Tuesday, 02 March 2010 19:54 By Maya Prabhu
March could mark a turning point in the fight against cervical cancer in Uganda. In the context of the increasing international availability of a new vaccine, government officials and NGOs involved in the struggle against cervical cancer will launch a strategic plan to combat the disease.
Prevention International: No Cervical Cancer brings care, training and equipment to clinics and hospitals in 8 countries, screening and treating poor women.
At the same time, Mulago Hospital, Makerere University, and the organisation PATH will begin joint research into new methods of screening for the illness. Efforts also include a pilot vaccination distribution programme currently taking place in two districts, which aims to gather sufficient information to make possible a future national vaccination strategy. Furthermore, the Uganda Cancer Institute will contribute to plans for a comprehensive national policy on cancer.
In Uganda and in Sub-Saharan Africa more widely, cancer is largely overshadowed by cynically dubbed ‘celebrity diseases’ like HIV and Malaria. In the eyes of donors and the vulnerable public, the severity of the disease’s impact in this country has been obscured. While reliable figures on cancer in Uganda are not easy to come by, a WHO/ICO report last year estimated that 1,932 Ugandan women die of cervical cancer alone each year, with 2,429 being diagnosed with the disease annually. Only 13% of diagnosed cases in Uganda survive this, or indeed any cancer (with the notable exception of breast cancer, for which survival rates are higher), for five years or more, says a damning statistic published by the Lancet Oncology journal this month. By contrast, countries like South Korea, China and Turkey enjoy five-year cervical cancer survival rates of up to 79%.
However, cervical cancer more than most cancers, is a preventable problem. In the last three to four years, vaccinations against HPV (Human Papillomavirus) have entered the market. Given that researchers have discovered a 99% correlation between instances of cervical cancer and the 15 strains of HPV that are considered oncogenic, or cancer-causing, the vaccine is anticipated to be a boon in the struggle against the disease.
While history has shown that new vaccines tend to take decades to come to Africa, owing to financial and infrastructural challenges, Uganda is currently one of four sites worldwide where a pilot demonstration programme on HPV vaccination, led by global health organisation PATH in partnership with the pharmaceutical giant GlaxoSmithKline (GSK), is underway. The programme is currently operating in two districts, Ibanda and Nakasongola, and Dr Emmanuel Mugisha, country manager of PATH Uganda is positive about the progress, as well as the outlook, of the project. He hopes that in another year, the vaccination programme might be taken to another ten districts, and even considers it conceivable that vaccinations could go country-wide within four years.
But of course, the programme has limitations. In the wake of the third stage of the project, during which PATH gathered information on usage of the existing infrastructure for vaccine delivery, and currently in its fourth year, the project plan anticipates its end in mid-2011. And the 50,000 doses of HPV vaccine donated by GSK won’t last forever. Dr Mugisha told The Independent, ‘What we are doing is to provide the critical information to help the Government make a decision to introduce the vaccine... it is so much about the Government’s decision.”
Similarly, beyond the initial donation to PATH and a further donation of 35,000 doses of its vaccine to the Ministry of Health, GSK’s immediate future seems to be necessarily restricted to the private sector. Despite a drastic lowering of the price of Cervarix, the brand-name of the company’s HPV vaccine, from Shs 160,000 to Shs 50,000 early this month, an employee of GSK Uganda told The Independent that, as this price is still unaffordable for the vast majority of Ugandans, the vaccine is currently only available in four private clinics nation-wide.
Cervical cancer screening in Nigeria
The responsibility to make the vaccine publicly available- seems, therefore, to rest primarily with the Government. In the run-up to the March conference, to be chaired by the First Lady herself, the Government seems to be very much on board. The head of the Ugandan Cancer Institute, Dr Jackson Orem, anticipates that the Institute’s position as steward of national cancer policy will be increasingly effective, and regards the Institute as the future central hub of a streamlined, comprehensive government plan on cancer, in which the strategic plan on cervical cancer will only form a sub-section. Dr Orem also mentioned plans to extend the Kampala Cancer Registry’s method of surveillance throughout Uganda, as a means to better study and understand cancer in this country, and increasing the availability of cancer-related services at the community and district levels.
