Last January, Susan Cu-Uvin returned to the U.S. from Kurigram, Bangladesh, where she had been in the process of training hundreds of workers to perform cervical cancer screening and to provide some of the screenings herself. The 62-year old doctor joined Health and Education for All (HAEFA) in October 2019 in partnership with Dr. Ruhul Abid to lead the cervical cancer screening program in Kurigram, a district in northern Bangladesh. “Ruhul is relentless,” she laughed. “I am over-committed with many other countries, but he convinced me that there’s a lot of work that needs to be done in Bangladesh.”
Originally from the Philippines, Cu-Uvin did not plan to become a doctor. In fact, she asked her friends to not invite her to any career information sessions or talks because she thought it would not be inspirational. Coming from a conservative Chinese family, the expectation was that after completing her education, she would get married and have children. But Cu-Uvin did not want that. “I asked my mother, ‘After high school, what’s the longest possible course (of education) in the world?’ She said, ‘Medicine.’”
Cu-Uvin wanted to build on the healthcare services HAEFA already offered to garment factory workers throughout Bangladesh by adding cervical cancer screening. The program proved a success, leading to their successful application for a grant from the United Nations Population Fund. With the grant, the two doctors were able to shift their focus and perform population-based screening, which allowed for follow-ups with patients and opportunities to improve the screening process. But with population-based screening, they also had to define a location to provide the services to. “I didn’t want to go and work in places where they already have cervical cancer screening access,” said Cu-Uvin. She thought, “Let’s choose a place… in Bangladesh where there are no current services right now.”
Kurigram, located in northern Bangladesh, is one of the poorest sub-districts in the country and had little to no cervical cancer screening available. Cu-Uvin and Abid were able to secure the grant for the district and moved forward with the initiative.
The population-based screening in Kurigram required a different approach than with the garment factory workers. Rather than waiting for women to go to the facilities, Cu-Uvin and Abid started a massive campaign, using field workers to go to the communities to help prospective patients learn about the importance of cervical cancer screening. “In low-income countries, (patients) come in with advanced cervical cancer,” Cu-Uvin said. “There is really nothing much more that you can do, except for palliative care, and it’s a death sentence for many of them.” The best course of action, she continued, is to identify those with pre-cancerous symptoms and treat it before it advances to cancer. But it is not easy to start a program from scratch.
Apart from carrying out training on how to utilize the technology and on communicating with patients, the two doctors had to ensure that the rooms had internet access and all the necessary materials, including tables and chairs. One of the locations was so far away that it required two flights, a three-hour drive, nearly two hours of travel by boat, and miles of walking to get there. “We had to hire a horse and a cart to carry all our supplies to reach the community where we were going to do the screening,” said Cu-Uvin. “It’s logistically very challenging, but it’s worth it.” The program in Kurigram was so successful that even with all the trained staff, they had to implement a limit of 200 patients per day.
With any project, Cu-Uvin noted, there are successes and failures. Recognizing the urgency of the Rohingya refugee crisis, Cu-Uvin and Abid wanted to bring the program to the camps in Cox’s Bazar, a city located on the southeast coast of Bangladesh. HAEFA had already been providing services to about 60,000 people in the community and had built a good reputation for primary care and prevention. Believing that their success with the garment factory workers and the communities in Kurigram would transfer over to the camps, they mapped the same program to the refugees. As before, Cu-Uvin ensured privacy for the patients. The room had no windows and a single fan was brought in to try to give some air flow. It began well. When they set up the facility and took in their first two patients, there had been a long line of women. But after the two, the line disappeared. “We forgot the difference in culture and messaging,” Cu-Uvin said. “It was a total failure… we had all our instruments, we had all the capability, but we didn’t get (the patients).”
With the screenings for the garment factory workers, it was successful in part because the female workers were financially independent, contributing money to the family, and were thus empowered to make decisions about their own health. In Kurigram, HAEFA had worked closely with the Surgeon General and community leaders, both of whom had large influence over the community. “In the Rohingya camps, we learned that we should have gone to the imam first,” Cu-Uvin said. “If we had the support of the imam, the imam would have gotten the support of the husbands, who literally control the lives of their wives.”
“We were too cocky,” she continued. “We thought that if we brought modern technology and experts, and (if) we offer free health care, that they would come, but we forgot all about cultural differences and… the little empowerment of the women in that setting.” Due to the ongoing health crisis with covid-19, Cu-Uvin and her team has not yet been able to return to the camps to offer the services again. Reflecting on the project, Cu-Uvin hoped that HAEFA will be able to utilize what it has learned to better market the program. “The successes are easy to take, but the failures are really the ones that will make you more successful,” she said.
Her resilience has carried through with her throughout her life. As with medicine, Cu-Uvin did not fall into her current specialty. After graduating from medical school, she wanted to be a pediatric surgeon. However, in the 70s and 80s, surgery was dominated by men. In one interview, the doctors refused to train her, citing that she would probably get married and never use her skills. “And that was the end of my interview,” said Cu-Uvin, “So I thought, what’s the next surgical specialty that would probably be more welcoming for me?” She found obstetrics and gynecology.
Her work extends beyond cervical cancer screening. In fact, much of Cu-Uvin’s research is on HIV. In the 80s, Cu-Uvin began receiving female HIV-infected patients. She was at a loss. When the epidemic hit, it was widely considered a disease that affected gay men and injection drug users, and much of the activism against HIV was on behalf of gay men. It was during this that Cu-Uvin met Charles Carpenter, a leading researcher of HIV and the founder of the first women’s HIV clinic in Rhode Island. “He said if it reaches gay men, if it reaches drug users, it will reach women,” said Cu-Uvin, “And nobody is studying women.”
Inspired by Carpenter, Cu-Uvin applied for the Rhodes AIDS Foundation grant to come to the U.S. to study with Carpenter for three months. The three months then turned into a three-year fellowship on HIV. It was a tough decision. At the time, her mentors in Ob-Gyn discouraged her, saying it would be the “death knell” of her career. There was no cure or vaccine for the disease, and most of the patients were dying in their 30s. The women who were pregnant were having abortions because it was not yet known how severe the mother to child transmission would be. “But Dr. Carpenter was very convincing, or I was stupid, naïve, or stubborn,” she continued, “I said, ‘Okay, death knell of my career, but I will take the fellowship anyway.’ And here I am, 29 years after, still doing HIV and women care.”
And she has done so. Apart from her work with HAEFA, Cu-Uvin is a professor of Obstetrics and Gynecology at the Alpert School of Medicine as well as a professor of Health Services at the Policy and Practice at the School of Public Health at Brown University. She is also the director of the Brown Global Health Initiative and the director of the Providence/Boston Center for AIDS Research. Even with all the accolades, Cu-Uvin still believes in the importance of following your heart. “It may be the wrong or the right thing,” she said. “As long as you can correct your course, that’s the most important thing… You have to go do what you want to do.”