Year of the Nurse and Midwife
#Nurses2020

Nurses lead Botswana’s drive to eliminate cervical cancer

National self-collection effort puts prevention in women’s hands
By Maryalice Yakutchik
Photos by Kate Holt
Step into the Clinic

The jacaranda tree in front of Madiba Clinic gives shade, but not enough. Even before 9 a.m., women open red and blue umbrellas against a blazing Botswana sun.

Nurse Senyana Galeage, a specialist in cervical cancer screening who visits this clinic once a month, will begin seeing patients soon, one by one, in private.

A woman shields herself from the morning sun. The entrance to the Madiba Clinic. Nurse Senyana Galeage offers health information.

Aided by a mega flashlight—she never travels without her “trusty torch”—and using a simple vinegar solution, Galeage will swab the cervix, the neck of tissue connecting the vagina and uterus, of each of the 30 women who signed up for cervical cancer screening. She’ll apply cryotherapy, a relatively simple technique that uses freezing gas, to any white patches of abnormal cells she detects, effectively arresting precancerous conditions revealed by this simple, inexpensive screening technique known as VIA, or visual inspection of the cervix with acetic acid (vinegar).

But before she begins that work, Galeage delivers a lecture for all to hear, no matter what prompted them to visit this clinic today—whether testing for TB, treatment for HIV or a baby’s croupy cough. Her mission is educating everyone about the top cancer killer of women in this country: cervical cancer, a disease that’s highly preventable and easily treated if caught early.

“Don’t wait for symptoms,” she warns. By the time there’s pain or bleeding, the disease likely will have progressed to an advanced stage after having gone undetected for decades. Prevention is key, she says.

Nurse Bakgaki Ratshaa (right) shines a light as Nurse Senyana Galeage examines the cervix of a woman using a vinegar solution to screen for precancerous lesions. 

Kereng “Molly” Rammipi and Bakgaki Ratshaa listen as Nurse Senyana Galeage lectures about cervical cancer prevention at the Madiba Clinic. 

Approximately 570,000 cases of cervical cancer and 311,000 deaths from the disease occurred worldwide in 2018.

Botswana has promoted free cervical cancer screening for decades—first Pap tests and, more recently, VIA—but most women still haven’t taken advantage of these preventive services. Last year in Botswana, a country of just 2 million people, 333 women were diagnosed with the disease, and 166 died of it. The country’s cervical cancer burden remains high.

This is why Botswana is now investing in human papillomavirus (HPV) DNA self-collection as an alternative strategy.

This DIY innovation offers women autonomy, privacy, ease and accuracy. It puts disease prevention into women’s own hands, with a speculum-free screening alternative. Now in its initial phase, the nationwide rollout—designed and driven by the country’s nurse-dominated health workforce—is focused on those at highest risk of developing cervical cancer: 25- to 49-year-olds living with HIV and on antiretroviral therapy. In Botswana, the HIV prevalence rate among women aged 15–49 is 24.6 percent. The rate for all adults is 24.8 percent, among the top three highest in sub-Saharan Africa.

Until the HPV DNA campaign fully unfolds to include all women, Galeage stays the course, offering women VIA—and reminding everyone why it matters.

Galeage, who holds a bachelor’s degree in nursing sciences and trains other health care providers in the practice of VIA, explains to the audience that a common, sexually transmitted virus (HPV) causes cervical cancer. A lively question-and-answer session ensues, with Galeage concluding that each and every one of them needs to be vigilant and proactive: “I say you need to know about your health to seek health!”

Among Africa’s poorest nations in 1966 when it achieved independence, Botswana now is middle-income and middle-aged.

Galeage’s lesson is in lockstep with an ongoing Ministry of Health and Wellness effort to promote self-responsibility, says Kereng “Molly” Rammipi, a nurse and coordinator of Botswana’s National Cervical Cancer Prevention Program. “We’ve been pushing for the past several years for individuals to stand up for their rights in ensuring they get all the health screenings and are attended early enough to avoid complications.”

“If I was within the screening target age, I would opt for self-collection,” Kereng “Molly” Rammipi says, referring to HPV-DNA testing.

The new self-collection strategy fits in well with Botswana culture, Rammipi says, shaped as it is by botho, a philosophy that recognizes interconnectedness and promotes mutual respect. “In teaching women the new screening method, nurses invite women to participate in their own care and prompt them to take responsibility for their own health,” she says.

While investing in patient education and self-care, Botswana also is integrating cervical cancer prevention services at primary care clinics like Madiba, as well as at infectious disease care clinics that offer HIV testing and treatment.

Unlike many of its low- and middle-income neighbors, Botswana has been on the leading edge of adopting innovative, low-cost technologies, according to Celina Schocken, executive director of TogetHER, a global partnership working to eliminate cervical cancer.

Alluding to the 2015 rollout of a nationwide HPV vaccination program for school girls and the 2019 launch of the HPV DNA self-collection strategy, Schocken credits Rammipi with relentlessly pushing her country’s cervical cancer prevention agenda forward. Meanwhile, Rammipi is quick to acknowledge her nurse colleagues at the Ministry of Health and Wellness—namely Tlhomamo Pheto, a training coordinator with the National Cervical Cancer Prevention Program. From October 2017 to March 2018, these nurse researchers partnered with Jhpiego to investigate self-collection’s feasibility and acceptability. Among the findings: 97.3 percent of 1,022 participants reported little to no discomfort and would recommend the new method to others. Thirty-two percent of women received their result the same day and 93 percent within 1 week.