Dr Josephat Byamugisha, Director of the Obstetrics and Gynaecology Department at Mulago Hospital, in which Gynaecological Oncology is a sub-specialisation, also seemed confident in government involvement and support when he told The Independent of plans to introduce an upcoming research project on new methods to screen for cervical cancer, at the meeting in March. Proposals for this project, a collaboration between Makerere University, Mulago and PATH, have already been cleared and Byamugisha expects that research will begin in late March of this year.
Despite their hopeful outlooks, both Orem and Byamugisha highlight the challenges insufficient funding and poor organisation present at the moment. Both remember that, in 2001, as party to the Abuja declaration, Uganda pledged to devote 15% of the national budget to public health, and both agree that in 2010, funding for health still falls far short of that.
Lack of awareness among the women of Uganda also presents a crippling problem to medical workers in the field. Few women go for regular cervical cancer screening, and some, according to Dr Byamugisha, even avoid appointments, ashamed to expose themselves to the routine, but somewhat invasive, procedure of a Pap Smear or VIA screening. As a result, the Gynaecological Oncology ward at Mulago sees a majority of late-stage, inoperable cervical cancers. Dr Byamugisha says, ‘In these cases, we do not talk about a cure, we talk about survival rates.’
A visit to the Gynaecological Oncology ward at Mulago hospital brings one face-to-face with the challenges people working on the ground, like specialist Dr Judith Ajeani, face each day. ‘Here in Mulago,’ she says, ‘we are just overwhelmed. The patient numbers are just too many.’ The ward has roughly 35 beds for patients awaiting diagnosis, which are always occupied, and on slightly busier days, an additional 5 to 10 women lie on blankets on the floor. All patients with inoperable cancers have free access to radiotherapy. ‘But the question is when’ says Ajeani: the waiting list is long, and the single, old machine has a tendency to break down. Chemotherapy, on the other hand, is expensive, and women who require it risk being sent home without this crucial additional treatment if they can’t afford it. ‘I say treatment is “free”‘ says Ajeani,’ because this floor is non-paying... but the drugs just go out of stock, and then the patient has to pay.’
Ajeani explains her frustrations: the ward needs more doctors, more training, administrative research into means to decongest the wards and equip regional hospitals to better cope with the cancer, as well as closer co-operation with, for example, the radiotherapy team which takes on cervical cancer patients for their 5-6 week treatment. Co-operation with the palliative team is good, but planned meetings with the radiotherapy unit happen infrequently owing to the heavy workloads borne by staff of both departments. The doctor dreams of the day when improved screening and awareness means that she sees more curable, pre-cancerous lesions than inoperable fatal cancers.
In this context, one has to wonder whether the Government is equipped to turn plans to combat cancer, and cervical cancer more specifically, into an actual, functioning part of public health policy. At the moment, the majority of funding to cancer institutions is procured from international donors. Dr Orem and Dr Mugisha both expressed hopes that the Global Alliance for Vaccines and Immunisation (GAVI) will list the HPV vaccine, thereby making it potentially available to the Government of Uganda at a greatly subsidised price. Expectations that GAVI would make an announcement to this effect in late 2009 were disappointed, but neither doctor is discouraged. With increased awareness and interest in cervical cancer, with available screening, and the new, reduced price of Cervarix, Dr Mugisha of PATH says, ‘I see a very bright future.’
Dr Ajeani, like others involved with the struggle against cervical cancer, is encouraged by the increased interest that is being shown in the disease. But her hope is blunted by scepticism: ‘If you work in this ward which is always full, and are brought to tears seeing these women who can’t stand up and speak for themselves...it gets you mad to see people just talking in a meeting. I want to see it translate into work on the ground, numbers changing.’ The problem, she says, is sustainability.
A one-off vaccination drive won’t fix the problem of cervical cancer. For a profound, meaningful impact to be made, the vaccine will need to be stocked permanently; screening will need to be systematic. Ultimately, it up to the Government to co-ordinate efforts, and find the funds to make this a reality.