After losing her stepmother to cervical cancer, Sanyu Robinah feared she faced the same fate. Photo: PATH/Tom Furtwangler.
How Uganda is beating cervical cancer—and lighting the way for the rest of Africa
Sanyu Robinah is tense. It’s her third visit to the cervical cancer screening clinic at Nakasangola Health Center, and she is certain the news will be bad. Certain her seven children will bury her from this cancer just like she buried her own stepmother.
But Sanyu doesn’t tell the nurse, Jane, any of this.
She is quiet through Jane’s description of what has been done on previous visits and what they will do today: the first screening that found precancerous lesions on Sanyu’s cervix, the cryotherapy procedure to destroy the lesions, and now, a repeat screening to determine if the cryotherapy was successful.
Sanyu doesn’t make a sound until Jane shares the latest results. “You are negative,” she tells Sanyu. “The lesions are cleared.”
Then Sanyu laughs out loud.
To drive away fear
Cervical cancer is the most common and lethal form of cancer for women in Uganda and many African countries. It is caused by human papillomavirus (HPV), a common sexually transmitted infection that usually resolves on its own but can become cancerous over time. Wealthy countries use Pap tests to screen for cervical precancer, but most developing countries lack the laboratories and technicians for the expensive test.
Without early screening, women aren’t diagnosed until they experience symptoms. By then, treatable precancerous lesions have turned into late-stage cervical cancer. As a result, 85 percent of women who die of the disease live in poorer countries.
Cervical cancer can be treated if it is caught early, Dr. John Kamulegeya tells women at the Nakasangola Health Center in Uganda. Photo: PATH/Will Boase.
For Dr. Jackson Orem, director of the Uganda Cancer Institute (UCI), this situation is untenable. “The majority of the population in Uganda are women, and the majority of people who drive our economic activity are women. Our challenge is making sure the infrastructure for early detection is there and that women are counseled.”
His goal: “To drive away fear and replace it with knowledge.”
With PATH’s support, he’s achieving this goal by turning the Cervical Cancer Center at UCI into a center of excellence for Uganda and a regional training center for other African countries. It’s one part of PATH’s comprehensive approach to addressing cervical cancer, based on our deep expertise and a “toolkit of innovation” to prevent, detect, and treat the disease.
Uganda leads the way
When it comes to innovating solutions for cervical cancer, it’s fair to say that Uganda is leading the way. PATH began partnering with the country in 2006, and together we have tested and introduced a number of cost-effective strategies to prevent, detect, and treat cervical cancer.
We studied the optimal way to introduce the HPV vaccine to protect young girls in Uganda, and the country has since committed to nationwide coverage. At the same time, we’ve been partnering to ensure that screening is available for adult women, who may already be infected.
Through our partnership with UCI, health workers across the country have been trained on a simple, effective, and fast screening method that doesn’t require specialized personnel, infrastructure, or equipment—visual inspection with acetic acid (VIA). They have also been trained to use cryotherapy—which freezes precancerous tissue—as a simple and effective treatment method.
Uganda was also among the first countries in Africa to assess the PATH-supported careHPV test, a high-tech DNA test that was adapted to allow women to gather screening samples themselves. When it is rolled out worldwide, it is expected to play a key role in reducing cervical cancer.
In ten years, the country hopes to cut the number of women with cervical cancer in half. “It is ambitious,” Dr. Orem says, “but achievable.”
When treatment is out of reach
Tools and training for early detection are critical, but only the first step. There are hurdles to treatment as well. Cryotherapy requires either carbon dioxide or nitrous oxide gas to freeze the affected cells. The gas is costly, and many clinics cannot afford to keep it stocked. Even hospitals occasionally run out.
“Imagine traveling 400 kilometers to get a diagnosis,” says Dr. Orem. “There is the cost to get there and the cost to the family of the mother being gone. And then the hospital tells her to come back because they are out of gas. Sometimes women don’t come back, and we lose them.”
In 2017, Uganda was the site of a regional meeting on precancer treatment organized by PATH and WHO/AFRO. Representatives from eight countries (Ethiopia, Ghana, Kenya, Malawi, Tanzania, Uganda, Zambia, and Zimbabwe) came together to learn about new treatment options like thermal ablation and to gain experience with a new planning tool developed by PATH to help ministries of health determine the best scenarios for deployment of treatment equipment to maximize coverage.
A happy day
The staff at Nakasangola are deeply grateful for the cervical cancer screening program. “When it started, we had very little knowledge about cervical cancer, and we had never seen anyone screened,” Dr. John Kamulegeya says. He nods toward the full waiting room and adds, “These women would not have any opportunity for screening if it were not for this place.”
In the screening room, Sanyu has found her voice again. She tells Jane that she’s going to urge her cowives and friends to be screened. She also wants her three daughters to get the HPV vaccine.
“I am so happy today,” she declares before she leaves. “I can’t wait to go home and tell my family.”