The east, central and southern regions of Africa have some of the highest incidence rates of cervical cancer in the world, making the area the epicentre of the disease. It is the most common cancer among sub-Saharan African women. Worldwide three quarters of cervical cancer cases occur in developing nations where programmes for screening and treatment are seriously deficient. Screening and early treatment are crucial in the prevention of the disease. Vaccination programmes are beginning to be implemented in a number of countries, offering hope for the younger generation that this preventable disease can be tackled in a significant way and end the suffering which it causes.
Health systems in developing countries can lack the capacity and infrastructure to provide proper treatment, while screening of patients is often carried out at a late stage. Such issues are compounded by patients not having the capability to access treatment services which do exist. This can be due to a range of factors including affordability and geographic constraints. A recent report from the only public cancer treatment centre in Kenya indicates that almost half the women being treated “disappeared” from their programmes.
Vaccinating girls against the Human Papilloma Virus (HPV) has become a vital intervention in many countries. HPV is the main cause of cervical cancer. It is spread through sexual contact, it is therefore important that girls are vaccinated before they become sexually active.
Responding to the growing level of morbidity associated with cervical cancer, Kenya has initiated a HPV vaccination programme for all girls of primary school age. Demand for the vaccination has exceeded supply and the £30 per dose cost is prohibitive for many families. The Global Alliance for Vaccinations and Immunisation (GAVI) have assisted the Kenyan health service in distribution of the vaccine on a national scale. They argue there is a vital need to reduce costs so the vaccine is available for everybody.
Similar programmes have begun emerge across a variety of developing Commonwealth countries in the region. In Rwanda cervical cancer is the most common cause of cancer among women. In response the small nation became the first low-income African county to achieve nationwide access to the vaccine. Such a programme has been facilitated by the immense progress made by the health sector in Rwanda which has strategically positioned itself to tackle preventable diseases.
In South Africa, where the disease is the second biggest killer of women in the country, the government has announced that all girls in public primary schools will be vaccinated to prevent the disease. Any child who goes through Grade 4 will receive the vaccine, offering hopes for a new generation of women protected from the cancer.
The African Centre of Excellence for Women's Cancer Control reports the incidence rates of cervical cancer in Zambia as the second highest in the world. To address the heavy burden of the cancer in the country the Cervical Cancer Prevention Program in Zambia (CCPPZ) was established. This has aimed to offer girls at selected primary schools the vaccine with a view to expanding the programme nationwide. Further, the CCPPZ also aims to educate families and communities on the potential benefits of the vaccine so more girls can be reached. It also looks to tackle any stigma associated with invasive treatments for those diagnosed with the disease.
Overcoming cultural barriers and reluctance is a major concern for programmes across the continent. In Kenya women have been noted to ignore symptoms and seek traditional medical practitioners. Such actions delay diagnosis and prolong treatment, allowing the cancer to develop and become more difficult to treat.
As with a range of other conditions, vaccinations provide a crucial means with which to combat the burden of preventable diseases on developing nations. It is imperative that struggles in implementing national vaccination programmes are overcome. With continuing investment, global advocacy and assistance the problems which face vaccination programmes, be they due to poverty, remoteness or a failing health system can be challenged. Similarly cervical cancer remains one of the biggest killers of women in the developing world. However, the programmes highlighted in Rwanda, Zambia, Kenya and South Africa offer hopes for an alternative future. Strengthening of health system capacities and continued international support are key to achieving reductions which may one day see the threat of this preventable cancer diminished.
Written by Michael Cavanagh
Nigeria, the biggest Commonwealth country in Africa with a population of nearly 190 million, was never going to achieve the goal of a basic education for all children by next year, 2015. Rough estimates suggest that as many as 10.5 million are not in school. But what is worse is that, due to the insurgency in the Northeast, the statistics are now in retreat.
Almost every day the Boko Haram sect, which combines radical Islam with an exploitation of poverty and unemployment among young men, commits atrocities. “Boko Haram,” literally, means “western education is forbidden.” President Goodluck Jonathan has declared a state of emergency in three Northern states – Borno, Yobe and Adamawa – but raids have taken place elsewhere in the North. Last year, for example, there was an attempt on the life of the octogenarian Emir of Kano, in which a number of his bodyguards were killed. The British Council was forced to close its beautiful office and theatre in Kano, decorated in traditional Hausa style, and cut its staff there from over 30 to four.
Boko Haram, which has demanded that President Jonathan convert to Islam, has declared war on modernity, traditional rulers, western education and particularly girls’ education. An attack in February on a Federal Government College in Yobe led to the deaths of 29 secondary students. These “unity schools” are the prestige institutions of public education, and five colleges were closed after the assault, affecting 10,000 students.
