Cervical-Uterine Cancer in Cuba and the World

Erasmo Calzadilla

HAVANA TIMES — I’m shaken up. In less than a year, three friends of mine have been diagnosed with and treated for cervical cancer (CC) – three young women saved from a slow and horrible death.

I dedicate this post to all those battling this condition.

More than 270,000 women die every year because of this condition. It is the second most common type of neoplasia among females and the fifth most common cause of cancer death. Mortality rates associated to CC are growing worldwide. The World Health Organization estimates this trend will worsen.

The saddest thing is that this is a preventable condition that can be cured with a minimum of resources. This is the reason that 80 percent of females who die of it live in “developing countries,” where these basic resources are conspicuously absent or where elites aren’t interested in using them to save human lives. Cuba demonstrates how much a poor country can do in the struggle against this ill.

One of the most efficacious and cheapest way to combat the condition is through prevention. Since the mid-20^th century, it’s been known that 99 percent of cases begin with a sexually transmitted disease. Some strain of the Human Papilloma Virus (HPV) can make cells on the cervix and other tissues in men and women malignant.

Safe sex is, therefore, the first line of defense against HPV and cervical cancer. Informing people of the danger and facilitating access to condoms constitutes the simplest and cheapest way to save millions of lives. In this crazy world, however, it proves more “interesting” to develop sophisticated and expensive pharmaceuticals than to promote healthy habits.

In the last five years, pharmaceutical companies have been selling two vaccines that protect against some of the more dangerous strains of HPV. The World Health Organization recommends their use, but their price continues to be too high and very few countries include them in their mass vaccination campaigns.

Another effective way to avoid the development of the condition is through screening campaigns aimed at high-risk populations. With some rare exceptions, mass screenings implemented by “developing” countries do not even cover half of the risk population.

We are dealing, then, with a condition associated to poverty, ignorance and the lack of political will in terms of treatment. Having sketched out this preamble, let us now head to Cuba.

Cuba

The social changes that began in 1959 revolutionized the country’s health system. The results were immediately felt. In 1965, the Cervical Cancer mortality rate was 20 for every 100,000 women (typical of countries where next to nothing is done to prevent or treat CC). Five years later, the figure had dropped to four. To get a sense of the magnitude of this achievement, the United States took nearly half a century to achieve a similar rate (1). Either the statistical reports are false or this is a great feat.

The National Program for the Early Diagnosis of Cervical Cancer was created in 1968. The program aimed to conduct mass Pap smears (known in Cuba as “cytological tests”) and to cover nearly 70 percent of the risk population. It is not a very discrete exam, but it has saved the lives of millions of women.

Since 1970, however, CC trends have done nothing but worsen in Cuba. The mortality rate is today twice what it once was.

Countries in the region which were once behind us in this respect rolled up their sleeves and caught up to us.

When a dangerous condition begins to spread, the most logical thing to expect is for the Ministry of Health to set up a commission to investigate the causes of this, and to publish its conclusions. On the Internet, I came across countless scientific articles and official reports on cervical cancer, conducted in Cuba by medical doctors, journalists and researchers. Not one of them set out to determine the reasons behind the exponential growth of CC in our country.

While we wait for an official study and its publication somewhere accessible, let us pretend to be Sherlock Holmes and try to solve the mystery ourselves.

CC mortality rates may be growing for two different reasons: a rise in the incidence of the condition and a rise in the mortality of those women who develop it. Which of these two is happening in Cuba? Both of them.

Rise in Cervical Cancer incidence

According to data from the Yearly Health Statistics Report, the incidence of CC has more or less been growing since 1990 (I don’t have any previous information).

The increased incidence of CC cases is the result of greater exposure to risk factors (2). In the case of CC, these are:

Sexual precociousness and promiscuity, early and frequent pregnancies, smoking, failure to get tested, advanced age, poor socioeconomic conditions and infection with oncogenic strains of the Human Papilloma Virus, among others. Which of these are affecting Cuba?

Let us examine each of the factors.

