In Puno the city in the sky

We arrived in Puno over the weekend and began working on Monday. Puno is a small city and overlooks Lake Titicaca. The weather is perfect sunny, 60-70s and crispy at night. 

On Monday we met close to 40 midwives called "obstetriz" and a few doctors who wanted to participate in the PINCC  VIA (visual inspection of the cervix) training. We were all overwhelmed to say the least. How were we going to possibly train all these highly motivated and interested students. We started with a didactic and sadly only saw a few patients.

Today Tuesday we got a system down. We have 6 US providers and 2 Peruvian providers who can train/teach the students. We buddied up 6 students per provider for the full day. That way we created a sort of buddy system and the provider could really get to know their group of students. It worked well and we saw 40 patients.

Our group of volunteers are really sweet. Carol our fearless leader has unbelievable patience and is an amazing leader. Linda is a family nurse practitioner from the Boston area who has done work in Guatamala and works part time at a Harvard affiliated public health clinic in Jamaca Plains. Virginia is an ob/gyn who was a solo practitioner in Monterey, California for 30+ years, closed her practice recently and now works part time for the Salinas Department of Public Health. Carol who goes by "Carolina" here is a recently retired public health nurse from San Francisco and is on her 5th trip with PINCC. Tara is in her final year of residency at Kaiser Oakland in ob/gyn. She was in El Salvador with Carol last week and was in Nicaragua on a PINCC trip in 2011. Jamie is a PA originally from Utah who lives and works in NYC, loves to travel and this is her first PINCC trip. Suzanne is a family practice doc who practices at Clinica de la Raza in Concord and this is her first PINCC trip. Eve is an ob/gyn from Kaiser Oakland and this is her 2nd PINCC trip.

Juana is our local midwife, was trained by PINCC a few years ago in Lima and is helping to get us started in Puno. Enrique is a local ob/gyn from Lima who was also trained by PINCC and is working to get things going in Puno as well.

We have an amazing group and we're working hard to get things going. The altitude is incredible 12,000 feet and when you walk up a small hill you get winded. The food is great here. Trout is fresh from the lake and the vegetables are awesome.

Wanted to get something started on the blog. the next entry will be mostly photos.

Final Screening / Training in Mysore

We concluded our fifth four day camp at JSS Hospital in Mysore on Friday afternoon, November 9. It was a very busy camp, with 242 women screened and numbers of medical students, faculty, guests from Biocon and Rotary coming to observe. We were up to the challenges however, as we had an incredible team of four volunteers -- Dr. Debra Levinsky, Dr. Ginger Ruddy, Dr. Marie Johantgen, and Lauren Sokolik, FNP. While Lauren and I did most of the out front work, Rhoda and the doctors kept the screening tables "turning over" throughout the four days. One vo;unteer had too return home suddenly on the morning our camp was to start, due to a death in the family -- an event that made us all very sad!

The reason for this fifth camp was to solidify a LEEP referral center at JS hospital, to further our contribution to the course work for Gynecology students, to foster planning for a large scaling up of the PINCC protocols over the coming years, and to continue to build on the collaborations that we have been establishing across Mysore.

On the first evening, we were treated to a second meeting with the Swamiji of JSS who continues to be committed to our program. We started out with him, along with two research pharmacists from Penn State, and then went for "prasadum" (gift snacks) in his special dining room. We (just PINCC) were called back for a further few minutes after the light dinner. Auspiciously enough, he and Marie Johantgen were on the same flight out of Bangalore Friday night!

Following two wonderful weekend days of touring local palaces, tomb, battle sites, temples and gardens, we went on Monday morning to help Inaugurate PHRII's (our main Mysore partner) new larger women's clinic. Then we went for meetings with the medical college principal to talk further about curriculum, and also about how to scale up these screening and prevention services.

On Tuesday, the three remaining team members, Dr. Rhoda, Lauren and I, go to Bangalore for a Wednesday morning site-visit with the Biocon Foundation clinic doctors. We have rising doubts that it we can create a screening program in Biocon, but will give it a great effort.

On Wednesday evening the three of us head for Puttaparthi for a 6 day (1 day for Lauren) "time-out" at our Ashram. Then we will do further site visits in Hyderabadand the Indo-American Cancer Hospital and in Siliguri at the Sunitha Cancer Society

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India report by Rhoda Nussbaum, MD

We had a great and auspicious first day of camp.  We saw 56 women, many returns from the last camp or between camps, did 4 LEEP and 2 cryo and many other biopsies.  Dr. Suma will be certified to do LEEP by tomorrow or the 3rd day and AP Chandrasekar has deported another OBG professor to learn LEEP, Dr. Somia.


Tonight we had a visit with Swamiji arranged by Dr Suma who's in-laws are very close to Swami ji.  We thanked him for his support and described our goals of screening 75% of eligible women by 2020.  He talked about brining training to other parts of Karnataka.

The Vice Chancellor was also at the visit with Swami and we talked a bit about our proposal.  So in the last few days we have met all the important decision makers at JSS expect the principal  land we expect that will happen later this week.

The woman who represents the wives club of Rotary stopped by and two men from Rotary as well.  We will try to get a few of our  California Rotary friends connected with these Mysore clubs and see if we can get buddy support from US and India Rotary for cervical cancer prevention.

So it was a good day.  We are exhausted and satisfied.

India November 2012

 We met with Drs. Vijaya, Bhavana,Reshma, Poornima and our team at PHRII.  Dr. V had evolved her thinking over night and seemed to accept our strong recommendation that "See and Treat" was the only choice in this environment.

We brainstormed any barriers to carrying out See and Treat  in a village.  Drs. Bhavana and Reshma are so astute and have the ability to think about the larger system.  They pointed out that a women who had received biopsy or cryo and had some complaint thereafter would go to the PHC.  If the DHO and PHC staff were unaware that PHRII was doing Cx CA See and Treat  prevention and a women showed up at the PHC, that might cause a problem.  They strongly recommended that we talk to the  DHO and get his permission

The second barrier identified was getting consent for procedures from the women.  It was suggested that women be counseled during the awareness program that Biopsy and Cryo would be recommended if a precancerous lesion was found.  They could bring their husbands to screening  or call them if needed but by setting the expectation that these simple procedures might happen for at least ⅓ of the women screened, issues of refusing treatment because the husband hadn't consented should be minimalized.

 We went to see the DHO this evening.  He is aware and gives his acceptance that biopsies and cryo will be done in the villages.  A process for letting the local PHC staff understand what was done and why and  what post procedure side effects are expected will need to be worked out.

My eyelids are drooping as I write this email so I will say goodnight and will continue to let you know what is transpiring each day  so that a sustainable prevention program will be well on its way and that a program for how to scale up is being worked on.