The Screenings Saving Lives in Rural Guatemala

It’s 9:30 a.m. and Juliaticia, a woman dressed in vibrant traditional garments, strolls down a hill in Candelaria, a small village nestled in the remote Guatemalan highlands’ Chimaltenango department. She’s headed to a cervical cancer screening clinic that’s been set up in her village for the day. 

When Juliaticia, who asked to be referred to by first name only, arrives, a nurse directs her to sit in a green plastic chair situated in front of a pale yellow building with a rusting corrugated iron roof. Within 30 minutes, more than two dozen women have gathered outside the inconspicuous building to wait for a comprehensive educational demonstration on female reproductive health and a potentially life-saving, free cervical cancer screening.

In Guatemala, cervical cancer is a stealth predator. It is the primary cause of cancer deaths among Guatemalan women, and silently and disproportionately claims lives in low-income rural communities, where access to basic health care ranges from limited to nonexistent.

The World Health Organization’s 2021 cervical cancer country profile for Guatemala reported 872 cervical cancer deaths in 2019 and suggested that this number has remained relatively stable in recent years. However, with more than 60% of Guatemala’s population living in rural areas where there’s a chronic lack of access to health care, there’s a high likelihood that causes of death aren’t properly attributed.

“With so much of Guatemala’s population living in poverty or extreme poverty, the cost of traditional [pap smear] cervical cancer screenings is maddeningly out of reach,” says Andrew Raphael, executive director of Nursing Heart, an Antigua-based grassroots nonprofit aiming to address this issue. 

“Assuming [there’s an opportunity for a pap smear] at all, it could be months before test results are returned from the lab, at which point it might be near impossible to communicate them to the patient and her family,” he continues. “Even if the results come back [positive] and make it to the patient, the financial and personal cost for treatment in the case of a positive result can be insurmountable.”

But there is an alternative: The visual inspection with acetic acid (VIA) is a simple, low-cost, and straightforward screening method that uses vinegar, halogen lights, and a microscope to identify abnormal cervical cells—and lower some of the world’s highest rates of premature female deaths due to cervical cancer. 

The VIA procedure is currently the only viable alternative to pap smears—the standardized cervical cancer screening method in the West—for the majority of staggeringly under-resourced communities in rural and urban Guatemala.“With this VIA procedure, we can detect abnormal or cancerous cells right there, right now, and take action straight away,” says Raphael.

Detection in a Matter of Seconds

Since 2011, Nursing Heart has used VIA to perform more than 4,000 mobile cervical cancer screenings in more than 40 rural communities in the Chimaltenango, Sacatepéquez, and Sololá departments that lack basic health infrastructure. 

Nursing Heart’s rolling mobile clinic program is composed of a team of advanced nursing students; local VIA-accredited Guatemalan practitioners; and Faith in Practice’s Dr. Patty de Baiza, one of Guatemala’s foremost experts on both cervical cancer and the VIA procedure. 

The team collaboratively operates several mobile reproductive health and cervical cancer screening clinics in rural, underserved Guatemala communities every year. Patients who attend Nursing Heart’s mobile clinics are assessed by the nursing students under the supervision of and in tandem with local VIA-accredited Guatemalan practitioners.

So far, hundreds of women who have tested positive for abnormal or cancerous cells have received immediate referral and free life-saving treatment on the spot. If cervical cancer is detected, patients can choose between two treatment options: the cryotherapy technique, which uses liquid nitrogen to remove abnormal or cancerous cells on the cervix in roughly 20 minutes, or thermocoagulation, a process that takes just 30 seconds. 

Patients, some of whom wait hours to be seen and are anxious to return to their workplace or families, tend to prefer the latter procedure due to time pressures. However some patients report that thermocoagulation is a more painful procedure, which can be a deterrent. But while the treatments can be painful, they work. And with around 4% of women tested at Nursing Heart clinics showing abnormal or cancerous cells, Raphael says it’s already saved “hundreds of women’s lives.”

