- Cervical cancer is the most common cancer in women in Rwanda – 940 women died from it in 2019. However, the country has made great strides in raising awareness of the disease and is running a successful vaccination program for 12-year-old girls.
- The World Health Organization will consider cervical cancer eliminated if all nations record just four new cases of the disease per 100,000 people each year.
- Rwanda has made good progress in eradicating the disease, but the high cost of vaccines against human papillomavirus (the virus that causes cervical cancer), inadequate budgetary resources and indifference to women’s health remain stumbling blocks.
It’s 10 a.m. Thursday and midwife Patricie Mukarukundo is holding up a swab and explaining to the crammed benches of women and babies how they are tested. About 40 women are at the Rubona Health Center in Huye District, Rwanda for their first screening for human papillomavirus (HPV), an infection that can cause cervical cancer. Among them is Olive Uhutesi, 39.
“A woman in my village had cervical cancer and died. If she had been screened, she could have been saved,” she says.
“It’s a very dangerous disease. Knowing about this early on is beneficial because it can then be treated.”
Cervical cancer is the most common cancer in women in Rwanda. In 2019, 940 women died from it. But the country is rapidly expanding testing for cervical cancer and has deployed tens of thousands of health workers to raise awareness of the disease. Coupled with a successful HPV vaccination program for 12-year-old girls that has surpassed other countries – including the United Kingdom (UK) – in terms of coverage, officials believe Rwanda is on track to become the first country in Africa and possibly the world to eliminate cervical cancer.
“We are among the front runners,” says Francois Uwinkindi, head of the noncommunicable diseases unit at the Rwanda Biomedical Centre, part of the Ministry of Health. “Australia is probably the first country that could potentially eradicate cervical cancer.” But Rwanda could get there first, he adds.
Community health workers are going door-to-door in the villages, warning of the dangers of cervical cancer and encouraging women to get screenings. That’s how Uhutesi found out about it.
She worries the test will be painful, but nothing beats childbirth, she says, so she’ll “hang in there.”
The results should last 10 days. If the smear test is positive, Uhutesi will be contacted either by phone or by a community health worker, who will tell her to return to the health center for a thermal abrasion, a treatment that uses a heated probe to destroy precancerous cells in the cervix.
In Huye, southern Rwanda, the Screen and Treat initiative started last year and reached 13,377 out of a total of 63,953 eligible women. According to Uwinkindi, just over half of Rwanda’s health facilities have functional screening services. “In two years we should have all facilities covered,” he says.
How the COVID pandemic reversed some advances in the fight against cervical cancer
According to the World Health Organization (WHO), cervical cancer is the fourth most common cancer in women worldwide. About 90% of deaths from the disease occur in low- and middle-income countries.
It usually takes 15 to 20 years for cervical cancer to develop. In women with a weakened immune system, such as B. Women with untreated HIV, it can take five to ten years.
“We know that cervical cancer is a preventable cancer that is also potentially curable if we can diagnose it early enough,” said Princess Nothemba Simelela, WHO Deputy Director-General for Family, Women, Children and Adolescents. “Women continue to die needlessly from this cancer.”
The burden is greatest in Africa, she adds, as access to public health services is limited and screening and treatment for the disease is not widespread.
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The WHO has tried to mobilize efforts to control the disease. In 2020, she adopted the Global Strategy to Eliminate Cervical Cancer by 2030. To eliminate cervical cancer, all countries must achieve and maintain an incidence rate of less than four per 100,000 women. In Rwanda the rate in 2020 was 28.2. In Eswatini it was 84.6 – one of the highest in the world. In the UK, meanwhile, the rate was 9.9 and in Australia it was 5.6.
To meet the target, countries must ensure that 90% of girls are fully vaccinated with the HPV vaccine by age 15; 70% of women need to be screened by age 35 and then again at 45; 90% of precancerous women should be treated while 90% of women with invasive cancer should be treated.
In 2011, Rwanda became the first African country to implement a national HPV vaccination campaign, offering vaccines to all 12-year-old girls in schools. Since its inception, the program has consistently achieved over 90% coverage. More than 1.2 million girls and women were fully vaccinated with two doses.
Before the vaccine was introduced, the teachers explained to the students the importance of the vaccine and the threat of cervical cancer. Community health workers went door-to-door, explaining the benefits of the vaccine and dispelling myths such as links to infertility.
Coverage has declined over the past two years as the COVID-19 pandemic forced schools to close. Hassan Sibomana, who works for Rwanda’s Ministry of Health and is responsible for coordinating vaccination programs, says catch-up campaigns are underway.
What would it cost to fund a cancer-free future?
But eliminating cervical cancer doesn’t come cheap. The HPV vaccination program is funded by the Rwandan government and Gavi, a global immunization alliance.
“More than 80% of the cost of vaccines is covered by Gavi, so you understand that maintaining this program is not easy,” says Sibomana.
Screening is also expensive. An HPV test costs $25 (R444). The Rwandan government is paying part of the cost, with the rest coming from Unitaid (through the Clinton Health Access Initiative), Partners in Health and the World Bank.
Uwinkindi plans to include the screening program in Rwanda’s municipal health insurance plan, which costs $3 (R53) per person for a year.
WHO’s Similela admits that “Cost [of preventing and identifying cervical cancer] are unaffordable,” but says work is underway to change that. She wants manufacture of vaccines, tests and equipment to be moved to Africa.
She believes the cost is so high because cervical cancer affects women, not men. “I think if this was a cancer that affects men the way it affects women, we would have a different conversation,” she says. “Advocacy and allocation of resources would be a whole different ball game.”
She adds: “What I see [worldwide] Women get a lot of attention when they’re pregnant, but beyond that, there’s really nothing in the public health system for women.”
Rwanda seems to counteract this narrative. “In our culture, we see women as the heart of the family,” says Uwinkindi. “We know that when you empower women, you empower the entire family and society.”
The country offers chemotherapy and radiation therapy for cervical cancer, and gynecologists can learn how to perform advanced procedures through a fellowship program. Uwinkindi admits that some women who are diagnosed with cervical cancer “get lost in the follow-up care”.
Similela recognizes that Rwanda is “a trailblazer” on the road to cervical cancer elimination and an example for others to follow. Gambia and Malawi are also doing well, she adds.
She believes Rwanda could be the first country to eliminate cervical cancer. “[I feel it] very strong because of their political leadership, the commitment you see when you talk to them and the belief in their efforts.”
This feature was originally published from The Guardian’s global development project — Part of Guardian News & Media Ltd.
Sarah Johnson is a reporter specializing in human rights and global development.