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
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
It is estimated that in 2012 approximately 6.6 million children, 18,000 children per day, died before reaching their fifth birthday. This represents a reduction of almost half the number of under-fives who died in 1990, when more than 12 million children died. The average annual rate of reduction in under-five mortality accelerated from 1.2% a year for the period 1990-1995 to 3.9% for 2005-2012. While significant, this remains insufficient to reach MDG 4 which aims to reduce the under-five mortality rate by two thirds between 1990 and 2015. As the region with the highest child mortality rates in the world, sub-Saharan Africa faces huge challenges. A rate of 98 deaths per 1000 live births has meant that a child born in the region faces more than 16 times the risk of dying before their fifth birthday than a child born in a high income country.
Of the 2012 figures, close to 75% of the deaths are attributable to just six conditions: pneumonia, diarrhoea, neonatal infection, measles, malaria and HIV/AIDS. These conditions are all preventable or manageable with adequate treatment. Malnutrition and a lack of safe water and sanitation contribute to half of these deaths. The impact of poor living standards upon health can be profound. For those living in poverty such issues are exacerbated by a lack of access to affordable and good quality healthcare.
Global support and continued investments are essential to strengthen health systems in developing nations so that all children are able to receive the care they need. Developing health systems are however faced with a variety of issues which must be challenged and overcome if effective and equitable services for children are to emerge. Expanding the scale and scope of health interventions is crucial, as is tackling barriers which may hinder advances.
A lack of funding at a macro-level and low heath system capacity can constrain positive developments. Critically many developing countries are facing a health worker crisis. It is estimated that sub-Saharan Africa will require an additional 860,000 workers to scale up its healthcare provision to meet the health related MDG targets. Efforts are already under-way to promote and increase the number of community health workers who operate at a local level, improving the scale and distribution of coverage.
Access to healthcare remains a key issue. Proven cost-effective interventions for deadly diseases such as malaria, diarrhoea and measles exist but can fail to reach vulnerable groups. Weak health services at a district level can create inequalities between regions. Strengthening district health services can contribute to the delivery of primary care services to marginalised children and families at a community level.
The chart below indicates under-five mortality rates from 1990-2012 set against MDG 4 targets for all African countries in the Commonwealth, it also includes Pakistan, India and Bangladesh.
Developing Commonwealth countries have seen variable degrees of success in reducing child mortality. India and Nigeria, who together account for more than a third of all under-five deaths, have seen significant reductions, though neither has reached its MDG target. Nigeria has not yet halved its child mortality rate from 1990 while India is also unlikely to reach its target despite a greater level of reduction. Sierra Leone, long considered one of the worst countries in the world for child mortality is yet to reduce its 1990 rate by a third. A combination of chronic underinvestment in health programmes, malnutrition and harmful cultural practices in a post-conflict setting have acted to keep mortality rates high. Scaling existing programmes up has been noted as a particular area of difficulty. Botswana, Lesotho and Swaziland have all witnessed a small increase in child mortality for the period 1990-2012. Poor sanitation, dirty drinking water, malnutrition and the HIV/AIDS epidemic have been indicated as key factors for the increases. By contrast Malawi, Tanzania and Bangladesh have taken huge strides in reducing their child mortality rates. All three countries have met their MDG 4 target.
The need to prevent and treat the conditions which contribute to child mortality has been accepted as a global imperative. Regular immunisations, vitamin A supplements, rehydration for children suffering from severe diarrhoea and use of bed-nets by women and children to protect them from malarial mosquitoes have all been proven to be simple and effective ways of keeping children alive. Ensuring access to these life-saving interventions is crucial.
As the 2015 MDG deadline approaches numerous initiatives have emerged to tackle these issues. The Global Vaccine Action Plan is working towards universal access to immunisation by 2020. A strong immunisation programme is an integral part of a well functioning health system. The WHO and UNICEF have joined other partners in establishing a new Global Action Plan for Pneumonia and Diarrhoea which aims to have proven preventative and treatment measures in place for all children by 2025. Such a focus is encouraging. It is vital that these developments are matched by a strengthening in the capacity of emerging national healthcare systems, so that they can provide access and quality care for all citizens.
Written by Michael Cavanagh