When I first arrived on Christmas Island, arriving from the hustle and bustle that is Honolulu, I was struck by the overwhelming beauty. It looks like a paradise. But to the women of Christmas Island, their lives are not always a paradise.
We went to Christmas Island not because there is no access to health care but because many of the women there, as around the world, decline to seek care from male physicians. As a result, the vast majority of women have never had a gynecologic exam. The marvelous nurses on the island handle the prenatal care and the uncomplicated births but most have not been trained to perform pelvic exams or to recognize even the most common gynecologic disorders. As a result, many women “suffer in silence” with months or years of pain and discomfort. We came to Christmas expecting shy and reticent women who possibly would not be willing to have such an intimate exam from non-I-kiribati doctors. Instead, we found women who were open and comfortable with our women only team. Poor Carlton was chased out the Manebwa more than once. Our clinic was make shift exam rooms created by hanging sheets strategically in the manebwas in each village. On the first day we expected to spend the morning in protestant manebwa and the afternoon in the Catholic but soon changed our strategy when we realized it would take too much valuable time from our patients to uproot the carefully constructed clinic and move across the street. Fortunately, The non-protestant women did not seem to mind attending clinic in the protestant manebwa. We quickly discovered that the majority of problems the women were facing were infections easily treated but which they had been suffering with for months or years. In addition, many women had difficulty with urinary incontinence as a result of multiple or difficult births. In the US these would be treated with elective surgery that was not possible in the facilities on Christmas. Although not an emergency or life threatening condition, these women experienced profound effects on their quality of life. We were also surprised by the many women who came to us concerned about infertility. In a culture where children and family are highly valued, the inability to conceive was a big problem for these women.
Fortunately, most women did not have serious or life threatening illness and we were able, hopefully, to contribute to their overall health by simple interventions with appropriate antibiotics for infections. We were able to give some exercises to the women who were experiencing incontinence in the hope it would help a little. There was one woman we saw with end stage cervical cancer. It was heartbreaking to see her and know there was nothing we could do other than to support her and encourage the use of palliative pain medications. Cervical cancer is still a big problem worldwide even though there are excellent means to screen and treat at pre-cancerous stages. Cervical cancer is caused by the human papilloma virus (HPV) and there is a vaccine against HPV. Fortunately the young girls of Christmas receive the vaccine. This will hopefully decrease the incidence of cervical cancer for the younger generation. Meantime, the routine pap smear that American women take for granted is not available to the women of Christmas island in part because there is no one to do them and secondly because when they are done by the one nurse who has the skill, the specimen must be sent to the capital city of Tarawa, a 2 week boat trip away. Frequently the specimens never reach Tarawa and when they do, the results may never come back. Although it is unlikely Christmas will ever have the benefit of a pathologist on island, protocols for newer and simpler methods to evaluate for early changes are being tested by World Health Organization (WHO) in resource poor areas like Christmas that hold great promise.
The women of Christmas can benefit immensely through just a few rather simple interventions that we hope to accomplish on a subsequent visit. The system of 4 village clinics run by nurses where the women already feel comfortable coming for prenatal care and deliveries, can be used to deliver basic women’s health care. We only need train the nurses to perform speculum exams and take appropriate samples that can be diagnosed with a simple microscope. In the US this is a common practice done in most doctors’ offices by physicians, nurse practitioners, physician assistants, and nurse midwives. Eventually, the nurses can be trained using recommended WHO protocols to look for abnormalities of the cervix with just the application of vinegar solution ( acetic acid) and to treat appropriately with freezing. All in all- it’s a lot healthcare bang for very little buck.
Because we are family medicine doctors who, in addition to treating many GYN conditions, also evaluate and treat children and adults for a variety of conditions, we saw many women who had other conditions besides gynecologic problems. For example, the island suffers from an extraordinarily high level of diabetes and obesity and with those two problems also comes hypertension and heart disease. Some other problems were easy to address, and others left us puzzled. We were able to take pictures of some highly unusual skin conditions and get advice from experts here the US. Interestingly, they also were often perplexed but could give suggestions we happily relayed to our new friends and colleagues on Christmas.
I felt a great honor to be given the privilege to meet the people of Christmas Island and to hopefully play a small part in bettering the health care of the women of Christmas Island. They are the most generous, open , and genuine people I have ever met. We hope to return to the island within the next year to begin the process of training the clinic nurses in women’s health issues.
By Dr. Theresa Woehrle