Cervical cancer is wreaking havoc in Haiti. The country would even be one of the world champions in this sad field. The root cause of this silent killer is the human papillomavirus (HPV) that is transmitted through sexual contact. Most women are infected early in their sexual activity. Yet a simple vaccine could save thousands of lives. Why then do Haitian women continue to suffer and die from cervical cancer? Enquet’Action went in search of some elements of answers.

Part 1

Cervical cancer, “the tallow mast” of Haitian women!

Investigation

Cervical cancer is the leading cause of cancer-related death among women in Haiti. It represents an estimated 1400 deaths per year, very similar to maternal deaths, according to the Pan American Health Organization / World Health Organization (PAHO / WHO). The country has no less than 10 thousand new cases of cancer each year, reveal combined estimates. Much of this figure relates to cases of cervical cancer that often are not diagnosed in time.

Thus, this cancer represents a hindrance to the country’s development because of its debilitating nature and its prevalence among women of working and childbearing age, thus sustaining the cycle of poverty in which the Caribbean country has been languishing for several decades.

Regional, Latin American and Caribbean statistics reveal that Haiti has the highest incidence rate for cancer of the womb – 94 per 100 thousand with an estimated mortality rate of 53 per 100 thousand. Alarming figures revealing the lack of care for women – but they are far from reflecting the reality of the country because of the very often undiagnosed cases and the absence of a national cancer registry.

“We have a lot of cases. On 100 exams, it is possible to find about 25 women who have pre-cancerous lesions or who are already in an advanced stage of cervical cancer, ” says Dr. Chantal Sauveur Jr Datus, medical director of Maternity Isaiah Jeanty and Léon Audain (MIJ-LA), commonly known as Chancerelles Hospital, which deals with women’s health – reproductive health and reproductive health .

A silent killer …

The situation is not too different in other hospitals in the country.

“This is the [type of] cancer seen most at the Haitian Institute of Oncology (IDHO) and even in private consultations. It is the most diagnosed [female cancer] in Haiti, yet it can be avoided if women knew the importance of doing a Pap test every year. This would help to detect well before any trace of cancer and suddenly prevent its degeneration, ” continues Dr. Elsie Carrenard, founding member of the Haitian Society of Oncology (SHONC) institution that manages the IDHO. The latter’s mission is to educate and train medical personnel, but also the civil society on cancer in order to reduce the rate of morbidity and mortality in Haiti.

For Christophe Millien, head of the Department of Gynecology and Obstetrics at the University Hospital of Mirebalais (Zanmi Lasante / MSPP), cancer should be a public health priority. “The materialization of such a priority is not made,” he says. Given the change in eating habits across the country and around the world, he argues that cancer cases will continue to rise

With 528 thousand new cases diagnosed and 270 thousand deaths estimated in 2012, cervical cancer is the fourth most common cancer among women worldwide. Nearly 9 out of 10 deaths, or a total of 231 thousand deaths, occurred in low- and middle-income countries. It is the most common cancer in women in 45 countries, and it kills more women than all other forms of cancer in 55 countries including Haiti where it is the second most common cancer after the prostate.

” The average age of sex in Haiti is 15 years old. But it’s not only in Haiti, but also in the United States where many teenage girls are sexually active early, “says Dr. Millien. “In the issue of cervical cancer, the fact that there is no national registry, it appears unspoken that prevent better fight [this disease] and act effectively.” It recalls that the statistics around the disease are the result of estimates made by international organizations.

There are two methods to diagnose cervical cancer: the Pap smear, commonly called Pap test or Pap-smear or Pap smear test by the name of its inventor Dr. George Papanicolaou, which is a simple and painless examination serving to detect abnormal changes of cervical cells thus preventing the development of cervical cancer. And, the Visual Inspection with Acetic Acid (IVA), a vaginal examination with a speculum during which a health staff applies diluted acetic acid (vinegar) (3-5%) on the cervix. The abnormal tissue is temporarily visible because it whitens when exposed to vinegar.

Any woman who is sexually active should have a Pap test or an IVA. This is not the case in Haiti. In fact, many women do not even know about these tests.

“We know its origin – this does not prevent it continues to do damage,” said Dr. Carrenard administrator of the IDHO who is screening, prevention and management of cancer.

