Cervical Cancer is Solvable

And so with very low resources, very little resources, without doctors, without even clinics, we can go and screen women out in provinces, in schoolhouses and workplaces, and we can defeat cervical cancer. And really what we're talking about doing is preventing cervical cancer. That is doctor Vince Gennaro. He's an internal medicine doctor, a global health specialist, and a social

justice advocate. It now here unsolvable. We do not shy away from the biggest problems, and this one certainly qualifies. Cervical cancer is a disease that's fueled by social, economic, and political inequities. The World Help Organization puts the situation in pretty blunt terms. Nine out of ten women who die from cervical cancer are in poor countries. Cervical cancer is both preventable by vaccines and education, and it's treatable.

But when prevention and treatment are missing, it means that some of the most vulnerable women in the world are dying unnecessarily. It probably goes arout saying that this is not fair. In Sub Saharan Africa, cervical cancer is the number one cancer killer of women. It's so sad because we've seen these amazing health gains for women made in maternal health and HIV care around the world, so it's kind of a disaster to see that rising cervical cancer

debts undermine those gains. The International Agency for Research on Cancer made some really scary sounding projections that show that unless preventative measures are implemented asap, by twenty forty, there'll be almost half a million deaths from cervical cancer per year. Here in the US. Sadly, more than four thousand women die from it each year. That is too many, but it's nowhere close to the scale that it is in

low and middle income countries. Any woman listening that's here in a wealthier country will know about vaccines or are going for a smear test. Not fun, but just something that we do and it works. We just have to share it. Preventing and treating women's cancer in low income countries is doctor Vince Gennaro's life's work. He is so smart and passionate that he makes this challenge, which we know is seius and deadly, seem manageable. He's worked in

seven countries. He speaks five languages, all of which you'll hear in this interview. No you won't, he is just being English. In this interview, he talks to an apple bound about cancer research here in the US, about how politics and education intersect with help, and how the nonprofit that he founded, Innovating Health International, does this huge work in countries like Haiti and Rwanda to look after women and to teach us to look after ourselves. Okay, take

a listen. What's the problem? In a nutshell? Can you describe it in a couple of sentences? Globally, over half a million women are dying of cervical cancer every single year. It is a leading killer of women in low income countries, even though it's not even in the top ten cancer killers in US and Europe. So there's a huge disparity between what we know we can do and what we

are actually doing. And when we're talking about a half a million desk globally women, these are women who are in their economically most productive years, in their forties and fifties. They are young mothers still, they're raising children, and when cervical cancer affects their life, it affects society at large. And what is it about this problem that makes you want to tackle it. I think in every society women

are the backbone of it. The huge disparity, I think is what makes it so such a problem that it's like, well, Okay, we know we can fix this. You know, when HIV was an issue in the early two thousands in we were treating it just fine in US and Europe. We talked about expensive medications and difficult regimens and testing that was difficult. And so we're real technological challenges to rolling

out widespread HIV treatment in lower income countries. With cervical cancer, we can screen with tests that cost two dollars, that has plastic speculum, and regular store bought vinegar and a light. Those are the three things that we really need to screen a for cervical cancer. So it really is something that can be done literally anywhere a woman can lay

flat in privacy. It's a question then, of how to reach those women, How do we engage them in the health system, to the point that they understand the issue, that they realize the value of it, that they understand the longer term consequences of it, even in the immediacy of the life that they're living, which may often be in poverty or difficulty feeding and educating their own children. To get women to come in and engage with the

health system is more the problem. To get the health system to reach out to these women and offer these simple services is more the issue than anything to do

with having enough doctors or having enough clinics. So when you're faced with a problem like this one where you have the perspective of many millions of women in Haiti, for example, who don't know about cervical cancer, don't know about testing, often don't realize they have cancer until it's too late to treat, how do you begin thinking about it? What are the first depths you take? How do you

