Former Minister of Health, Professor Isaac Adewole and Chairman of the National Task Force on cervical cancer, in this interview with SADE OGUNTOLA, speak on steps to curtail women dying from cervical cancer, a preventable cancer caused by a virus in Nigeria.
In 2022, 660,000 women were diagnosed and about 350,000 women died. What are the current figures and how would you assess Nigeria’s strategy in eliminating this?
The current figures actually will be about a year behind whatever is announced, and so for Nigeria, we’re looking at about 12,000 women with cervical cancer diagnosed every year, and about 8,000 of them dying from the disease. Globally, we say every two minutes, a woman dies from cervical cancer, but in Nigeria, every hour, a woman dies from cervical cancer.
What is the major cause of this and perhaps what should the average woman look to as a form of prevention?
Knowledge as of today indicates clearly that the cause of cervical cancer is a virus called human papillomavirus (HPV), which is likely to be transmitted sexually. Within two years of sexual debut, there is the possibility of the acquisition of human papillomavirus by women. But then the body’s immune system clears this virus over some time. However, a few women are unable to clear the virus. Among these few, some would develop lesions that we consider to be pre-malignant, occurring before the onset of cancer. Then, rather few again would go on to develop cervical cancer. So, we describe cervical cancer as a rare complication of a common sexually transmitted infection.
How do Nigeria’s cancer control plan and health priorities align with the elimination strategy employed globally?
In 2018, looking and relying on the body of knowledge that we have, the WHO Director-General Tedros Ghebreyesus announced publicly that the world is at the threshold of eliminating cervical cancer, and therefore sent a resolution to the World Health Assembly, which was approved in 2020. So, for the first time in the history of the world, the world as a whole is committed to eliminating cancer. Nigeria took the bull by the horns and established a national task force, which I’m fortunate to chair, to eradicate cervical cancer. And that’s where we are and the strategies we adopt are broad. One, we try to integrate its prevention with early detection of cervical cancer, and then put in place structures for treating those who already have cervical cancer.
Can you talk about the major steps that you took as a former Minister of Health to ensure that Nigeria reduce cervical cancer to the barest minimum?
Let me be clear upfront that the decision to bring the vaccine into the country started when I was Minister of Health, but we were largely constrained by the absence of the vaccine and the amount of vaccine that Nigeria will require given Nigerians population. But then, the vaccine was also in short supply because the initial strategy was to provide three doses of the vaccine. Now, about 15 years ago, my colleagues and I wrote a paper that say that with one single shot of this vaccine, combined with screening, we could be on the threshold of eliminating cervical cancer. This paper was not accepted. But it is interesting to know that that single dose vaccination now is what the world has accepted, and so we have started in Nigeria.
I am proud to say that Nigeria has conducted an introductory vaccination programme, the largest of its type in the world. Over nine months, we vaccinated close to 12.5 million girls aged 9 to 14. It’s unprecedented, and no country has ever done that.
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How did Nigeria get to vaccinate that amount of people, without having some pushbacks?
Well, one is good planning, good logistics, investment, and international collaboration. Having vaccinated 12.5 million girls, we can tell you that we did not record any major complications in Nigeria. But we had pushback because I can tell you that where we are today, Lagos state had the lowest acceptance rate. Lagos state had, in fact, an acceptance rate of 36%, compared to 98% in Taraba State. There was pushback in about three states where we did not do well enough: Lagos, Enugu and Ogun States. But in other states, it was a superb performance.
In those three states, there’s a lot of reaction from anti-vax groups, social media reactions, rumours against this vaccine, there’s anti-fertility, which is not true, and the fear of complications, which is also likely unfounded.
Misinformation is not peculiar to Nigeria. It’s a global event in which some people deliberately peddle rumours against vaccines. For me, it is one of the issues that we have to deal with, particularly in the health sector, where there’s a trust deficit. People do not trust their government or anything that comes from outside Nigeria. And then, with social media, people peddle any rumour and tell the whole world a false narrative.
Well, this is one of the issues we discussed at our retreat. We looked at the lessons that we learned from that introductory effort. One is that we need to do more communication. We need to gain entry into the community. We need to stay ahead and build robust partnerships to scale up and let people know that this vaccine has no side effects and that when you take it, it will likely prevent cervical cancer.
Can you talk about its symptoms?
