A Woman's Worth

A USC-led health program aims to develop affordable and easy-to-use cervical cancer screening techniques to save women in El Salvador.

by Alicia Di Rado

As a fourth-year medical student, Miriam Cremer could not believe what the local health-care worker was telling her.

It was 1999, and Cremer was a University of Wisconsin student learning firsthand about community health in a small rural town in El Salvador. A lay health practitioner came to her with a crisis: Too many women in the village were dying far too young, victims of cervical cancer.

Cervical cancer—the same disease that has all but been snuffed out in the United States.

So Cremer sped to the only pay telephone in town, called a family doctor back home and pleaded: “We need to get these women Pap tests.”

Five years later, Cremer, now an M.D., is a Keck School of Medicine of USC gynecology fellow at LAC+USC Medical Center. But she is still advocating for the women of El Salvador. She founded an organization called Basic Health: El Salvador, which aims to set up appropriate and sustainable health care for the people of the war-torn and earthquake-struck nation.

And she has gathered growing numbers of believers in the cause. About 20 physicians—many of them from USC—as well as a dozen students and numerous other health professionals recently accompanied her on the group’s biggest mission to El Salvador yet. They returned from the mountain town of San Sebastián in late January, after providing hundreds of gynecological exams, pediatric office visits and other much-needed services.

“Dr. Cremer really outdid herself this time,” says Juan Felix, M.D., professor of obstetrics and gynecology and pathology at the Keck School, who participated in the mission. Felix himself has traveled about two dozen times to health programs in Central America, including USC’s cooperative project with the Costa Rican government to reduce cervical cancer incidence in that nation.

Rates of cervical cancer and deaths from the disease have declined in the industrialized world, where screening has become routine and advanced treatments are available. Worldwide, though, cervical cancer remains the third-most-common cancer. About 470,000 women are diagnosed with it every year, and nearly 230,000 die—mostly in developing nations.

Cervical cancer has become the leading cause of cancer deaths among women in these nations, mostly because they cannot get adequate screening. Many countries simply lack the expensive labs and highly trained technicians needed to analyze test samples, just for starters.

That just makes Cremer more committed.

“The fact that these women are still dying of cervical cancer is a civil rights violation—this is a preventable disease,” Cremer says. “There is no excuse for women dying of this disease.”

Felix noted that Cremer shaped a research component for the most recent trip, centering on creating a more affordable and easy-to-use screening technique for cervical cancer in developing nations.

“The idea was to figure out how to be able to screen for cervical cancer in Salvadoran women, but without an enormous infrastructure,” he says.

Currently, groups such as the Pan American Health Organization favor a simple visual inspection test that is inexpensive and convenient. While a woman reclines on a table, a health professional inserts a speculum in her vagina and her cervix is visualized using a special light source. The health worker swabs the cervix with vinegar, which turns potentially abnormal cells white. White patches seen on the cervix might mean cancer or precancerous lesions.

According to physicians, the problem is that some white areas turn out to be perfectly healthy.

Cremer turned to Johns Hopkins University gynecologist Paul Blumenthal, M.D., a screening expert, for other ideas. Blumenthal suggested using a digital camera to take an image of the cervix. Technicians can then enlarge images on a television screen to look at them more closely.

So Cremer and her fellow gynecologists enrolled 526 San Sebastián women in a pilot study of the screening methods. Each woman had a lengthy informed-consent process before the procedure. For each participant, they took a Pap smear, performed a visual inspection and snapped a digital image. All of the women also underwent colposcopy and cervical biopsy.

The team shipped the slides and tissue samples back to Los Angeles. The PathNet Esoteric Laboratory Institute read all samples without charge, Cremer says. Cremer and her colleagues plan to evaluate the effectiveness of screening methods and determine whether digital imaging could be adopted as an affordable, sustainable screening method.

In April, a small team of gynecologists returned to San Sebastián to treat the women who were found to have cancerous or precancerous lesions.

Not all the Salvadoran patients were women seeking cervical cancer testing, Cremer says. Twice as many patients flocked to the clinic for help with colds, coughs, aches and pains, and a crew of volunteers from pediatrics, family medicine, internal medicine and other disciplines helped treat them. They also provided vision exams and glasses.

Fernando Cortez, a Red Cross physician in San Sebastián, headed an effort to create a makeshift clinic for the visiting physicians in a church courtyard. Hammering away at plywood sheets, the volunteers created six examining rooms where health-care workers interviewed and examined patients.

“He promoted this event prior to our arrival and had it incredibly organized,” Felix enthuses. “Without the Red Cross, this project would never have taken place.”

Besides Cremer and Felix, USC participants also included Women’s and Children’s Hospital research nurses Blanca Ovalle and Claudia Sanchez and Keck School gynecologic oncologist Laila Muderspach, M.D. Two other obstetrics and gynecology fellows, Ann Steiner, M.D., and Marie Soleil Wagner, M.D., also participated.

Additional participating physicians came from all around the U.S., from New York to Oregon. Students in the program came from Hampshire College (Smith College and Mt. Holyoke College), Cremer’s undergraduate alma mater.

Eventually, Cremer would like to turn the burgeoning program into a non-governmental organization. But for now, it remains a grass-roots effort with projects funded through grants from groups such as the Einhorn Family Charitable Trust and the Buffett Foundation, donations from companies such as Cytyc Corp. and support from friends.

For more information on Basic Health: El Salvador, or to help with donations of medications, eyeglasses or other supplies, contact Miriam Cremer, M.D., at cremer@usc.edu or visit www.basichealthelsalvador.org.