Zambia
At the N’gombe health clinic in Lusaka, Zambia, residents—and many from afar—venture to the clinic for free health services. (Lauren E. Bohn )

Medicine

Tackling Cancer With a Dab of Vinegar

A new, simple test pioneered by Johns Hopkins is revolutionizing cervical-cancer detection rates in rural areas of Africa. Lauren Bohn reports from Zambia.

In a sun-starched village slouched on the edge of Zambia’s capital, 15 women lined up at a free health clinic to see a woman they adoringly call “the lady healer.” Like many in this southern African country of staggering inequalities, mangled by crumbling infrastructure and a health-care brain drain, it was their first visit to a health-care facility.

“She saved the lives of three women in my family and now me,” said 28-year-old Sally Siame, with a wide-eyed reverence usually reserved for celebrities. “Everyone knows about HIV and AIDS here, but cancer down there?” she asked, squinting into the sun, still confused of the concept. “I didn’t hear about it until she said I had signs of it. It’s the new killer.”

Cervical cancer is the second-leading cause of cancer in women in the developing world. Eighty percent of cervical-cancer cases occur in underdeveloped countries, where simultaneously more than 95 percent of women have never had a Pap test, the main mode of detection. Though treatable if caught early, the survival rate in sub-Saharan Africa is more than three times lower than in the United States. According to the Cervical Cancer-Free Coalition, Zambia has the highest cervical-cancer mortality rate in the world.

“Every day I find a precancerous lesion on a woman,” says “the lady healer,” Susan Banda, a nurse at the N’gombe health clinic in Lusaka, Zambia’s capital.

“It’s the crisis AIDS was years ago,” she said, noting the incidence rate of HIV/AIDS among Zambian women is still at 16 percent. “We’ve only just started getting that in control the last decade. Now this is the big target.”

But in the N’Gombe clinic and across the impoverished country, where technology beyond paper and pen is almost fictional and a functioning laboratory is often hundreds of miles away, one household fixture has morphed into a lifesaving game changer in combating cervical cancer: vinegar.

Lacking the technology for Pap-smear detection, licensed nurses and community health workers—who tend to be the primary-care givers, due to dwindling medical talent and a dearth of facilities—use vinegar tests, otherwise known as visual inspection with acetic acid (VIA), a method developed by the Johns Hopkins medical school and endorsed by the World Health Organization in 2010, to detect precancerous lesions.

The process is low tech, specifically designed for low-resource settings. Practitioners like Banda simply brush the patient’s cervix with vinegar, and within minutes, using a digital camera to assess the cervix, one can see whether precancerous lesions exist, because the vinegar turns them white. The lesions can then be frozen off during the same visit through a freezing technique called cryotherapy, which entails applying liquid carbon dioxide to the lesions via a simple rod. The single-visit approach is crucial, as most women don’t have time or resources to visit the hospital again for further treatment. In a country with only a handful of pathologists for a population of 13.5 million, it could otherwise take months to get results from a Pap test.

In an era when many are increasingly fixated on Silicon Valley solutions and technology as a silver bullet to solve global health problems, Harshad Sanghvi, the vice president of innovations and medical director at Jhpiego, the Johns Hopkins University–affiliated nonprofit health organization that helped develop VIA, says simple solutions are often more difficult to achieve.

“Sophisticated technological solutions aren’t the ones we need ... We need simple technology that people without many resources can use,” he said. “The elegance of a simple solution is a difficult thing to achieve, but we have with these vinegar tests and the single-visit approach.”

One household fixture has morphed into a lifesaving game changer in combating cervical cancer: vinegar.

For the N’gombe health clinic’s community health-care manager, Ignicious Bulango, the method is indeed transformative, but the country still has a long way to go. “Cervical cancer, and cancer in general, isn’t necessarily on the radar like malaria and HIV/AIDS for the majority of Zambians and most of Africa, but we’re getting there,” he said. “It’s a process."

Pharmaceutical companies have also caught on, seeking to introduce their vaccinations against human papillomavirus (HPV), the sexually transmitted virus that can lead to cervical cancer. In countries like Zambia where sexually-transmitted-disease rates are high, the link to cervical cancer is pressing. Merck and GlaxoSmithKline, makers of the HPV vaccines, announced last spring that they would lower the prices for their vaccines to less than $5 a shot. In the U.S., each shot costs more than $100.

"By 2020 we hope to reach more than 30 million girls in more than 40 countries," Dr. Seth Berkley, CEO of the GAVI Alliance, said in a statement. The organization, which aims to increase access to immunization in poor countries, said it will begin its support for HPV vaccines in Kenya, followed by Ghana, Laos, Madagascar, Malawi, Niger, Sierra Leone, and Tanzania.

Separately, Zambia recently launched a pilot vaccination campaign for teenage girls. Last year, in conjunction with the country’s Ministry of Health, Merck donated doses of Gardasil, the HPV vaccine widely used in the United States, to vaccinate 25,000 girls. The first lady of Zambia, Christine Kaseba, a gynecologist, has made cervical cancer her main platform. At a recent Stop Cervical Cancer in Africa Conference in Mozambique, Kaseba said 24,172 young girls had so far been vaccinated.

But in a country choked by stark urban and rural divides, most of Zambia’s bottlenecks lie in access and awareness. While the vinegar test is relatively simple, training workers and reaching patients in isolated, roadless areas can be next to impossible. Two thirds of Zambians live without electricity on less than $2 a day, with 60 percent live in hard-to-reach, sparsely populated rural areas. The average distance to a hospital for most people in the country is 53 miles.

In Zambia’s Eastern province, a bumpy and scorching 11-hour bus ride from the capital (or a $700 charter flight for the precious few who can afford it), volunteer community health workers like Evelyn Phiriare are trying to fill in the cracks.

Evelyn and a handful of other women in their small village of Chilenga are supported by the NGO Plan International and trained to administer basic diagnostic tests and procedures, as well as to monitor thousands living with HIV/AIDS, tuberculosis, malaria, and other common diseases.

“I was tired of seeing people not getting the treatment they deserved,” she explained. “I’m no doctor, and don’t want to be, but this is just about helping your friends, people in your community.” A few times a week, she bikes an hour to the nearest clinic to pick up medications for patients in her village. She says she hopes to soon perform cervical-cancer screenings in her village. “If you want things done,” she says, “you have to step up. You can’t wait for someone else to do it for you."

Sanghvi, who pioneered the vinegar test, says community health workers like Evelyn are the future of global health care in many destitute countries. “It constantly blows me away, these semiliterate workers who are on the front line, providing the treatment right away, on the same day,” Sanghvi said. “A simple screening process is what can saves lives in a country like Zambia. Why should the poor, the majority, be the ones who suffer?”

Back in the teeming N’gombe clinic, Banda tidies her examination room and gets ready for her 10th patient of the day, all while occasionally laughing—as though she still can’t get over the simplicity of it all.

“It’s like a kitchen in here with all this vinegar,” she smiles widely, the pockmarked walls behind her covered with cervical-cancer-awareness posters. “We’re making better lives.”


This reporting was made possible in part by a fellowship from the International Reporting Project.

Zambia
“Lady healer” Susan Banda, a nurse at the N’gombe health clinic in Lusaka, Zambia. (Lauren E. Bohn )

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