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Cervical carcinoma is the second most common cancer in women worldwide, but especially in developing countries, where it is the most frequent cause of mortality 1.
The causes of cervical cancer can be attributed to poverty, lifestyle, inaccurate or lack of information that the population has regarding risk factors. There is also a lack of functional medical consultation services and limited access to health care centers.


HIV/AIDS is highly prevalent in the sub-Sahara region of Africa 5. In these areas screening for cervical carcinoma would be very important, since HIV-positive women have a greater incidence of persistent HPV infection. They also have a higher incidence of pre-invasive and invasive lesions. The diagnosis of invasive illness is 10 years above the median 6.
Effective preventive and therapeutic interventions for cervical carcinoma do exist, as demonstrated by results in countries with higher income standards 7-9. But, in developing countries, public health gives little attention to cervical-carcinoma and to chronic diseases in general due to limited funds. These pathologies are not a priority for public funding, unlike infectious diseases which remain the focus of attention 2,10,11.
The control of cervical-carcinoma has been included among the Third Millennium Goals set by the United Nations Organization 12.

AMU (Azione per un Mondo Unito), translated as Action for a United World Association, has therefore launched a project of International Healthcare Cooperation by forming a partnership, approved by the Italian Region of Tuscany, aimed at responding to the local healthcare needs of the Fontem region in Cameroon, where the Fontem Hospital and Fonjumetaw Dispensary (recognized as quality healthcare centers) are located.
We have seen that the institution of an international collaboration can be a way of supporting these countries in developing low-cost strategies to control pathologies which most commonly afflict the population.
The composition of the partnership is as follows:
– Fontem Hospital and Fonjumetaw Dispensary in Cameroon;
– Maternal and Child D.A.I. – Careggi Hospital (Florence);
– “Misericordia e Dolce” Hospital headquarters of the Italian national health subsidy (USL) unit in Prato (central Italy);
– “Medicine – Dialogue – Communion” Cultural Association;
– G. La Pira International Student Center;
– “Mondo Unito” Cultural Association;
– New Humanity’s Salus Association for AIDS patients.

The following also contributed as Donors to the project:
– Banca Popolare of Etruria and Lazio (Italy);
– Unicoop – Florence;
– CSPO = Center for Oncological Studies and Prevention – Region of Tuscany (Italy).

The general objective of the project is to reduce the incidence and mortality of cervical-carcinoma in a circumscribed area. Its specific objectives are: 1) To create a health education program for the local population and to implement a screening program; 2) To set-up and manage a citodiagnostic laboratory and a colposcopic clinic through formation courses offered to the local health personnel.
In November 2005, an oncological prevention service for cervical pathology was initiated. The conventional screening for cervical-carcinoma is done on HIV positive patients scheduled for follow-up and on members of the local population who may be interested.


2. Ethnographic approach

The project is implemented in a health care context which presents many needs (professional, instrumental, infrastructural and economic) especially for oncological pathologies. It aims at gradually promoting the development of local health care through the professional formation of local health personnel: by teaching screening methods with the use of low-cost instruments and by installing medical equipment which guarantees effective and low-cost treatment.
In order to ensure the effectiveness of the intervention, steps were taken to evaluate its acceptance by the local population, through an integrated information campaign among healthcare workers and among the general populace. The purpose was to determine and eventually reduce those elements which might create resistance - not only individual but also cultural barriers within the community. These would include: ethnic traditions, previous experiences of illness and practices imposed by traditional and popular medicine; economic barriers (cost-effective evaluations); and physical barriers which have to do with mobility and communications (considering the wide spread population across the territory).
It is hoped that by promoting initiatives for the formation of medical, nursing and technical personnel, favorable conditions may be created for the development of expertise and the establishment of appropriate clinical activities. Such initiatives could be: choosing appropriate technological centers for tele-teaching and tele-assistance as well as providing sanitary articles and instruments according to the resources available.


