JOURNAL | GLOBAL PERSPECTIVES By: Meg Taylor
Women are one of our greatest assets in the Pacific Islands region. Over the generations, in communities throughout our vast oceanic region, our women have been valued for their vital roles in home and community life, as mothers, wives, caregivers, transmitters of traditional knowledge and as decision makers. Losing our women and girls, who contribute so much to the development of our families, our communities, our broader societies, to a preventable killer in cervical cancer is not only grossly unjust, but it has a material impact on our sustainable development.
We all know women who have been affected by cervical cancer. And despite the medical advances that have been made to combat this disease, in the Pacific we continue to fail our women and girls by not making the required preventive vaccinations available. In our setting, the impact of cervical cancer is felt most acutely in the poorest of our countries and among the poorest women across our countries. Pacific Island leaders have taken up the fight against this disease in my region, as they understand the harm caused by cervical cancer to our women and girls, and their families and communities. In 2015, leaders of the Pacific Islands Forum made a decision to prevent cervical cancer across our region. It was a health as well as moral imperative, given the number of lives at stake and given that the disease is entirely preventable. And this political will to do something has been so crucial to ensuring we make progress against this disease.
Regional approach to a regional concern
The Framework for Pacific Regionalism, endorsed by Pacific Islands Forum leaders in 2014, represents our renewed emphasis and focus on regionalism as a means to achieving our sustainable development goals and aspirations, as these have been expressed through the vision of our leaders for the region. Inclusivity is an underlying principle that drives regionalism in the Pacific. The broad concerns and issues of ordinary citizens, including women and girls, must inform regional priorities that Forum leaders adopt. And the regional solutions to our development challenges in the Pacific must be relevant to people throughout the community and across the region if they are to be meaningful and impactful.
The issue of cervical cancer was identified through a regional public consultation process that has been established under the Framework for Pacific Regionalism. The Specialist Subcommittee on Regionalism, tasked with making recommendations to our leaders regarding issues requiring regional action, referred the issue of cervical cancer to the leaders, noting that the burden that cervical cancer places on the Pacific region is substantial and the current response insufficient. In their advice, they noted that a regional approach, particularly through countries engaging in collective or bulk procurement of cervical cancer vaccines, could make the difference and save the lives of many women and girls. But they noted that such a collective approach would require the political will of Pacific leaders to drive momentum and action in response to this issue. Based on this advice, Forum leaders directed regional agencies to work together.
The decisive factor that has led to the prioritization of cervical cancer at the regional level is the fact that it is entirely preventable. Women and girls do not have to die from the disease. Yet, for Pacific Island countries with available data, incidence rates for cervical cancer are alarming.
Melanesia has been cited by the International Agency for Research on Cancer as a subregion with one of the highest incidence rates for cervical cancer (see Figure 1 below). The age standardized incidence rate for cervical cancer in Melanesia is 33.3 cases per 100,000 females per year. Polynesia has an age standardized incidence rate of 11 and for Micronesia it is 8.7. Age standardized mortality rates for Melanesia are 20.7 cases per 100,000 females per year. For Polynesia it is 5.1, and for Micronesia it is 2.7. In a report from the HPV Center, estimates for new cervical cancer cases in Melanesia, Polynesia and Micronesia were 1,257 for the three subregions. Other studies have reported similar figures. Estimations for 2012 reported that, for Pacific Island countries, the number of mortality cases from cervical cancer could be around 684 or more.
A systematic review of cervical cancer incidence and mortality in the Pacific region highlighted that while the cervical cancer burden is significant for the region, the delivery of preventative programs is insufficient. The study highlighted the availability of cost-effective, evidence-based and feasible primary and secondary cervical cancer prevention and treatment modalities that could be adopted across the region. The systematic review concluded that to address the burden of cervical cancer in the Pacific, a regional approach was necessary with large-scale screening and vaccination.
Cervical cancer is largely a women’s health issue, and with the current burden of other diseases such as noncommunicable diseases, the threat of cervical cancer is somewhat obscured in the Pacific region. Cervical cancer not only places a medical burden on the patient, but it also has added social and economic impacts, including for the patient’s immediate and wider family. Cervical cancer also places an unnecessary burden on our health systems, which in many cases across the Pacific are already severely under-resourced. Across the region, there is a strong call to meet the challenge of cervical cancer in line with the United Nations Sustainable Development Goals. Among them are goal numbers three (good health and well-being) and five (gender equality). The “Every Woman, Every Child Global Strategy for Women’s, Children’s and Adolescent’s Health” makes recommendations in terms of evidence-based health interventions, including those related to cervical cancer screening and management.
