Health communication dilemmas: preventing HPV or cervical cancer?

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Sarah Boseley’s Guardian article on the keen interest of many African countries in rolling out the HPV (human papillomavirus) vaccination, which will help prevent a large proportion of cervical cancers, is very encouraging.  The article quotes the CEO of the Global Alliance for Vaccines and Immunisations, on the importance of the HPV vaccine:

“A woman dies every two minutes from cervical cancer,” said chief executive Seth Berkley at the forum. “There are about 275,000 deaths [every year]. If we don’t do better in preventing it, there will be 430,000 deaths by 2030, all of which are occurring in the developing world. It strikes women down at the absolute peak of their lives.”

As with any public health discussion that goes anywhere near sex, there are controversies around the introduction of HPV vaccination, which unlike many other immunisations is best introduced to pre-adolescent and adolescent girls.  But just like in Europe and the US, conservatives are claiming that the vaccine will encourage promiscuity:

“There are a lot of myths and rumours. The reaction from religious groups has been that talking about sexuality is encouraging them to be sexually active. We have had to start to refine our message,” said Kaseba. The government is now talking about cancer prevention, rather than blocking sexual transmission of a virus.

That last statement, The government is now talking about cancer prevention, rather than blocking the sexual transmission of a virus, is worth thinking about.  To be sure the main reason that the HPV vaccination is being recommended, from a public health point of view, is because of its effect on cervical cancer – not because of its effect on HPV.  So in some ways this message is correct, as it flags up the primary reason for the intervention being introduced.  But the primary purpose of the intervention is to prevent HPV – and there’s certainly merit to that (not just for women and girls but for men and boys too).  Moreover it would be ethically wrong to hide from vaccine recipients (and their parents, since they are by and large minors), what the actual effect of the vaccine is.  And besides, there is no evidence that having the vaccine does cause girls to have earlier, riskier, or more sex; but while standalone biomedical interventions such as the HPV vaccine will protect girls and women from HPV and cancer, there are many other medical and social issues in the realm of sexual and reproductive health that will be neglected.  Rolling out the vaccine while avoiding the topic of sex won’t improve this situation.

So what’s the answer? Is it right that messaging should focus on forging the path of least resistance in order to get the job done on HPV and cervical cancer?  What other options are there?

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Rethinking Global Health

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Michel Sidibe, Executive Director of UNAIDS, made an important speech on Novermber 11th, outlining his vision for a new approach to Global Health.  He is joining a growing chorus calling for the lessons of the global response to AIDS to inform an approach to health that emphasises a more people-centred approach.  Moreover he calls for an approach that convinces Ministers of Finance that health is not a cost, but an investment.  An approach that considers improving health as a question of justice: “AIDS forever changed the focus, role and participation of affected communities as essential partners in global health responses.”

The speech should be welcomed; personally though I agree that the response to AIDS can be an inspiration, we need to be clear that it has not been an unmitigated success.  Learning from the AIDS response also means learning from the mistakes.  In particular, the considerable amount of effort and money that has been poured into not only unproven, but also implausible responses.  And the massaging of egos of national and community leaders just because they talk about AIDS, irrespective of the validity of what they are saying.

What most stands out for me in Sidibe’s speech, however, is this section:

Most critically, it means completely rethinking our approaches to delivery. We can gain real advantages through community-based and task-shifting approaches, and by tapping into non-conventional capacities and alternative delivery mechanisms. We must no longer think of a community health worker as a nice person who helps out. We need to try and make them an integral part of the structures of health. 

He’s right. And yet most health systems thinking is stuck in the dark ages: a focus on doctors, nurses, clinics, drugs and policies, that continues to ignore the social and structural factors such as gender inequalities and human rights violations that can impede health.  I’ve spent some time recently discussing with colleagues how to define and more effectively support the broader version of health systems that Michel Sidibe is talking about. It’s going to take a lot more than adding the word “community” to every health systems document.  There’s work to do.

We don’t like to talk about sex here

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There is in article in today’s Guardian, on the use of SMS and phone hotlines to promote sexual health for young people in Nigeria.  It’s great to see increasing use of technology to reach people who are seeking advice.  But what caught my eye was the opening quote: 

“There’s this terrible thing we have in Nigeria where people don’t want to admit we have sex,” explains Fadekemi Akinfaderin-Agarau, the director of Education as a Vaccine (Eva). In Africa’s most populous country, where vast swaths of society are highly religious and conservative, there is often a culture of silence when it comes to talking about sex – and sexual health.

I’ve been working in this area for 14 years; I’ve probably worked in about 15 countries.  And I can’t think of a single one where I haven’t heard someone saying that, in their country, sex is a taboo, or that people don’t want to talk about sex.