Megan Huchko, MD, Associate Professor of Obstetrics & Gynecology, describes her experience and motivation that led her to a career as an implementation scientist, what led her to conduct research in East Africa and the effectiveness of cervical cancer prevention.
How did you originally get interested in global health?
I have always been interested in traveling, and in college, had the opportunity to study abroad in Madrid, Spain. While I was there, I was immediately struck by the entrenched gender roles and overt masculinity that seemed to permeate both professional and personal spheres. Every day on the way to class, I would pass by the Institute of the Woman, which was a government agency created by the relatively recent constitution to ensure equality between the sexes. I developed that curiosity into a research project on the women’s movement in Spain that I was able to carry out through a Fulbright Award after I graduated. During my Fulbright year in Spain, as I was interviewing activists and feminists in Spain about political and social advances for women over the previous two decades, there were several egregious instances of domestic violence that inspired something of a national soul-searching. I decided to use the legal and social climate around domestic violence as a case-study to illustrate the limitations of the women’s movement and the absolute centrality of health and safety from violence to a person’s well-being. While this case-study was not uniquely “global health,” the experience jumpstarted my interest in the political, social and cultural drivers of health, which are often seen most acutely in global health.
Why have you focused your work in East Africa?
During my fellowship in Reproductive Infectious Disease, I started working at the Family AIDS Care and Education (FACES) program in western Kenya. My mentor had started FACES through a US government funding program called PEPFAR, which provided funding for HIV care for the hardest hit countries in the world, the majority of which are in sub-Saharan Africa. In addition to having an incredibly high HIV-prevalence, this region had poor maternal health outcomes and poor access to reproductive health care. At the same time, Nairobi is one of the most cosmopolitan cities in Africa, with an increasing number of people interested in public health research. I was able to capitalize on my mentor’s infrastructure and relationships as I established my own research program. When I came back to Duke a few years ago, I found that the Global Health Institute had strong relationships in Kenya, Tanzania and Uganda, so it made sense to develop a Center for Global Reproductive Health with a focus area in East Africa.
Can you describe the type of research that you do?
I am an implementation scientist, which means that I work on strategies to bridge the gap between evidence-based interventions and the populations they are targeting. Specifically, I have worked to develop implementation strategies for cervical cancer prevention for women in low-resource settings, mainly in East Africa. The focus of the work has evolved as the technology and funding for cancer prevention has advanced. In my early career, I worked to help develop evidence for various screening strategies in different populations and settings. At this point, my main focus is on working with guidelines committees to develop strategies for specific populations, and working with key stakeholders to identify ways to successfully implement these strategies.
What are some of the most exciting advances in cervical cancer prevention in the past few years?
Progress in cervical cancer prevention has driven the WHO to issue a Global Call for Elimination within the next 100 years. Although this is an ambitious target, it has lead to increased funding to spark creativity in the development and implementation for the latest tools and strategies to deliver primary and secondary prevention. Clearly the biggest impact has come from the introduction of the HPV vaccine almost 20 years ago, now available in a formulation that provides protection against up to 96% of cervical cancer. This aligns with further developments in HPV testing, both in molecular genotyping and in advances that make this technology more feasible in low-income settings (evidence for self-collection and lower cost, more durable testing platforms). One of the most exciting recent advances is the development of visual algorithms for the diagnosis of cervical cancer precursors, which some are calling artificial intelligence. If successful, they could increase the accuracy of cervical assessments over HPV testing alone, in areas where coloposcopy and pathology are not available. This would decrease the burden of overtreatment on the individual woman and on the health care system. The technological advances in screening and vaccination leave remaining challenges in devising implementation strategies that will meet the needs of the populations most in need.
How can lessons learned in East Africa translate to effective cervical cancer prevention in the US?
We live in a state with marked disparities in cancer rates between urban and rural populations. Working in the cervix clinic, I can see firsthand the burden that some patients have to get to the 1J; they have to drive hours from their home, and then navigate a somewhat complex medical system. Some of the engagement and follow-up strategies we are working on in Kenya and East Africa may help address attendance: mHealth education and reminders. More ambitiously, I was part of a multidisciplinary group that included the Pratt School of Engineering and the Margolis Center to develop and evaluate new models of decentralized care across the screening, diagnosis and treatment cascade. While there are unique challenges and assets in the US, many of the strategies we described derived from our work in East Africa.
How have students or residents been involved with your work?
I’ve had students and residents work on various aspects of the cervical cancer prevention and health systems strengthening work, both through on-site rotations and through data analysis in the US. The Center for Global Reproductive Health has a network of researchers in East Africa who are working on various projects, from HIV care and prevention, women’s mental health, safe motherhood, and big data analytics around family planning – we are always happy to work with learners to see if there is a fit for research interests, or ways we can work together to develop new ideas.