The Other Half of the Story: The HPV Vaccine in Rwanda
Several weeks ago, as GOP presidential hopefuls Michele Bachmann and Rick Perry wrangled over the ethics and implications of vaccinating preteen girls against the human papillomavirus (HPV)—the virus that causes cervical cancer–Rwanda began rolling out the world’s first comprehensive nationwide effort to eliminate the disease. That effort, made possible by a donation of the vaccine Gardasil by Merck & Co., kicked off with the first round of vaccinations for preteen girls at primary schools throughout the country.
Yet while the Bachmann-Perry spat made headlines for days on end—revealing in the process the candidates’ rather hazy grasp of the facts–the major papers never made so much as a mention of Rwanda’s pioneering initiative. Or the irony that even as social conservatives in America blasted Perry for his 2007 decision to require the vaccination of all sixth-grade girls in Texas (a mistake, he quickly admitted) one of the most Christian and socially conservative countries in Africa was celebrating 97% adherence to the so-called “sex shot.”
“We saw that we can make a great impact on women’s cancers because the biggest killers are breast cancer and cervical cancer, and for cervical cancer there is a vaccine,” says Rwanda’s Minister of Health Agnes Binagwaho. “So we designed a national plan to reduce its impact: We prevent, we detect and we treat.”
Such is the pragmatism of the government of Paul Kagame, the Rwandan president and former leader of the Tutsi exile army that took the country back from the Hutu Power architects of Rwanda’s 1994 genocide. Ever since then, Kagame has sought to remake the country in the style of Singapore with policies that favor foreign investment and private enterprise, fierce anti-corruption laws and data-driven decision-making.
And like Lee Kwan Yu, the founder of modern Singapore, he has pursued this agenda with both repression and a kind of benign and often quirky authoritarianism. Examples of the latter include a ban on plastic bags; a requirement that every Rwandan wear shoes; an aggressively applied keep-off-the-grass policy; and rigorous enforcement of traffic laws, among other measures.
When the celebrated Harvard public health specialist Paul Farmer, co-founder of the non-profit organization Partners in Health, began working in Rwanda nearly a decade ago, he told New York Times columnist Nick Kristof about the first time he was stopped by a policeman. “I thought ‘Oh no! Am I going to get kidnapped, or worse?” said Farmer. “I rolled down the window, and the policeman said, ‘Put on your seatbelt.’”
Much has been written about Rwanda’s remarkable economic recovery. And Rwanda’s leaders rightly pride themselves on the country’s newfound prosperity. Per capita income has nearly tripled since the 1990s. Some 40% of Rwandans own cell phones. And Rwanda was ranked a “Top Reformer” on the 2010 Doing Business Report, the first time since Doing Business started tracking reforms that a sub-Saharan African economy has led the world.
Less talked about, however, are the massive improvements in Rwanda’s public health system—of which the campaign to prevent cervical cancer is but one impressive piece. Others include an equally ambitious nationwide circumcision campaign, nearly universal health insurance and an effort to make family planning tools like condoms and injectable contraceptives freely and widely available.
“Rwanda is determined to do what works,” says Josh Ruxin, assistant professor of public health at Columbia University’s Mailman School of Public Health and founding director of Rwanda Works and the Access Project, non-profit organizations that partner with the Government of Rwanda to build critical health infrastructure and provide management oversight at health centers.
What works, though, often isn’t a top priority for international donors. According to the Washington DC-based Worldwatch Institute, between 1994 and 2007, family-planning aid dropped from 30% to 12% of overall health aid. Compounding the problem in Rwanda, one of the most densely populated countries on the planet, is the fact that the Catholic Church, which manages about half of the health centers in the country, refuses to provide contraceptives on site, even to men with HIV.
In spite of this, says Ruxin, Rwanda has made major strides in making family planning more widely available—in part by cleverly circumventing those religious barriers. As he wrote in a recent article for Nature, some government and partner programs have set up family-planning centers just outside the doors of the Catholic facilities. “In our experience,” says Ruxin, “when women are offered family-planning measures discreetly and for free, they take them.”
Yet perhaps nothing better illustrates Rwanda’s pragmatic approach to problem-solving than its efforts to prevent cervical cancer. The third most common type of cancer in women and the second most frequent cause of cancer-related death worldwide, the sexually-transmitted disease accounts for some 275,000 deaths every year. Experts predict that by 2030 that number will exceed 474,000.
And while several other African countries are currently piloting projects targeting cervical cancer, only Rwanda has vowed complete coverage. Officially launched last April by First Lady Jeannette Kagame, the campaign concluded the third and final phase of vaccinations targeting girls ages 12 -15 last month.
“We did not have a problem convincing our women to have their daughters vaccinated,” says Binagwaho. “We only had to explain to them what cancer is. The people we’ve had to work hardest to convince are our international partners because they didn’t believe we could do this.”
In addition to Merck’s donation of Gardasil—a 3-year arrangement–Quiagen, a Dutch maker of sample and assay technologies, will supply Rwanda with its DNA screening test for HPV. All women between the ages of 35 and 45 will be invited for screening. Meanwhile, doctors are being trained in radiotherapy and the specialized surgery required to treat cancers of the cervix.
“We all have friends that have died of cervical cancer,” says Binagwaho, who is also a senior lecturer at Harvard Medical School. “At our time, there was no vaccine. But now, if we let those teenagers die when we can give them three injections, what kind of human beings are we? It’s a moral issue.”
Asked if she is at all concerned that vaccinating preadolescent girls against HPV might lead to promiscuity, as social conservatives in the United States have warned, Binagwaho responded sharply: “You believe that the day we have a vaccine for HIV, we are going to fight it? In Rwanda, people don’t link this vaccine with sex,” she said. “They link it with a cancer that kills women.”