Cervical cancer (CaCx) is the second leading cause of cancer-related death in women in developing countries, and about one in four of these deaths occur in India. This high death toll is primarily because India does not have a CaCx prevention program with routine screening to detect early lesions. Two recently licensed vaccines against the most common strains of HPV, the virus that causes cervical cancer, have the potential to save hundreds of thousands of lives. These vaccines are commercially available in India in the private sector, but they are expensive and will not be accessible to a large proportion of the population without a government-sponsored vaccination program. The WHO recommends that countries incorporate these vaccines into their national immunization programs if it is programmatically feasible and cost-effective. In addition, GAVI has announced it will purchase the HPV vaccines to support their introduction in eligible countries, including India.
In 2009, the global health NGO PATH began a study in two states in India to determine the feasibility of a policy for universal vaccination of adolescent girls. After seven of the nearly 24,000 teenage girls participating in the study died, the study came under fire. Although investigations revealed that the deaths were clearly unrelated to the vaccine (one girl drowned, for example), they uncovered irregularities in the ethical conduct of the study. Human rights groups, women’s groups and others petitioned the government to halt the trial, and the media sensationalized the story, adding fuel to the flame. The government yielded to the pressure and halted the trial in 2010.
With no progress being made on the HPV vaccine front anymore, the problem of CaCx in India has once again been shifted to the back burner. Indian activist groups such as Sama and the People’s Health Movement need to recognize that promoting women’s health is a goal that they share with PATH, and that fighting within the camp will only serve to weaken their cause. On the other hand, PATH must respect the concerns of these groups and learn how to partner with them. All the stakeholders need to converse openly and transparently, without pre-existing biases and hidden agendas, on how to best proceed with feasibility studies to build the evidence base necessary for policy makers. If they do not, millions of adolescent girls will never have access to these lifesaving vaccines.
Tags: women's health
Social, Cultural & Behavioral Issues in PHC & Global Health 
March 13, 2012 at 5:52 am |
Check out Jhpiego …
“Working with stakeholders and partners, Jhpiego pioneered the single visit approach (SVA), a unique, medically safe, acceptable and effective approach to cervical cancer prevention for low-resource settings. The SVA consists of visual inspection using vinegar or dilute acetic acid (VIA) to detect precancerous lesions on the cervix, followed by the offer for treatment using a freezing technique (cryotherapy), in the same visit.
“Jhpiego first conducted early clinical trials of VIA in Zimbabwe in 1995. Subsequently, we implemented projects to assess the safety, acceptability, feasibility and effectiveness of the SVA and found that it is a cost-effective intervention that can be practically implemented in low-resource settings. Jhpiego has since provided technical assistance to establish and scale up cervical cancer prevention programs in Ghana, Guyana, Indonesia, Malawi, Philippines, South Africa and Thailand, and has participated in advocacy initiatives in Ethiopia, Kenya, Mozambique, Nepal, Peru and Tanzania.
“Jhpiego implements a comprehensive approach to cervical cancer programming with the following key components …” read full story at: http://www.jhpiego.org/en/content/cervical-cancer-prevention-and-treatment
March 13, 2012 at 9:04 pm |
Just wait until the Indian men get head and neck cancer which is coming from the HPV virus. My thoughts are when the dominent Indian sex (males), has HPV issues something will be done.
March 14, 2012 at 6:54 pm |
This topic of cervical cancer prevention in developing countries is a passion of mine and so I was thrilled to see your post! I have worked in Nicaragua since 2008 with teams that have partnered with a Nicaraguan NGO to set-up pilot clinics to provide the “See-and-Treat” approach in addition to screening to addressing cervical cancer which sounds like the same approach that Jhpiego is doing. The pilot’s have been effective and planning with the NGO and the Ministry of Health to scale-up the program is beginning.
However, a vaccine allows for primary prevention that the “See-and-Treat” method does not address. I agree that incorporating the vaccine into regular vaccine schedules is vitally important to preventing cervical cancer and I hope that India finds a way to re-consider the utilization of the vaccine.
Also, is access to care for women an issue in general? Do most girls get the scheduled vaccines? If not then perhaps, the vaccine and cervical cancer are not the main issue and improving access to healthcare may yield better health outcomes for women.
