Women´s health and infection control

Yesterday I spent all morning working with the OB/Gyn who works at CFLAG. She does all of the Pap smears for the HIV positive women in the clinic, cares for all HIV positive pregnant patients, and also works for the Hospital San Juan de Dios as an OB/Gyn (separate from the clinic). I really enjoyed working with her. I´ve always liked women´s health, as well as hands-on activities like pelvic exams - so it was a good day. The pathology seen during the pelvic exams consisted of vaginal candidiasis, vulvar/vaginal atrophy, and quite a lot of genital warts. After we finished doing pap smears we went across the hall to watch colposcopies. It was really interesting, since I had never seen colposcopy before. (For my non-medical friends and family, colposcopy is a procedure in which a speculum is introduced into the vagina, just like a regular PAP or pelvic exam, acetic acid is applied to the cervix, and the doctor then looks at the cervix with a microscope, and any part of the cervix that turns white with acetic acid is biopsied. It is a way to look for possible malignancies).

When I first arrived in the clinic for PAPs I was relieved to see that there was paper on the exam table. Finally - a place within the hospital where the bed covering is changed between patients. (In the general HIV clinic the beds are covered with sheets that are not changed in between patients). The PAP exam table had a long strip of brown paper on it, and after we saw the first patient, I reached towards the table to remove the used paper, and was immediately told that the paper is not changed until the end of the day - after all of the pelvic exams are finished. "But these women are sitting on the paper with naked bottoms, dont you think we should change the paper?" I asked. "No. We change it after all the patients are finished. We dont have enough paper to change it after each patient visit," I was told. (Despite the fact that there was a full roll of brown paper under the examination table). And to make matters worse - there was just one cloth gown that all of the women had to change into for their PAP smear!! All of the patients that we saw were HIV positive, many of them with genital warts, many of them with vaginal discharge, and all of them sharing the same brown piece of paper and cloth gown. Also, despite the fact that there was a fully functional sink with a full bottle of soap and a full towel dispenser (a rarity in Hospital General San Juan de Dios), no one used it throughout the day but me. The gynecologist washed her hands at the sink after we had finished seeing all of the patients. This is a trend that I have seen throughout my month here in Guatemala. The majority of practitioners (of course, there are exceptions) wash their hands after having seen all of their patients. It seems that hand washing is perceived more as a means of protecting oneself than of protecting patients.