3. Interrelationships

The existing collaboration among the partners is rooted in their familiarity with the local situation, and their working together in a common action to improve the health conditions of the more disadvantaged populations.
In this way, each person’s contribution – be it professional, economic, instrumental or cultural – is developed in the framework of integration and interdisciplinary dialogue that fosters cultural and personal interaction.
This communication has proven to be the proper methodology to better respond to a situation of professional, technical and economic underdevelopment such as that of healthcare in the area of Cameroon.


4. Working proposals for an Interdependent Healthcare Framework

In this connection, international cooperation appears to be the way to put into action a form of Healthcare Interdependence 13 consisting of a system of positive relationships involving the economic, cultural, political, social and health components. The communities would condition each other in such a way that each community and social reality would eventually develop itself as it contributes to the development of the others.
This international cooperation has promoted the development of specific professions such as a cytodiagnostic oncological technician and a colposcopist in a disadvantaged area like the Cameroon. It has also provided the opportunity to prove the efficacy of high-level scientific and professional competencies in contexts where the practice of medicine had previously been unsuccessful and to discover other possible solutions in a collegial effort.
Various factors, however, contribute to the state of health and healthcare services. But, they are only part of a system where food, education, water accessibility and housing are the indispensable minimum required to assure the well-being of an entire population.
It is necessary to effect a multi-sector integration in order to have a stronger global impact on the socio-economic development and on the state of health that should not be measured just on the basis of the incidence of illness.
Other feasible working proposals have been identified, such as:
1) Health education (school and service programming for women).
2) Vaccination program facilities for HPV.
3) AIDS and cervical-carcinoma control.
4) Multi-disciplined healthcare system.
5) Research, development and transfer of biomedical technologies in favor of developing countries.
6) Digital Devices and Telemedicine.

Lastly, the creation of a national and international collaborative network among healthcare structures that can foster projects that would eventually be able to plan and carry out “cooperative clinical trials”. It would be a way to attain the “gold standard care” and to improve the quality of therapeutic care in countries with limited resources. At the same time, these networks could also delineate a way of organizing research activity according to methodologies which acknowledge the human person as the subject of care in the framework of a positive mutual dependence among countries that have different healthcare standards. Thus the ethical dimension in research that proposes treatment and healthcare management will also be promoted.

by Laura Falchi

 

Bibliography

1. Sankaranarayanan R, Ferlay J. Worldwide burden of gynaecological cancer. The size of the problem. Best Pract Res Clin Obstet Gynaecol. 2006 Apr; 20(2): 207-25.
2. Preventing chronic diseases: a vital investment. WHO global report – 2005.
3. Narayan D, Chambers R, Shah M, Petesch P. Voices of the poor crying out for change. Oxford University Press for the World Bank, New York, NY 2000.
4. Hulme D, Shepherd A. Conceptualizing chronic poverty. World Development, 2003, 31: 403-23.
5. 2006 Report on the global AIDS epidemic. Available at: http://www.unaids.org/en/HIV_data/2006GlobalReport/default.asp.
6. Comprehensive Cervical Cancer Control. A guide to essential practice. © World Health Organization 2006.
7. Gustafsson L, Ponten J, Zack M, Adami HO. International incidence rates of invasive cervical cancer after introduction of cytological screening. Cancer Causes Control 1997; 8: 755-63.
8. Sankaranarayanan R, Budukh AM, Rajkumar R. Effective screening programmes for cervical cancer in low- and middle-income developing countries. Bull World Health Organ 2001; 79: 954-62.
9. Rose PG. Advances in the management of cervical cancer. J Reprod Med 2000 Dec; 45 (12): 971-78.
10. Advances in cervical cancer management from North American cooperative group clinical trials. Barman ML. Yonsei Med J 2002 Dec; 43 (6): 729-36.
11. Chirenje ZM, Rusakaniko S, Kirumbi L, Ngwalle EW, Makuta-Tlebere P, Kaggwa S et al. Situation analysis for cervical cancer diagnosis and treatment in East, Central and South African countries. Bull World Health Organ 2001; 79: 127-32.
12. Health and the Millennium Development Goals. Geneva, World Health Organization, 2005.
13. Ioannes Paulus PP. II. Sollicitudo rei socialis. 1987.

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