epidemiology

It's been interesting what diseases occur here and don't occur here.  I have seen no coronary artery disease and no lung, breast, or colon cancer, although that may be partly because we lack the imaging or procedural technology to catch the cancers early (CT scanning, mammography, colonoscopy).  However, I have seen multiple women with cervical cancer, something I never saw in the US.  It is on the differential diagnosis for any woman with a watery vaginal discharge, especially if she is HIV-positive.

Pap smears, the common screening tool used in the developed world to detect early pre-cancerous cervical changes, are hard to do on a regular basis here since it requires sending off the obtained scraping to Lusaka for pathology results some three months later.  It requires an infrastructure for following up and treating abnormal results as well, which is hard to put into place.  And it simply isn't part of women's thoughts for health maintenance when they're more likely to be thinking about how to make it through till the next harvest or whether their malnourished fifth child is going to be hospitalized for this episode of diarrhea or fever.  On top of this, immunocompromise (as with HIV, a relatively common infection here) makes cervical cancer progress since its pathophysiology is related to the viral HPV infection, and cervical cancer actually is one of the determining criteria for which stage of immunocompromise an HIV-positive patient is in.

So these musings amounted to the fact that last OT (operating theatre) day we told two women in their fifties that they had stage IIIB cervical cancer (extending to the lower third of the vagina), which has a 40% 5-year survival rate in the best of circumstances with radiation therapy.  These women will most likely not get in at the University Teaching Hospital (UTH) in Lusaka, the only place where these types of services are available in the country, in a timely manner to enable them to get the radiation.  So they're sentenced to living and dying with advanced cervical cancer as it metastasizes through their pelvises, bringing difficulty passing stool and urine as well as pain.  Even the pain of advanced cancer is difficult to treat where we have limited supplies of one opiate, pethidine.  If any place in the world needs the HPV vaccine, which has caused such controversy among some communities in the US, this is certainly one place I would distribute it!

We had an interesting though sad case on rounds a few nights ago.  The patient was being evaluated for lower abdominal pain, hematuria (blood in the urine), and amenorrhea (no periods) for three months.  They did an ultrasound to rule out an ectopic pregnancy and found instead a large renal mass, palpable on re-examination of her abdomen.  Again, there are no resources here to do a nephrectomy (removal of the kidney), and it is unlikely she will get in at UTH soon enough to make a difference in her prognosis...

On a positive note, I had a conversation with the ultrasonographer, a young Zambian man who is pastoring a local church while doing perhaps 200 ultrasounds a month through his job at the hospital and is in further training for ultrasounds.  He mentioned the offers he has received to go to Botswana or elsewhere to earn more money for his job.  His ultrasonography course is through some place in Canada, so that also opens doors.  But "if you want to see change in your country," he said, "you have to be patriotic."  Knowing there are other options available to him, he is choosing to stay here where he is needed and can make a difference.  And make a difference he does since ultrasound and X-rays are our only imaging technologies.  Thank you, God, for people who choose to give up what they could have for the longer-lasting reward of a life lived faithfully and well in service to those in need.  May I remember his example.