By Bill Frist, MD and Saketh Guntupalli, MD
Aug. 15, 2015 | Forbes
In the United States, our health system is far from perfect, but we like to pride ourselves on delivering the highest quality and newest innovations in care. But one area where we lag behind even some African nations is in preventing cervical cancer – the most common gynecologic cancer worldwide.
In Rwanda for example, as breast and cervical cancer rates began to rise in 2010, Rwanda’s Minister of Health, Dr. Agnes Binagwaho, quickly responded by launching a national campaign to vaccinate schoolgirls against HPV—the human papilloma virus that causes nearly all cases of cervical cancer. Among eligible girls, vaccination rates of 93.2 percent and 96.6 percent were achieved in 2011 and 2012 according to the Rwanda Ministry of Health.
The move seems obvious: a proven-safe vaccine can snuff out a virus that we know causes deadly cancer. Yet what was accomplished in Rwanda is still desperately needed across parts of the world—and here at home.
An HPV viral infection causes cancer in over 400,000 women globally each year. In developing countries, a woman dies every two minutes from cervical cancer, with 230,000 lives lost annually. In sub-Saharan Africa, it is the number one cancer-killer of women.
Screening programs, such as the Pap test, have been effective in industrialized countries at catching precancerous lesions before they develop into cancers—thus saving us from the alarming death rates. But a Pap test does nothing to clear the underlying viral infection and prevent cancerous cells from growing in the first place. And as a screening tool, it is hard to enforce in the developing world due to high costs and lack of patient follow-up.
Groups such as the public-private partnership Pink Ribbon Red Ribbon have been seeking to reduce cervical and breast cancer deaths in underdeveloped regions. Soon after Dr. Binagwaho launched the vaccination program in Rwanda, Pink Ribbon Red Ribbon began working to vaccinate over 42,000 girls Zambia and Botswana and perform cervical cancer screening for over 180,000 women for cervical cancer in Zambia, Botswana and Tanzania.
Yet only thirty-five percent of American girls and young women receive the vaccination.
The current vaccine routinely used in the United States, Gardasil, can prevent up to seventy percent of new cases of cervical cancer, and is approved for children and young adults ages 9 to 26. A newly developed European vaccine, effective against nine variants of HPV (the so-called “nine-valent” vaccination) hopes to improve on this further, with an estimated prevention rate of ninety percent. Gardasil has been available in the U.S. for nearly a decade and has been shown to be both safe as well as exceedingly effective. In Australia, for example, uptake rates are as high as 80%.
Why, then, is the U.S. so hesitant to accept a vaccine that could save hundreds of thousands of cancer diagnoses each year? The reasons include safety concerns propagated by the anti-vaccine movement and worries that a cervical cancer vaccination will increase promiscuity.
Neither argument is compelling. The vaccine has been shown to be exceedingly safe with minimal side effects, and is supported by the pediatrics community and the American College of Obstetricians and Gynecologists. It works so well at clearing viral infections that it has also been approved for boys as well, and can prevent penile and anal cancer caused by the same viral infection. The advent of the new 9-valent vaccine from Europe has the potential to truly cure this cancer and eradicate it—a first in human history. Fears of increased promiscuity are a strawman argument at best. The vaccine only addresses one sexually transmitted virus, and protecting women from HPV would in no way suggest other protections.
The U.S. shouldn’t take its access to this cure for granted; we must change our attitude and health practices here at home.
Various programs have been instituted to help in the uptake of the cervical cancer vaccine. The Vaccines for Children (VCF) program, for example, is a federally funded program that offers free vaccines for low-income families, including the Gardasil vaccine. But we need to reach beyond the demographic targeted by VCF.
An educational approach including both schools and healthcare professionals should elucidate what the health benefits of the vaccination are, their indications for administration, and the proven safety data. The lack of education about the advantages of receiving the vaccine among healthcare providers remains one of the greatest barriers to increasing compliance rates. Health care workers must be educated and trained to inform the young women in their care of the availability of a vaccination against HPV.
We also need increased coordination between our nation’s regulatory bodies, such as the Centers for Disease Control (CDC), the National Institutes of Health (NIH) as well as state and local health care agencies. The lack of harmonization in health-care policy among the states, further engenders misinformation and decreased vaccination rates. A coordinated national policy would alleviate these issues. New York is in the process of passing legislation to offer the vaccine through the public school system, while Hawaii and Texas are attempting to legislate an increase in HPV education vaccine awareness as a matter of policy. While these remain important and promising steps in the right direction, more work remains to be done.
In truth, the eradication of cervical cancer from the United States is low hanging fruit. We now have a cost effective, easy method of cancer prevention, and the time for excuses has come to an end. We must ensure that our young women have the chance to enter this century free from preventable diseases such as cervical cancer, so they can realize their maximum potential.
By Emily duBois, Frist Global Health LeaderMy colleagues and I have settled into a routine and I have been able to foster relationships that are built on honesty and trust. Trust to do things the way I know and honesty to discuss why certain practices are in place and how to best improve them.
By FGHL Mike SalisburyIt is an interesting thing reflecting on the nature of care I saw in Guyana. I found myself struggling to keep up with state of the art techniques while practicing in a setting having to comply with the status quo. My favorite mental exercise while practicing down in this resource poor environment was “what drug can I give this patient today”. So much of the time in the states the answer is fairly easy and has a protocol behind it. Often the hospital in Georgetown would run out a typically used drug, which forced me to stop and think. I feel this made me a better physician.