Gender and economic equality
Gender equality is vital to health and to sustainable development more broadly. In many developing countries, cervical cancer is the number one cancer killer of women. An estimated 266,000 women die from cervical cancer every year, and we know that cervical cancer kills at a relatively young age. Families lose their loved ones, but they also suffer economic losses. Eighty-five percent of women who die from cervical cancer live in low-resource settings. It is an economic equity issue: cervical cancer is unequally distributed globally in ways that are unnecessary, avoidable and unjust.
The burden of cervical cancer reflects gender equity issues. Health systems in low-resource settings often do not provide sufficient or appropriate services for adult women, beyond pregnancy-related care. The burden of cervical cancer also reflects age equity issues: the same health systems seldom provide sufficient or appropriate services for adolescents, whether they be girls or boys. Women living with HIV are more likely to develop persistent HPV (human papillomavirus) infections at an earlier age and develop cancer sooner. Gender inequalities, limited access to sexual reproductive health services and high incidences of sexually transmitted diseases and HIV further increase the risk of cervical cancer for women and girls.
Given this, we need to employ a holistic solution to address cervical cancer, inclusive of comprehensive sexual reproductive health rights education, which is so important to such an approach. Cervical cancer is an avoidable tragedy because we know how to prevent it and we have the tools to overcome the social, economic and political disadvantage that is linked to disparities in cervical cancer incidence and mortality. The gender inequalities, roles and worldview of many of our women limit their access to information, services and agency. Women’s economic dependency and lack of access to financing further limits their access to expensive HPV vaccinations, screening and treatment programs.
Vaccinations save lives
Cervical cancer infection and spread is largely preventable through vaccination. The most successful primary prevention method, the HPV vaccine, is readily available and the World Health Organization estimates it has the potential to reduce the global burden of cervical cancer by between 70 and 80 percent. Following the introduction of the National Cervical Screening Program in Australia in 1991, deaths from cervical cancer halved, from four to 1.8 deaths per 100,000 women.
A regional approach to cervical cancer across the Pacific could address this issue, particularly through collective bargaining and bulk purchase of vaccines, as well as through shared learning and support with regard to effective prevention policy. A current estimate of the cost of HPV vaccinations for 13-year-old girls for one year across all Pacific Islands Forum countries is $2.1 million. This is highly affordable, particularly if obtained through a regional bulk purchase approach. At the 2016 Pacific Islands Forum Leaders Meeting in the Federated States of Micronesia, leaders considered “the need for the development of a regional bulk procurement program for the cervical cancer vaccine (and screening and related equipment where possible).” Forum leaders highlighted an existing bulk procurement program managed by the United Nations Children’s Fund (Unicef) and urged members to avail themselves of this program.
In their consideration of this issue, Forum leaders recognized that cervical cancer can be prevented with vaccines and well-established pre-cancer screening, and that deaths could be averted with treatment methods that avoid progression to invasive cancer. But such measures are only effective if people are aware of them and, most importantly, have access to such services. Forum leaders are also aware of the barriers that each country faces in trying to procure HPV vaccines on their own, particularly due to the high vaccine costs. They noted that lobbying manufacturers as a group through a bulk procurement mechanism would likely ensure some cost reduction. The Vaccine Independence Initiative, a bulk procurement mechanism for vaccines that currently exists in the Pacific and is administered by Unicef, is the obvious extant mechanism through which bulk procurement of HPV vaccines should occur.
Progress toward vaccination
While the introduction of new vaccines such as HPV has progressed in developed countries and some low-income countries thanks to support from Gavi, the Vaccine Alliance, many middle-income countries (like almost all Pacific Island countries and territories) have not been able to introduce the new vaccines in routine vaccination programs due to their high cost. Successful introductions of some new vaccines in Fiji, Kiribati, the Solomon Islands, the Federated States of Micronesia, the Marshall Islands and Palau have been achieved only because of significant donor support.
The next graphic shows five countries that have introduced HPV as a new vaccine into their immunization programs, and five countries that have at least a tangible plan for the introduction of new vaccines such as HPV. The remaining Pacific Island countries and territories have no identifiable plan or policy in place for new vaccine introduction. In addition, four countries (Samoa, Tonga, Tuvalu, and Vanuatu) are earmarked for funding support from the Asian Development Bank, and it is anticipated that they will prioritize the purchase of HPV vaccines with this funding. Unicef is negotiating for the inclusion of Kiribati in the ADB funding, as well as with other donors for support to other countries, including Nauru, Niue and Tokelau. The Pacific Islands Forum Secretariat supports these efforts by advocating for the prevention of cervical cancer and by lobbying development partners and donors to support the introduction of HPV into countries’ immunization programs.
