Nairobi, Kenya — At age 22, all Martha Achieng' Ooko really craved was freedom and a place to call her own. She was working hard as a beautician, giving manicures and pedicures in the western Kenyan city of Kisumu, saving to open her own salon one day. People who knew Ooko, the eldest of five children, believed she had what it takes to succeed.
Last December, at the age of 25, Ooko was dead. Not from a car crash, nor a complicated childbirth, and not from HIV/Aids - crises that typically claim young lives. In fact, when doctors at Nyanza Provincial Hospital had first diagnosed Ooko with Stage 2b cervical cancer a year earlier, her sister Joy was convinced it was a mistake.
Days after receiving the bad news, Ooko, her sister and their mother traveled to Nairobi's Kenyatta National Hospital (KNH) for a second opinion. This time, the diagnosis was worse - Stage 3. The family could afford treatment, so Ooko immediately began a series of six radiotherapy and two chemotherapy sessions. But it was too late.
"It took less than a year from her diagnosis to her death," says 20-year-old Joy, her face still blank with disbelief and shock.
Unlike many Kenyan women, Lucy Ooko, her mother and sisters were aware of cervical cancer, but assumed it was a disease afflicting older women, and that it was possible to live with it for decades after diagnosis.
Ooko's death underscores a policy question for developing countries like Kenya: How best to spend limited health resources? Non-communicable diseases such as cancer have not, in the past, been seen as a priority.
Many public health specialists are saying that must change.
Lack of Screening
"Every year, Kenya loses approximately 3,400 women to cervical cancer," says Dr. Lucy Muchiri, a pathologist who specializes in the disease at KNH and the University of Nairobi.
Muchiri also notes that Kenya loses a similar number of people to road accidents each year. "Despite the similar fatality rates," she says, "the government invests so much more on road safety awareness compared to awareness for cervical cancer and screening."
In fact, Muchiri suspects that the numbers of cervical cancer fatalities are much higher. "Not everyone has access to laboratory diagnosis," she says, "so a lot of Kenyans die of disease or are being treated at home without medical diagnosis."
In fact, overall cancer prevalence nationally is hard to determine because of poor record keeping and the lack of an accurate tally of cancer rates in rural areas. Statistics from the Nairobi Cancer Registry indicate that in Nairobi, Kenya's capital, gyneacological cancers - breast, ovarian and cervical - are a major burden for the city's 1.8 million women.
"While breast cancer accounts for 23 percent of all the cancers that are diagnosed among Nairobi's women, cervical cancer comes a close second at 22 percent," says the registry's manager, Anne Korir.
Health advocates and researchers estimate that fewer than five percent of Kenyan women are screened for cervical cancer annually. In contrast, Muchiri says, "in Europe and North America, where they have national cervical screening programs, cervical cancer is not even one of their top 20 public health problems". The widespread use of the pap smear for cervical screening has reduced the incidence of invasive cervical cancer by 50 percent.
Vaccine Use Elusive
The last decade has added a powerful preventive tool, alongside diagnostic screening, to the fight against cervical cancer. In 2006, the Merck pharmaceutical company released a vaccine called Gardasil, and GlaxoSmithKline released the Ceravix vaccine. Both are designed to protect women from contracting the human papiloma virus (HPV), which causes cervical cancer. By 2009, 33 developed countries had included the HPV-vaccine as part of their national immunization programs.
In most developing countries, in contrast, the cost of the vaccine has been seen as too high. But Kenya's neighbour Rwanda has pursued a public-private vaccine delivery strategy that demonstrates what can be accomplished. With vaccine donated by Merck, Rwanda began in 2011 to roll out an ambitious nationwide distribution programme that aims to provide vaccine protection to all girls within three years.
Muchiri wants every Kenyan girl vaccinated. She has seen the devastation of cervical cancer firsthand.
"Women arrive with abnormal vaginal bleeding, which starts as post-coital spotting," she says. "As the cancer grows and starts to ulcerate," she says, "infection results in an awful odour. It just strips a woman completely of her dignity and her womanhood."
In Kenya, it is mandatory to vaccinate children fully against childhood diseases such as diptheria, whooping cough, tetanus, polio, measles and tuberculosis. Although some projects in Kenya have recently offered the HPV vaccine, Kenya's National Reproductive Health Strategic Plan is addressing cervical cancer largely through the roll-out of a low-cost screening tool known as VIA (visual inspection of the cervix using ascetic acid).
For the past two years, the government has aggressively trained healthcare workers to use this "see and treat model". VIA requires no laboratory back up. The physician manually applies ascetic acid (or vinegar) onto the cervix to allow for a better view of the surface. If lesions or abnormalities are detected, they can be quickly treated. It is an important addition to prevention of advanced cervical cancer, which policy makers adopted relatively quickly.
Owning the Problem
According to the American National Cancer Institute, widespread vaccination has the potential to reduce deaths from cervical cancer around the world by as much as two thirds. Additionally, the vaccine can reduce the need for medical care, biopsies and invasive procedures associated with follow-up from abnormal screening results, thus helping to reduce health-care costs.
Health workers say the vaccine is even more crucial for women in developing than in developed countries, because so few women are screened and there is little access to medical treatment if cervical cancer is diagnosed.
Research among Kenyan women to find out how much they know about cervical health suggests another hurdle. A 2010 study conducted in Kisumu by the University of North Carolina-Chapel Hill found that while 89 percent of the study population knew of cancer in general, only 15 percent had ever heard of cervical cancer. None of the women in the study knew about the HPV vaccine.
Culture and tradition also complicate treatment of reproductive tract illnesses. "These are socially complex diseases," says Muchiri. "A woman in the village might not feel at liberty to talk about such a disease to her husband, because she could be accused of promiscuity. Before you know it, she has been kicked out of home." In short, Muchiri says, "Her body doesn't belong to her, it belongs to her husband as well."
Muchiri sees the biggest challenge as the need for wide-scale public awareness. "The concept of screening and annual check ups is really not part of our vocabulary," she says. "In Kenya, you go to hospital when you're sick, you don't go to hospital to look for disease."
Up to now, appeals to Kenyan law makers - including targeted lobbying of women representatives - has failed to achieve provision of the HPV vaccine as part of the implementation of the government's reproductive health strategy. But government health agencies have told AllAfrica that they are beginning the process of applying for HPV vaccines to enable mass vaccination campaigns. KNH's Dr.Gathari Ndirangu cautions, however, that more than acquiring vaccines is needed. Careful planning, he says, will be required to handle the HPV vaccine, which must be kept at an appropriate temperature. "Logistics for vaccines," Ndirangu says, "take up much more resources than the actual procurement."
Public education about the need for screening and vaccines could yield additional positive developments, Muchiri believes. "Once the public owns this problem and pushes for it, then the government would be forced to implement the strategy in full."
NOTE: This article has been updated to include additional policy developments.