Sustainability down the road is a primary goal. Our success depends on creating long-term relationships with government officials and the people in the communities we serve.— Robert D. Hilgers, MD
Cervical cancer incidence and mortality rates—perhaps more than any other chronic disease—shine a grim spotlight on global disparities of care. It is one of the most preventable of human malignancies, yet it is the leading cause of cancer deaths in women around the world. It kills 260,000 women annually; about 90% of these deaths occur in developing nations, where it is the leading cause of death among women. Haiti, the tiny nation 700 miles off the coast of Miami, Florida, has the highest recorded death rate from cervical cancer in the world—approximately 50 times that in the United States. In short, Haiti is a condensed model of the global cervical cancer pandemic.
Multiple Factors: Poverty Is Number One
Cervical cancer is unique among common cancers: It has a single, known cause—human papillomavirus (HPV)—and highly effective low-cost screening and prevention tools have the potential to eliminate nearly all deaths from the disease. However, cost is a decidedly relative term. In high-income industrialized nations such as the United States, Papanicolaou (Pap) tests and HPV vaccines are standard items rolled into health-care plans. But in Haiti, unemployment and underemployment are rampant. Most striking, the annual per capita income of Haitians is less than $400.
In short, when the average Haitian wakes up in the morning, the first thought probably is on subsistence survival. A preventive health test for a disease they currently do not suffer from may not be on their priority list. Therein lies the major reason why most Haitian women present with late-stage cervical cancer. When you add an unstable government, public mistrust of do-gooders, and a fractured infrastructure to Haiti’s health-care scenario, the challenge for health-care organizations to implement cervical cancer screening and treatment programs is epic.
The ASCO Post recently spoke with the head of one such organization: Robert D. Hilgers, MD, President and CEO of the Women’s Global Cancer Alliance (WGCA), who shares his thoughts on building community support to address the cancer care needs of those in developing countries such as Haiti; raising public awareness regarding screening and treatment of cervical cancer; and developing outreach programs to educate women and their communities on the importance of prevention.
Building Community Support
Dr. Hilgers, a board-certified gynecologic oncologist, said the vision of WGCA is to advance women’s health, addressing particularly those in need of cancer care in developing countries. Dr. Hilgers decided to focus his efforts in Haiti after visiting the nation in 2008. “I learned then that Haiti had the highest incidence of cervical cancer in the world, and that really turned on my lights. I was in a point in my career in which I was trying to define and tie down my work in global health. Haiti offered that opportunity,” said Dr. Hilgers.
Dr. Hilgers said that his organization attempts to apply global principles to a local community health situation. “But we did not always follow those principles, word for word. We wanted to take the best from the global principles and work them into the specific needs of the community. We believe that all cancer is local. In a sense, we wanted to write our own script, based on the experience that we gain while working with members of the community and their leaders,” he added.
“Our strategy is to partner with the local leadership and the people of the community to advance a cervical cancer program, something that most of the people have never been exposed to,” explained Dr. Hilgers. Building trusting relationships within the community is a vital first step. The people of Haiti have seen too many flash-in-the-pan organizations that arrive with good intentions but ultimately lack stamina and leave. “When I arrived in the city of Gonaives in 2010, I didn’t know anybody. It took me 4 years to build trusting relationships. You have to show sustainability to gain trust among Haitians,” revealed Dr. Hilgers.
He continued: “Our first goal was to establish a cervical cancer screening and prevention clinic. A year later, we had a clinic that operates 5 days a week for 50 weeks a year. Most of the women we screen are unaware of cervical cancer and the long-term medical issues associated with the disease. Our services are provided at no cost, which eliminates one barrier in the delivery of care. A Pap test is cost-prohibitive for all but the affluent.”
Furthermore, there is a major shortage of labs and pathologists in Haiti. Dr. Hilgers said that Haiti has 9 pathologists for a population of over 10 million people, and all of them are located in the capitol city of Port-au-Prince. Asked whether the Haitian government has been supportive of his efforts, Dr. Hilger responded, “The government is in a state of flux and is not able to control many issues affecting health care. That said, we have worked closely with the Minister of Health and have established a good working relationship. The bottom line is that you need to be upfront and honest about your short- and long-term plans.”
Raising Public Awareness
Besides the cost and infrastructure issues that pose access barriers to cervical cancer screening and treatment, Dr. Hilgers stressed that lack of public awareness is a huge roadblock to care. “Most Haitians do not see a doctor until they’re sick, which puts us in the position of being the sole provider of screening and information. It’s a known fact that cancer of the cervix follows poverty. That is true in the United States, and it is true outside the United States. You’re not going to get as much attention under those sorts of circumstances, generally speaking. So we want to raise the level of awareness of this problem among the public in Haiti,” remarked Dr. Hilgers.
He continued: “I happen to be one who thinks that given adequate resources, we could prevent this disease by employing universal HPV vaccine programs. But in Haiti and many other developing nations around the world, vaccine programs are cost-prohibitive.”
An Arduous Road to Diagnosis and Treatment
The stark reality is that women generally arrive at Dr. Hilgers’ clinic after symptoms present. “At that point, we take a biopsy, which has to be put on a 120-mile bus trip to the path lab in Port-au-Prince. We get a lab report back in about 3 to 5 months, compared with the 48-hour turnaround time in the United States. The cancer continues to grow without any access to treatment, because in Haiti, a patient needs a written diagnosis before gaining access to oncology services, which don’t exist in Haiti. Once a cancer diagnosis is made, a woman then has to go to the neighboring Dominican Republic for treatment. But first she needs a visa, which can take another 3 months.”
However, this tortured peregrination for women with cancer of the cervix is largely a moot subject, as treatment in the Dominican Republic costs upward of $7,000, an unreachable amount of money for all but a few Haitian women. “This leaves us in the dire position of caring for women dying of cancer of the cervix, without the tools to palliate their suffering,” said Dr. Hilgers.
Asked about his goals moving forward, Dr. Hilgers responded, “Sustainability down the road is a primary goal. Our success depends on creating long-term relationships with government officials and the people in the communities we serve.”
He continued: “We also plan to increase awareness of cervical cancer prevention in the United States and other wealthy nations. These governments are much more focused on acute conditions that have immediacy, such as malaria, diarrhea, and infectious diseases. It’s harder to focus on a disease that doesn’t cause morbidity and death until years after diagnosis. But cancer has become the leading cause of disease-related death in the world. And since cervical cancer is largely preventable, it makes sense to allocate more time and resources to a deadly disease that can one day be eradicated.”
Screening and Outreach
Cervical cancer prevention in resource-poor settings requires affordable and effective screening programs that incorporate communities and their needs. Unless funding becomes available to bear the cost of the HPV vaccine, it will not realistically be available to women in developing nations such as Haiti.
However, none of these technologies will truly be effective without outreach programs, to educate women and their communities on the prevention of cervical cancer. Unless we are able to address the marginalization of women in these regions and empower them to make decisions about their lives and health, introducing simple technologies will not reach girls and women in developing nations. Oncology is an interconnected worldwide community that faces enormous challenges as our global populations age and develop cancers.
Cervical cancer—the number one cancer killer of women worldwide—is preventable. Therefore, it makes clinical and fiscal sense to rally around Dr. Hilgers and others who have paved the way in the fight against this pandemic disease. With a long-term concerted effort, cervical cancer, like some infectious disease scourges of the past, can be all but eradicated. ■
Disclosure: Dr. Hilgers reported no potential conflicts of interest.