by Saemmool Lee
Cervical cancer is the fourth most frequent cancer in women globally, and about 90 percent of deaths from the disease occur in low- and middle-income countries, according to the World Health Organization. The deaths are preventable with vaccines and early diagnosis, but existing resources remain largely inaccessible to women in low-resource countries. Visualize is a nonprofit organization dedicated to address the issue.
In collaboration with midwives in Ghana, Visualize designs, builds, and implements low- cost training devices that assist in teaching healthcare providers how to screen for cervical cancer. Visualize was co-founded by Julia Kramer, a UC Berkeley mechanical engineering Ph.D. student, and Maria Young, a medical student at Loyola University Chicago Stritch School of Medicine. Kramer has been working at the CITRIS Invention Lab with Berkeley students for the past three years to continue developing the device.
The project was started in 2013, when Kramer and Young were undergraduates at the University of Michigan. The two were part of a team of five undergraduates who traveled to Ghana for two months to identify needs in maternal health that could be met with engineering solutions. The two students focused on cervical cancer screening training, as the cancer was the leading cause of cancerous death for women in the country. A regular screening with a Pap smear (a test for cervical cancer by collecting cells from cervix) has been shown to lower risks for developing invasive cervical cancer because precancerous lesions can be treated before they develop into cancer. While the test is widely used in the US and other high-income nations, Young and Kramer recall not seeing a single Pap smear at the hospitals where they were working over their first month in Ghana.
Because the Pap smear requires the use of a cytology lab, it is an inaccessible option for many women living in low- and middle-income countries. Visual inspection with acetic acid (VIA) has been shown to be a satisfactory alternative screening method to be used in low-resource settings. It is an inexpensive method that requires only acetic acid (or table vinegar) and a trained midwife. Furthermore, when paired with other medical procedures it can be used as a “see and treat” prevention method. Young and Kramer learned that while midwives support the use of VIA, it is not widely used because of a lack of education and training on the method.
Young and Kramer designed the first Visualize prototype in Michigan, and returned to Ghana for feedback. Shortly after the trip, Kramer graduated from college and started her Ph.D. program at Berkeley. Since then, the project has received funding from many sources, including Big Ideas@Berkeley, Berkeley Crowdfunding, and Clinton Global Initiative University Innovation Fund. Thanks to this funding, the team has been able to continue developing the device at the CITRIS Invention Lab. There have been challenges in developing the device, such as how to make sure someone who might be assembling it for the first time is still able to utilize it, and how to make device assembly as repeatable and easy as possible. “It’s those types of questions that the folks in the Invention Lab have been really helpful in thinking through,” says Kramer.
The Visualize trainer simulates the exact steps of typical VIA in a simple way: It has a set of flashcards that include images of a real patient’s cervix before acetic acid is applied. After the trainee using the device “applies” acetic acid to the simulated cervix (the trainee can dab a dry cotton ball on the flashcard but not a cotton ball soaked in acetic acid), an LCD screen tells the trainee to go through each step of the screening procedure to see if the cervix pictured on the flashcard is suspect for pre-cancer or not. “Our chief novelty isn’t necessarily in the technology, but it’s in simplifying the simulation experience down to its core elements,” says Kramer.
The team has been continuously getting feedback from collaborators in Ghana. “The strength of Visualize is fueled by the incredible, intelligent, hard-working, and passionate group of midwives that we work with,” says Young. “Visualize is an opportunity for us to assist them in even the smallest way to do the incredible work that they do, bringing healthcare to their communities.”
Berkeley undergraduates participated in the project, with as many as six students at its peak.
Hailey Windsor, a junior in the College of Environmental Design and CITRIS Invention Lab super user, spent a year working on physical prototypes of the device. “I was just compelled by the story Julia told, a very concrete way to try and solve the problem through design,” says Windsor. She traveled to Ghana with Kramer for six weeks last summer to do user testing. “It was really rewarding to get to meet these people that I’d been taking feedback from but never actually met in person,” she says.
The device currently costs about $100, and Visualize targets a price around $25 or $30. Currently, there aren’t any other training tools available for purchase that were specifically designed to train for VIA, says Kramer. Visualize is now figuring out how to manufacture the device at scale, develop a training curriculum, and implement the device and the curriculum in Ghana.
The challenges associated with cervical cancer are not unique to Ghana. India represents 26.4 percent of all women dying of cervical cancer globally, with China, Bangladesh, Pakistan, Indonesia, and Thailand also showing high death rates, according to the Cervical Cancer Coalition. “There is a huge opportunity for this to be taken to a global scale,” says Kramer. “In the long term, once we’re established in Ghana and have a good idea of what health training looks like around the world, I envision that this could be used in midwifery and nursing training around the world.” She and Young registered Visualize as a nonprofit organization last June to better implement the project by having a formal body to continue running outside of the university environment.
All 10 of the countries with the highest cervical cancer mortality rate (per 100,000 people) are found in Africa, including the 8th highest country Ghana (27.6), according to the Cervical Cancer Coalition. In the U.S., the mortality is 1.7. “We see very low rates of cervical cancer mortality in the U.S. compared to low and middle-income countries,” says Young. “This is the biggest motivator to me. Women all over the world, no matter where they are born, or live, or die, deserve access to comprehensive, quality healthcare and should not be dying of preventable diseases.”
Last February, a research paper in the Lancet Oncology journal predicted that, due to vaccination and screenings, cervical cancer could be reduced into a level that could be considered effectively eliminated in most countries by the end of 21st century. “We are really focused on a discrete amount of time where right now people are dying of cervical cancer because they can’t get screening,” says Kramer. “In those next 81 years, it’s about making sure that people aren’t dying unnecessarily.”
Photo by Adriel Olmos