A World Health Summit panel calls for joint action to eradicate cervical cancer
According to the World Health Organization (WHO), more than 300,000 women died of cervical cancer last year and more than 570,000 new cases were diagnosed. The distribution of incidence and mortality reflects broader disparities in women’s access to health services: although cervical cancer is both preventable and treatable, far too many poor women lack access to the HPV vaccine and to screening and treatment. In May 2018 the WHO Director-General, Dr Tedros Adhanom Ghebreyesus, issued a global call for the elimination of cervical cancer and urged ‘anyone and everyone’ who can help reach this goal to get on board.
On October 30 a panel at the World Health Summit in Berlin, moderated by Prof. Jalid Sehouli, Director of the Department of Gynaecology at Charité – Universitätsmedizin Berlin, took up this challenge. Representatives of the German government, international organisations, clinicians, academia and the private sector explored the types of partnerships that could help to ensure better access to health care for women, particularly in low-resource countries.
Strong health systems and strong partnerships can help close gaps in access
‘Women often suffer the most from gaps in medical care,’ said Dr Maria Flachsbarth, Parliamentary State Secretary at the German Federal Ministry for Economic Cooperation and Development (BMZ). ‘Cervical cancer is a case in point.’ Noting that 90 per cent of women who die of cervical cancer are from low and middle-income countries, Dr Flachsbarth said that the huge disparities which exist in women’s and girls’ access to the vaccines, screening and treatment are not acceptable in the 21st century.
‘Individual diseases can only be fought efficiently if overall health systems are strong,’ continued Dr Flachsbarth, which is why the German government sees the attainment of Universal Health Coverage as the way to close such gaps. Through its bilateral and multilateral development cooperation, Germany focuses on strengthening health systems in their entirety and on making sure that the way they are funded makes services affordable for everyone.
Germany also fosters and strengthens partnerships at all levels. Through a hospital partnership scheme supported by BMZ, experts from German institutions are linked with their counterparts in partner countries to tackle shared priorities. ‘When medical practitioners, technical staff, researchers and nurses work with one another across borders, they are able to come up with down-to-earth solutions that benefit both sides.’ She highlighted hospital partnerships between Charité – Universitätsmedizin Berlin and University Hassan II, Mohamed VI Cancer Center in Morocco, and between Martin-Luther-Universität Halle-Wittenberg and Addis Ababa University in Ethiopia, which specifically focus on improving diagnostics and treatment of cervical cancer.
Dr Flachsbarth concluded by stressing the need to get a wide range of stakeholders involved, including the private sector. She held up GAVI as an example of an initiative that balances private sector interests with public welfare. Germany has contributed 600 million Euros to GAVI over the period 2016-2020 to support its efforts make sure that vaccines, including HPV, are available at reasonable prices. ‘We have a shared responsibility to achieve shared goals,’ she said. ‘To achieve the Sustainable Development Goals we must all pull together.’
No apologies for ambitious targets on cervical cancer
Dr Princess Nothemba Simelela, Special Adviser to the WHO Director-General, picked up the thread about partnerships and encouraged the many different institutions working on cervical cancer at the local, national and international level to come together behind the WHO’s strategy on the elimination of cervical cancer as a public health problem. ‘Many feel that our strategy has prescribed ambitious targets, but we make no apologies. We’ve got the wherewithal to do something, and we’re urging our partners to support this through a lens of solidarity and equity.’
Dr Simelela went on to describe how the Director-General’s call is catalysing important conversations between actors working on women’s health in general and on cervical cancer in particular: ‘We’ve seen at country level that it’s possible to organise people around a common objective, and it’s possible at the global level, too. This has been tried and tested with other diseases and I think there is room for this kind of approach.’ Pointing to the Global Action Plan on Health and Well-being, in which leading multilateral institutions have committed to changing the way they work together to attain Sustainable Development Goal targets, Dr Simelala said: ‘This is a chance to test how we can work together.’
