Silence to Solidarity
Carolyn Dunderdale
Unlike most of the patients, she came in alone. Two long black braids, a wide-brimmed sunhat atop an embroidered dress, she appeared much like the other Bolivian patients I had seen in the gynecology clinic that week. Yet this woman shuffled into and out of the clinic room without the guiding arm of family.
I approached her as she stepped out of the clinic room, and I ran through my rehearsed statement in my head, asking in Spanish with my thick American accent, “Hello, I am a medical student working with your doctor on research about your experience with healthcare, would you be interested in answering a few questions?” With one confident glance up and down, she determined she would be the one in charge. She nodded, and I explained further that we were interviewing patients with cervical cancer about their experiences in learning about their diagnosis and what health information they knew about beforehand. To the women at this clinic, I did not have to explain why. Cervical cancer, and even pap smears, are rarely discussed openly. Conversations about sex are taboo, let alone questioning a husband’s fidelity. As a result, the topic of contracting HPV and its link to cervical cancer has been hushed.
In a space alone, woman-to-woman, her stiffness softened and her honesty flowed. She was in her 60s, lived in the rural outskirts, and had completed only primary school. She was a housewife, proudly catholic, and about a year ago traveled the three hours to the clinic here in the city when she started bleeding without end. Her doctor bluntly stated it was from el virus de cáncer, the local term for HPV, and had spread aggressively after being unchecked for years. The HPV had caused cervical cancer.
In asking who she could trust to talk about her diagnosis, she said “nadie”. No one. Her husband? She scoffed, she wouldn’t trust him anymore. Her doctor? Who never even explained she needed to get annual pap smears. Someone else? “Well, maybe other women like me, who are going through this.” I scribbled, realizing that even in a culture where this type of cancer is taboo, women will still seek each other out for support. I returned her smile, finding the tightness of her expressions softening from being able to talk about what she is going through.
I finish my usual questions by asking if she has any comments on helping prevent cervical cancer. She nods, “Women listen to women. Daughters to mothers. Neighbors to neighbors. Friends to friends. But cervical cancer is not discussed if women are too scared to talk about these kinds of things. I want to talk about what happened to me.” Her pace picked up, and I caught glimpses of what she was expressing; “he cheated and yet I am the one with the consequences”, “there is nothing they can do now for it”, “I now tell everyone to get checked”. My pen lay flat as I listened to her empty out what she has been feeling for a year now. Her frustration, grief, and fear all came through even when I didn’t understand every word.
She finishes with a sigh, and I thank her for everything she shared, emphasizing how her comments will help us in our research that will go on to instruct Bolivian doctors how to address the rising crisis in cervical cancer cases. To begin the conversation on preventing cervical cancer rather than reacting to it. She adds, “Please know that I will do it. And I am sure I am not the only one. Any one of my neighbors who listens will hear my plea to not follow my path. To get themselves to a doctor, despite the cost, and get checked. To not ignore when they feel sick. To know that they can save themselves from this cancer.”
Cases like this sit heavy in my stomach. Had she been born where I was, there would be more conversation and medical advice to get pap smears and tests for HPV. Maybe she could have even gotten the HPV vaccine and prevented all this. But she was born at a place and time where she was failed by the medical system and failed by her husband. What do you do when the people you should trust fail you? From her story, the answer is to find new people to trust. A different doctor. Other women. She was single, at her appointments alone, but she was now in charge of her life in the time she had left.
I finished the interview, copying down her final comments so I could submit them to our records. I return to the gynecology waiting room, packed with women of every age twisting their braids between their fingers, shaking their covered knees, picking at the corners of their paper medical records. Some women chat together, bonded by the same pre-appointment nerves. For some of the patients here, it may be too late to prevent cervical cancer. But for the younger women who have a chance at being put on a new path, the older women are willing to speak up for them.
I now compile our data from the interviews we did this summer, compacting it for our lead Bolivian investigator, who is forming a plan. There is a new petition, one for the government healthcare budget to be put to combating cervical cancer. Bolivian gynecologists are fighting for resources to fund HPV vaccines, expand healthcare education, and hold public presentations.
The woman I interviewed reminded me that medicine is more than procedures and prescriptions. It is trust, conversation, and the courage to name what is hidden. Data and petitions will shape policy, but it will be women themselves, speaking to each other in homes and markets and clinics, who will determine whether Bolivia’s daughters face the same fate. If even one child, one neighbor, or one friend listens, the tide can begin to turn. Cervical cancer prevention in Bolivia will come from women like her, ones with traditional braided hair under a sunhat, standing tall in the face of silence, determined that the next generation will not carry the same burden.
Carolyn Dunderdale is a MS2 at UMass Chan Medical School who is interested in women's health, global health, and epidemiology. She found the perfect opportunity this summer to combine travel, learning different cultures, and clinical research through characterizing cervical cancer in Cochabamba, Bolivia.
