Thursday, April 24, 2014
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Learning from Rwanda

GENEVA – How is it that Rwanda, among the world’s poorest countries – and still recovering from a brutal civil war – is able to protect its teenage girls against cancer more effectively than the G-8 countries? After just one year, Rwanda reported vaccinating more than 93% of its adolescent girls against the human papillomavirus (HPV) – by far the largest cause of cervical cancer. Vaccine coverage in the world’s richest countries varies, but in some places it is less than 30%.

In fact, poor coverage in the world’s richest countries should come as no great surprise, especially when one considers the demographics of those missing out. Where available, evidence suggests that they are mainly girls at the lower end of the socioeconomic spectrum – often members of ethnic minorities with no health-care coverage. This implies that those who are at greatest risk are not being protected.

It is a familiar story, one that is consistent with the global pattern of this terrible disease, which claims a life every two minutes: those most in need of protection have the least access to it. Of the 275,000 women and girls who die of cervical cancer every year, 88% live in developing countries, where mortality rates can be more than 20 times higher than in France, Italy, and the United States. That is not just because vaccines are not readily available; it is also because women in these countries have limited access to screening and treatment. Without prevention, they have no options if they get sick.

Alarmingly, in some of the wealthy countries, where both screening and treatment should be readily available, vaccine coverage now appears to be declining, raising a real danger that socioeconomically disadvantaged girls there will face a similar fate. If it turns out that girls at risk of not receiving all three doses of the HPV vaccine are also those with an elevated risk of being infected and missing cervical screenings as adults, they may be slipping through not one but two nets.

It is still not clear why this is happening. What we do know is that HPV is a highly infectious sexually transmitted virus, which is responsible for almost all forms of cervical cancer. HPV vaccines can prevent 70% of these cases by targeting the two most common types of the virus, but only if girls have not yet been exposed to the virus, which means vaccinating them before they become sexually active. Yet efforts to communicate this to the public have been met with skepticism from some critics, who argue that the vaccine gives young girls tacit consent to engage in sexual activity, ultimately leading to an increase in promiscuity.

However, quite apart from the evidence to the contrary, intuitively this makes no sense. To suggest that giving girls aged 9-13 three injections over six months gives them a green light to engage in sex and sets them on a path to promiscuity is utter nonsense. It is like saying that people are more likely to drive dangerously if they wear a seat belt; in fact, the opposite is more often the case.

Whether such attitudes and misinformation account for poor vaccine coverage in places like France and the US is still not known. It may simply be that some parents or girls mistakenly believe that one shot of the HPV vaccine is enough to provide protection, or that some socially disadvantaged girls lack sufficient access to in-school vaccination services. Or perhaps the cost of the vaccine is a barrier in some of these countries. Whatever the reason, unless coverage for all three doses increases, cervical cancer and pre-cancer rates will increase.

In countries like Rwanda, people know this only too well, which is why they have been so eager to tighten the net on HPV. They have seen the horrors of cervical cancer, with women in the prime of their lives presenting with late-stage disease and suffering slow and painful deaths. Without changes in prevention and control, deaths from cervical cancer worldwide are projected to rise almost two-fold by 2030, to more than 430,000 per year.

And now, with help from my organization, the GAVI Alliance, a public-private partnership created to improve access to new vaccines for the world’s poorest children, other low-income countries are following Rwanda’s lead. As of this year, Ghana, Kenya, Laos, Madagascar, Malawi, Mozambique, Niger, Sierra Leone, Tanzania, and Zimbabwe have all taken steps to introduce HPV vaccines, with more countries expected to follow.

G-8 countries’ generous contributions to organizations like mine show that they understand the importance of childhood immunization. But, while HPV infection rates may be falling in some of these countries, are they falling fast enough? In the US, for example, the G-8 country for which we currently have the most data, infection rates have halved in the six years since the vaccine was first introduced. Yet failure to reach the 80% coverage mark means that 50,000 American girls alive today will develop cervical cancer, as will another 4,400 girls with each year of delay.

So it is worth remembering that even in wealthy countries, there is an urgent need to overcome challenges in protecting the hardest-to-reach girls, who often are at high risk of HPV infection. Overcoming these challenges is essential to reducing cervical cancer and pre-cancer rates in the coming years. Rwanda’s success should be the norm, not the exception.

Read more from our "Visionary Voices" series

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