PUBLIC HEALTH CRISIS

A highly preventable disease with a vaccine is silently killing Indian women in their prime

Quartz india
Quartz india

A cancer with an effective vaccine is killing thousands of women.

Last year, nearly 70,000 Indians died of cervical cancer, more than anywhere else in the world. It’s the second-most common cancer among women in the country, accounting for 23% of all cases. It’s a hidden disease, often taking 20 years to show itself.

“We lose one mother every eight minutes, usually in their 30s or 40s, often just at the time when families need them the most,” said RK Grover, director and CEO of the Delhi State Cancer Institute (DSCI).

Cervical cancer, in most cases, is caused by the human papillomavirus (HPV), which is sexually transmitted. As India rapidly becomes more sexually liberated, girls will be more vulnerable. It’s time we saw this as a matter of public health affecting the futures of families, and not just a niche “women’s” issue. But even today, Indians remain ambivalent about the vaccine that can prevent this deadly disease.

Bad experience

After years of hesitation, the Indian government has finally launched a pilot programme to make the HPV vaccine a part of the public health programme. In November 2016 the Delhi government launched a pilot programme with girls aged 11-13 in government schools being vaccinated at the DSCI, and later that same month the Punjab government followed suit.”

In over 100 countries, the HPV vaccine, usually given to girls at the age of 11, is a part of public vaccination programmes. It has been so in the US and Australia for a decade. HPV can also cause genital cancers in men. Some countries, including the US, have now moved on to giving the vaccine to boys.

In 2007, PATH, a US nonprofit funded by the Bill and Melinda Gates Foundation, conducted a study of the vaccine on tribal girls in Gujarat and Andhra Pradesh, which most observers agree was badly handled. Seven girls died, and while the deaths were eventually found “unrelated to the vaccine,” a government committee ruled that proper consent was not obtained and follow-ups were inadequate.

Following the media outrage over Indians being used as “guinea pigs” by big pharmaceutical companies, the vaccine was shelved for years. The government and the medical community waited for the furore to die down. Meanwhile, vaccine costs began to fall, and India’s neighbouring countries began to adopt the vaccine. More evidence emerged of the vaccine’s efficacy in the US.

“We have waited far too long for this,” said Grover. Opposition to the vaccine now seems to be gradually dwindling amongst the government and doctors, but hurdles remain.

A key reason for the vaccine not being used in public health programmes is that it is unaffordable for most Indians. There are two brands: Cervarix made by GlaxoSmithKline (Rs2,190 per dose) and Gardasil by Merck (Rs2,975 per dose). Most girls need two to three doses, depending on their age.

The Indian Academy of Paediatrics and the Federation of Obstetric and Gynaecologists of India both recommend the vaccine. But even many affluent parents are delaying it. “I simply don’t know whether to give it to my daughter or not,” said Aparna Raghavan, an accountant who lives in Bengaluru and is the mother of a 15-year-old girl .

Raghavan is not alone. Google the safety of the HPV vaccine and what often comes up is scaremongering reports of deaths, side-effects, and vaccine hesitation by countries such as Japan, where 63 women are suing the government, claiming that the vaccine caused neurological conditions. The Japanese government found no evidence of this, but it has not begun recommending the vaccine again. Countries like Denmark and Ireland have now also expressed concerns. Hard data proving efficacy in the US and Australia is often buried in medical journals.

Unless one actually asks for the vaccine, most general practitioners often do not recommend it. It’s this apathy that frustrates supporters of the vaccine like Suneeta Krishnan, a public health researcher formerly with the Research Triangle Institute, a US nonprofit that researches health across the world. “The vaccine has no advocates on the ground. There’s just no awareness programme at all, unlike breast cancer or polio. As for rural areas, the situation is dire. Many women go to doctors only when they see symptoms, with no pap smears or other screening in between. By then, it’s too late.”

Opponents of the vaccine still think India should wait, and a debate rages over what kind of consent is needed. Delhi-based nonprofit Sama, which also works in women’s health, currently has a writ petition pending in the supreme court. It wants HPV to be excluded from the national immunisation programme until more evidence is found of its safety.

“I am not in favour of a complete ban on HPV vaccines, but I don’t think India has systems in place yet,” said Sama director NB Sarojini. “We don’t have a process for proper, informed consent, letting parents know the implications. Vaccines were given to poor tribal girls on the basis of bas, yeh tika lagwa do (just get this injection). No proper studies have been done on Indian girls.”

Vaccine supporters think such detailed consent is unnecessary. The MMR and polio vaccines have been given for years without such consent, says Krishnan, on the basis that they have worked worldwide on other girls. Besides, the HPV vaccine is not a trial vaccine on Indian “guinea pigs,” and has already been proven to be effective.

While all vaccines have occasional side effects, like fainting and dizziness, the benefits outweigh these.

But the problem of astronomical cost needs to be addressed, too. The Delhi government provides Cervarix free, buying it at a reduced price of Rs600 per dose from GlaxoSmithKline. Krishnan thinks India, with its huge population, can negotiate favourable financial terms with competing vaccine providers. Prices, she says, are bound to drop.

“We are a massive market and pharma companies will want to tap that,” she said.

Organisations like UNICEF and GAVI, the Vaccine Alliance, has helped bring in cheaper HPV vaccines in other developing countries. India also has a long history of teaming with GAVI.

Costly wait

Supporters of the vaccine believe the endless paranoia over the “foreign hand” is hurting Indian women, even as time runs out. The most important thing, they say, is to get a tried and tested vaccine at a cheap price. The HPV vaccine, after all, was first developed by university research, not big pharma. Meanwhile Indian companies such as the Serum Institute of India and Biocon are developing their own versions, which are likely to be much cheaper.

Sarojini wants more attention given to basic screening. She points out, rightly, that the HPV vaccine protects against most of the strains of cervical cancer but not all. Currently, the vaccine is thought to offer protection for about eight years, so screening is still an important weapon. “You don’t need expensive pap smears; visual screening with acetic acid is cheap and easy. We need scarce funds to be spent on screening and sexual education first, not a hasty vaccine.”

It is this “either/or” argument that has vaccine supporters alarmed. Why not do both, they argue?

India has a great childhood vaccination programme which is widely accepted and has nationwide reach through our schools. In contrast, with a few exceptions like Tamil Nadu, we don’t have a nationwide screening programme for women,” said Krishnan, explaining why it makes sense to get a jump on cervical cancer by targeting girls early.

Grover also agrees that India does not have the manpower for the screening it needs. “So far, our health strategy focused on communicable diseases. Now, we need to focus on lifestyle diseases; it’s a big leap,” she said. DSCI plans to expand the vaccination programme beyond government schools in the future.

Grover, who sees the worst cases at DSCI, is impatient. “Countries like Bhutan, with only 40 cases a year, have already introduced the vaccine. We are way behind the rest of the world. Enough talk, we need action.”

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