Gaborone — Cervical cancer is preventable and curable if it is detected early and managed effectively. It is the fourth most common form of cancer among women in the world.
For the first time ever, the world committed to eliminating cervical cancer when in 2018 World Health Organisation (WHO) Director-General Tedros Adhanom Ghebreyesus announced a global call for action to eliminate cervical cancer aiming to renew political will to make elimination a reality. Two years later the World Health Assembly adopted the Global Strategy for cervical cancer elimination.
A meeting organised by the Bill and Melinda Gates Foundation and the Graca Machel Trust held in Gaborone, Botswana, brought over 30 cervical cancer survivors, activists and caregivers from across the African continent where they shared challenges, solutions and future plans for fighting cervical cancer.
Professor Groesbeck Parham, a gynecologic oncologist, spoke with the women about the WHO Cervical Elimination Strategy and what it means for Africa. He also spoke about his work to fight against cervical cancer in Zambia and across the continent. Parham, who is also a senior clinical expert for the WHO’s Cervical Cancer Elimination Initiative in the director general’s office, said funding is the most important instrument that will ensure that the goal to eliminate cervical cancer is realised by 2030.
AllAfrica‘s Nontobeko Mlambo spoke with Professor Groesbeck Parham to discuss fighting cervical cancer in Zambia and across the African continent.
I am Professor Parham, I am a medical doctor, and I am a gynecologic oncologist which means I specialise in providing care for women who have malignancies, and reproductive tract cancers, cancers of the ovary, uterus, fallopian tube, cervix, etc. I am from the U.S., in a town called Birmingham, Alabama in the southern part of the US. I have been living and working in Lusaka, Zambia for almost 20 years. I came here in 2003 and then decided to come back and live and work here in 2005. Most of my work has been in collaboration with the Zambian government, to assist them in constructing a cervical cancer screening programme. Also to train young gynecologic doctors on how to provide surgical care for women who have gynecologic malignancies and most recently, because of some funding I have received from some donors, I have been able to work with a team of young Zambian doctors and nurses and some African American, breast and gynecologic cancer surgeons from the U.S. who do similar work in some African countries, South Africa, Rwanda, Democratic Republic of Congo Sierra Leone and Malawi.
What made you come to the continent of Africa to do this work?
I grew up in the 60s so when I was 14 or 15 years old I was a social activist. I was put in jail for a couple of weeks for marching with Dr. Martin Luther King and the civil rights movement for trying to integrate an all-white theatre on a Sunday afternoon and another one for being a part of an apartheid resistance movement led by young people in Birmingham, Alabama with 1000s of us who demonstrated and we were put in jail for that. And so when I was in college, I started reading and hearing about liberation movements in Africa, in Mozambique, Ghana, and Guinea Bissau. DRC, South Africa. So I decided at that time that I wanted to make a contribution to that global movement. I realised that what I was doing in Birmingham, Alabama, wasn’t just something associated with the southern part of the United States or the United States it was actually a global movement. And I wanted to become a part of that.
And so somewhere along the way, as I said, I was a student I was doing some studying in the UK in London, and a friend of mine who lived in Lesotho invited me to come there. And I went to Khartoum, Sudan, and worked at a fistula clinic for about three months. And that’s when I decided that I saw the conditions there and thought I could make a contribution to Africa. If I went back home to the U.S. and got some skills that weren’t there, such as cancer skills, and cancer surgery skills, and I decided to come back and quit my job in the US.
As the senior clinical expert for the elimination of cervical cancer at WHO, what is your view of this initiative?
I think the initiative is revolutionary in the sense that it is the first time that the World Health Organization has ever made a declaration to eliminate a cancer, there have been declarations to eliminate infectious diseases, some non-communicable diseases but not a cancer. I think it is noble and it is a very progressive initiative. And the goal is to try to do that, over a period of time by vaccinating 90% of all young girls with the Human Papillomavirus Vaccine (HPV), screening 70% of adult women with a high-performance screening test, and those women who were screened who were found to have pre-cancer, treating 90% of them. So it’s called the 90/70/90 initiative. So I think it’s very progressive.
