PINCC: El Salvador and Peru

Posted by Tara Hulbert, MD  (a fourth year OBGYN resident from Kaiser Permanente, Oakland while on a global health elective in San Salvador, El Salvador and  Puno, Peru with Prevention International: No Cervical Cancer PINCC).

International healthcare carries many ethical challenges.  Seven guiding principles have been developed to address these challenges: mission, collaboration, education, service, teamwork, sustainability, and evaluation.

During my recent strip to El Salvador and Peru, I experienced the truly sustainable nature of Prevention International No Cervical Cancer (PINCC) and how this organization follows the seven guiding principles of international healthcare.  The mission of PINCC is to create sustainable programs that prevent cervical cancer by educating women, training medical personnel, equipping facilities in developing countries, utilizing proven, low cost, accessible technology methods.

What makes PINCC strong is their collaboration with each individual country’s ministry of health to establish a long-term collaboration.  This allows the healthcare professionals we train to be available for the weeks when PINCC comes.

My first week in San Salvador was spent working with healthcare professionals who had been trained by PINCC during several trips over the last 5 years. The goal of our education program during this visit was to help the already trained healthcare providers to teach other providers, the “trainees”, in the World Health Organization’s “See and Treat Method” of cervical cancer screening.  This is esentially a naked eye colposcopy where any lesions seen can be treated or followed up in the same visit.  In low resource settings when patients often have considerable challenges in getting to a clinic, this method can significantly reduce a women’s risk of getting cervical cancer with only one clinic visit.

Our group spent one day rehearsing how we would train the “trainers” with challenging clinical scenarios.  As a resident, I am an active trainer and trainee, which contributes to my understanding of the importance of  adequate teaching.  We observed approximately 20 “trainers” throughout the week assessing their ability to teach the trainees.   We gently guided them to ask their trainees clinical questions rather than give up the answer, have patience while the trainee struggled through the procedure, and knowing when to take over when it was clinically appropriate for the patient’s comfort or safety.

We had a great week and the ministry of health put on a ceremony at the end of the program. We certified five trainers and felt that the group was strong enough to continue the training process on their own, thus completing PINCC’s mission in El Salvador.  The plan is to continue checking in every 3-6 months with decision for another visit dependent on their progress and maintenence of the program.

PINCC’s program director and I then headed off to the mountains of Peru where we would meet another group of volunteers.  At an altidude of 12,000 feet,  I immediately felt short of breath and palpitations as my body acclimated.  After arrival, we met with the new group of volunteers and were greeted by our hosts.  This was PINCC’s initial visit to Puno so we all braced ourselves for a challenging week.  The first day we were greeted by over 40 excited students invested in women’s health and anxious to start the process of reducing cervical cancer in the area.  The students were  nurse midwives along with a few doctors from the surrounding areas.  We spent the first few hours going through the basics of cervical anatomy, the progression of cervical dysplasia, and the evidence behind and purpose of VIA (Visual Inspection with Acetic Acid).   The challenges of the week included altitude adjustment which was impossibleto ignore,  figuring out a way to teach a large amount of  students in an effective manner, and recruiting patients to screen!  Our hosts in Puno did a great job with advertisement and by the end of the week, we had over 100 patients waiting outside the door to be screened. At this point, we had found an efficient way to make sure all of our students learned what they needed to start the process of getting certified to perform VIA on their own.  We didn’t certify anyone that first week, but we developed the structure needed to come back later and continue the training. Our students inspired us with their tenacity and eagerness to learn.  It was clear they were truly dedicated to their community and patients.  This kept us motivated during the long work week and PINCC is very excited to start a longstanding program with the community.

Our week was full of great Peruvian food and friends.  We ended our week with a night out with the trainees singing Karaoke and a wonderful day trip on Lake Titicaca visiting the famous islands.

My second trip with PINCC proved to be more inspiring than the first.  I witnessed the full process of the training program from Puno where we met with brand new students to El Salvador where we finished the training program after PINCC visits for the last 5 years.

