Questioning what we do and changing what we do based on best available evidence

Sunday, December 18, 2022.

Yesterday, one of our young doctors asked me why I am so passionate about cervical cancer prevention. I promised to get her an answer so that is my motivation for writing this.

In April 2009, I was a young Specialist in Obstetrics and Gynecology (Member of the Ghana College of Physicians and Surgeons) in Catholic Hospital, Battor. I had gone round our district with our Public Health Nurse, Ms. Rejoice Adaletey, and realised we had to use different approaches to reach out to the poor women in the very remote and poor communities. The methods we were using then were not achieving this.

Two papers and an editorial in the New England Journal of Medicine in 2009 moved me to do what I am currently doing in cervical cancer prevention.

I share the first two paragraphs of the editorial (and attach the full editorial):

From India to the World — A Better Way to Prevent Cervical Cancer

From India to the world – a better way to prevent cervical cancer

In this issue of the Journal, Sankaranarayanan et al.1 report the results of a randomized clinical trial of screening for cervical cancer involving more than 130,000 women in India. The authors conclusively showed that a single round of screening for human papillomavirus (HPV) dramatically reduced the incidence of advanced cervical cancer and cervical-cancer mortality within 8 years far more than a single conventional cytologic test or visual inspection of the cervix with acetic acid (VIA).

The implications of the findings of this trial are immediate and global: international experts in cervical-cancer prevention should now adapt HPV testing for widespread implementation. Low resource countries do not need to establish large cytologic-testing (Papanicolaou) programs whose effectiveness requires repeated screening. VIA that is performed by health workers, the least expensive but least accurate option, may reduce mortality slightly.2


This was the ‘eureka moment’ for me. I immediately realised that the Community Health Nurses in the Community-based Health Planning and Services (CHPS) could be used for cervical precancer screening using HPV testing. I was excited…

My disappointment began when I started to share this with others, especially some senior colleagues in the field. Some told me it would not work. Others were indifferent at best.
I did not give up. The rest, they say, is history.

The questions that came to my mind then (and which I ask myself every time) are:

  1. Are there new things that are superior to what I am currently doing (or have been doing all these years)?

  2. What are they?

  3. How can I change to use better methods?

  4. Does new evidence or change always have to come from elsewhere?

The editorial was: “From India to the world…”
Could we have something “from Ghana (or Battor) to the world”?

We have also gathered evidence in Battor in the last couple of years that we believe can improve cervical cancer prevention in low resource settings globally, and we continue to share them in scientific publications.

Dr. Kofi Effah is a Gynaecologist and head of the Cervical Cancer Prevention and Training Centre (CCPTC) in Catholic Hospital, Battor in the North Tongu District of the Volta Region of Ghana.

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