While this disease is taking on a worrying dimension and represents a heavy burden for the health sector, the Haitian authorities have shown no political will to introduce human papillomavirus vaccine into the Expanded Program on Immunization (EPI). This, despite the recommendations of the Pan American Health Organization / World Health Organization (PAHO / WHO).

Vaccinate in small doses

The vast campaigns of the national NGO Zanmi Lasante (ZL) in collaboration with the health directorates of the Center and Artibonite, between 2009 and 2018 have allowed to vaccinate against HPV, more than 34 thousand children aged 9 to 14 years especially in the Central Plateau (Mirebalais, Belladère, etc.), St Marc, Petite Rivière de l’Artibonite and Verrettes. Between US $ 5 and US $ 6 million would have been spent for these programs (including cost of vaccines, transport, storage, campaign operations). The vaccine would cost between 11 and 13 US dollars per person for the series. Two vaccines per person.

” PAHO / WHO is working with the Ministry of Health and Population to introduce human papillomavirus vaccine into its Expanded Program on Immunization,” reads a document from this agency to Enquet’Action . Challenges still remain to be recognized, namely: “To ensure that women are aware of the importance of screening, to ensure equal access to testing services, to cover vaccine costs and to overcome sensitivities. in this area “, continues the document.

Apart from the ZL programs, nothing concrete has been done by the Haitian authorities. Inserting the HPV vaccine into the country’s national immunization program could cost less – since some of the bases used for other immunization programs already exist.

“Because of the unprecedented low price of HPV vaccines, the poorest countries can vaccinate millions of girls against devastating female cancer,” reads Gavi’s website, an organization that supports the introduction HPV vaccine at the national level and the vaccination of multiple cohorts of girls aged 9 to 14 years. Thanks to this Swiss-based organization that brings together the private and public sectors, the vaccine now costs only US $ 4.50 per dose, and supplies can be organized where the burden of disease is highest.

In Haiti, Parliament’s budget is higher than Health, while the price of HPV vaccines has never been so low. The share reserved for Health in the 2017-2018 national budget is 6.1 billion gourdes, which gives a percentage of 4.3%, or about 512 gourdes per capita, in a country where there would be 2 million boys and girls who need vaccination in general.

This clearly shows that Health in general, and cancer in particular, is not a public health priority in Haiti. WHO, the Alliance for the Prevention of Cervical Cancer, the Action Against Cancer Coalition cervical cancer and the United Nations Population Fund have called for a comprehensive program to prevent cervical cancer, including vaccination of girls, screening and treatment of cervical cancer. women.

“It’s not a priority yet. There are many other things that still need their attention, ” says Dr. Vincent De Gennaro, head of Innovating Health International (IHI) – an international NGO that has been implementing a huge anti-cancer project in Haiti since 2013.

The IHI inaugurated in April 2018 in Tabarre, a Cancer Treatment Center, the second largest and most effective program of diagnosis and treatment of cancer in Haiti, after that of the University Hospital of Mirebalais (HUM). From the Bernard Mevs hospital where the project was housed when he arrived in Haiti, he spent a few years at St Luc Hospital in Tabarre before buying his own premises in front of the Sun Auto a few meters away. the American Embassy in Haiti.

“From 2013 to date, we have treated more than 600 women with breast cancer. 1500 patients in total are treated, ” says Gennaro. “The program continues to grow every day. Because there is a need. According to the manager, this is not only a cancer center, but also and especially a health center for women. With its meager means, the institution helps patients to go to the Dominican Republic for radiotherapy care for several years.

“The problem that persists with us is the lack of resources,” he regrets. “This is the first step, but not the last, the next is the construction of a radiotherapy center , ” concludes the manager. https://haitiliberte.com/innovating-heath-international-ihi-inaugure-un-centre-de-traitement-de-cancer-en-haiti/

In an exclusive interview with ENQUET’ACTION , Gaëlle Mondestin, Communications Manager at IHI, highlights the complex situation of women victims of cancer. “The majority of patients have no means and do not know what cancer is,” she says. “In Haiti, when you are told cancer, everyone thinks you will die.”