Self-collection, Pheto says, makes the elimination of cervical cancer a real possibility. “We are hopeful that come 2036, we will look back and say we made a mark. We are moving fast when it comes to [improving] screening coverage.”

1. Nurse Motlalepula Masiele explains self-collection. 2. Nurse Tlhomamo Pheto believes disease-elimination is possible. 3. HPV DNA self-collection is simple, painless and accurate, and puts prevention into women’s own hands.

“Screening with HPV tests is more effective in preventing future cervical precancerous lesions and invasive cancers than screening with Pap smears…. Moreover, HPV testing can be done on specimens taken by the woman herself, offering opportunities … to reach women who otherwise would not participate in screening by enabling self-sampling,” a 2019 Lancet study concludes.

Even as the number of women screened continues to increase, self-collection will relieve pressure on health facilities and staff, Schocken says, “because it requires less time by health care workers who, in Botswana and elsewhere, are overwhelmed.”

Nurses—who are the backbone of Botswana’s health system—are wholeheartedly embracing the self-collection approach, nurse Bakgaki Ratshaa says. Ratshaa, who heads up Jhpiego’s cervical cancer prevention program, is equally enthused about her country’s recent introduction of thermocoagulation, a treatment approach that zaps precancerous tissue with heat generated by a small, battery-powered device. Given its portability, it soon may end up freezing out cryotherapy, which involves the transport of unwieldy tanks full of gas.

“With funding from TogetHER, we have procured four thermocoagulation machines and are piloting the treatment in four districts,” she says. “Our expectation is to roll this out nationwide, just like self-collection.”

These new screening and treatment strategies collectively are paving the way toward cancer elimination, Ratshaa says, by tackling limited access to care and avoidance of pelvic exams.

A case in point: Koketso David, a 33-year-old hair stylist in Gaborone, avoided screening for years, until she visited the Nkoyaphiri Clinic in Gaborone this past winter and learned that it was now possible to collect her own HPV DNA specimen in private.

Then and there, David ventured into a consult room, where a nurse encouraged her to feel the soft brush designed for swabbing herself and showed her how to swirl it in a specimen vial filled with liquid preservative. A machine would analyze the specimen, detecting any presence of high-risk HPV even before visible changes occurred in her cervix. She’d get accurate results fast, a big advantage in a country where women often wait months for Pap results—or never hear back—because labs and pathologists are few.

Instilled with a new confidence, David retreated to the bathroom, alone, with the brush and vial. Later, she spoke of the new method’s appeal in Setswana, her native language, except for one word. “Speculum,” she said in English, loud and clear, and with pronounced distaste.

Cervical cancer ranks in the top three cancers affecting women younger than 45 in 79 percent of 185 countries.

Ease, simplicity and respect all added up to such a positive experience for David that she agreed to schedule her next screening visit before leaving the clinic. With a relieved smile, she insisted that she will return in August 2021 to self-collect. She knows that regular testing—every 2 years for those living with HIV and every 5 for others—is vital for preventing cervical cancer over her lifetime.

David’s stunning conversion—from being screening averse to now advocating for self-collection to friends and family—gives Rammipi hope, even as suffering and despair remain all too common. During a visit to a patient, she watches protectively as Kooleboge Mabifi, 66, hobbles from inside her daughter’s house toward a plastic chair in the yard, where several visitors sit under a tree.

1. Nurse Galeage encourages women to sign up for screening. 2. At Nkoyaphiri Clinic in Gaborone, Nurse Motlalepula Masiele counsels Koketso David, a 33-year-old hair stylist, about HPV DNA self-collection. 3. Koketso David (front row seated, third from left) listens with interest as Reetsang Rammoni talks about a new screening method, HPV-DNA self-collection, that is available at Nkoyaphiri Clinic in Gaborone.

In 2018, the global average age at death from cervical cancer was 59.

“She has a lot of dizziness and nausea today,” Kooleboge’s daughter Batalifi says, smoothing the rumpled collar of her mother’s blouse.

Kooleboge Mabifi is living with her daughter Batalifi while undergoing treatment for stage 4 cervical cancer. She was never screened for cervical cancer until after symptoms developed.

The chemo drugs she’s taking won’t cure her, Batalifi adds quietly, “but maybe will help with the symptoms.”

Neither she nor her mother had any kind of screening until after the elder woman started feeling sick, in June 2018. When Kooleboge found out she had cervical cancer, the disease already had progressed to stage 4.

All her life, the mother of seven lived in the village of Kopong and worked as a farmer. Now she is dependent on Batalifi, who lives 19 miles west of Gaborone, closer to a hospital that provides cancer care.

She misses plowing the fields, Kooleboge says, misses harvesting beans, maize and watermelons.

“It’s really painful to see someone like her,” Rammipi says. “We have the staff and the resources to save lives. One day, [our prevention efforts] will fall on fertile land.”

Kooleboge Mabifi tells her daughter Batalifi how much she misses being able to plow the fields of the farm where she’s lived and worked for six decades.