Whether To Prevent Cervical Cancer in Africa: Debate from Rwanda Spills into the Lancet

[Jeff Meer]

After the dust settled from the UN High Level Meeting on Non Communicable Diseases (NCDs) in September, the really hard work began.  Delegates from around the globe who had heard speech after speech about the depth of the problem, returned to capitals and began to grapple with their own health planning processes. In many places, there is a clear consensus on the need to put national programs in place to prevent, detect, and treat NCDs.  However, in other places, the decision is not so clear cut.  Case in point: Rwanda.

According to the World Health Organization's 2011 NCD country profile, roughly 29 percent of all deaths in Rwanda stem from NCDs including cardiovascular disease (12 percent), cancer (5 percent), respiratory diseases (3 percent), diabetes (2 percent) and other NCDs (7 percent).  Rwanda does have a unit within the Ministry of Health for dealing with NCDs, but there is no funding available at the moment for NCD surveillance, prevention or treatment.  There are no specific plans for any of the main NCDs, or for encouraging prevention through the four main risk factors -- alcohol, tobacco, unhealthy diets and insufficient physical activity.

One of the most pervasive cancers in women in Rwanda, just as it is in other African countries, is cervical cancer. Because there is no national surveillance program for cancer, nor a cancer registry, accurate statistics are hard to come by.  One study by the National University of Rwanda concluded that the incidence is probably about 49 per 100,000 women, which ranks Rwanda as the 17th highest rate of cervical cancer in the world.

And yet, in a letter to the Lancet in July, three researchers concerned with health in Rwanda led by Nobila Ouedraogo of Ruprecht-Karls-University's Institute of Public Health in Heidelberg, express "serious doubts that a [national immunization program for cervical cancer] is in the best interest of the [Rwandan] people." How can this be? Ouedraogo and colleagues note that there are many other vaccine-preventable diseases to deal with in Rwanda.  They also state that the effectiveness of the vaccine to stop human papillomavirus (HPV), which causes most cases of cervical cancer, is unknown.  And finally, they argue that the cost of vaccinating every woman in Rwanda would be unjustified, given the relatively high cost of the vaccine (shots cost about $130 in the United States, and the lowest available price is still around $17 per dose).

On the other side of this debate is Rwandan Health Minister Dr. Agnes Binagwaho, who notes in her own letter to the journal that Rwanda is already vaccinating more than 95 percent of its population against measles and tetanus.  She says that the scientific evidence is clear the HPV vaccine is safe and effective.  Lastly, she argues that the cost of the vaccine is not "immutable," and can be changed by the forces of market dynamics.  For these and other reasons, Dr. Binagwaho and colleagues have recently embarked on a national campaign to vaccinate girls aged 12-15 against HPV, using 2 million donated doses from the pharma company Merck.  Rwanda is committed to purchasing the vaccine at a greatly reduced cost once the donation is used up, as well as following up with testing of women aged 35-45 for the presence of HPV using a test supplied by Qiagen.

One interesting aspect of this discussion, from a historical point of view, is the similarity it has with early differences of opinion about whether it made sense to try to treat AIDS in low resource settings.  As Dr. Binagwaho points out in her rebuttal, Ouedgraogo and colleagues' argument "reminds us of nihilistic claims against provision of antiretroviral therapy in Africa."  Indeed. Let's hope the debate is settled long before thousands of Rwandan women die from preventable cervical cancer.