This is an overview of a visit to St. Albert’s Mission Hospital from Oct. 30 to Nov. 7, 2014. I was there with Dr. Lowell Schnipper of Beth Israel Deaconess Medical Center and Harvard Medical School, to learn how we can further help St. Albert’s cervical cancer prevention project. Dr. Schnipper is collaborating on the project with Better Healthcare for Africa (BHA) and with Dr. Julia Musarir, director of St. Albert’s, and Dr. Neela Naha, obstetrician and gynaecologist, and director the prevention program.
St. Albert’s initiated the prevention project 1 August 2013 with support from several sources: equipment provided by the United Nations Population Fund (UNFPA), training provided by the Zimbabwe Ministry of Health and Child Care, a grant from the Serita Kenedy East Foundation to Dr. Schnipper and BHA, and donations to Better Healthcare for Africa.
The program has screened nearly 2,000 women from its beginning on 1 Aug. 2013 through 31 Oct. 2014. The findings include:
- 102 women showed changes on the cervix that were probably pre-cancerous (i.e., they were VIAC-positive); many of these cases were treated with cryotherapy or cone biopsy to prevent them from becoming cancerous;
- 32 women had lesions that were possibly cancerous (officially categorized as “suspicious for cancer”); for these cases, a biopsy is taken and sent to a laboratory in Harare to determine if the lesion is cancerous or due to infection or other noncancerous cause;
- 20 percent of screened patients were HIV-positive, and 11 percent of these were VIAC positive.
- An added benefit of the program: The cervical exam reveals previously undiagnosed noncancerous conditions such as cervical polyps, cervicitis, and schistosomal infection. Many of these women received treatment for their conditions, which were determined to be resolved at follow up visits.
The VIAC clinic
The clinic is located in a small room in the hospital’s new outpatient clinic building. We arrived an hour before the clinic opened, and women were already queing up on benches in the hallway. We examined the VIAC equipment and reviewed VIAC images of cervical findings on a computer screen with two VIAC nurses and Dr. Neela Naha, the obstetrician/gynecologist at St. Albert’s. (You can see many of them here.)
VIAC Clinic Power Problem
Zimbabwe has rolling electrical blackouts that leave the hospital and the area around it without electricity for many hours at a time. During our visit, the hospital experienced daily power outages (for three days from 6:30 a.m. to 9:30 p.m.), and it’s not unusual for the hospital to be without power for 15 hours or more at a time.
And when power was lost, the VIAC clinic to shut down. Women who came for screening then have to wait for the electricity to return. Some leave and don’t make the long journey again.
Parts of the hospital are backed up by solar power. (The hospital also has a backup generator for critical needs, but it is used sparingly to conserve diesel fuel and because spare parts are difficult to obtain when it breaks down).
To solve the problem, BHA provided funds to equip the clinic with solar power. An email from Dr. Musariri in mid-December said that installation of the system was complete, and the VIAC clinic could continue see patients during power outages.
VIAC outreach initiative
The VIAC outreach initiative is needed because some women living in remote areas cannot travel to the hospital.
It will bring cervical screening to three of the 11 rural health centers overseen by St. Albert’s: Mazarabani, Hoya and Chadereka. The last, located near the border with Mozambique, is one of St. Albert’s most distant rural health centers. (Rural health centers are basic clinics staffed by nurses and overseen by the hospital.)
We worked with Dr. Neela and VIAC staff to plan how best to conduct the effort, set to begin in 2015. It was decided that the team would visit each clinic monthly, rather than weekly. This allows the team to:
- Work with the hospital’s other outreach programs, such as the community home-based care and the male medical circumcision programs, on how best to share the one available vehicle;
- Gauge demand for VIAC screening in those rural areas;
- Assess unforeseen logistical challenges.
Once under way, the effort will be reviewed to determine if greater frequency is needed and is possible.