March 15, 2012 at 1:37 am |
I find it interesting that while most people talk about finding a cure for cancer as the highest possible achievement, when a successful preventive treatment comes along people find issue. Perhaps it is because cervical cancer and HPV are considered “sexual” that so many protest. I think of HPV as pre-malignant and cervical cancer as malignant. Why wouldn’t I want to keep my child or my patients from getting cancer? Unfortunately, with every treatment there are side effects, which can be horrific. But as has been shown with other vaccination campaigns, the positive public health outcomes outweigh the cons. It is important for individuals to remember that the HPV vaccination is not about morality but rather about trying to prevent disease and death.
March 15, 2012 at 7:40 pm |
A similar scenario happened in Taiwan in 2009, when the universal vaccination campaign against pandemic flu was associated with a higher rate of adverse effects, such as neuropathies. Because of fear, uncertainty, and loss of confidence, the vaccination policy was halted, resulting in even higher mortality from flu. From the course of Social and Behavioral Foundations of Primary Health Care we learned that the factors of a successful policy we should consider are more than its implementation, but also include the analysis of health behavior, personal perceptions and beliefs, and diagnosis of networks at multi-level.
In this case, HPV vaccination does not preclude from other interventions of primary prevention. Pap smear screening for precancerous lesions is essential and public education of the associations between cervical cancer, HPV infection and screening should be reinforced. Change in beliefs and behavior is a stepwise process that cannot be done with a leap.
March 16, 2012 at 6:51 am |
Nice blog on an interesting and important topic! I was involved with a telemedicine program in Botswana which utilized mobile phone-based cameras and a store-and-forward telemedicine platform in an attempt to increase screening of women, especially in remote areas of the country which lacked skilled health care providers. The camera phones allowed unskilled workers to take amazingly high quality photos of the cervix and transmit these images securely to volunteer physicians in the US, Europe and Australia who provided a telediagnosis and treatment advice. Some treatment could then be carried out locally, or more advanced treatment required transfer of the women to a district hospital. This expanded screening effort made a difference in the number of women who were screened and therefore diagnosed with cervical lesions before they began more advanced.
It is interesting to consider the vaccine as an additional strategy at a primary prevention level and to look at the novel challenges in acceptance, cost, etc. which go along with it. Likely different combinations of these approaches will work best in different locations and cultures.
March 16, 2012 at 2:06 pm |
Absolutely brilliant piece and points on access, perceptions/behaviour and different degress of approach combinations across differing cultures. I guess we’ve come a long way since ‘Jacobson Vs. Massachusetts’ when exposure to a health problem/concern was involutary such as inhaling (small pox virus) to when behaviour drives an exposure (sexual responsibility association with CA cervix). The case may play out differntly today considering this.
However, there exist a number of inequality and inequity issues such as vulnerable populations who maybe exposed via sexual exploitation/abuse, limited access to information and knowledge prior to seual debut in cerain populations as well as the extent of outcomes (potential mortality as oppossed to just wrat growths) in females when compared to males.
Despite some cultures/populations having say a ‘negative’ attitude towards this sort of policy feasibilty trial in India (similar to a meningitis medication that resulted in impairment of childern following a drug trial by pfizer in northern Nigeria witha ‘questionable’ ethic protocol), I’ll very much promote and advocate for such trials levaraging on inequities and inequalities in distributon of the risk as well as outcomes but with a different organization and with more open protocols (especilly ethics).
March 16, 2012 at 11:52 pm |
This is a very interesting blog!I think there are several reasons the vaccination of cervical cancer has been “shifted to the back burner”. In general, as time passes by, interests and focus of people (especially donors, for example) switch. So what might be the headlines one day, is likely to be replaced by something else very soon. Considering that India has an abundance of health issues to shift your attention to, it is very easy for people to change focus.
Another issue I would be interested in is how conservative the Indian communities are in general. I know that even in the United States HPV vaccination is met with some resistance because it deals with sex and vaccinates girls at an early age. Thus, many parents, for example, are resistant to seeing their daughters as sexual beings at such an early age and others think that such a vaccination will encourage the daughters to have sex at an earlier age. I wonder if such problems exist in India and if they do, it would be very important to address them. Maybe it is partly why the vaccine is met with such resistance there.