Fighting Cervical Cancer With Vinegar and Ingenuity
Thailand — Maikaew Panomyai did a little dance coming out of the
examination room, switching her hips, waving her fists in the air and
crowing, in her limited English: “Everything’s O.K.! Everything’s O.K.!”
Translation: The nurse just told me I do not have
cervical cancer, and even the little white spot I had treated three
years ago is still gone.
What allowed the nurse to render that reassuring diagnosis was a
remarkably simple, brief and inexpensive procedure, one with the
potential to do for poor countries what the Pap smear did for rich ones:
end cervical cancer’s reign as the No. 1
cancer killer of women. The magic ingredient?
Every year, more than 250,000 women die of cervical cancer, nearly 85
percent of them in poor and middle-income countries. Decades ago, it
killed more American women than any other cancer; now it lags far behind
cancers of the lung, breast, colon and skin.
Nurses using the new procedure, developed by experts at the
Johns Hopkins medical school in the 1990s and endorsed last year by
the World Health Organization, brush vinegar on a woman’s cervix. It
makes precancerous spots turn white. They can then be immediately frozen
off with a metal probe cooled by a tank of carbon dioxide, available
from any Coca-Cola bottling plant.
The procedure is one of a wide array of inexpensive but effective
medical advances being tested in developing countries. New cheap
diagnostic and surgical techniques, insecticides, drug regimens and
prostheses are already beginning to save lives.
With a Pap smear, a doctor takes a scraping from the cervix, which is
then sent to a laboratory to be scanned by a pathologist. Many poor
countries lack high-quality labs, and the results can take weeks to
Women who return to distant areas where they live or work are often
hard to reach, a problem if it turns out they have precancerous lesions.
Miss Maikaew, 37, could have been one of them. She is a restaurant
cashier on faraway Ko Chang, a resort island. She was home in Poyai, a
rice-farming village, for a brief visit and was screened at her mother’s
The same thing had happened three years ago, and she did have a white
spot then. (They resemble
warts, and are caused by the
human papillomavirus.) It was frozen off with cryotherapy, which had
hurt a little, but was bearable, she said.
Since she has been screened twice in her 30s, her risk of developing
cervical cancer has dropped by 65 percent, according to studies by the
Alliance for Cervical Cancer Prevention, a coalition of
international health organizations funded by the
Bill & Melinda Gates Foundation.
The procedure, known as VIA/cryo for visualization of the cervix with
acetic acid (vinegar) and treatment with cryotherapy, can be done by a
nurse, and only one visit is needed to detect and kill an incipient
Thailand has gone further than any other nation in adopting it. More
than 20 countries, including Ghana and Zimbabwe, have done pilot
projects. But in Thailand, VIA/cryo is now routine in 29 of 75
provinces, and 500,000 of the 8 million women, ages 30 to 44, in the
target population have been screened at least once.
Dr. Bandit Chumworathayi, a gynecologist at Khon Kaen University who
helped run the first Thai study of VIA/cryo, explains that vinegar
tumors because they have more DNA, and thus more protein and less
water, than other tissue.
It reveals pre-tumors with more accuracy than a typical Pap smear.
But it also has more false positives — spots that turn
pale but are not malignant. As a result, some women get unnecessary
But freezing is about 90 percent effective, and the main side effect
is a burning sensation that fades in a day or two.
By contrast, biopsies, the old method, can cause bleeding.
“Some doctors resist” the cryotherapy approach, said Dr. Wachara
Eamratsameekool, a gynecologist at rural Roi Et Hospital who helped
pioneer the procedure. “They call it ‘poor care for poor people.’ This
is a misunderstanding. It’s the most effective use of our resources.”
At a workshop, nurse trainees pored over flash cards showing cervixes
with diagnosable problems. They did gynecological exams on lifelike
mannequins with plastic cervixes. They performed cryotherapy on sliced
frankfurters pinned deep inside plastic pipes. Then, after lunch, they
broke into small groups and went by minibus to nearby rural clinics to
practice on real women.
Because cervical cancer takes decades to develop, it is too early to
prove that Thailand has lowered its cancer rate. In fact, Roi Et
Province, where mass screening first began, has a rate higher than
normal, but doctors attribute that to the extra testing. But of the
6,000 women recruited 11 years ago for the first trial, not a single one
has developed full-blown cancer.
VIA/cryo was pioneered in the 1990s simultaneously by Dr. Paul D.
Blumenthal, an American gynecologist working in Africa, and Dr.
Rengaswamy Sankaranarayanan in India.
Dr. Blumenthal said he and colleagues at the Johns Hopkins medical
school had debated ways to make cervical lesions easier to see, and
concluded that whitening them with acetic acid would be effective.
Freezing off lesions is routine in gynecology and dermatology; the
challenge was making it cheap and easy. Liquid nitrogen is hard to get,
but carbon dioxide is readily available.
Thailand seems made for the vinegar technique. It has more than
100,000 nurses and a network of rural clinics largely run by them.
Also, while poor rural villagers in many countries go to shamans or
herbalists before they see doctors, poor Thais do not. Thailand has a 95
percent literacy rate, and doctors are trusted. The king is the son of a
doctor and a nurse; his father trained at Harvard. One of the royal
princesses has a doctorate in chemistry and an interest in cancer
But the real secret, Dr. Wachara said, is this: “Thailand has Lady
Dr. Kobchitt Limpaphayon to her colleagues at Bangkok’s Chulalongkorn
University medical school and “Kobbie” to her
classmates long ago at New York’s Albany Medical College, she is the
gynecologist to the Thai royal family. “Kobbie is a force of nature,”
said Dr. Blumenthal, who has taught with her. In 1971, as a young
doctor, she moved from Albany to Baltimore to help start the Johns
Hopkins Program for International Education in Gynecology and
In 1999, she read one of Dr. Blumenthal’s papers and asked him to
introduce VIA/cryo in Thailand. Without her connections and powers of
persuasion, said Dr. Bandit, it would have been impossible to get the
conservative Royal Thai College of Obstetricians and Gynecologists to
give up Pap smears, or to persuade Parliament to allow nurses to do
cryotherapy, a procedure previously reserved for doctors.
The free screenings at public clinics are crucial to people like
Yupin Promasorn, 36, who was part of Miss Maikaew’s group.
She sells snacks in Bangkok, and her husband drives a tuk-tuk
motorcycle taxi. With two children, she has no time to wait at Bangkok’s
jammed public hospitals, and she is too poor to see a private doctor. So
she and her husband drove the 12 hours here, to her native village, in
his tuk-tuk. When she found out she was negative, she sat in a chair
“I feel like a heavy mountain is gone from my
chest,” she said.