According to WHO statistics, cancer of the cervix is the second most common cancer in women worldwide, with about 500,000 new cases and 250,000 deaths each year. It's a sobering thought, especially in a country such as India where basic health care and reproductive choices are a luxury for most women. The Human Papilloma Virus (HPV) lies dormant for years before it manifests itself as cancer. Hence, the belief that the earlier a girl is vaccinated against HPV, the better her chances of survival. But, the HPV vaccine comes with its own controversies. In Bhadrachalam, Kothagudem and Thirumalayapalem in Andhra Pradesh, where poverty cuts through large swathes of the land, four young girls recently died allegedly from complications after being administered the vaccine. Two others died in Gujarat. This has brought to attention the hazards of exposing women who were not necessarily in the best of health to this kind of medical trials. We spoke to activists and doctors on the urgent need for gender-related health care.
Our public health care system needs a comprehensive approach. In India, we need to address issues of maternal mortality, food shortage, inadequate Primary Health Centres and basic vaccine shortage, before we address specific targets such as the HPV. The HPV vaccination drive should be part of an overall public health policy, but there should be a proper protocol in place before it is launched. It needs to address the issues of side effects, informed consent, the target population for the vaccine and their selection. Also, this vaccine tackles only one type of sexually transmitted disease and is effective against just a few strains of HPV. Our focus should be on introducing health hygiene and first aid education in schools. Also, it is wrong to assume that only certain populations are prone to STDs. Social equity must be addressed.
Dr. Mira Shiva
(Coordinator, Initiative for Health Equity and Society and Coordinator All India Drug Action Network, New Delhi)
Change in ideology
Cervical cancer occurs mostly after the age of 40, with a higher rate of incidence in the developing world. Early marriage, early initiation of sexual activity and multiple sexual partners are known risk factors. Immuno compromise, for eg. HIV infection, is a risk factor.
Although the demonstration project of the vaccine has been stopped, it is still available in the private sector. Also, there is no need to treat HPV infection — a large majority of it is usually self-limiting. What needs detection and treatment is cervical dysplasia, i.e. cellular changes in the cervix that could result from HPV infection and that could be a precursor to invasive cancer.
Since 1994, the language of our policies and programmes has made a move towards reproductive health. But, this seems to have remained at a rhetorical level. Population control for demographic goals still is the dominant ideology. Reproductive health care as a continuum through a woman's life cycle, and reproductive health as a right are rarely recognised.
We need a systematic screening programme for cervical cancer through the public health care system. The HPV vaccine episode brings out the need for a rational vaccine policy and also stringent ethical regulations of clinical and other trials.
Dr. B. Subha Sri
(Director, Reproductive Health Clinic
Rural Women's Social Education Centre, Tamil Nadu)
Nutrition and hygiene
Gramya Resource Center for Women works to promote girl child rights and the rights of women to live a violence-free life, among others. All over the world, screening, particularly pap smear is the only-known method to identify cancer of the cervix. This has helped reduce incidence of cervical cancer in the developed world by 68 per cent. A vaccine will not necessarily prevent cancer; even if the vaccine is given now, its efficacy is not known beyond five years.
The public health system focusses only on controlling the fertility of women, not on her other problems. If cervical cancer rates are to be reduced, we must ensure women have access to nutritious food, since folic deficiency is known to be associated with cervical cancer. Clean water to ensure basic hygiene is also necessary.
Also, the risks of multiple partners leading to a variety of STDs should be disseminated among the general population, with a focus on men.
Dr. V. Rukmini Rao
Gramya Resource Center for Women, Secunderabad)
Lack of awareness among women about cervical cancer, lack of health personnel who can do visual inspection or pap smear, and inadequate treatment facilities even after diagnosis lead to high mortality rates.
In recent years, maternal health has got a lot of focus. However, the tendency to view women's lives in bits and pieces has always resulted in failure. Why don't we train the health worker who can insert an IUD, to take pap smears? We need trained health workers with good referral support and access to the required drugs, equipment and materials.
HPV vaccine has been used effectively in many countries, but how well will it work in India, where the delivery mechanism is faulty, there is poor follow-up and the cost is prohibitive? Both the science and the ethics of the research is questionable. The use of vulnerable participants is worrying. We need transparency and accountability in health research.
Most important, we should recognise the need for a holistic view of women's health needs.
(Centre for Studies in Ethics and Rights, Mumbai )