By Sally Greenwald
Balance has been an inherent priority of mine that I have cultivated and practiced throughout the years. There are only so many hours in a day, and ultimately in a lifetime, to spend pursuing the things that mean the most to us. I feel lucky to have made it to medical school while holding onto the other parts of me that make my life complete and balanced such as being an avid traveler, flute player, athlete, cook, dancer, yoga practitioner and friend to many. Global Health is one such passion of mine. It’s intensely rewarding, it’s a calling, and it has the power to completely consume me more so than other passions and I have struggled to enter it into my life’s balance.
My commitment to Global Health was ignited in Haiti. The high prevalence of cervical cancer in the region inspired me to initiate a screening program. I was compelled to work hard my first year of medical school to put together an IRB proposal, track down physician mentors, apply for funding, organize site visits and finalize logistics abroad. The goal was to train local Haitian physicians to screen for cervical dysplasia using white vinegar, a technique recommended by the WHO known as VIA, or Visual Inspection with Acetic acid. It is a low cost alternative to the Pap smear and can be done with minimal technology.1 I received funding for 300 Pap smear kits along with a pathologist’s time to read them so that I could compare the efficacy of VIA to the gold standard of screening in the United States. Crafting a protocol on par with international standards was something these women at high risk deserved.
This project took priority over many of the other activities I valued in my life and although parts of me were lessened, they were not lost. I left dinner parties early so I could head home and submit proposals before midnight. I listened to recorded lectures on double speed at night so that I had my mornings free of class and open for meetings regarding the project. Finals came and I was thankful to have exams in the morning leaving me the rest of the day to visit the travel clinic, pick up supplies and medications, and pack for my summer in Haiti. I sent out three months worth of birthday cards caked in glitter in advance. I turned off my cell phone and left on an early morning 12-seater airplane from Miami to Cap-Haitien.
Once in Haiti, I recruited women from churches in the rural, northern village of Milot where I was staying. I worked with a local physician and performed 110 of the projected 300 Pap smears and VIAs. The Pap smears were being taken by volunteers back to a pathologist in Boston. We were well on our way to meeting our goal and I prepared to have my mom meet me in Haiti. It was her first trip to a developing nation and I was proud of the work we were doing and proud of the way in which I had balanced my time to accommodate both my professional and personal obligations.
I was caught completely off guard when I received the long distance call from Boston that there were not enough cells for the Pap smears to be read. At the last minute we switched kits from one where the cervical brush is swirled in the liquid to one where the brush must be left in the liquid, and we were using the former instructions. I spent hours on the phone to the U.S., checking in with my mentors and devising a plan for volunteers to bring down another 150 donated kits. I went back to the churches to re-recruit the women I had already seen.
My mom flew in that Monday and aside from picking her up from the airport, I only saw her before bed for the duration of her week-long stay. I spent 12 hours a day in the gynecology clinic pap smearing women whenever they could come back. My mom, no stranger to my professional and academic commitments, was understanding and supportive. She made the most of her trip and I’m happy she did. I just wish I could have experienced it with her.
In my second year of medical school, the final pathology report came back from my project. Results showed that VIA, with 60% of the women graded positive, was not going to be a cost effective screening tool. Additionally 31 (or 10%) of the women in the study were found to have either low or high grade squamous intraepithelial lesions (LSIL or HSIL).
My statement of follow up in my IRB proposal required me to treat the women diagnosed with LSIL or HSIL. I could never have translated onto paperwork my dedication to these women who had walked all morning to the clinic to then sit on a bench in the sun in 110 degree weather, waiting for hours for me to perform their Pap smears.
It was my decision whether or not I would go back to Haiti over Thanksgiving. My mentor on the project was an OB/GYN physician with a busy practice and that was her only available weekend. I could either spend the holiday providing follow up care in Haiti, or I could wait until the New Year and search for another physician to take on the project.
I spent days on the phone with my sister, my parents and my grandparents trying to get a sense of their feelings about me missing our holiday together. I had been to Haiti five times but I hadn’t been home in almost a year. I assessed the situation from an emotional standpoint as well as from a financial one. Was it even possible to refund my cross country ticket home? It was when we confirmed that the ticket could not be refunded that I realized that it wasn’t about the money. It wasn’t about missing my family or feeling guilty about it. It was about my passion for providing care to these women, about my commitment to Global Health, and about the struggle of working through the challenge of incorporating this calling into my everyday life. I was spending Thanksgiving in Haiti.
The women returned to the clinic and were treated using colposcopy to magnify the cervix and visualize possible areas of dysplastic cells and cryotherapy which uses liquid nitrogen to freeze off the top layers of cells where the dysplasia is seen. Biopsies were taken for confirmation and two were ultimately found to have cervical intraepithelial neoplasia (CIN) 2,3 which was treated by the cryotherapy. The local physician was trained on the World Health Organization’s (WHO) see-and-treat protocol2 and left with the equipment to carry out colposcopy and cryotherapy on his own as a cervical cancer screening program.
I finished up the semester in Boston and cried with relief when I got off the plane in California and saw my entire family for the first time in a year.
Working in Global Health is a privilege that allows me to participate in the care of those most in need. It makes me feel fulfilled. It makes the strenuous journey abroad, the personal sacrifices, and the challenge of balancing other needs and commitments worth the struggle. If asked what I’ve learned, I would clearly explain that this is a work in progress. However, I now know to be mindful of the sacrifices I am making, acknowledge them, and then make decisions. Becoming a physician means I will always be tempted by doing noble work, and I will always feel the pull to put this work ahead of other things in my life. Global health is worth the balancing act.
Sally Greenwald is a 3rd year MD/MPH student at Tufts University. Her current research interest is responsible medical and public health efforts in developing countries through academic support with a focus on the potential role of U.S. medical trainees. She has spent much of her last few years traveling between Boston and Haiti working to establish a public health rotation site for medical students and started a cervical cancer screening program in rural Haiti.
Works Cited
1 Goldie, S., Gaffikin, L. Cost-Effectiveness of Cervical-Cancer Screening in Five Developing Countries. NEJM. 2005 Nov. 353:2158-2168.
2 Strategies for cervical cancer prevention using visual inspection with acetic acid screening and cryotherapy treatment. Report of the PAHO Workshop for Latin America and the Caribbean. Guatemala City, 1-2 June 2011