Every year around 300,000 women worldwide die from cervical cancer. In the U.S. it's closer to 3,000 and that number should soon decrease due to the new Gardasil vaccine. What makes the difference? Pap smears...one the most effective screening tests for cancer. If you catch it early, which is totally possible with annual pap smears, then a straight forward colposcopy and possibly a LEEP can basically take care of the problem. However, once cervical cancer spreads things become much more complex. In much of the developing world annual pap smears simply aren't possible (food and water may be a higher priority) and so many cases are caught when they are much more advanced and the options are limited. Although Gardasil is great and could soon almost eradicate HPV in the U.S. (as long as we start vaccinating boys too) it will never have that much of an impact on our cervical cancer numbers because they are already low due to all the pap smears (maybe too many pap smears...apparently with the liquid prep that is more accurate and now most frequently used you only need to be screened every other year meaning that at the clinic where I was working and most everywhere else women are actually being over tested, not that there's any downside...just a little more cramping...but it could be seen as an unnecessary waste of resources). Where Gardasil could have a major impact is if it was available to women around the world at a reasonable price. Now that would really be something.
I've just finished up my OB/GYN rotation, survived (hopefully) the NBME test and the OSCE and sat through another meeting on ethics, one of our competencies for this rotation. The core ethical principles are all important...Beneficence, Nonmaleficience (hopefully most doctors aren't setting out to do harm) and Autonomy (I think this is a much bigger deal in the U.S. then elsewhere). Those are all well and good and you constantly deal with them on a case to case basis, but the one I think really deserves more attention is Justice. Treating individuals according to what is fair, due, or owed to them. And this is where the whole conversation explodes. I would argue that everyone in this country is entitled...yes, ENTITLED...to a certain basic level of health care. It sure seems self evident to me...but obviously there's a very vocal group who disagree. On a related note, rest in peace Ted Kennedy, I wish you could have stuck around to finish the fight. But health care reform is a topic for another day, what I really want to talk about is Women's Rights.
So yesterday I had my annual gynecologic exam which seemed a fitting way to end the rotation. Doctors in general might be better informed if they had to go through all the things they do to their patients (not that they should undergo needless operations, but being a patient gives you a whole new perspective). For convenience I went to the clinic where many of the patients we had seen at Methodist get their care...it's open to people without health insurance and serves a different population than the private clinic where I worked the past two weeks. You can definitely tell the difference. I mean, it was totally adequate, I got my pap smear and my birth control prescription which was all I needed anyway, but that was really it. No comprehensive physical exam or extended chat about how life's going. Which is fine, I didn't want that anyway. But it would have been nice to get a proper blood pressure reading (if only my BP was 100/61, but I guarantee it isn't, not by a long shot). And no pelvic exam? No breast exam? I don't mind that it was a midwife and not a doctor, but I started to mind the wait. Still I was receiving care and that's a vast improvement over much of the world.
On my half hour drive to the clinic I've been listening to "A Thousand Splendid Suns" by Khaled Hosseini and it really got to me...in a driving down the highway with tears streaming down my face kind of way. Not that I thought things were rosy in Afghanistan (we'll see what happens with the recent undecided election), but seriously. Women have no where to turn for help if they are stuck in an abusive relationship. Hell, they can't even walk outside alone. Unfathomable. In one of the most wrenching scenes the main character has to have a C-Section without anesthesia because there's none in the women's hospital where she's forced to go. That's just crazy. CRAZY. I saw 11 C-Sections in my month on OB/GYN and trust me, when someone yanks your uterus out of your body and sews it back together you don't want to feel it.
The New York Times recently ran and article, "The Women's Crusade", which touched on many of these issues and some of the ways change might be possible. Maternal morbidity and mortality around the world, especially in Africa, is out of control. No one should have a one in ten chance of dying during child birth in their life time. That has serious ramifications for the economic prosperity of a country...and it's just ridiculous. Of course, many of these countries have horrible things going on beyond the disgusting treatment of women...but implementing programs for proper health care for women and children seems like a sensible place to start. Last summer when I was working with Mayan Medical Aid in Santa Cruz La Laguna, a Mayan village in Guatemala, we were all about prenatal care and women's health. It gives you the best chance to start out little children on the right foot and hopefully bring about transformation of a community. Give mothers protein and proper baby brain myelination will follow. Provide education for children with well myelinated neurons and you can change the world!
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