By Julie Guinan, CNN
Aug. 12, 2015 | CNN Español
This is a difficult statistic to understand and even more difficult to ignore in the second decade of the century.
According to the World Health Organization, nearly 800 women die each day from complications related to pregnancy and childbirth worldwide.
All but 1% of these deaths occur in developing countries and perhaps most tragic of all is that 80% of them are preventable.
When speaking of maternal deaths, much of the focus is on Africa, which represents about 50% of global statistics.
But the problem goes far beyond the borders of sub-Saharan Africa; Guatemala, in Central America, has the highest maternal and child mortality rates in the region.
Maternal mortality in Guatemala
While in Guatemala maternal deaths have decreased since the United Nations included improving maternal health in their Millennium Development Goals in 2000, the rate is still unacceptably high.
According to WHO, 140 deaths occur for every 100,000 births. Most of these deaths occur among indigenous peoples, most of them Mayans where poor women are the least likely to receive adequate medical care and where fertility rates are highest.
Poor maternal health is one of the key issues at the center of the malnutrition crisis in Guatemala ... and very young children are the undeniable face of hunger. The first 1,000 days of a child's life - from conception to his or her second birthday - are the most important.
But in Guatemala, almost 50% of children under five are chronically malnourished to such a degree that they remain stunted for life, both physically and in their development, as indicated by UNICEF
According to the World Food Programme, Guatemala has the fourth highest rate of stunting in the world.
This can lead to severe developmental delays, poor performance in school and reduced productivity throughout their adulthood. But despite the many problems that can result from an unwanted pregnancy, many women have no say as to whether or not they get pregnant or how often.
Family planning, the big challenge
This can be particularly difficult in part because it is a patriarchal society where women's health is not considered a priority. But also because many families have much value and contraceptives are at odds with the culture and tradition.
Dr. Jenny Eaton Dyer is the executive director of Hope Through Healing Hands (HTHH) based in Nashville, Tennessee. Its aim is to educate Americans about family planning and maternal and child health around the world, and increase funding for these causes.
Earlier this year, Dyer traveled to Guatemala with the humanitarian organization CARE with a diverse delegation. The delegation traveled to Quetzaltenango, in the western highlands, to visit Mayan women and learn about nutrition, how to care for themselves and their newborns, and to discuss some of the main challenges they faced.
One of the main problems they found was that women had limited access to health services, especially in rural areas. Part of this is due to lack of transport, but also women have no influence on the decision-making process.
Because of this, many women don't space their pregnancies, as recommended by the UN to wait at least two years after delivery.
This creates another set of problems. Pregnancies too close together can lead to health problems for both mothers and newborns, and that's one of the underlying causes of child mortality.
Dyer said that educating families on this issue is a primary goal of HTHH. "If we can help empower women to improve both the timing and how long they wait between pregnancies, they have the opportunity to continue to study, get a job or a profession and become economically independent."
The benefit, according to Dyer, extends beyond the immediate family. "This then is a virtuous circle that women have healthier and stronger children, stronger families and ultimately, stronger nations."
Although programs designed to help indigenous women learn about the value of nutrition, family planning and healthy spacing of pregnancies, much remains to be done, not only in Guatemala but throughout the world.
The Faith-Based Coalition for Healthy Mothers and Children campaign says that maternal, newborn and child health, along with the healthy timing and spacing of pregnancies (HTSP) is "an axis of global health," and one of the most cost-effective and powerful strategies to empower women.
"If we are able to improve maternal health and child survival, mothers can return to work, which increases the GDP per capita for the family and fights extreme poverty and hunger," says Dr. Dyer.
"If family planning is linked, children can stay in school because if there are fewer children, parents can afford to pay for their education, women can stay in school and finish high school and even go to college if they can prevent pregnancy ... and if women can get an education and compete for jobs because they make healthy choices for themselves and their families, this supports maternal health promoting gender equality," she adds.
By David Smith, Africa correspondent
Aug. 11, 2015 | The Guardian
Africa has achieved a year without any new cases of wild polio for the first time, but experts warn that violent insurgencies could yet prove their “achilles heel” in finally eradicating the disease.
The poliomyelitis virus attacks the nervous system and can cause irreversible paralysis within hours of infection. No cases have been identified in Africa since 11 August last year in the Hobyo district of Mudug province in Somalia, meaning that the continent is two years away from being certified polio-free.
But both Somalia and Nigeria, which also saw its last polio case in 2014, are battling Islamist militant groups – al-Shabaab and Boko Haram respectively – raising fears that vaccines will not reach children displaced by conflict.
“I just hope Boko Haram will not be the achilles heel of our work,” said Oyewale Tomori, professor of virology at the Nigerian Academy of Science, who has dedicated four decades of his life to polio research. “Unless we get rid of the insurgency, we cannot be sure we will eradicate polio.”
In Nigeria there is a target cohort of 5 million to 6 million children each year, he added, and vaccines must reach 90%-95% of them to prevent polio recurring. “Getting vaccines to displaced people will be crucial,” said Tomori.