Optimism, Hope, and Satisfaction

6/27/11

Posted by Tara Hulbert, DO (a second year Ob/Gyn resident from Kaiser Permanente, Oakland serving a global health elective in Jalapa, Nicaragua with Prevention International:  No Cervical Cancer (PINCC)).

The first day is always chaotic.  That is what Carol, the Prevention International No Cervical Cancer (PINCC) director told us.  I felt myself relax and remembered why I love working abroad.  We come with goals and ideas of how we want to help and make a difference, but the local environment will ultimately dictate the work done.  And the environment is difficult to predict. PINCC has a successful track record of working in many different countries in a variety of settings, so this “chaos” is something written into their agenda.  I had come on the trip with Dr. Gupta, one of my own OB/GYN attendings who is fluent in Spanish and well-versed to international work.  So I knew whatever the day and trip would bring, there would be plenty of support.

Briefly, PINCC is a unique, truly sustainable educational NGO that focuses on bringing the World Health Organization’s “see and treat” method for preventing cervical cancer to different communities worldwide. In developing countries, cervical cancer is the leading cause of cancer mortality in women – which is in stark contrast to the rare incidence of this disease in developed countries which illustrates how preventable it really is.  This method is important where pap screening programs are not possible due to cost, resources, and access.  PINCC strives to bring these methods to local doctors and nurses with rigorous training and close follow-up over several years.  The volunteers on my leg of the trip had just returned from San Salvador where they watched a PINCC trained and certified local doctor training several other medical personal from around the community in a busy clinic.  Some of the volunteers had been to the first trip several years prior where that doctor was first being trained.  It was an emotional moment for them as they were truly seeing the sustainable nature of PINCC’s work.

The first day’s agenda included reviewing VIA (visual inspection with acetic acid), with the attendings and residents from the local OB/GYN residency program and then we would see about 40 of the pre-screened women with difficult cases from the community.  Some of these doctors had already been trained and certified from PINCC. This is what makes PINCC so unique and special – the follow through which ensures that the education and training is being practiced. Once we started seeing patients, I was assigned a few local doctors to work with. As a resident, my job was to observe how they went through the steps of VIA and chose the appropriate treatment and follow up. I surprisingly felt comfortable with my limited Spanish giving my opinion on diagnosis and plan. I worked closely with my own attending and medical director for any questionable cases. We worked with this same group of doctors the rest of the week, did cryotherapy and LEEPs (both treatments for cervical dysplasia), and put on educational sessions with the residents including simulation labs with the LEEP machine. The week ended with a wonderful evening out on the town with the PINCC volunteers and dancing with all the Nicaraguan doctors we had made friends with.

VIA training

The second week proved to be much more challenging.  We trained primary care doctors from outlying towns for the first time. The VIA method takes a lot of time and practice to become proficient, which became very clear with this new group of doctors.  I also learned how much misinformation the patients were getting about cervical cancer and HPV, the unnecessary worry and stress over vague lab results, the difficult situations and distances these women had faced coming to the clinic, and how challenging filling prescriptions and getting lab results was.

The rest of the week was spent doing lectures and seeing patients with this lively group of doctors.  Dr. Gupta and I were exhausted every night but we were rewarded by the motivation and progress of the group.  The PINCC volunteer group was amazing and absolutely devoted to the project which helped to make our work as providers seamless.

In conclusion, my global health experience with PINCC was everything I hoped it would be. Most work trips I have done in the past have left me wondering if I really made any difference at all.  This trip was different. I understood I was part of a process, a meaningful process that would help to transfer a specific life-saving skill to the hands of the local doctors that could and would help to save many women’s lives from a preventable cancer.  And I left with optimism, hope, and satisfaction that PINCC was truly doing something positive in every community they touched and I was honored to be a part of it.  My self growth was also very apparent throughout this trip and was very fortunate to accompany and learn from Dr. Gupta, who is an inspiring obstetrician/gynecologist devoted to global health, on this trip.  I look forward to being a future PINCC supporter and volunteer in the future.

Me, Dr. Gupta, and fellow PINCC volunteers