At the end of 2015, MSc Public Health (2013) alumna, Dr Shalmali Radha Karnad single-handedly coordinated a county wide cervical cancer screening treatment camp for nurse midwives to try and address the problems of late diagnosis/under-screening of cervical cancer in Kenya. In this week’s alumni report Dr Karnad describes the programme and her experience of setting it up.
Cervical cancer has become the most common cancer in women of reproductive age in Kenya. Although it is relatively easily prevented and controlled through vaccination, screening, early detection and treatment of precancerous lesions, the majority of eligible women in the country have never been screened. In an effort to reduce the incidence, morbidity and mortality associated with cervical cancer, the Government of Kenya released the National Guidelines for Prevention and Management of Cervical, Breast and Prostate Cancers in 2012, the National Cervical Cancer Prevention Program Strategic Plan 2012-2015, and the National Cancer Treatment Guidelines in 2013, which include screening and treatment guidelines for cervical cancer. Despite this, no fully fledged national cervical screening program exists, and there is a lack of diagnostic and treatment capability within referral centers. Many women who are screened fall through the referral net and never obtain further care due to distance to referral facilities, cost, fear of stigmatization, and competing health (and other) priorities. The coverage of cryotherapy and Loop Electrosurgical Excision Procedure (LEEP) is low and, until recently, cancer staging and biopsy, a prerequisite to treatment, was only offered at Kenyatta National Hospital. Radiotherapy services are available in only four hospitals, all located in central Nairobi.
Partnerships for healthcare
I qualified as a doctor in 2007, and completed an MSc Public Health (Health Services Management) at the London School of Hygiene and Tropical Medicine in 2013. My personal experiences of the very structured system of cervical cancer screening, follow-up and call back in the US and the UK, my clinical experiences as a doctor performing cervical screening and colposcopy, and my interest in reproductive public health have fostered my deep commitment to improving cervical cancer service delivery.
I moved to Nairobi with my family in early 2013 and began working at Jacaranda Health, a chain of hospitals providing high quality, affordable reproductive, maternal, newborn and child health (RMNCH) services. My role included overseeing clinical quality within the facilities, training and skill-building of the staff, and exploring evidence-based, low cost interventions to improve care within the organization. Through this last objective, I was extremely fortunate to come across CureCervicalCancer.org, a US-based 501(c)(3) nonprofit “dedicated to the early detection and prevention of cervical cancer around the globe for women who need it most”. CCC.org train local frontline healthcare providers – nurses, clinical and medical officers, and doctors – to provide sustainable cervical cancer services using a single visit see-and-treat approach – cervical cancer screening, treatment of precancerous lesions with cryotherapy, and referral if required. Their “Clinic in a Suitcase” contains all the necessary materials for training, from gloves and tissues to cryotherapy guns, and the organization donate these materials to the trained providers to establish cervical cancer screening and treatment clinics. It is a simple, inexpensive, and impactful model.
Our conversations on partnering began early in 2015, and we faced two immediate challenges: changes in the tax regulations for donating medical equipment and supplies to Kenya, and difficulty in recruiting the number of patients required for the training – assuming a positivity rate of 10%, every provider would need to screen 100 women to identify and provide cryotherapy to 10 women during the training.
Again, fortune was on my side. The USAID-funded APHIAplus Kamili team in Kiambu County visited Jacaranda Health, and were extremely enthusiastic to partner for cervical cancer. They had identified EIGHT untouched and unused cryotherapy guns, including full tanks of CO2, that had been donated to public hospitals in the county but never used. The few senior staff who had been trained were either transferred or promoted, and no one remained with the knowledge and skills to use the equipment. For close to four years, this equipment lay dormant in dark storage rooms at the back of hospitals, while women in the county died of cervical cancer.
The team advised us on the tax regulations – which involved visits to the county health management team and Governor to obtain letters of support, and visits and numerous calls to the Treasury Department for letters of permission – and used their extensive network of community health volunteers to mobilise patients to attend the screening. In exchange, the training grew to include providers from four public facilities with unused cryotherapy equipment.
Shifting the Tide, One Woman at a Time
In early November 2015, CCC.org, APHIAplus Kamili and Jacaranda Health came together to train 16 providers from six public and private facilities in Kiambu County. With support from Ruiru SubCounty Hospital and Langata Githurai Hospital, we were able to integrate family planning counselling and method provision and HIV testing and counselling alongside the cervical cancer screening, leading to a huge influx of women at both facilities. For a full five days, the trainees rotated through three roles: registering the long queue of waiting women, conducting screening and cryotherapy, and cleaning and decontaminating the equipment.
A total of 680 women were screened for cervical cancer, 60 received cryotherapy, and additional 10-15 were advised to return at a later date (either due to personal choice, or clinical circumstances). Close to 100 more were provided family planning and HIV services. More importantly, 16 competent, confident, and committed healthcare workers are now available to continue to provide the skills they were taught.
To quote trainee and nurse Christine Mumo from Githunguri Health Center in Kiambu County “For the last two years I’ve had to refer about 50 women for cryotherapy to Kiambu County Hospital. I feel empowered by this training…. I am now able to not only screen women for cervical cancer but also treat lesions by cryotherapy. It is my feeling that now Kenyan women, especially from Kiambu county, will not die of cervical cancer.”
Images: Main image – The teams from APHIAplus Kamili, CCC.org and Jacaranda Health and 16 trained providers at the cervical cancer screening and cryotherapy training “graduation”
Image bottom right – Women queueing up at Langata Githurai Hospital in Kiambu County during the screening camp