break down the problem? You know? I think initially in twenty sixteen, Innovating Health International and our partners, we carried out a survey across the country of Haitio, interviewing five hundred women and men to talk about what their attitudes were towards cervical cancer and breast cancer. You know, we have to understand is that what it is that they know, what it is that they believe, what it is that they have access to for in order for us to be able to formulate a plan to attack it. And

so we found some pretty stunning things. Between twenty and thirty percent of women don't know didn't had never heard of cervical cancer, They didn't know what the symptoms were, they didn't know what the tests involved. Most stunningly, seventy five percent of Haitian women couldn't identify where their cervix is. So if I'm trying to convince you to take a test that for every thousand women screen we're going to

save ten lives. But if you don't know where the cervix is, what cancer of the cervix causes, where around you to get the test? Why would you get the test? You have immediate concern you have to You're worrying about feeding and educating your children, taking care of your family, So we start there. Obviously, that's a pretty big uphill task.

If we're looking at those kinds of numbers of seventy five percent of women don't know where their service is, how are we going to convince you to take this test? And the importance of it. So looking at it like that and then we say, okay, then it has to start with education, it has to start with awareness, and most importantly, it's got to start with what we call engagement with the health system. That it's not just Okay, we're going to give you a little lecture, it's more

than that. Part of it is them knowing where the nearest health center is, knowing the times it's open, knowing its services they offer, Knowing the prices that they may have to pay if there are user fees. These are the things that, again, a woman who is struggling to work and raise a family at the same time may not have access to that information. So we want to reach out to them with the health system as well

as teaching them where to go. The other problem is that we're talking about preventative health, and when we're talking about preventative health, that's a more difficult thing for places for people who will again are focused on the here

and now and surviving through today. We know that when care is free, when we have had free cervical cancer screenings, that major hospitals around the country of Haiti, that the screening numbers are very low because the most common bearers are actually not economic, even in a poor place like Haiti, they're structural. So that's what we talk about when we talk about engagement with the health system, and that really

for us was the starting point. What about prejudice? Are people disturbed by the idea of that kind of exam Is it a cultural problem as well? It certainly is in many cultures in Haiti, not particularly, but in Malawi with another place that I work it can be. And then certainly in other culture is in Asia that's an issue.

I think that's why one of the things that we're doing is self vaginal swabs, meaning that the woman doesn't have to be examined at all, meaning that she inserts a Q tip into her vagina and that is enough sensitive enough the test for us to be able to determine if they are at risk for cervical cancer or not. So you adjust the test depending on where you are. Yeah, those kinds of technologies. Cool thing about this is, you know, I said we can do this with simple no technology,

and that's certainly true. But a technology like that that HPV test with a self swab opens up a whole new level of possibilities. It means that we don't need a doctor because the doctor is generally necessary to do a cervical exam on a lot of patients, or even a highly trained midwife. We can have someone with a high school education do the education for the patients and

teach them how to do the swab. So and it's not subjective at all, it's scientific, is very sensitive and just about as much as a PAP smere that we would get in the US. So those kinds of technologies are helping us leap frog, and they also helping us overcome barriers that maybe they're culturally. I think one of the barriers is certainly sexism, gender based violence, gender stigma. Those are the things that really cut across culture. Is even in the US and Europe, those are true barriers.

In a place like Haiti, where the male partner is paying for testing, then they certainly have a say in what tests that the women undergo. In our study, that we had forty percent of our breast and cervical cancer patients had been victims of gender based violence, whether it was physical, sexual, economic, and that was compared with twenty

eight percent in the general population. So we know for a fact that globally that gender based violence increases the risk of cervical cancer because it increases the risk of transmission of HPV. And now we know in Haiti at least that the women who have cancer are more likely to be victims of gender based violence. So these kinds

of things matter. And even when we did to our survey, the most common cited cause for breast or cervical cancer in Haiti was were sexual violence, so rough play with breast during sex, certain sexual positions they thought would lead to cervical cancer. So there is an association in the women's mind at least between some form of sexual violence, whether it's consensual or not, as being linked to these problems.

