The most recent data from Nepal around Cervical Cancer screening looks more encouraging, showing better outcomes in terms of prevention (click here for latest info). However, the monsoon season is currently affecting figures as people cannot travel for treatment. As we prepare to bring 4 nurses and doctors from Nepal for additional training in November we re-visit this article published in 2009.
First published in the Royal College Of Obstetrics And Gynecology International News – March 2009
Cervical cancer is a major cause of death and morbidity among women of reproductive250,000 women die each year of the disease. The consequences to the extended family are immense as it is usually the women who hold the family unit together. In the West, we are seeing less of the disease and the major burden is in the developing world. This ‘hidden’ disease is frequently advanced on diagnosis and treatment is often not available. This first report highlights the work of the UK charity PHASE and its collaboration with doctors in Nepal. Gerda Pohl, a GP from Rotherham and trustee, writes.
Since June 2006, a group of UK colposcopists, coordinated by PHASE (Practical Help Achieving Self Empowerment) Worldwide, has been working with Nepalese colleagues in Kathmandu. We work to increase the capacity of Nepalese centres to prevent, diagnose and treat cervical intraepithelial neoplasia (CIN) and cervical cancer. The mortality from cervical cancer is just one of the many problems of Nepal, the second poorest country in South Asia and 12th poorest in the world. Because of its unique geographical situation, landlocked between its two large neighbours, India and China, and with very few natural resources (the one exception being hydropower) and decades of poor governance and violent conflict, there has been very little progress in Nepal’s development in recent years. Its health indicators are among the worst in the world: maternal mortality 281/100,000; mortality under 5 years 61/1000 (these figures are much higher in the rural areas).1
The burden of infectious diseases is still high, but non-communicable diseases are slowly entering the focus of public health. Cervical cancer is the most common female cancer in Nepal. In the UK, most women present with stage I or II disease and survival rates are around 80%. In Nepal, most women present when symptomatic in stage III and IV and mortality is over 80%. As the disease mostly affects women in their late 40s and early 50s, when they are usually the person holding the extended family together, this has devastating effects on their families, too.
The Nepal Network for Cancer Treatment and Research (NNTCR) started screening programmes for cervical cancer several years ago, using visual inspection of the cervix with acetic acid and Lugol’s iodine (VIA/VILI) as a low-cost, effective screening method.
As women who were screen-positive were referred on for diagnosis and treatment of CIN and early cancers, it became apparent that there were too few facilities for minimally invasive treatments in Nepal and many women had unnecessary hysterectomies for CIN. At this stage, the cooperation between PHASE and the NNCTR started, financially supported by the British Society for Colposcopy and Cervical Pathology and by private donors. This is a cooperation with seven hospitals in Nepal which are committed to cervical cancer screening and prevention. Three times since June 2006, consultants and nurse colposcopists from Rotherham and Dewsbury, and later Nottingham City Hospital, have visited Kathmandu for one-week workshops where women who were screen-positive were called for further treatment: After a theory day, which has always been very well attended, the UK consultants teach Nepalese gynaecologists hands-on in colposcopy and minimally invasive treatment methods.
In between workshops, four Nepalese doctors have visited the UK for a few weeks to gain insight into the workings of a well-organised national screening programme and to collect ideas they can take back to their respective hospitals. We have also been able to contribute extra colposcopes, which are given on loan to participating hospitals. In the two and a half years since the first workshop, great progress has been seen in the services of several participating hospitals and the learning and the training continues to date.
There are still many problems to overcome before most women in Nepal will have access to cervical screening: most relate to the difficulty of accessing the rural population. It is very hard to support qualified staff in remote locations and to transport equipment and supplies. Even supplying larger hospitals with colposcopy equipment can be problematic, as there is no budget for it. We are also still looking for a supplier of cervix coagulators in India or Nepal. But there is progress, too. Recently, the Family Health Division of the Ministry of Health in Nepal has convened a technical working group to develop a national policy for cervical cancer screening and prevention. The main problem this group has to address is how to roll out screening facilities to reach a significant part of the rural population.
Most of the doctors who are members of this working group have been involved in the PHASE/NNCTR cooperation.
PHASE Worldwide is a small charitable organisation based in Rotherham. With our partner, PHASE Nepal, we work to deliver high-quality primary care services and to improve the health status of remote communities in Nepal. We are also adding our voice to all those advocating for better government services. Many of the communities in which we work are more than three days walk from the nearest road and families depend mainly on subsistence farming and seasonal migratory labour. PHASE projects include providing staff and materials for the deserted health posts in remote places. PHASE staff see about 300 patients a month on average but they also conduct home deliveries, deliver antenatal and postnatal care, health education, family planning, vaccination programmes, tuberculosis diagnosis and treatment; they support village sanitation and toilet building programmes and make a huge difference to public health in their working area.
An important aid to the health work is a set of clinical guidelines in Nepali language for firstline health workers in remote rural areas. This is highly appreciated by the staff of PHASE and two other organisations who have access to them and they are about to be printed and distributed nationwide.
1. Ministry of Health and Population Nepal, New ERA, Macro International Inc. 2007. Nepal Demographic and Health Survey 2006. Kathmandu, Nepal: Ministry of Health and Population, New ERA and Macro International Inc; 2007 [/FR191/FR191.pdf].