PERSONAL COMMUNICATION

I had the pleasure of interviewing the overqualified Dr. Vijaya Srinivas. Dr. Vijaya is the current Senior Research Physician at PHRII, and she has over forty years of experience working in women’s reproductive health. She received her MBBS from Madras Medical Council of India and worked at the Health and Family Welfare Service for the Government of Tamil Nadu, India, where she operated as a Woman Assistant Surgeon for five years. She moved to Karnataka and joined the Association of India, Mysore as a Lady Medical Officer. She worked with the association for over twenty years as a family planning, medical termination of pregnancy, and mother and child health consultant. She is affiliated with the Indian College of Maternal and Child Health, Kolkata for her Obstetrics and Gynecology Diploma. She has prolific experience working in women’s reproductive, sexual, and preventative health. Ultimately, she is an indispensable member of PHRII’s team.

A visit to one of PHRII’s mobile HPV and cervical cancer screening sites sparked my interest in the HPV epidemic. Afterwards, Dr. Vijaya graciously allowed me to conduct the following interview*:

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• In relation to your work at the mobile cervical cancer screening clinics and with HPV in general, what are the needs and challenges that need to be addressed for advancements in global health? Challenges that we face, India is a very big country. 1.2 billion population . . . so we are in a position to screen women to find out HPV infection. Women thirty to sixty years need to be screened. So we are going to identify those women in rural areas in such a way so that women never fail to come to us. They should be interested to come to us . . . Our team will personally go and meet the women’s group and explain to them, “These are all the projects.” They will tell the women it is not only cervical cancer screening; it is going to be examined by the woman doctor so that any other problem in the health system also will be known to them . . . So the women like to come to us. That is one thing. Another reason: the government at present is collaborating with us because the government does not have an organized education group . . . They do not have our NGO type of education group. Our education is trained in such a way so that women believe our mission and would like to come . . . Some women they will come. They may lose some government benefit if they don’t go. Here they will come . . . That is one challenge. And second challenge is many women don’t want to come for a pelvic examination. So we create such an advanced procedure that it will not hurt any women . . . by delivering examinations, privacy, confidentiality, and belief on our organization, our women . . . Otherwise no women will come for a pelvic exam in a camp . . . Private doctor any woman will come and tell what is her problem. That is “opportunity screening.” But our screening is asymptomatic women screening. It is just to identify pre-cancer. It is not “opportunity screening.” So we go for the asymptomatic women; we may not go to the symptomatic women. In a private setup only, when they get the opportunity they go to the doctor. There they will take a Pap smear and go. But ours is more screening. We create an atmosphere in the community, in the community women. We don’t bother them. We make them like our examination. And our report also is given and collected and referred to other services. In the correct way we follow-up. Our research is related to global research. We do [the examination] by the VIA that is recommended in all the developing countries by the WHO for everybody that wants to do VIA only . . . Lastly, PHRII is one of few organizations that knows how to do the VIA. [Private] doctors only use the Pap smear; they do not care to learn how to do VIA.

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• Do you believe that the research existing on HPV globally agrees with that? Yes, research globally agreed with that.

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• What is unique to India that influences the HPV Cervical Cancer epidemic? Why are they important? Could you understand the HPV epidemic without knowledge of these influences? What is special in India in HPV and cervical cancer is that India, every year, 122,000 women gets the cervical cancer, and 67,844 women dies due to cervical cancer. This is due to lack of education, lack of awareness, lack of screening procedures. And everybody cannot go to Pap smear screening. Cytological screening is not available in India. So it needs expense; it needs specialized cytopathologists. So only for this opportunity screening, women will go to a private doctor . . . That is why mainly India ranks in the second place in cervical cancer. Long back, it was first place. Now it has come to the second place because of the screening. Now breast cancer is the first. That is unique to India to influence the HPV cervical cancer epidemic.

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• As a medical doctor, what do you think the role of the global community is? Do you think the global community could realistically achieve this goal? We are the only people for the past six years. Now more NGOs come for the screening. Some of the states in India take over this project. Many NGOs . . . are taking more care for screening and preventing. The Indian government has accepted the screening, but that influence is different from state to state. Some of the states increased it and started many women’s screening. But some of the states still have to improve. But they have the program of VIA. They want to take all [levels of healthcare personnel] to train them [in VIA] and refer [actual HPV] cases to the doctor . . . The community is now coming with us. Other organizations need to try to help us: So mobilizing the woman, minor funding. For example, [organizations] can pay some funding, for the camp, for monitoring. Little by little, not much.

• What do you think my role is in addressing this issue? Do you think I could realistically achieve this goal? Fundraising. Another thing, what you can do, you can help us write grants . . . You can identity and help me in grant writing . . . That will be helpful for me.

Essentially Dr. Vijaya highlighted several obstacles in working with women on HPV and cervical cancer prevention. She explained the importance of maintaining good relationships with the rural women. The slightest misinformation may lead the women to decline PHRII’s health services. Dr. Vijaya emphasized that many women lose government benefits by going to NGO sites. But, she stressed, government clinics do not regularly practice preventative healthcare. Women solely attend government clinics when they have serious medical complications, not routinely for checkups. NGOs like PHRII work in preventative healthcare, making their work exceptionally important. Another challenging facet of Dr. Vijaya’s work involves receiving women willing to undergo a pelvic exam. As my experience at the mobile clinic confirmed, some women who visited the site that afternoon had never seen a gynecologist, despite many of them having already borne children. Certain social and gender stigmas diminish the importance of women’s healthcare, and so routine prevention is uncommon.

In India particularly, Dr. Vijaya stresses the use of VIA for HPV prevention. VIA is “visual inspection of the cervix with acetic acid.” A gynecologist needs only apply a few drops of acetic acid to the cervix. Any change in the color of the cervical tissue is indicative of HPV infection; healthy tissue remains unaffected. Only when she suspects HPV infection in the woman does Dr. Vijaya conduct a Pap smear. Hence, VIA is virtually free; it requires only staple lab materials and the eyes of trained physicians. Despite not being as accurate as HPV or cytological testing, research maintains that VIA is useful and particularly reliable in detecting Cervical Intraepithelial Neoplasia (Sankaranarayanan et al., 2009). As Dr. Vijaya mentioned, VIA is recommended in developing countries because the costs associated with Pap smears are simply unaffordable in many rural and public sectors of the Indian healthcare system. She additionally noted the importance of HPV and cervical cancer education, as cervical cancer is second to breast cancer in the country but is highly preventable. Finally, she supplicates additional screening work from other NGOs in the country. For students like myself, fundraising and grant writing are the most feasible means of indirectly helping alleviate the Indian HPV epidemic. Her urges are realistic feats.

Research supports the importance of HPV screening and prevention in India. Over 469 million women in India are at risk of developing cervical cancer, and 20.2% of women in India have cervical cancer (Bruni et al., 2017). Strikingly similar to what Dr. Vijaya mentioned, annually 122,844 new cases of cervical and other HPV-related cancers exist in India, and roughly 67,477 women die from these cancers yearly. Again, cervical cancer is the second leading cause of female cancer in the country, and it is the second most common cancer in women aged fifteen to forty-four. Yet, HPV is a potentially preventable disease. HPV16 and HPV18, both of which are preventable by vaccine, constitute over 70% of all cervical cancer cases. The vaccine is costly, though, and has yet to be implemented by the Indian government. HPV is a widespread epidemic in India, but the implementation of screening sites is making notable reductions in HPV infections. Education, awareness, and funding will bring the demise of the HPV epidemic, and global communities can aid this movement.

*This interview was abridged for brevity and clarity.