But is that true. Certainly not. The rough sex and those kinds of things don't increase the chances of HPV, but more partners does, And so I don't know about the association between the people who have more partners and gender based fines. But When a woman generally can't choose your partners, when she can't negotiate condom use and those kinds of things, then she is at a higher risk of getting HPV. How did we persuade women in the United States to take these tests? Is there a history

to this story? Yeah, I mean, the papsmer has been around for eighty years, and so that's part of it. We all grew up knowing about the PAPS mirror since we hit puberty and had the birds and the bees talk. So it's something that's been ingrained in us from day one. It was ingrained in our mothers as well, and our grandmothers would probably be the ones who could tell us what they remembered when they first heard about the PAPS mirror. But so we're talking about that kind of level where

twenty percent know what several cancer causes. So if we're at that level, what do we do In the US. We've had access to the care for a long time. Right now, we have NFL football players wearing pink bracelets and pink cleats for breast cancer. So those kinds of things where the awareness is everywhere, right, it's it's almost unavoidable to talk about going to get your mamogram because of breast cancer. Obviously, in the US we've now we're

past cervical cancer, so we don't even talk about it anymore. Man. That may be one of the issues with HPV vaccination in the US is that people don't really remember cervical cancer because they don't know anybody who's had it. Whereas in Haiti, these women they're dying in their forties and fifties. It's a really terrible death, it's it's it's quite the downer. But at the same time, I think we've forgotten that somewhat in the US and Europe, and that's possibly why

that there's still a half million women dying globally. I think we're we're there a bit with cervical cancer where we are complacent, where we can actually have a discussion about whether it's worth it or not to have an HPV vaccine. Of course it is, and of course it's needed, and of course it's gonna you know, we know it's having huge impacts on HPV prevalence in the United States

and Europe. So not only how do we get there in Haiti, but how do we reawaken that consciousness in the US and Europe that we're thinking about why we need the HPAVY vaccine, and we're thinking about how do we push our governments and our companies to be more aware of these problems in low income countries to expand

the services that are available. I was very struck by I watched a video clip you made about some of the work you've done in Haiti in the past, and you spoke about giving treatment to some women who had just been identified as having cancer, some who had late stage cancer, giving them an extra two or three years of their lives that they might not have had otherwise.

And you kept repeating that you wanted to give them care just like in the United States, as the kind of treatment they would have if they were in a different country. This is a more personal question, but that struck me. It's clear that you have a sense of injustice that people in Haiti in other countries that you've worked in aren't getting the same level of healthcare that Americans get, or that people in the developed world get. Where does that sense of justice come from? Certainly for

my parents, lots of love and gratitude to them. I think also I was raised Catholic, but I think that the Catholics tradition of service to the poor is one of the reasons I am where I am, and I think that, you know, whatsoever you do onto the least of my brothers, you do onto me. And that's something again we've forgotten in the United States, but I think it's important. And I think that's something that drives me more importantly than that is. Once you're there, you're experiencing

and living with these people. Cancer patients they come in. We run a chemotherapy center as well, and Atentivating Health International, and we do breast cancer and cervical cancer, and the women come in and they're getting chemotherapy and surgery for months, and so you really get to know them. You know, the Haitians are very emotive, expressive people, and it's hard

not to fall in love with them so quickly. So I've watched a lot of women that I love and respect die, and that is it has to have an impact on you. Some points it was too much, and and I withdrew. And now I've gotten to a place where I can be present and experience the sadness and grieve with the family, and then use that sense of injustice to drive us to do more. It really was heartening to know that we can make that difference because I cried a lot of nights in twenty thirteen, fourteen,

and fifteen about those women. And to see those numbers is you know, we're making an impact. Give me an example of one of your patients. How does how can chemotherapy change a family's life or change the way, you know, change the way a child grows up. Even when a woman comes in with stage four, we can still treat them both breast and cervical, and so the chemotherapy for breast or ovarian cancer, we can extend their life for

