It’s 10am on Thursday and midwife Patricie Mukarukundo holds up a swab and explains to the packed benches of women and babies how they will be tested. About 40 women are at Rubona health centre, in Huye district, Rwanda, for their first screening for human papillomavirus (HPV), an infection which can cause cervical cancer. Among them is Olive Uhutesi, 39.
“A woman in my village had cervical cancer and died. If she had been screened, she could have been saved,” she says.
“It is a very dangerous disease. Knowing about it at an early stage is advantageous because it can then be treated.”
Cervical cancer is the most common cancer affecting women in Rwanda. It killed 940 women in 2019. But the country is rapidly expanding cervical cancer testing and has deployed tens of thousands of community health workers to raise awareness of the disease. Along with a successful HPV vaccination programme for 12-year-old girls, which has surpassed other countries – including the UK – in terms of coverage, officials believe Rwanda is on track to become the first country in Africa, and possibly the world, to eliminate cervical cancer.
“We are among the frontrunners,” says Dr Francois Uwinkindi, manager of the non-communicable diseases division at Rwanda Biomedical Centre, part of the Ministry of Health. “Australia is probably the first country that might be able to eliminate cervical cancer.” But Rwanda could get there first, he adds.
The human toll of non-communicable diseases (NCDs) is huge and rising. These illnesses end the lives of approximately 41 million of the 56 million people who die every year – and three quarters of them are in the developing world.
NCDs are simply that; unlike, say, a virus, you can’t catch them. Instead, they are caused by a combination of genetic, physiological, environmental and behavioural factors. The main types are cancers, chronic respiratory illnesses, diabetes and cardiovascular disease – heart attacks and stroke. Approximately 80% are preventable, and all are on the rise, spreading inexorably around the world as ageing populations and lifestyles pushed by economic growth and urbanisation make being unhealthy a global phenomenon.
NCDs, once seen as illnesses of the wealthy, now have a grip on the poor. Disease, disability and death are perfectly designed to create and widen inequality – and being poor makes it less likely you will be diagnosed accurately or treated.
Investment in tackling these common and chronic conditions that kill 71% of us is incredibly low, while the cost to families, economies and communities is staggeringly high.
In low-income countries NCDs – typically slow and debilitating illnesses – are seeing a fraction of the money needed being invested or donated. Attention remains focused on the threats from communicable diseases, yet cancer death rates have long sped past the death toll from malaria, TB and HIV/Aids combined.
'A common condition' is a new Guardian series reporting on NCDs in the developing world: their prevalence, the solutions, the causes and consequences, telling the stories of people living with these illnesses.
Tracy McVeigh, editor
Community health workers go door to door in villages warning about the dangers of cervical cancer and encouraging women to attend screenings. That’s how Uhutesi heard about it.
She worries the test will be painful, but nothing is as bad as childbirth, she says, so she will “persevere”.
Results should take 10 days. If the swab comes back positive, Uhutesi will be contacted either by phone, or by a community health worker who will tell her to go back to the health centre for a thermal abrasion, a treatment that uses a heated probe to destroy precancerous cells in the cervix.
In Huye, in the south of Rwanda, the screen-and-treat initiative began last year, reaching 13,377 women out of a total of 63,953 who were eligible. According to Uwinkindi, a little over half of health facilities in Rwanda have functional screening services. “Two years from now, we should have all facilities covered,” he says.
According to the World Health Organization (WHO) cervical cancer is the fourth most common cancer in women worldwide. About 90% of deaths from the disease occur in low- and middle-income countries.
Normally, it takes 15 to 20 years for cervical cancer to develop. It can take five to 10 years in women with weakened immune systems, such as those with untreated HIV.
“We know that cervical cancer is a preventable cancer, which is also potentially curable should we be able to diagnose it early enough,” says Dr Princess Nothemba Simelela, assistant director-general for family, women, children and adolescents at the WHO. “Women continue to die needlessly from this cancer.”
The burden is the greatest in Africa, she adds, because access to public health services is limited and screening and treatment for the disease have not been widely implemented.
The WHO has sought to galvanise efforts to tackle the disease. In 2020, it adopted the global strategy for cervical cancer elimination by 2030. To eliminate cervical cancer, all countries must reach and maintain an incidence rate of below four per 100,000 women. In Rwanda, the rate in 2020 was 28.2. In Eswatini it was 84.6 – one the highest in the world. In the UK, meanwhile, the rate was 9.9 and in Australia, 5.6.
To achieve the goal, countries must ensure 90% of girls are fully vaccinated with the HPV vaccine by the age of 15; 70% of women must be screened by the age of 35, and again at 45; 90% of women who are pre-cancerous should be treated while 90% of women with invasive cancer should have the condition managed.
In 2011, Rwanda became the first African country to introduce a national HPV vaccination campaign, offering vaccines to all 12-year-old girls in schools. Since it began, the programme has consistently achieved over 90% coverage. More than 1.2 million girls and women have been fully vaccinated with two doses.
Before the vaccine was introduced, teachers told students about the importance of the vaccine, and the threat posed by cervical cancer. Community health workers went from house to house explaining the benefits of the vaccine and dispelling myths, such as links with infertility.
Coverage over the past two years has dropped as the Covid-19 pandemic forced schools to close. Dr Hassan Sibomana, who works for Rwanda’s ministry of health and is responsible for coordinating immunisation programmes, says catch-up campaigns are under way.
But eliminating cervical cancer isn’t cheap. The HPV vaccine programme is being financed by the Rwandan government and Gavi, a global vaccine alliance.
“More than 80% of the cost of vaccines are covered by Gavi, so you understand it is not easy to sustain this programme,” says Sibomana.
Screening is also expensive. An HPV test is $25 (£20). The Rwandan government covers part of the cost, says Uwinkindi, and the rest comes from the Clinton Health Access Initiative, Partners in Health and the World Bank.
Uwinkindi has plans to get the screening programme included under Rwanda’s community health insurance plan, which costs $3 per person for a year.
Similela, at the WHO, admits that “costs [of preventing and identifying cervical cancer] are prohibitive”, though says work is being done to change this. She wants to see manufacturing of vaccines, tests and devices move to Africa.
She believes costs are so high because cervical cancer affects women, not men. “I believe that if this was a cancer that affected men in the way it does women, we would be having a different conversation,” she says. “Advocacy and allocation of resources would be a different ballgame altogether.”
She adds: “What I see [worldwide] is women get a lot of attention when they’re pregnant, but beyond that nothing exists really in the public health system for women.”
Rwanda appears to be going against this narrative. “In our culture, we consider women as the hearts of the family,” says Uwinkindi. “We know that if you empower women, you empower the entire family and society.”
The country provides chemotherapy and radiotherapy for cervical cancer, and gynaecologists can learn how to perform advanced procedures through a fellowship programme. Uwinkindi admits some women who are diagnosed with cervical cancer “get lost in follow up”.
Similela recognises that Rwanda is “a frontrunner” on the path to eliminate cervical cancer and is an example for others to follow. The Gambia and Malawi are also doing well, she adds.
She says she thinks Rwanda could be the first country to eliminate cervical cancer. “[I feel it] very strongly, because of their political leadership, the commitment that you see when you speak to them and the conviction of their efforts.”
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