Cervical Cancer in Botswana

As we have noted in previous postings, Botswana has a high HIV prevalence rate, especially among women of childbearing age. Today, we went to a reproductive health clinic that serves this population at a local hospital. Women from within and outside of Gaborone come to this clinic for services which are not as readily available elsewhere. Most of the women we saw ranged from 20 to 40 years of age, and were visiting either for a follow-up from a previous treatment, were referred to the clinic due to an abnormal Pap smear, or were there to receive treatment. The clinic usually sees around 10 women each day; however, some women cancel their appointments due to issues such as transportation costs.

The most common cancer among women in Botswana is cervical cancer. Unlike in the U.S. where cervical cancer is regularly screened for with Pap smears and easily treated in early stages, in Botswana women are more likely to die from cervical cancer. Women with both HIV and cervical cancer tend to have more severe cases of cervical cancer than those without HIV. While Pap smears are available for free with government funding, women may not obtain them because of fears about pelvic exams or having a result that requires treatment. Additionally, treatments such as LEEP procedures, colposcopies, and biopsies are more difficult to obtain here with long waiting lists for appointments, a lack of providers trained in these procedures, and delayed results from out-sourced laboratories.

While we were at the clinic, we had the opportunity to observe treatments in the examination room. In comparison to other clinics in Gaborone, this particular clinic appeared to have more access to medical supplies, such as gloves and hand sanitizer. They even have access to an autoclave for sterilizing equipment. The healthcare providers seemed cognizant of maintaining sanitization procedures, and attempted to be thorough with cleaning the equipment between each patient. However, with our frame of reference in the U.S., we were struck by the differences in sanitization procedures. For instance, we emphasize disposing single-use supplies. This clinic would reuse items such as sheets with each patient as opposed to laundering them with every use. We felt uncomfortable observing their cleaning procedures coming from U.S. healthcare institutions. Where we would have changed the sheets, they attempted to clean them with disinfectant spray, leaving visible stains. Perhaps with better funding and access to supplies, this clinic would have the ability to improve their level of sanitation.

In terms of patient privacy, we also experienced a cultural difference. Whereas in the U.S. where we have government policies guaranteeing patient privacy and a standard of practice to not interrupt during patient examinations, such expectations do not seem to be as prevalent here. For example, during pelvic exams the door was frequently opened without warning and staff entered and exited freely, such that the woman was sometimes exposed. To us this felt like a major privacy violation and would make the patient feel very uncomfortable, but the patients did not seem bothered or surprised. We thought this was an important learning experience since we need to respect their cultural norms.

Posted by Trudy Kao and Erin Schelar