two three four years. You know, our median survival is about eighteen months, which is pretty close to what it is in certain middle income in high income countries. Okay, well, so the woman's only going to live in another eighteen months, what's the point. Well to her ten year old son, who then becomes a less even before she passes, that matters. That's two more years of schooling he gets to go to with her working because she's not in bed, she's

back at work. She's caring for him. For a husband, if he's there, that matters in terms of having help raising the kids, and for the woman, of course, it matters to have two more years of life. And like we said that that is something that they deserve as human beings. Healthcare as a human right no matter where in the world you live. And you know, when we

get them at earlier stages, we can cure them. And you know, my mentor, Paul Farmer, would always say, it's almost as if they had a treatable disease, because it is treatable. It's just a question of getting to them

with these simple treatments. We can treat a woman chemotherapy and surgery and all that for about twelve hundred bucks per woman, which sounds like a lot, but we spend fifty thousand or a hundred thousand per case of breast cancer in the United States, so it really is not much in terms of the global resources, and those prices will come down as chemo prices come down and volume goes up. You scale this because you know you're one doctor and you can only be in so many places.

How do you spread these tactics to others? Yeah, it's all about education and training. There are six doctors at the Innovating Health International Cancer Center in Haiti right now, and they are seeing the patients on a daily basis. We trained them to give chemo. And you know, I'm not an oncologist, I'm an internal medicine doctor. There are no fellowship trained oncologists in Haiti, and realistically we don't really need them yet in any low income country. What

we need is access to basic care. So we're kind of again back to where HIV was in two thousand and three, two thousand and four, where we have the tools, but there's no specialists in it. Globally, HIV is treated by generalists. In the United States, it is generally treated by infectious disease doctors. So in the United States, cancers treat you by oncologists, and globally we need to have

generalists or internists treating cancer. So we need to be training lots and lots more internal medicine doctors to give chemo, to give it safely, to give it properly into the patients who need it, and how and went. But it is not that complex. You know, in the United States and Europe, it's gotten a whole lot more complex with genetic testing and higher order things. But if we're talking about ensuring first line care and ensuring a basic standard

of care. Then it's not that difficult, it's not that expensive, And we can train a doctor who's an internal medicine doctor in a week to give chemo, and we've given

chemo at four different public hospitals in Haiti. We are launching a permanent program now in the North and Capation and train doctors and nurses to do it, and they come watch us for a week, We give lectures, we have discussions about it, and then after that we're in touch by phone and email and to talk about all right this particular case, is it fall within the algorithm

or not? As we expand treatment, That's the way it's gonna That's the way we're gonna do it by training other doctors and nurses and not waiting for oncologists to come down and train. So in Haiti, we have probably ten different doctors given chemo through our program over the last five years, and I've trained them all, watch them, we accompany them. You know. That's the way things are going to move forward, and not through donations of medicines

and foreign doctors coming in and treating patients. It's going to be through training and a local workforce to do this exactly like we did at HIV, and that's as a result of rolling out services with algorithms and in simple, low cost ways, and cancer care is there. We're there, it's just a question of doing it. In order to do this, obviously, you need to speak the language of

local people, so you speak Creole. UM. Maybe you could say a few words about how you learned it, and then you had to design a campaign in Creole, you know, to reach very poor people. Can you talk a little bit about how the um you know, how you thought about preparing the education campaign. Yeah. I've been blessed to speak a couple of languages. I speak about five languages, and so I learned Creole in South Florida growing up.

And you know, I think anything that we do. You know, I'm an American and when I go to Haiti or go to Malawi, I try to stand on the side because this is not my place, it's not my country, it's not my culture and not my people. And so I want to be there to support the local staff to be able to roll out those things. So when we talk about the survey that we did, we had five different Haitian organizations. There was ten people in the room, two of whom were foreigners, and eight who were Haitian.