“In Guatemala, the mother is the pillar of the family; she takes care of everybody. But nobody takes care of her,” explains Blanca López, better known as Blanqui, a VIA-certified cervical cancer technician and pharmacist who works on Nursing Heart’s mobile clinics. “It’s a tragedy when a mom or young woman dies of a preventable form of cancer and leaves her family to fend for themselves, when it’s a really simple and straightforward procedure that can save their life.”

It’s not just women’s lives at stake when it comes to early detection of cervical cancer. Early detection and treatment of cervical cancer, which is sometimes caused by the common human papilloma virus (HPV), is a crucial lifeline for families in remote, underserved communities that don’t have access to the preventative HPV vaccine that’s available in the West. 

Put simply, more women being tested and educated about their reproductive health means fewer preventable deaths. “At the most fundamental level, the VIA procedure is portable, cheap, produces immediate and clear results, and promises isolated and marginalized women something that is horrifyingly rare in Guatemala: knowledge of their bodies and how to prevent an otherwise avoidable death,” says Raphael. “[These women] deserve so much more, but this is a crucial and promising first step in that process.”

Rural Access Riddled With Roadblocks

Dr. de Baiza, Guatemala’s leading VIA practitioner, has personally treated thousands of women in Guatemala’s most underserved communities with Nursing Heart and Faith in Practice. However, it is still complicated for women in these rural communities to access these mobile clinics, with de Baiza attributing this disparity to lack of availability of quality services, lack of sex education and overall lack of knowledge about cervical cancer, and patriarchal attitudes about women’s sexual and reproductive health. 

“Women often require permission from their partners [to attend the clinics],” says de Baiza. “And often, due to ignorance [and cultural and religious stigmas], their sexual partners don’t allow them to undergo such exams.” Guatemala is one of Latin America’s most conservative countries; not only are women often required to get permission from their spouses or caregivers to undergo the cervical cancer detection screening, Raphael says “the woman often ‘needs to be accompanied,’ which means the male ‘caregiver’ might need to take the day off of work to accompany his partner or wife to a facility where cervical cancer screening services are available.”

To put this into perspective, at Nursing Heart’s last mobile cervical cancer clinic in Candeleria, three women tested positive for abnormal or cancerous cells. Three of the women with positive diagnoses were treated by Dr. de Baiza. However, one woman who tested positive disappeared before she could be treated. Nursing Heart staff were unable to confirm why the woman left before receiving treatment but suspect she may not have received permission from her husband, succumbed to negative stigmas about the treatment process, or simply needed to return to work.

“For some of our partner communities, that’s a two-hour ride on the one public bus per day that makes that trip: a rough journey over dangerous roads that implies lost wages and out-of-pocket expenses for something that could be deemed a luxury, as it’s not addressing an acute illness rather checking for something quiet and insidious,” says Raphael. 

That’s one of the reasons the mobile clinics also offer comprehensive sex education lessons, which Raphael says is “virtually unheard of in some of Guatemala’s most rural communities, where machismo attitudes, along with social and religious stigmas, can prevent women from understanding their reproductive health and well-being.” 

“It’s not just about the exclusion of women from conversations that affect their bodily autonomy and their right to ask questions about their bodies,” he continues. “It’s also about geography and the broken infrastructure that isolates already marginalized communities and families.”

For women like Juliaticia, the VIA screening and reproductive health workshops Nursing Heart teams provide are a lifeline. “We’re so grateful that the Nursing Heart clinic has come to visit us here,” she says. “We wouldn’t have an opportunity for a health check like this without them.”

How to Practically Scale VIA 

Though Nursing Heart coordinates mobile clinics, brick-and-mortar clinics devoted to reproductive health rarely exist or are only open a few times per month. The nurses who staff the latter have to cover wide swaths of land and multiple communities, often using their personal vehicles for little to no remuneration.