Out of the three pillars of the strategy which are vaccination, screening, and treatment, which one do you find to be the most difficult or challenging?
I think the one that requires the least amount of organisation and that’s cheapest to implement is the one that’s easiest to do and that’s HPV vaccination, but you’ll see that it will take longer to see the results of that. Because you are vaccinating young girls and you won’t see the impact of that until they get of age where they would have ordinarily developed cervical cancer which is 30, 35, 45, and 55 years and that’s when you go back and you will screen these young girls and you’ll see that the rates of cancer are very low. We now know that one shot in the arm can probably be more effective than two or three doses or shots in the arm.
Cervical cancer screening requires a larger workforce, it requires more training. It requires more clinics, it requires more instrumentation, and machines. And so it requires, you to start working with large numbers of people, it requires organisation, leadership, and efficiency and transparency and supply chains have to be efficient, and laboratory tests, timely reporting of laboratory results, but that’s much more complex than … giving them the shot of vaccine in the arm.
The most difficult one is the treatment of the real cancers. Radiation therapy machines cost millions of dollars to put in place and they have to be maintained. You have to have these highly skilled doctors and health care providers, physicists, etc., to deliver the care if you are going to perform surgery, it requires a significant amount of time to train those surgeons and you have to have operating rooms and blood and anaesthesia and anaesthesia gases, etc. So, I would say the simplest, and the one that will have the most durable and long-lasting effect but will take us longer to see the impact is vaccination, the more complex is treating the actual cancers. When you look at countries that have the highest rates of disease, they tend to have weaker healthcare systems, shortages of pathologists in the laboratory, and difficulty in maintaining these expensive radiation therapy machines. So at the end of the day, it’s much more cost cost-effective to prevent cervical cancer than it is to treat it.
Are there any myths or practices that you have noted that impact women’s health and reproductive health rights negatively in Zambia or Africa as a whole?
I think lots of myths still exist and also a lack of education, and lack of knowledge, not because of the women but because I think as health professionals we have not done a very good job of educating women and their husbands, families, and the general society about cervical cancer, what causes it, etc. So there’s a lot of stigma attached to it. There’s a belief that if you have cervical cancer it means you have been promiscuous, that you may have had sexual affairs with married men, and that it could be associated with witchcraft.
There are some unhealthy practices like vaginal douching. The vagina, creates its own healthy environment, through some secretions and those secretions when one washes them out, you are impacting the natural immunity of the vagina because you are washing away those substances, chemicals produced by the vagina and the cervix, that can kill viruses and bacteria and fungi. I think douching is one of the more harmful practices and also women insert things into their vaginas to increase sexual enhancement, some of these things that they call Chinese medicine, sometimes snuff which is tobacco. So they could be inflammatory, could be carcinogenic. Those are some of the myths and misconceptions and some of the practices … but the bottom line is even if those things exist, if women had access to cervical cancer screening, and young girls had access to the vaccines, even in the face of the myths and misconceptions and douching, we could significantly reduce the rates of cervical cancer.
The importance of prevention and early detection?
Treatment is expensive, it has complications, sometimes people can even die from treatment, you can be in an operating room and organs can be damaged during surgery even in the hands of the best-trained doctors. Radiation therapy has long-range, side effects, shrinkage of the vagina, shrinkage of the rectum, constipation, bleeding from the rectum, and bleeding from the bladder. Again, surgery can damage the intestines you can damage these parts of the urinary tract. And so treatment is expressive to set up all that infrastructure. And so it’s always much better, cheaper, and more effective if you can prevent a disease than it is if you have to end up having to spend all this money to build infrastructures for treatment. We need all of them.
What stands out for you during this fight against cervical cancer?
I think I’m most proud of the fact that I was able to overcome my fears and leave behind the Western world, to come to Africa and live. You know, they say the best fertiliser for growing anything is your own footprint in the soil. So I’m happy I was able to overcome those fears. I think I’m also happy I was able to figure out how to establish a cervical cancer screening programme with my Zambian colleagues in a very low-resource environment where the programme is still standing after 20 years. How we were able to figure that out? The fact that it helped to promote cervical cancer prevention and treatment across the globe. I think what we did in Zambia was very instrumental in letting other people know that it could be done, even in places where you didn’t have a lot of money and a lot of trained personnel.