The survey was written in Creole. It was never written in English and then translated. It was carried out in Creole. The results were entered into a Creole spreadsheet. We had to teach an artificial intelligence program to interpret the data in Creole because we didn't want to translate it into and lose that authenticity with it. So same thing with our awareness materials. The pictures in it, and we're all drawn by a graphic designer who's the son of a

patient of ours. The videos we have on our website, concert Point Coom, it's an all Creole website, have all breast cancer and cervical cancer survivors as the actors and actresses, and they're the ones who wrote it actually, So I, you know, I've had very little to do with it other than you know, to facilitate um, you know, help people, give them the resources. The Haitians are in particular super creative and so they're they're really good at at at

those kinds of things. And the videos are you know, they're not just someone talking to the camera. It's a conversation. It's a little bit of a soap opera and people get involved in them even though they're only three minutes long. So it's more about accompaniment and helping our colleagues in low income countries to express themselves. And you know what they need is they need some time space money to be able to accomplish those things. And it's not really

about um us doing it. It's about us standing standing aside and letting them do their thing like we would do here. But we just have a whole lot more resources. Give me some examples of success. So how do you know you're succeeding? This is a vast problem. You're tackling it from different angles. You're doing prevention, you're doing new kinds of treatment, you're training doctors. What makes you think you can can solve this problem? You know, we talked

about the personal aspect. Now I'm by sitting in office and talk and write grants and think of ideas and look at numbers and so those numbers are really what we're talking about, and it's it's impersonal. But at the same time, if I say we screened four thousand women at a factory for cervical cancer, then we know we saved at least ten lives. We know that that was a successful program because we did what we set out

to do it with the budget we had. We know that we've handed out sixty thousand booklets for breast and cervical cancer awareness. We know, like I said, we've trained fifty doctors and ninety nurses and cancer treatment over the last three years. That I said, the statum most proud of is the fact that we've decreased the number of women coming in in stage four breast cancer from forty percent to twenty two percent in five years. Because I

know that is huge numbers, A live saved. Our populations also getting younger, there's more women under forty coming in. We're going to treat close to three hundred women with breast cancer this year alone. We've already we've treated over a thousand in the last couple of years. So the numbers, while impersonal, are certainly telling. And then you know, you look at like on our website, there's Nadine who's twenty six.

When she came in with breast cancer. She had the support of loving husband, so she not only found the mass, but sought out care and got to us quickly, and you know she's cured she's now thirty years old, she's got two kids. Every time I see Nadine, you know, it makes me smile. It's those two sides. It's the numbers, number of doctors trained, the number of people that were treating and screening, and the lives touched. We know we have the tools, we know we have we're making progress.

The fact that I'm sitting here speaking with you tells me that we're onto something, that this is an issue that people care about and want to hear about, and this is an issue that's moving forward. You know, we just gotta we gotta get over that hump to the point where we are now rolling these programs out. We're

not talking about pilot programs or small scale that. We're talking about national, international, global, and really decreasing that number of half a million women dying every year from cervical cancer, and it's totally solvable. What kind of decrease are we talking about and by when? What would be your guests?

So even if we were to test every woman in low end, middle income countries for cervical cancer even once in their lifetime, one papsmere, one HPV test, one test with vinegar, we'd reduce cervical cancer mortality by eighty or ninety percent, So we really don't have to set up an infrastructure where they're getting paps members every three years.

That would to get to one hundred percent, we would, but to get eighty percent, which then we're talking about four hundred thousand lives saved, we just have to screen them once. That's why we're talking about mobile screening. We're going to go out into a clinic in the middle of nowhere with a community healthcare worker with a backpack full of HPV swabs. She talks to the women, gives them a lecture on not only cervical and breast cancer,

but also sexual reproductive health. They do breast exam, she teaches them how to do a self breast exam, and then the women do insert the HPV self swab. We come back to that same town two weeks later with a midwife and for all those women who are HPV positive it's around twenty five percent. We treat them right then and there with a battery operated piece of equipment that basically uses heat to remove the pre cervical cancer

from the cervix. It's battery operated, it's portable, it's about the size of a large cell phone or a tablet, and it can be done anywhere a woman can lay flat, we can do it in a church on a church pew, behind a curtain. You know. Those kinds of things are or I think what makes this feasible. There's other technology