“Then, the facilities are usually devoid of medications, sometimes lacking even a fridge to keep supplies at the appropriate temperature,” says Raphael. “All these factors create a culture of distrust and disdain for government services, which understandably are viewed as unreliable, dysfunctional, and sometimes demeaning to communities that may not speak Spanish.” There are 24 officially recognized Indigenous languages in Guatemala. 

Blanqui believes building relationships with women leaders in rural communities is a crucial first step to creating awareness and beginning to dismantle the stigmas, shame, and fear around women’s reproductive health. “[If we don’t], women won’t take advantage of these kinds of services,” Blanqui says. “The key is gaining their trust so that they understand the procedure, the risks and benefits, and what’s happening to their bodies because women’s health isn’t talked about in the family home.” 

Dr. de Baiza says a solid next step could be educating medical practitioners on a local level. “Training a greater number of people who can offer this service, with efficient and adequate training is key,” says de Baiza.

However, with the current state of Guatemala’s chronically underinvested public health care system, where less than 3% of the country’s GDP is allocated to health—one of the lowest in Latin America—such extensive training would require significant funding from private donors. Raphael says there’s “widespread, systemic corruption in Guatemala,” so the country “invests so very little in its public health and education systems while enriching politicians and business leaders who abscond with the resources that should be going to those systems of care. Preventative health care shouldn’t be a luxury.”

In order to meaningfully scale cervical cancer screening training, Raphael says that this systemic corruption, which has historically deprived rural communities of basic health care services, must also be addressed.

“Guatemala has one of the lowest nurse-patient ratios in the world, and the public health care system is chronically underfunded and understaffed,” he says. “Few have the facilities that can assure patients of dignified screenings, a major issue in a country where more than half the population belongs to historically marginalized ethnic and linguistic communities, and for whom a visit to a medical professional happens seldomly, if ever.” 

But despite Nursing Heart’s promising data, some research questions the efficacy of the VIA technique. A 2022 study published in the Asian Pacific Journal of Cancer Prevention found that though VIA is treated as an alternative to pap smears, “Its effectiveness in terms of reducing invasive cancer and mortality is uncertain.” Instead, “Some trials have shown that there is a significant reduction in mortality after VIA screening while others have failed to prove this.”

But ​Dr. Stephen Holtzclaw, the CEO of the U.S. Orthopaedic Partners who previously educated and mentored future medical practitioners at Johns Hopkins University and attended the Nursing Heart’s clinic in Candeleria, vehemently disagrees with this finding. 

“As they say, ‘The enemy of good is great,’” he says. “The procedure doesn’t have to be perfect to save a ton of lives. You literally can wipe out cervical cancer in a matter of seconds.”

As the VIA gains traction, there’s another looming challenge that might limit access to preventative care: the global phasing out of halogen lights.

In August 2023, the United States implemented a ban on the manufacture and sale of most halogen light bulbs due to their low energy efficiency. But while certain specialty bulbs, such as those used for medical purposes, are technically exempt from the regulation, their availability has significantly decreased.

The phase out has made it difficult for Nursing Heart and other nonprofit organizations using the VIA method to procure halogen lights. “It’s been a major weakness/vulnerability for us,” Raphael says. “Even the products we used to purchase on Amazon are no longer listed on the website. For all intents and purposes, we’re about to face a major shortage.”

Additionally, it is unclear what the impact of the Trump administration’s foreign aid cuts will have on Nursing Heart’s mobile cervical cancer screening clinics. But should the clinic’s funding be impacted, Raphael says, the chain of care that would be needed for them to benefit from a more formal type of screening would not be feasible and would eradicate the limited opportunities women have to find and treat cervical cancer.

“These women live several hours from proper laboratories, and even if they were able to get to those labs, the cost of that service is often well beyond their economic means,” he says. “The roads that take them there, the medical devices that provide that information, and the technicians to operate them… all are deficient in terms of the investment required to make them accessible to the people who most need them.”

That would be devastating for women like Juliaticia. “It’s so important they keep coming back, for all of us,” she says. In places where access to health care is scarce, these clinics offer something invaluable: care that comes to them.