Not surprisingly, this is having a woeful impact on educational standards in the Muslim North, which have long lagged behind those in the largely Christian South. National Bureau of Statistics figures for 2012 show that while the national attendance rate for primary schools was 71 per cent, an increase of 10 per cent on 2008, the figures for the Northeast were only 42 per cent, and for the Northwest 47.8 per cent. It is likely that these will have declined since. The impact of the insurgency on literacy rates for women aged 15 to 24 is serious. The rate for these Nigerian women as a whole has fallen to 66 per cent in 2012, down about 14 per cent on 2008. In the Northeast states the comparable literacy rate is only 30.1 per cent.
Statistics suggest that Nigeria has been making progress on other MDGs. For example, maternal mortality has fallen from 800 per 100,000 in 2004 to only 350 per 100,000 in 2012. There is, however, an unmet need for family planning, with only 17.3 per cent of women aged 15-49 using any type of child spacing, and almost none ( 3.3 per cent ) in the poorest households.
There has been criticism of the Nigerian government’s security and negotiation responses to Boko Haram, which has bases in neighbouring countries also. The UN, whose office in Abuja has been attacked, has been slow to define it as an international terrorist organisation. But it is absolutely clear that, without an end to this insurgency, Nigerians in the North of the country will not enjoy the fruits of the MDGs.
Richard Bourne, Secretary of the Ramphal Institute, has been visiting Nigeria for research purposes.
Millennium Development Goal 4 (MDG4) aims to reduce child mortality from its 1990 level by two thirds by 2015. Globally the child mortality rate has been reduced significantly. However, at a national level success in achieving the MDG 4 targets have been highly variable. Disparities have been found both within and between regions. While child mortality rates remain stubbornly high for some countries, three of the least developed countries in the Commonwealth have made impressive gains, achieving their MDG 4 targets. Despite facing similar health issues and socio-economic concerns as their neighbours, these countries have witnessed considerable success. According to UNICEF progress can be made “when concerted action, sound strategies, adequate resources and strong political will are harnessed in support of child survival”. Reversing these trends requires action on multiple fronts – reducing poverty, decreasing maternal mortality, boosting education and gender equality and environmental sustainability. With this in mind we will consider the case of Malawi, which has met its MDG 4 target, seeing the fastest rate of reduction for child mortality in Africa.
In 1990 Malawi's under-five mortality rate stood at 244 deaths per 1000 live births, placing it firmly in the top ten countries globally with the highest rate of child mortality. Since then the country has made huge progress. Of all low-income, high mortality countries, Malawi is second only to Bangladesh in achieving the highest annual rate of reduction, with a score of 5.6%. It now registers a lower level of child mortality than its neighbours Zambia, Zimbabwe and Mozambique. The provision of healthcare has been a central theme in the Presidency of Joyce Banda – who rose to prominence as a relentless women's rights advocate. Through numerous initiatives for maternal healthcare and engagement with traditional leaders she continues to promote gender equality in largely male dominated society. UNICEF indicates that during President Banda's administration there has been a dramatic decline in the rate of under-five mortality
Public health experts attribute the continuing decline to increased use of key health interventions. These include immunisations, the use of insecticide treated bed nets to prevent malaria, rehydration tablets, improved sanitation and Vitamin A supplements. Innovative technologies have also contributed to the reduction. Fast delivery of HIV test results through mobile phones has allowed for quicker treatment. Further, the “baby bubble” - an adaptation of western respiratory devices - has been used to help babies in respiratory distress due to acute infections such as pneumonia. The device uses air pressure to keep babies' airways open and has been designed to work on its own as hospitals may not have wall mounted air supplies.
Despite these gains, the health system, as in many developing countries, is weak. This has affected the availability, access, utilisation and quality of health services. Supply chain management is poor and there is a shortfall of qualified staff. Meeting the needs of the population outside urban centres has proved particularly difficult. In 2002 Malawi adopted the Essential Health Package (EHP) which aims to reduce poverty and improve equity of access to health services. It addressees the major causes of disease and death: vaccine-preventable diseases, malnutrition, infections and common injuries.
Currently pneumonia is the most prominent cause of death among under-fives, accounting for 14% of deaths. This is followed by premature birth and HIV/AIDS which stand at 13%. Birth asphyxia and diarrhoea are also responsible for a significant number of deaths. Of particular concern is the relationship between acute malnutrition and HIV/AIDS, with up to 50% of identified acute malnutrition is associated with HIV/AIDS.
Malawi has made rapid progress in reducing its child mortality levels. Further gains will require ongoing investment, targeted responses and the continued support of a strong leadership. Current efforts need to be sustained and scaled up in order to continue recent positive trends.
Written by Michael Cavanagh