Three meetings during the 2014 trip
At the Zimbabwe Ministry of Health and Child Care
Dr. Naha from St. Albert’s, Dr Schnipper and I met with Dr. Collen Madembo, director of VIAC training for Zimbabwe; Dr Anna Nyakabau, radiation and medical oncologist with the Ministry and at Parirenyatwa Hospital; and Mrs. Muchaneta Mandara, representing the Ministry’s office of Reproductive Health.
- The officials encouraged Dr. Neela to move forward with the outreach effort.
- All agreed that the lack of treatment for patients with advanced disease remains a big problem, with no good solution at this time.
- Neela and Dr. Nyakabau worked out a way to improve the referral of women from St. Albert’s to Parirenyatwa Hospital in Harare (120 miles away) so that management decisions can be made during the patient’s initial visit, making the process less burdensome for the women.
With the Provincial Medical Director
We met with Dr. Clemence Dzidzai Tshuma, the Provincial Medical Director for Mashonaland Central at his office in Bindura. He also encouraged the VIAC outreach effort.
We met with Dr. Edwin Mpeta, programme specialist in reproductive health, for UNFPA in Zimbabwe.
UNFPA had generously provided the equipment that St. Albert’s needed to establish the hospital’s VIAC clinic and continues using today. Dr. Neela updated Dr. Mpeta on the St. Albert’s VIAC program and presented the planned 2015 VIAC outreach project. A decision about whether UNFPA will provide equipment for that effort is pending.
Visit to Karanda Mission Hospital
Early one morning we drove to Karanda Mission Hospital about 80 miles from St. Albert’s to meet with Dr. Paul Thistle, an obstetrician/gynaecologist. We discussed developing a closer working relationship between Karanda and St. Albert’s and possibly collaborating on VIAC screening. In particular, the expertise at Karanda in surgical therapy of cancer may provide an alternative referral site for St. Albert’s patients with early-stage disease who have lesions that can be treated with radical hysterectomy alone.
We bought two bags of donated medical supplies to the hospital. These included 219 sutures from Global Links, suture and other medical supplies from Brother’s Brother Foundation, and suture and additional supplies from a third donor. A third bag contained children’s books and a few dolls the pediatric unit and other items for the doctors.
Last, here are four patients who were undergoing treatment at St. Albert’s during our stay. They are examples of the kinds of cases the doctors at St. Albert’s must treat with few resources.
- 38-year-old woman with breast cancer. Her tumor had ulcerated and created a raw cavity the size and depth of half an orange. She strained to inhale. Perhaps there was fluid in her chest compressing her lungs or a tumor mass inside her chest. In the U.S.A., a CT scan would have immediately identified the cause, and doctors could relieve it. But imaging is not an option at St. Albert’s, so one of the two young doctors, Dr. Tapiwa Dhliwayo, who are currently at the hospital inserted a needle in the hopes of relieving the pressure. If not done right, the needle could puncture a lung, but Dr. Dhliwayo carried out the procedure safely. Only a small amount of fluid drained from the chest, however. The unfortunate woman died three days later.
- A child, age 13, with a compound fracture of the femur that occurred when she was run over by a scotch cart.
- Child with a compound fracture of the left femur caused when he fell from a scotch cart.
- A newborn boy found abandoned along the road was brought to St. Albert’s before we arrived. The infant’s head was swollen due to hydrocephalus. The child needed a shunt to relieve the pressure on the brain and reverse the swelling. The surgery could not be done at St. Albert’s but it could be done at Karanda Mission Hospital about 80 miles away at a cost of $300. A visitor who happened to be at St. Albert’s donated $150 toward the expense, and a group of students at St. Albert’s secondary school raised the remaining money. The surgery was a success, and infant was back at St. Albert’s during our visit and doing well. Melania Nymakuwa, director of community programs at St. Albert’s, was working to identify an orphanage that would care for the child.
All in all, it was a busy and productive visit!
Stay well everyone…Darrell