Wendy Grube, PhD, CRNP, Practice Assistant Professor
How does your work relate to global women’s health? Dr. Wendy Grube regards women’s health as “more than just healthcare. It is political voice, economic power, and the ability to make change in your own community,” and feels her notion is represented in the West Virginia Project she directs. First, she notes that when it comes to addressing global women’s health, it must “start right here at home.” For seven years now, Dr. Grube and a group of her graduate students (of the Women’s Health Nurse Practitioner and Midwifery programs here at Penn) have made a weeklong spring break trip to Webster County, West Virginia to offer pelvic exams to women from the region. This is a poor, rural, very low-resource region where almost a third of the population is below the poverty line. What’s more, there is no doctor in the region that specializes in women’s health. Instead, the limited numbers of doctors in practice in the region all specialize in primary care, where they “put out the fires,” which includes medical conditions like diabetes, hypertension, and serious accidents. Meanwhile, the routine, preventative care that saves women’s lives is being neglected. Dr. Grube points out that such neglect is inexcusable when one considers that it is happening within the healthcare infrastructure of the United States, which routinely pays for free breast and cervical cancer screenings for women everywhere. And so, the West Virginia Project set out to get screenings in motion.
The Project began when women from the Webster County community reached out via the Appalachian Scholarly Network, a listserv where women can share ideas with one another electronically, asking for help with a health fair in their region. Dr. Grube realized that this would be an interesting way to gather women’s health-related data because the process would occur within the women’s own community context in West Virginia. In 2006, she recruited several graduate students to accompany her for assistance with this fair. At that time, the state had morbidity and mortality rates of cervical cancer (a preventable cancer) that were equivalent to those in a number of developing countries, and women were dying of the cancer at a rate 51% higher than the national average. Before she could offer tangible healthcare assistance, though, Dr. Grube set out to identify why these women were not being screened for prevention in the first place. While the Center for Disease Control (CDC) pointed to factors such as high rates of poverty or rural roads with limited accessibility to reach clinics, and concluded that the problem must be access-related, Dr. Grube was not convinced. She wondered, “Did you ever ask the women why they are not going to get screened?”
The answer was no. Essentially, these women were getting “lost” in our healthcare system because they were not foreign born, of an ethnic minority, or recognized as culturally different, and therefore given no “excuse” that explained why they were not seeking screening. In turn, Dr. Grube and the accompanying graduate students engaged in meaningful dialogues with the women of Webster County, focusing on concepts like, “What does cancer mean to you?” What they found was that given the many fundamental religious sects present in the region, it was a common notion that cancer tends to be associated with punishment for sin. Dr. Grube explains, “Add to that a cancer that’s related to a sexually transmissible organism and all of the sudden you have punishment for sexual sin.” The women were concerned with the surrounding community’s public perceptions if it were to become known that they were diagnosed with sexually transmitted conditions. Dr. Grube and her students asked what it would take for them to go to screening, and they responded, “If you ladies come down here and do our screenings, we’ll go.”
The West Virginia project was born from such dialogues, and Dr. Grube says proudly that it is “bona fide, true community collaboration.” She emphasizes that the women of the region own this project, and are equal partners in its operation, adding, “We work very hard to keep that balance of power equal.” She affirms that the women of West Virginia who have reached out to demand women’s health care are some of the most powerful women one could ever meet. She laughs and notes that when the time approaches for she and her team to go down for their annual visit, these women actually go door-to-door soliciting other women in the community, saying, “You know, the ‘pap women’ are coming!”
What are some of the practical applications of the West Virginia Project? Obviously, the preventative healthcare the annual pap smears offer these women is essential. Dr. Grube says she tells her students, “I don’t care how long you have to spend with a patient, this is the only clinical rotation you are going to have; I don’t care if you spend four hours with that woman, because this may be the only care she gets all year, or has gotten in years.”
Additionally, the graduate students working with Dr. Grube have put together useful “preparedness packets” on rural women’s healthcare to distribute, detailing the challenges often faced when it comes to relevant healthcare in light of these women’s context. Challenges include routine GYN care, dermatologic disorders, melanoma, and oral hygiene (dentists are scarce). Alongside the packets, a gift bag of sorts is assembled with items like toothbrushes, toothpaste, dental floss, sunscreen, mole assessment instructions, and sensitive skin soap (all of which is made possible by dedicated fundraising).
“But the most practical application of all,” Dr. Grube shares, “is to trust the women.” When you are looking for answers, you must ask the community in question first and respect them as “experts” on their own lives. As an example, Dr. Grube points to the fact that outsiders had neglected to take into consideration the symbolic implications when one examines reproductive healthcare in the Appalachian region. She says that put simply, “context is key.”
What girl or woman stands out in your mind as someone who has influenced you? “Gosh, there’s so many,” she says, and begins with Roz Watts who “sparked a fire” as an important mentor, providing guidance for Dr. Grube’s self-exploration process upon coming to work at Penn. Marjorie Muecke “keeps the fire going” by helping Dr. Grube think critically about herself, the actions she takes, and “what’s happening in all of the world in which I move. Both ways—how it affects me, and I affect it.” She also greatly admires Dean Afaf Meleis’s work, noting that on the first day of her Women’s Health and Primary Care course, she takes ample time to reference excerpts from the Dean’s book, Women’s Health and the World’s Cities, because it speaks so poignantly to all of the factors that affect women’s wellbeing. Lastly, Dr. Grube adds Mary Hufford, a “brilliant” ethnographer who “planted the seeds” of feminist theory for her and piqued her interest of studying women within the contexts of their lives; and Julie Fairman, who helped her “learn how to find my own voice in my work.”