Over 800 women screened for cervical cancer in East Africa mission

Eleven UCI School of Medicine Students Traveled to Tanzania to Conduct Cancer Screenings

Eleven first year UCI School of Medicine students, “Team Tanzania 2018”, traveled with Dr. Krishnansu Tewari, Professor of Obstetrics and Gynecology and Interim Director, Division of Gynecologic Oncology, this past July to Mwanza, Tanzania. This is the fifth student group from UCI to instruct and conduct ultrasound research at the Tandabui Institute of Health, Education, Science and Technology (TIHEST).

Justine Maher, now a second year medical student, led much of the planning for the cervical cancer screen-and-treat that was facilitated by the students who participated in the Tanzania trip. Justine learned about the Tanzania global health trip on her interview day at UC Irvine. She knew that she wanted to join if she was admitted. “Our team consists of 11 members, each drawn to the trip for their own reasons. For me, the trip’s longitudinal emphasis on women’s health was most important: alongside other projects, UCISOM students have facilitated cervical cancer screen-and-treats in Tanzania since 2016 and I wanted to play a part in expanding that work.”

Much had to take place in preparation for the trip. “In previous years, UCI teams had worked with an NGO alongside local providers but it was suggested to us that our year collaborate with only Tanzanian groups in an effort to make a more sustainable impact,” Justine explained. “Along with providing the momentum and (wo)manpower for the mass screen-and-treat, our team had to buy, organize, and transport all necessary supplies. With the guidance of the UC Irvine Institute for Clinical and Translational Science (ICTS), we reached out to UCI Gynecologic Oncology faculty and found invaluable team members in Dr. Diana Pearre and Dr. Krishnansu Tewari. Without their enthusiasm and support, our team would not have made the impact that we did. Between January and late May, our team worked non-stop to complete IRBs, fundraise ($16,591 total), practice ultrasound, as well as learn basic vision screening and become comfortable with visual inspection of the cervix with acetic acid (VIA)—all while completing our first year of medical school.”

A Record Number of Screenings

Dr. Tewari became involved in this trip after learning about it from Dr. Robert Bristow, Chair of the Obstetrics and Gynecology Department, who shared that this could be a very valuable experience for the department and encouraged Dr. Tewari to consider leading this year’s trip. The four-week trip had 3 main projects:

• The first three weeks were split between screening 300 children for basic vision and eye problems with the help of local optometrists and ophthalmologists, and teaching ultrasound anatomy to 62 students at TIHEST.
• The fourth week was the cervical cancer screen-and-treat at an urban health center (Buzuruga) and a rural health center (Sangabuye).

Justine and the other students received training prior to the trip using World Health Organization (WHO) and International Association for Research on Cancer (IARC) training resources. Furthermore, “In the weeks prior, we had countless meetings to finalize plans for the cervical cancer project. Once underway, Dr. Tewari, Dr. Anjali Hari (OBGYN resident at UCLA, UCISOM alumna), Megan Bernstein (MS4), and Shella Raja (MS4 and member of Team Tanzania 2016) took the time to teach both our team and local providers how to screen and treat pre-cervical cancer.” Dr. Hari and Megan have been a part of Team Tanzania’s work since they joined as MS1s themselves. Dr. Hari has returned annually ever since, and both came back in 2018 to run rooms for the screen-and-treat alongside Dr. Tewari and local staff.

The cervical cancer screen-and-treat clinic was accomplished in partnership with Buzuruga Health Centre, a public hospital. To inform the community about the clinic, the students advertised on the ground as well as rented a van with loudspeakers to inform the community. “In resource-limited settings, acetic acid (bought at the market) can be used to visualize pre-cancerous changes to the cervical epithelium, which are then treated with cryotherapy to freeze/kill the pre-cancerous cells and prevent progression to cancer,” said Justine on how they identified and treated any pre-cancerous lesions in patients. “This is a low-cost, high-yield way to reduce morbidity and mortality from the 4th most common cancer among women worldwide and the number one cause of female cancer in Tanzania.”

Over 800 patients were screened for cervical cancer and approximately 198 pre-cancerous lesions and 10 lesions “suspicious for cancer” were identified.* Of the 161 cryotherapy-eligible women with pre-cancerous lesions, 143 were treated immediately with cryotherapy.* Those with possible cancers were referred to a local cancer center. “In addition to the standard screening, we developed a risk factor survey in the hopes of learning more about what factors put women at risk for cervical dysplasia in Mwanza,” said Justine. “We also integrated educational videos in Swahili into our screening workflow: one video about cervical cancer itself and the other about their new national HPV vaccine rollout for 14 year old girls. Women were also tested for HIV—with 39 screening positive—and counseled as necessary.” Buzuruga Health Centre has already hosted two screen-and-treats in the month after the UCI team left.