from Mobile ODT. It's the Eva Culpa scope and it's a it's a connected to a smartphone and it's got a little camera and magnifying glass to look at the cervix and we can take pictures and stream video and quality control with it. But the machine is actually going to be able to tell a normal servix versus an abnormal service come this fall. That's interesting. So you're talking about actually a combination of low tech and very high tech potentially. So then so part of the way to

solve it is to combine them together. Well, so we're talking about doing tomorrow's test for cervical cancer today, HAITI is leapfrogging in the United States. By using these HPV tests, our daughters will not be getting pap smears, and so HAITI is moving past that and leapfrogging, and that's that's important. We're pairing it with education and engagement we're coming to them, We're going to their workplace, We're going to their their

church on a Sunday and screening fifty women. And everything's battery operated. Everything can be you know, use internet or not Internet if there's no service out where they are. It is beautiful, simple technology, which means you don't have

to train the people as much. The cost of the you know, equipment is two three thousand bucks, which spread out over you know, is nothing comparatively speaking, and you know, because you're paying a community healthcare worker instead of a doctor, the costs have dropped significantly for the human resources side.

So using technology, going out there with a backpack full of supplies and engaging on a human level, convincing them to take the test, telling them how important it is, and then treating them right then and there in this one room schoolhouse in this church. That's what makes this a solvable problem, is is getting out into the community

to community based education, screening and treatment. So people listening to this program, what can they do to help solve the problem of high rates of cervical cancer in the developing world? I mean, I think the first thing we can do is make sure you're getting screened and make sure we're getting vaccinated at home. I think that's got to be baseline, and we have to have real conversations about the effectiveness of these interventions so that we understand

how effective they are in other places. If there's any doubt of how effective HPV vaccine is here in the United States, it's going to be hard to convince people of the solvability of this problem. I think advocating for cancer research is always helpful for us. You know, the cancer moonshot in the United States. Those are the things that produce technologies that help places like Haiti Leapfrog. I think, you know, it doesn't make sense to have this discussion

without talking about voting. Um you need you need to vote your conscience and vote where to make things better where people live. If we're talking about mass immigration and Europe and Central America, that that's partially because there's services don't exist where they live and they are coming for a better life. And then vote your conscience through your wallet by purchasing from companies like Gap and Levis and other companies that are using fair trade practices and providing

healthcare to the people who in the supply chain. And then finally be open with your with your heart, and with your wallet. I think it's important. America is the most generous country in the world. Two percent of all of our income goes to donations, and that's by far and away more than any other country in the world, and so I want to encourage people to get out there and give. The money does end up helping people? You know, do your research, do your due diligence, but

donate your time, don'tate your money. It matters. Such a great conversation now, cervical cancer, it's still a threat in the global north. But isn't it crazy how those of us lucky enough to live in some of the eighty four countries around the world with this HPV vaccine program. It's like we've almost forgotten about the diseases it's protecting us from. And an interesting side note is that more than twenty of those countries now give the vaccine to boys and girls. I'm sure it struck you as it

did me. How practical minded doctor de Gennio is at the same time as being really compassionate. He mentioned this book called Scarcity, The New Science of Having Less and how it defines our lives, which weirdly I happen to be reading at the moment, so I want to add my endorsement for what that's worth. Now that is your homework before next week's episode. No, it's not. I'm just kidding,

Thanks for listening. Solvable is a collaboration between Put Industries and the Rockefeller Foundation, with production by Laura Hyde, Hester Kant, Laura Sheeter, and Ruth Barnes from Chalk and Blade. Pushkin's executive producer is Neia LaBelle, Research by Sheer, Vincent, engineering by Jason Gambrel and the great folks at GSI Studios. Original music composed by Pascal Wise and special thanks to Maggie Taylor, Heather Fine, Julia Barton, Carli Mgliori, Jacob Weisberg,

and Malcolm Gladwell. You can learn more about solving Today's biggest problems at Rockefeller Foundation dot org slash solvable. I'm Mave Higgins. Now goost solve it.