It’s time for action to relieve the burden of cancer in Africa
The African continent is home to the highest incidence and mortality of cervical cancer in the world. Prof. Ibrahima Teguete shared his perspectives as a gynaecologist specialising in the prevention and management of gynaecological and breast cancers at the Centre Hospitalo-Universitaire Gabriel Touré in Bamako, Mali.
‘When we look at the six elements of quality – safety, effectiveness, patient centeredness, timeliness, efficiency and equity – there are big issues in Africa with all of them,’ says Dr Teguete. Resource constraints, while very real, are only one part of the problem. Cancer registries, which help to track incidence data, are barely available in Africa. Clinical diagnosis capacity among health workers is weak, there is a dire shortage of pathologists – in some countries, there is a single pathologist for millions of residents – and far too few students being trained in this specialty. The number of cancer specialists, including surgeons, is very low, and radiotherapy facilities are insufficient to treat the number of patients who are diagnosed.
While the needs are enormous, there are also causes for optimism: Dr Teguete’s team has been leading an ambitious cervical cancer screening program which has reached more than 150,000 women in Bamako and environs. ‘When women are informed, they’ll come to the health system and get screened,’ says Dr Teguete. This has led to a large jump in the number of women being treated for precancerous lesions, but also led to long waiting lists for cancer treatment. The urgency of the situation could not be clearer: ‘We have to move beyond the words. It’s time for action to relieve the burden of cancer in Africa.’
For this to succeed we all have to be leaders and followers
Dr Sean Kehoe, a professor of gynaecological cancer at the University of Birmingham, echoed the need for concerted action. As the current chair of the Committee for Gynaecological Oncology of the International Federation of Gynaecology and Obstetrics (FIGO), he recognises the magnitude of the task ahead, but sees opportunities as well.
In Dr Kehoe’s view the HPV vaccine is a game changer: ‘It’s the cornerstone for reducing cervical cancer in the longer term.’ Yet the challenges involved in delivering the vaccine at scale, and in diagnosing and treating women for whom the vaccine comes too late, cannot be ignored. Dr Kehoe sees opportunities to strengthen the skills of physicians and surgeons in low- and middle-income countries through twinning arrangements between specialist cancer centers. Telemedicine, for example, can be used effectively in the area of histopathology to improve the quality of decision-making.
‘There are things we can do now and we need to coordinate efforts,’ said Dr Kehoe, as he described the growing consensus on the need for a world consortium on cervical cancer. Pledging to join forces is one thing, but working out the operational details of collaboration is something else entirely. In this regard, Dr Kehoe sounded a note of caution: ‘For this to be as cost-effective as it can be, there also have to be difficult discussions about who is best at doing what. In other words, we will all have to be leaders and followers. This is difficult, but necessary.’
What can your organisation bring to the table?
The global health agenda doesn’t yet reflect the significance of non-communicable diseases in low- and middle-income countries,’ says Dr Andreas Ullrich, a visiting scientist at Charité – Universitätsmedizin Berlin who previously worked with the WHO’s cancer control programme. ‘But with the United Nations’ recent declaration of commitment to UHC, we have an opening to change this.’ Turning to the audience, he opened up the discussion portion of the panel session with a request to hear how organisations represented in the hall could get involved and contribute expertise to the emerging global effort to eliminate cervical cancer as a public health problem.
Members of the audience engaged energetically with questions and comments, ranging from the need for a blueprint on the adoption of telemedicine in Africa to the importance of operational and implementation research to answer questions about coverage barriers. There was a palpable sense that the time has come to act more decisively against the threat of cervical cancer, summed up in an impassioned input from a Canadian colleague: ‘We need to stop playing with the targets and get consensus that we want to hit them. We have enough lessons from around the world, we have amazing models, and we have vaccination programmes. The WHO goal isn’t too ambitious – it’s an amazing one that we should all rally around.’