Challenges

The trip had its share of challenges: “Although our two team leaders had Skyped with our longstanding community contact (Brother Erick Ogouta of the Church of the Nazarene) a few times, we were constantly emailing and trying to make detailed plans with people whom we had never met. If it weren’t for Brother Erick, who met with local healthcare providers on our behalf and helped garner community support for our work, this trip would not have been possible,” explained Justine. “Since these trips are largely student-run, the ability to “handoff” projects and information year-to-year is difficult—especially since MS2s are understandably dedicated to studying for USMLE STEP 1 while MS1s are planning their trips. In fact, many connections made in previous years were no longer relevant so we had to work hard to find new contacts or reconnect with others by finding their up-to-date information.”

The language barrier was at the root of most of their challenges. “Although Swahili and English are both official languages in Tanzania, being able to communicate directly in the native language would have been very helpful because most people with little formal schooling only speak Swahili (and/or tribal languages, as we learned),” said Justine. “A few group members tried to pick up some Swahili before arriving, only to found out that most educational resources teach Kenyan Swahili that is slightly different from that of Tanzania. We learned phrases here and there, but we relied heavily upon translators to iron-out logistics, collect data, and perform clinical duties, such as explaining results to patients or answering their questions.”

Dr. Tewari explained that the rooms for the clinic where the screen-and-treats were conducted were quite small and had broken, damaged or outdated equipment. In addition, there were only two cryostat probes that could be used and these needed to be cleaned for twenty minutes after each use.

“Lastly, it took some time for us to adjust to “Tanzania time”—meetings often run later than planned, et cetera,” Justine added. “We learned to embrace the meaning of the Swahili phrase hamna shida—“no worries” or “no problem”—and enjoy the ride.”

One of the most unexpected challenges, however, was the fact that the authorities at Kilimanjaro Airport confiscated the metal vaginal speculums, lubricant packets, patient drapes, and pregnancy tests that the students brought for the trip. The UCI-Tanzania collaboration is under a UCI Institutional (IRB)-approved protocol and the students told them that they were also going to conduct research which initially put a stop to everything. Fortunately, Dr. Juliet Wolford, a Gynecological Oncology Fellow, had developed 3-D printed vaginal speculums that were created after obtaining permission from the regulatory authorities to use them with patient consent. From Mwanza, Dr. Eugen Rutaisire of Buzuruga Health Center worked with the Tanzanian Food and Drug Administration to obtain all necessary permits and was able to retrieve the supplies in time for the campaign.

Lasting Impressions

Dr. Tewari’s first impression of Tanzania was that of a “beautiful country with amazing people who seem so happy with what little they may have.”  Justine was also affected by the natural beauty: “After traveling for well over a day, walking out of the airplane to see blue skies and a snowcapped Mt. Kilimanjaro was an unforgettable sight. In fact, we started our trip by climbing “Kili” as a group—and everyone made it to the summit! The trek was as beautiful as it was difficult, and it really helped us bond before working in Mwanza. The kindness and patience of our guides and the work ethic of our porters definitely set the tone for the rest of our trip, reminding us to be gracious and have fun even when cold, exhausted, and in pain.”

Dr. Tewari and Justine met so many incredible people during their time in Mwanza and explained how people truly went out of their way for them: “Brother Erick and his wife, Gertrude, welcomed us into their home from day one. Dr. Eugen Rutaisire flew to another city to bring back the medical supplies we fundraised to donate. Local politicians, like Richard Machemba whom previous trips had worked with, took the time to help us with anything communication-related, from negotiating document printing prices to bringing us church-to-church to advertise for the screen-and-treat and educate congregations about women’s health. Angeline Mabula, Member of Parliament for Ilemela District, heard about our work and made a TV commercial to promote our cause, even going so far as to come to Buzuruga to speak at the screening herself. Suzan Jeremiah, head nurse at Buzuruga, stayed late day after day to perform cryotherapy on women in need. Our translators worked tirelessly to fill out all forms, talk to patients, and make sure the screening ran smoothly. It also goes without saying that the women who were screened were brave, motivated, and patient.”

For Justine, her involvement in planning and executing the trip had a great impact on how she thinks about her future specialty. “I came into medical school with a background in public health and infectious disease, eager to delve into global health work. Unlike other group members whose interest in OB/GYN drew them to medicine, my interest in women’s health has grown dramatically since joining this team less than a year ago,” Justine said. “I feel so lucky to have had this opportunity, as it changed the way I think about my future specialty just as it shed light on the nuances of global health interventions. I hope to set up my clinical rotations in such a way that I can return to Mwanza to help with the screen-and-treat again. Beyond the clinical knowledge I gained, this trip taught me how to build meaningful relationships across culture and language, stay flexible in the face of logistical hurdles, and trust that with enough effort and collaboration, anyone can make a difference. These are not things that can be taught in a lecture or absorbed from review books. They have to be experienced first-hand.”