In 2014 I took my first trip to Kenya. After my plane landed in Nairobi I rode for 10 hours with my medical colleagues to Bungoma, a town on the western edge of the country. We set up our clinic in the local hospital and then spent the week training local healthcare providers on a technique called ‘Visual Inspection with Acetic Acid (VIA)’. This is an inexpensive method to screen for cervical cancer and pre-cancer in low resource settings using vinegar. As a part of the training we screened 189 women for cervical cancer in that week.
The Papaniculou (pap) smear was revolutionary in cervical cancer prevention. The incidence of cervical cancer in the United States has decreased from 14.8 cases per 100,000 women in 1975 to only 6.5 cases per 100,000 women in 2012.
However, despite this relative ease of screening for cervical cancer it is still a health crisis in less developed countries. Worldwide, approximately 500,000 new cases of cervical cancer and 274,000 deaths are attributable to cervical cancer yearly, making cervical cancer the second most common cause of death from cancer in women.
Ninety percent of all cervical cancer deaths are in developing countries. Women die at an alarming rate from cervical cancer in places like Kenya and El Salvador. The countries in Africa, Central America, and similar countries around the world have a multitude of problems that make screening challenging: Difficulty with accessing qualified people to perform a pap smear, poor infrastructure leading to difficulty getting the smear to a lab, and few pathologists trained in reading the pap smear once it arrives.
The VIA technique strives to alleviate these barriers to women’s preventive health care in low resource settings. It is a see-and-treat method which does not require much technical skill and it also makes a pathologist superfluous to the screening process. More importantly data shows that it is effective in decreasing rates of cervical cancer in a screened population.
Unfortunately, in the United States we are at risk of moving in the wrong direction on this statistic. In House Republican efforts to roll back Medicaid expansion, repeal the Prevention and Public Health Fund, and threatening an increase in premium while decreasing subsidies, the American Health Care Act (AHCA) could gut much of the preventive health care coverage that was mandated in the Affordable Care Act.
An amendment proposed by U.S. Rep. Tom MacArthur would allow states to opt out of federal essential health benefits requirements for exchange plans and create their own requirements, reducing access to preventive health services even more.
Making good on one of his campaign promises, just weeks ago President Trump signed a bill to remove an Obama-era regulation that blocked states from defunding health care providers for political reasons. This rule, signed in the last days of the previous administration, specifically protected Planned Parenthood clinics from losing Title X funds. This funding provides grant money to clinics that play a critical role in ensuring access to a broad range of family planning and preventive health services for low income women.
The remaining community health centers that receive funding would have to absorb an additional two million patients when Planned Parenthood clinics inevitably close.
Over the past 50 years the cervical cancer death rate has dropped by 50 percent. Currently, death from cervical cancer is exceedingly rare in a well screened population. Tellingly, we see higher rates of cervical cancer in women who come from countries with a less developed health care system and also in low income women from the United States who are uninsured or poorly insured.
Recommendations for pap smears have changed since they started being commonly used to screen for cervical cancer. Though the pap smear has historically been a part of the annual exam, over the past 10 years the American Society for Colposcopy and Cervical Pathology (ASCCP) has begun recommending less frequent screening, in most women every 3 to 5 years, making this bit of preventive care one of the least expensive and most effective ways to prevent a devastating disease.
When I was a new doctor in Memphis I took care of my first patient with stage four cervical cancer. She was a 47 year old single mother and had two teenage sons. She had worked two jobs to support her family and despite years of symptoms had only been diagnosed after she was able to get Medicaid coverage. Her disease had recurred after radiation therapy and a radical hysterectomy. It recurred again after a second surgery to remove most of her internal organs. She was admitted to the hospital as she lay dying because the metastases to her bones caused so much pain her symptoms could only be managed with a complex cocktail of narcotic medication. It was not peaceful.
Americans have forgotten things that people in other countries live with every day. In our world of easily accessible pap smears, mammograms and colonoscopies we don’t see that with just a few changes in policy we could return to those days when poverty and bad luck could lead to death from a disease that could be easily prevented. Barriers to care in less developed countries are certainly different than those in our country that is flush with money and infrastructure. But any barrier leads to the same outcome, an increase in suffering and death from preventable disease.
Dr. Ilana Addis is an associate professor in the Department of Obstetrics and Gynecology at the University of Arizona College of Medicine, chair of the Arizona section of the American College of Obstetricians and Gynecologists and a Tucson public voices fellow with The OpEd Project.