Abstract A37: A biocultural framework for understanding the excess cervical cancer incidence and mortality in Little Haiti, Miami, Florida

In Miami, Florida, Haitian women shoulder a disproportionate burden of cervical cancer incidence, morbidity and mortality. Between 2000–2004, the estimated incidence of disease in Little Haiti, the predominately Haitian neighborhood in Miami, was 38/100,000, relative to 9/100,000 for other low income, minority enclaves in the larger metropolitan area. This disparity reflects the interplay of multiple factors, including lack of access to, and underutilization of, routine Pap smear screening, untimely follow up for cervical abnormalities, and increased susceptibility to Human Papillomavirus (HPV) infection, the primary risk factor for cervical cancer. When compared to other racial/ethnic minorities and immigrant groups in Miami, Haitian women are less likely to report a history of Pap smear screening, and more likely to be infected with HPV, including high-risk, oncogenic viral types. As part of our ongoing Community-based Participatory Research (CBPR) in Little Haiti, we have found that the increased rate of HPV infection among Haitian women is likely associated with their practice of twalet deba, which involves intravaginal washing with herbal and chemical agents to cleanse, dry and tighten the vagina, primarily for enhanced sexual pleasure of male partners. Using data from a series of ethnographic interviews, we have begun developing a biocultural model to explain the socio-cultural significance of twalet deba, and how this behavioral practice can affect HPV transmission and, potentially, cellular transformation. Our model posits that intravaginal washing among Haitian women reflects cultural constructions of health, which uphold bodily fluids, including vaginal secretions, as indicative of infection and immorality. To sufficiently dry the vagina, Haitian women wash intravaginally with various agents, including potassium permanganate, aluminum sulfate, and boric acid, that may exfoliate the superficial layers of the cervix, exposing the basement membrane to HPV, and/or impair innate immunity, reducing the body's potential for clearing infection. Persistent infection with HPV, particularly high-risk viral types, is associated with cervical abnormalities. In communities such as Little Haiti, where women underutilize routine Pap smear screening, such abnormalities go largely undetected, thereby increasing the risk of disease onset and progression. We are currently conducting additional research to test the validity of our model and inform future intervention strategies. Preliminary findings suggest that understanding the complex interplay between culture, behavior, and biology is necessary to attenuate health disparity in Little Haiti, as well as, other ethnic enclaves that similarly contribute to excess cancer morbidity and mortality.