A favorable ground: misery

Haitian women have sex too early at a time when their womb is immature so unable to pay for sex, sometimes with multiple partners of different generations, but also sexual behavior daring. A range of factors that expose them to sexually transmitted infections and sexually transmitted diseases, including syphilis, herpes, genital tuberculosis, AIDS, which are significant cofactors, and sexually transmitted oncogenic human papillomavirus (HPV) – the determinant factor responsible for cervical cancer.

“We can not isolate the cervix, other parts, when we imagine how sex goes, we will have HPV in the throat, tongue and vocal cords. Since we swallow, we will have cancer in the esophagus, anus, etc. So this pathology should not be taken alone. It is correlational with other cancers according to how sex is done, ” says Dr. Jean Ronald Cornelly Executive Director of the National Center for Radiation Therapy, Chemotherapy and Nuclear Medicine (CNRMN) that exists only in draft. https://www.enquetaction.com/centre-radio-victime-debacle-seisme

The cervix is ​​the low, narrow part of the uterus. A cancer of the cervix is ​​a disease that develops on the lining of the cervix, in other words on the tissue that covers it. More precisely, it originates in the first layer of the mucosa which is called the epithelium.http: //www.e-cancer.fr/Patients-et-proches/Les-cancers/Cancer-du-col-de -l-uterus / Key Points

The most common symptoms of the disease are vaginal bleeding out of periods, during and / or after sexual intercourse, vaginal discharge, skin lesions, genital pain during intercourse, pelvic pain, etc. The poorest women and those living in disadvantaged neighborhoods and regions are the most exposed. Many of these factors and symptoms are unknown to Haitian women.

For some doctors, if in the most advanced countries, these symptoms are felt after 50 years for women, for Haiti – it is quite different. Many cases of cancer of women aged 25 to 30 years have been discovered. Sometimes, these are cancers that are in an advanced stage.

“It’s a purely scientific question. Haiti meets all the conditions for having this high rate of cervical cancer. Socio-economic conditions have a significant impact on the health problem in general, cancer in particular, ” says Dr. Cornelly.

“It’s a cancer that responds to a whole series of conditions: poverty, lack of information and unorganized health care. Women do not know that they need to do prevention, to avoid having sex with a lot of men [too early], to protect themselves and to see a doctor when they feel an abnormality in the vagina ” , adds Dr. Carrenard, administrator of the IDHO SHONC.

Dr. Millien refers to ” the social determinants of health that have a major impact on the development of the disease”. “These people are eating very badly. Tank or folds bad manje, tank or eskpoze ak maladi an “. Worse, “they are left on their own and can not do the screening”.

A study that says a lot!

There is a flagrant lack of information and awareness around the disease as is the case for many others, says Enquet’Action . An extensive survey conducted by Haitian non-governmental organizations and Innovating Health International across Haiti confirms this.

“Quantitative evidence indicates low levels of cancer knowledge in all geographic regions of the country between men and women. About one in five respondents said they know how a woman gets breast or cervical cancer, ” says the study, which states that low levels of knowledge of risk factors and symptoms impede prevention and care efforts. cancer control in Haiti.

Women know much less about cervical cancer than about breast cancer, adolescents know less than older women about cervical cancer and 40% of cancer patients said they are victims of gender-based violence, she reveals.

A Mixed Methods, Community-Based Investigation on Women ‘s Cancer Awareness in Haiti, developed by the leading Haitian experts in Oncology emphasizes that stigma, fear of rejection of the home or their community, high treatment costs, distance from Treatment centers, poor community support, low income, and low levels of education are among the factors that explain the insufficient follow-up and late presentation to the hospital of women with cancer in general, and the cervix in particular.

“The North West and the South are perhaps the least well informed, because they are also among the poorest regions of Haiti,” notes the document explaining that this situation is due to the fact that there is not much penetration of large-scale health or nonprofit education in these parts of the country.

Very few women have made it clear that cervical cancer is sexually transmitted.

Fear of violence and discrimination are big barriers for women seeking cancer care. Economic dependence and the reluctance of heads of households to pay for treatment may also lead to women being referred to different doctors as they seek cost-effective treatment, the report says.

Like women living with HIV / AIDS, women who are victims of sexual and gender-based violence are more vulnerable to contracting HPV and, as a result, developing cervical cancer.

More than 80% of women with cancer come to the hospital only when the disease is advanced (III and IV). Palliative care is the only option. This is due in part to the fact that women have limited access to screening and treatment of precancerous lesions.

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