The prioritization of cervical cancer at a regional level through the Framework for Pacific Regionalism has provided a unique opportunity to tangibly meet the challenge of cervical cancer in our region. And this prioritization is consistent with the United Nations Sustainable Development Goals – particularly goals three (good health and well-being) and five (gender equality), which make reference to cervical cancer. The prioritization of cervical cancer at a regional level that has been made possible will ensure that the percentage of Pacific Island countries that have introduced HPV vaccinations into their national immunization programs will rise from 60 percent to 80 percent. This is a terrific boost to the health and well-being of women across the region.
The Forum leaders’ decisions on cervical cancer, current work by Pacific countries in delivering on the health priorities under the Forum Leaders Gender Equality Declaration, as well as the Sustainable Development Goals, all provide pathways to ensure our women live healthy lives. The leaders of the Pacific Islands Forum have called for adequate funding support to ensure reproductive health (including family planning), education, awareness and service programs are implemented.
Current efforts across the region to address cervical cancer will ensure that the risks are addressed. The current decisions by Forum leaders provide options for accessing vaccinations for all women. “Survive, thrive, transform,” which is the Every Woman, Every Child Global Strategy, and its overarching objectives, are to end preventable mortality and to ensure that women, children and adolescents enjoy good health while playing a full role in contributing to transformative change and sustainable development.
The scarcity of effective services in low- and middle-income countries is not primarily a result of lack of understanding of the disease or how it can be prevented. Rather, it often results from a failure to launch or expand prevention programs due to the absence of dedicated funding, along with a lack of recognition of the urgent need to update policies and practices that hinder access to services. This is the case even though vaccination, screening and preventive treatment are relatively simple and inexpensive to organize and implement at all resource levels, and cervical cancer screening has been acknowledged as a highly cost-effective intervention. Because of this, there is also an attempt to develop a regional policy guideline for the prevention and treatment of cervical cancer in the Pacific, which countries can utilize to guide the development of their own national policy guidelines. Screening and prevention of cervical cancer in many Pacific Island countries is currently ad hoc and opportunistic, due to the absence of informed policy and programming that would allow for a systematic approach to address the disease.
It is within our power to prevent cervical cancer through integrated sexual and reproductive health services, coupled with bulk procurement of HPV vaccines. Supplementing these goals, it is also important to invest in data collection and management, so the Pacific has the right information and services on how women, young women, adolescents and youth in fragile settings are accessing basic services. This is one of my priorities as part of the High-Level Steering Group for Every Woman, Every Child. Members of the steering group have welcomed UN Secretary General Antonio Guterres as the group’s third and senior co-chair. He has stated his desire to ensure that the health of women, children and adolescents is at the forefront of his agenda. In addition, Guterres will be the group’s flag-bearer for the Every Woman, Every Child program. Members have recently reviewed its 2020 partners’ framework. As members, we recognized the importance of this framework, both in the context of a shifting and unpredictable development landscape and UN reform, and have endorsed it unanimously.
Effective implementation of the regional response to cervical cancer requires sustained political will and drive by Pacific Islands Forum leaders. The coordinated action across the range of regional and national institutions to deliver on this work must be driven by them. They must drive the implementation of this activity through regional and national institutions, ensuring adequate resourcing to support implementation and ensuring that development partners align their support to the delivery of this work. Innovative strategies that create pathways to reduce cervical cancer need to be employed in the context of access to lifesaving vaccinations for women. Our governments must commit resources for our women’s sexual reproductive health and rights, and to prevent violence against women.
We know that cervical cancer is thoroughly preventable. We know the vaccinations exist, and we know from best practice in other parts of the world, as well as from local success stories, what it takes to roll out an effective program of prevention. But none of this is possible without political will, born out of recognition of the burden that this disease presents for our women and girls, their families, communities and ultimately for our region. Political will is a prerequisite to address cervical cancer in the Pacific. The leaders of the Pacific Islands Forum have made a decision to address cervical cancer. If they maintain their collective will and resolve to deal with it, I have no doubt that we can defeat it within a generation. So, we look to our leaders to continue to take up this fight, for the good of our women and girls, and indeed for us all.
Meg Taylor is secretary general of the Pacific Islands Forum Secretariat, based in Suva, Fiji.