. I had heard a little about the method of visual inspection, and thought it was interesting.  But I never really thought of how I could incorporate that into my PC service. Peace Corps is so grassroots, after all, and a problem like this really requires some expertise, not a good-hearted and really interested, but non-medically trained, volunteer.

But hearing about how Kita District hospital doctors had collaborated to train their colleagues at the primary CSCom level made me consider the possibility. This training seemed like a way to take part in a broader movement to increase awareness of the disease by starting at the lowest level–the staff at the rural health centers. Mali is surely a long way off from being able to systematize Pap smears, which are far too expensive and require laboratory facilities that simply don’t exist at the local level. But visual inspection is a low-technology alternative, and it’s feasible here, since even non-doctors, if well trained, can perform it. And with a current screening coverage rate of about 3% in the rural areas….well, anything we can do is an improvement over the current situation.

 Over the course of discussing the process with other volunteers,  and gauging the knowledge and awareness level of the staff at my CSCom (zero),  at some point I decided this was something I actually wanted to work on. So I finally called a district hospital doctor I’d met a few times with this idea, not certain whether it would go anywhere. Then….whirlwind meetings, trying to explain myself in French (blah is all I have to say about that), budget snafus, running around in search of speculums in Bamako, scheduling headaches, more budget snafus, and here we are. Fast forward 4-5 months later, and I’m standing here in this pink exam room, the visual screening being practiced before me.

This is just a start, a small first step. We provided a basic training–covering the natural history, risk factors, and relevant anatomy of cervical cancer, in addition to the process of visual screening– to around 60 health personnel, a good proportion of the CSCom doctors and midwives in the circle, but not all. And if we ever hope to make cervical cancer an important issue in the circle, it’s going to require continual supervision by the district hospital staff and support to the CSComs in implementing screening campaigns, and on-going training. Then there’s the issue of even getting women in the door for testing; we had one participant during the practical session refuse to be screened because male doctors would be doing the inspection. So the issue of stigma around reproductive/sexual health issues is very real, especially since most women have never ever heard of HPV or CC. And, assuming women do accept the screening, we haven’t even begun to address issues of  local access to treatment for those women who need it, which is perhaps the biggest burden and most significant missing link in the chain. There is much, much to do;  and, me being, well, me, of course I think about all these things. Some barriers we can maybe do something about (sensitizing women at the village level about the importance of screening, working with the CSRef doctors on including Cervical cancer activities in their supervision). Others–mainly appropriate local access to treatment–involve bigger questions, partly dependent on national health priorities. But who knows.

Whatever the future possible challenges,  it does feel good to have played my own small part in laying the groundwork. The overall success of the training was due entirely to the hard work of the doctors who supported the project and agreed to serve as trainers. They spent many hours putting together content, organizing materials, and settling logistics. Still, I’m happy to have been along for the ride, to see this offhand idea blossom into something bigger than I imagined myself being able to play a role. I think most PCVs want to have something, some specific project or work area, that they are excited about in their service, something that they hope they’ll be able to leave memories with–and I’ve found it, surprisingly, in this.

Whether some of the health workers are inspired to use their new skills and start implementing village screenings…..well, that remains to be seen.  I have my hopes, but whether this training ends up being more than just consciousness raising and actually inspires real action is anyone’s guess.  I suppose in all development work there is this sense of, “okay, you’ve been guided this far, now make of it what you will.” We trained the doctors and midwives, we gave them all of the necessary medical equipment to do the screening (speculums, placental probes, and iodine/acetic acid), and –maybe– inspired a few to want to use what they’ve learned.  We can only hope. I know that there are a ton of healthcare priorities and challenges facing Mali, and cervical cancer is just one of them, perhaps not high enough on the list when we consider malnutrition, maternal mortality, malaria and the laundry list of health challenges in rural Mali. Still, it’s an injustice that so many women die here of a disease that has become so well-controlled in richer nations. And it’s a problem we can do something about. So let’s try.

 The commentary of one doctor who participated in the first volunteer’s training in 2010, and also came for this one, helped me to take heart: he went from having no knowledge whatsoever of the problem, to implementing village screening campaigns at his previous health center, to wanting to continue these activities in his position at a different center. So some, at least, are taking notice. Not all, but some.

Maybe, slowly, we’ll get somewhere.