The thing about cervical cancer is that many of us “love” cervical cancer because it takes about 10 to 20 years to develop. That gives us enough time to ambush this disease along the path of developing cervical cancer. And that’s where screening comes in. However, at the last survey, only 13% of Nigerians were screened. So there are quite many people who have never been screened, for quite many reasons. Part of this is because of the way we treat our genitalia. It differs from how we should do it to keep it healthy. Our women don’t want outsiders to look at their genitalia. We need to demystify the female genital tract; I think the issue of not wanting the genitalia examined must be behind us. But, when the vaccination and screening are missed and the disease has set in, it can be cured when it is picked up early. Unfortunately, about 80% of our women come in late. When women experience its earliest symptom which is bleeding during sexual intercourse, they stay away from the man, accusing the man of traumatizing them, not recognizing the fact that there must have been a problem with the cervix.
And when they move away from the man, the bleeding stops. And that will give them a false sense of hope. And then over the next two to three years, this disease will now go to a stage where we can no longer offer a cure. For now, we recommend screening every three years. However, once vaccination sets in, we will recommend it once in 10 years. But then if you miss it, if you have contact bleeding during sexual intercourse, please visit your doctor. And then, very importantly, is to insist on being examined.
In the African Women Against Cervical Cancer (AWACC) study we did in Ghana, Nigeria, and South Africa, the average woman with cervical cancer must have seen three to four doctors who did not make the right diagnosis. So there’s also a need to educate health professionals to make sure they diagnose the woman. They should take a sample of the cervix and send it to the lab for analysis. And that will confirm cervical cancer. But once it’s confirmed, we treat it. In the early stages, we are sure of a cure.
What kind of policies and legislative measures should be implemented to help promote and support this global policy to eliminate cervical cancer?
In terms of policy, we cannot force people to go for checkups, but we can encourage them through education and improved awareness, and that’s what we’re doing. And we intend to do this on a global scale. One of the sub-committees within the task force is one on communication and community engagement. We need to let people know about this disease because almost all deaths from cervical cancer are preventable through a multitude of approaches, which include vaccination, screening, and treatment, especially when we pick them early. We also need to encourage policymakers to invest and health providers to look at the cervix. By putting in an instrument to look at the cervix, we can see the cervix.
How do we ensure people in rural communities can assess this screening for cervical cancer?
Well, interestingly, it doesn’t cost much to prevent cervical cancer. One of the strategies we recommend and will put in place is downscaling to the primary care centre. And I did mention that we’ll train nurses and community health attendants to look at the cervix. So, with appropriate investment, education, and scale-up, we will ensure every woman can approach a facility next to her. And once we vaccinate a large number of people, we’re there.
Do you also encourage local methods to address cervical cancer?
I would not recommend that we have an effective vaccine for obvious reasons. Studies done, even from Scotland, indicated that in communities that have been vaccinated, they did not recorded a single case of cervical cancer over the years. So we have instruments to use. So there’s no point. When you are not in doubt, please go for the right thing. And I can assure you that we’re almost there.
How about stigmatisation and cervical cancer screening? How can the delays in screening be addressed? Are there diseases associated also with cervical cancer?
The greatest disease that is associated with cervical cancer is HIV infection. Those who are HIV infected are six times at risk of developing cervical cancer compared to those who are HIV-negative. Screening for cervical cancer is a major part of HIV treatment and care programmes.
Before the teaching, cervical cancer is common among those who are sexually active or have multiple sexual partners. Those are just indicators of risk. It is not the number of sexual partners. We’re trying to de-emphasise that so that anybody with cervical cancer will not have a sense of guilt. It is not about the number of sexual partners. Those are just indicators of risk. And then we should demystify the female genital tract. It belongs to the woman. Even though it’s a passage for bringing us to this world, that passage can become afflicted and should be taken care of.
Is Nigeria on track to eliminate cervical cancer by 2030?
With what we put in place, we should be able to get there. But we’re just starting; quite a few things have taken place in Nigeria. Many of us are incurable optimists. Nigeria has put in place a scheme that will enable notification on every case of cancer. Second, this country set up a National Institute for Cancer Treatment and Research (NICRAT). There is also a directive from the federal minister of health that nobody should manage a cancer patient without that patient being screened by a multidisciplinary tumour board, which is what will happen anywhere in the world. All we need to do is try and scale up here and there. And you know Nigeria, we didn’t start vaccination early, but when we started, we started big. We vaccinated 12.5 million women, almost the population of Rwanda, in nine months in Nigeria. That shows what you are capable of.
Can the vaccine treat the cancer?
Well, the vaccine is preventive. It doesn’t cure anybody with either an HPV infection or cancer. Researchers are going globally to look for a therapeutic vaccine, but we have none yet.