• According to official statistics, smoking is on the decrease in our country, so we can discard this.
• Precocious, promiscuous and unprotected sexual relations may well be on the rise. The spread of other sexually transmitted diseases and the veritable epidemic of abortions we’re seeing suggest this.
• Several factors suggest a progressive drop in the socioeconomic conditions of people since the onslaught of the Special Period in the early 1990s, something which is closely related to the item above.
• Cuba’s population is aging. The number of people susceptible to CC has therefore grown.
• As for screenings, though the number of women tested hasn’t stopped growing, we know that most females covered by the Early Detection Program does not get tested (3).
• As for the detection of carcinogenic strains of HPV, as far as I know there’s no study that reflects the spread of these strains among Cuba’s population.

A quick glance at this seems to suggest more than enough reasons for the rising incidence of CC. The reasons that are leading Cuban women to get tested less regularly should be immediately studied by Cuba’s health system. Informational campaigns may not be doing a good job, or perhaps the new wave of male chauvinism on the island is contributing to this.

Rising mortality rate of women who develop the condition

When we combine this “strange” suicidal behavior (of not getting tested) and the presumed (though unconfirmed) drop in the quality of screening procedures, owing to the fact the best medical technicians and doctors are working abroad, the result is the later detection of CC. This problem, which has worsened over the past decade, increases the chances of death from the condition.

Late detection may be coupled with a deterioration of the treatment phase (caused by personnel and medication shortages). These two factors could explain the rise in CC mortality among women with the condition. This variable is growing rapidly and figures are nearing pre-1970 levels.

Finally, here’s a general graph (below) of how I see the situation in our country:

Below is my conclusion on the above data: it’s time to look towards the future.

Battling Cervical Cancer in the future

Most of the Cuban and foreign research, journalistic pieces and official reports I was able to consult suggest the introduction of novel (biotechnological) techniques for the treatment of the condition, such as prophylactic vaccines and tests aimed at detecting carcinogenic strains of HPV.

The leading project based on these “methods” is the vaccine being developed by Cuba’s Center for Genetic Engineering and Biotechnology (CIGB).

But why copy the formula of wealthy countries?

All of these scientific geniuses forget that Cuba miraculously reduced mortality rates through informational campaigns, qualified personnel and microscopes made during the First World War.

Some choose to forget because they want to develop and sell pharmaceuticals (it’s their livelihood). Others forget because they cannot get past the paradigm that places technology at the center of the cosmos. The truth of the matter is that the forgetful lot constitutes the majority and it’s going to be very difficult to steer things in a different direction, unless… disaster strikes.

You already know what I think. The world economy and social health indexes will begin to plummet soon (if they’re not doing so already). The reason? Climate change, the decline in energy resources and other problems caused by the clash between expansionist capitalism and the limits of the system.

If the predictions of peak-oilers and global-warming experts are not mistaken, we will soon have to abandon our fancy biotechnological projects. And only then will we pay due attention to that glorious campaign of the 1970s.

We are living exhilarating times following the re-establishment of relations with the United States. Let’s hope the excitement and momentary rise in economic conditions won’t make us replace the old Pap smear with cutting-edge technology. It would be harder to get back from that later.

One last point: as we’ve seen, CC begins with an HPV infection. The logical thing to do would be to inform patients and their partners of this and to do an epidemiological follow-up, as is done in the case of AIDS. This is not standard procedure in Cuba. My friends with malign lesions on the cervix weren’t even informed of these issues by their doctors. I think this could be a simple and cheap way to combat the disease, even in the times of crisis.

Notes:

1. The incidence and mortality rates reported in this post refer to the number of women with the condition, or have died of it, for every 100,000 females.
2. As most cancer patients in Cuba are treated in hospitals and are therefore included in statistics, I have assumed that official “incidence rates” reflect the country’s real incidence.
3. Several scientific articles I’ve read devote small sections to the growing numbers of Cuban women who are not getting tested. One of them is: Trends in Cuba’s Cancer Incidence (1990 to 2003) and Mortality (1990 to 2007).

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