I think the most important part of the Zambian screening programme and why it worked and continues to work, I think the crux of it is women’s empowerment. The cervical cancer screening programme and treatment of cervical cancer in Zambia is led by female nurses and women, so we were able to train and empower nurses to offer treatment to other women, to give them options … and to be able to educate other women. Those women go out and educate other women. So I think, again, the key is that we empowered women to be able to provide a service to other women, and that is why I think it has been successful.
Please share your thoughts on the cervical cancer survivors’ meeting and why is it important that meetings like these take place.
I think this meeting of cancer survivors was phenomenal. Having cancer can be devastating because it’s life-altering, and it threatens your life, it threatens your whole being as a woman, as an individual person, as a wife, as a sister as a mother as a member of society, it is a traumatic cycle psychologically, and socially. And so I think those women being able to be around other women who had cancer is very supportive psychologically. So I think this is good for them to look around the room and see each other and to share their fears and experiences that they had and I think there’s nothing more important than community right?
But I also think that those women who have had cancer who’ve gone through the experience and survived it represent a very potentially powerful instrument. They live through it, they know what it’s like to have to scurry around to try to find money for treatment, know what their lives would have been like if they had been able to get screened and prevent this disease. They know the side effects of the treatment, they know the cost of fears that run through their mind whenever there’s a little pain, or they have a little discharge or something. I think they’re very powerful advocates. I would just like to see them come together and realize the power, the potential power, that they have to generate resources for the elimination of this disease because that is one of the biggest problems that exists now, is that there is an initiative by the WHO, but it’s not funded. It has nothing like the President’s Emergency Plan for AIDS. There’s nothing like a global Global Fund for malaria and TB. And so it needs funding, there needs to be a global fund for cervical cancer. And I think women could be very important advocates for that, as well as advocating for screening and vaccination in their own communities. When they speak other people will listen to the most authentic voices that we have.
What is your hope for African women health-wise?
African women I think are the most powerful women on the planet because of who they are, where they’re from, that this is the cradle of civilization. They have the power with the culture, the knowledge, the strength. I’ve never seen a group of women in my life as African women. They are phenomenal, I would love to see all that beauty, strength, and knowledge released into the world. The world is in trouble now with a lot of hatred and a lot of negative things going on I think African women’s representation could be elevated and organised and unleashed on the world spiritually, and emotionally. I think we’d be living in a better place and I think we really have to work hard to keep young girls out of trouble. And keep them healthy, so they can give to women and keep women healthy because the premature death of a woman is devastating. Particularly in Africa, it can result in young children becoming orphans and then having to fend for themselves in some of the harshest environments on the planet, it makes them vulnerable to the same kind of diseases that took the lives of their mothers. Orphans’ education tends to be shortened. So they end up representing a very cheap source of labour who can be exploited in all kinds of ways. I think it’s important for us to keep young girls, all women but particularly African women and girls healthy.
How can some of the biggest challenges we are facing today in eliminating cervical cancer be overcome?
Number one funding. Number two funding, three funding. I think we have to begin to look at cervical cancers not just through the lenses of medicine, and biology. Cancer is a malignancy disease, but that is it is a social disease, that has a great social impact. Those things I talked about the impact of the premature death of a mother, on the children, on the family, on the community, and on the economy of the country. The cyclical impoverishment that results when she dies. I think we need to help leaders across the globe understand the social, political, and economic impact of this disease instead of just looking at it through a microscope, here is a cancer that takes place in a woman’s body in the most private part of her body that can impact her reproductive potential.
So we look at it like it’s just another cancer when it is not just another cancer. This is a cancer of a woman and a woman who is very influential in her society and on the planet. I think besides funding we need to reframe cervical cancer, so so when we advocate we advocate, we advocate around not just its elimination but around those other negative impacts that it can have that can cause the results in premature death of women.
This interview has been edited for brevity and clarity.