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Rwanda Declares War on Cervical Cancer

Written by Dr. Agnes Binagwaho - Minister of Health of the Republic of Rwanda.

rwandaDeclaresWarOnCervicalCancerThe GAVI Alliance's decision to support the introduction of the Human Papilloma virus (HPV) vaccine in eligible developing countries that need it is a very welcome development that will contribute substantially to the efforts of countries, particularly in Africa, striving to reach the Millennium Development Goals (MDGs).

HPV is found in nearly all cases of cervical cancer, and is transmitted from one person to another by sexual contact. Most sexually active people become infected with HPV at some time in their lives, generally in their teens or early twenties. Of the 40 or so strains of HPV, a handful can cause cancer–not only of the cervix but also of the anus, penis, vagina, and throat. Every year, more than half a million new cases of cervical cancer are diagnosed worldwide and an estimated 300,000 women die of the cancer. That figure is likely to rise to more than 400,000 if action is not taken urgently. Strikingly, 76% of new cases and 88% of deaths occur in developing countries–cervical cancer is a disease closely linked with poverty.

Now, fortunately, radical action is possible thanks to the recent development of a safe and effective vaccine that can prevent up to 70% of cervical cancers. Cervical cancer is to date one of the few cancers that can be prevented by vaccination. For resource-constrained countries, vaccination is clearly an effective way of preventing cervical cancer. To be as effective as possible, the vaccine should be administered to girls between 10 and 13 years old—in other words, before they become sexually active and are exposed to the risk of HPV infection.

To combat cervical cancer, of course, one must have an integrated approach that includes not only vaccination but also regular screening to permit early diagnosis and early treatment. Well-designed and rigorous cost-effectiveness studies exploring the relative benefits of vaccination and screening will help to inform policymakers in the developing world. But such analyses should be used to better plan for integrated approaches rather than to pit prevention against screening and treatment as has often happened with other diseases.

In Rwanda, where cervical cancer is by far the most common cancer in women, we are giving top priority to making this vaccine available to our entire female population. This is a logical development for us. Our health statistics are moving in the right direction. Our people are living longer, but that increased longevity now exposes a larger proportion of our population than in the past to "non-communicable chronic diseases" such as cancer, heart disease, diabetes, and respiratory disease. These NCDs are only becoming more common and more visible in Rwanda, so our new health sector strategic plan aims increasingly at the priority chronic, non-communicable diseases. As we know that its viral cause is transmissible, cervical cancer straddles the divide between infectious diseases and NCDs–Rwanda is well positioned to tackle it with the new vaccine and to use these efforts as a springboard for addressing other cancers.

Our battle against the scourge of cervical cancer has already started. In April 2011, we launched an all-out three-pronged initiative designed to tackle the cancer in a comprehensive manner. One prong aims to prevent the cancer in women by vaccinating all girls between the ages of 12 and 15 years old against HPV, the main cause of cervical cancer. The second prong, still under development, will offer our female population screening services to detect girls and women infected with HPV and therefore at risk of developing cervical cancer. And the third prong will provide timely diagnosis and treatment for those who already have cancer. To my knowledge, Rwanda's is the first comprehensive national cervical cancer program in Africa.

Our ultimate aim is to free the country entirely from deaths due to cervical cancer over the next 40 years. We believe strongly we can reach this goal through regular vaccination and screening combined with timely treatment.

There are many obstacles that developing countries are likely to encounter in their efforts to protect their populations against cervical cancer. In Europe and the United States, vaccination programs can reach girls in schools before they become sexually active and are at increased risk of contracting an HPV infection. In many developing countries, not all girls currently have the opportunity to attend schools. While Rwanda has nearly universal school enrolment for both genders (more than 97% of girls are in school at Primary 6, when we vaccinate against HPV), we address the challenge of reaching those not in school by mobilizing our 60,000 community health workers to reach out in their communities and ensure that all eligible girls who want the vaccine through our opt-out program are included.

I certainly will put all my efforts into continuing the battle against cervical cancer. HPV vaccination will be our prime arm within our integrated approach, and it will be continued until cervical cancer becomes just a chapter in our history books.

Rwanda is also heavily committed to achieving the MDGs. Over the next five years, we shall be expanding the access of our population to integrated care for chronic diseases by building on our existing health care programs that have to date been primarily targeting infectious diseases. To achieve the MDGs, however, we cannot relax our efforts to reduce the burden of communicable diseases. Hence the need for a highly integrated approach that covers all public health concerns and provides geographic and financial access to all our people.

We are on track to achieving MDG-4, which requires us to have reduced the mortality of children under five by two-thirds between 1990 and 2015. We are also on the way to achieving MDG-5, which aims at reducing maternal mortality by three quarters and at providing universal access to reproductive health over that period.

We believe Rwanda's success in pursuing these goals is attributed to a great extent to our adoption of innovative performance-based financing mechanisms that have greatly paid off. Our adoption of these mechanisms brings us, I would add, very much in line with GAVI's modus operandi. In the coming years, our health system will continue to pursue simultaneously rights-based and evidence-based approaches to combat needless suffering and death from preventable and treatable diseases like cervical cancer. There remains much work to do, but with the support of our partners and the will of our people, I have no doubt that we will make it. GHD

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GHD Contributors - Winter 2013

David B. Agus, MD, Shamsia Anwari, F.E. Baralle, MD, PhD, Dr. Seth Berkley, Vittorio Cammarota, The Honourable Gunilla Carlsson, Francis Collins, MD, PhD, Dr. Suraya Dalil, Ambassador Mark Dybul, Dr. Thomas Evans, The Right Honourable Stephen Harper, Karl Hofmann, His Excellency Jakaya Kikwete, Gregory T. Lucier, Partha P. Majumder, PhD, Dr. Carole Presern, Scott C, Ratzan MD,MPA, Dr. David Reddy, Janet Hatcher Roberts, Professor Jeffrey D. Sachs, Dr. Sima Samar, His Excellency Dr. Jorge Sampaio, Dr. Ataulhaq Sanaie, Dr. Khaled Seddiq, Dr. Richard Sezibera, Dr. Ahmed Shadoul, Jill Sheffield, Michel Sidibé, Prabhjot Singh, Her Excellency Ellen Johnson Sirleaf, Kari Stoever, H.E Jakaya Kikwete, Hervé Verhoosel, Princess Sarah Zeid