It has been 10 months since 44-year-old Alice Akin* received a cervical cancer diagnosis. “Will the pain ever go away? It is better to die than to live like this, the pain is too much for me to bear,” She mutters at intervals, tears rolling down her face as she talks about her cancer journey.
“It started with what I thought was a normal waist pain. Routine visits to hospitals in my state always ended with being prescribed painkillers. As time passed, the pain became almost unbearable, so I travelled to Abuja and visited Gwagwalada Specialist Hospital. There, I was told I had a disc degenerative disease. The painkillers and drugs I was given did not seem to do much as the condition became worse.
Then one morning, I woke up screaming in pain; it was as if I was about to die. I was then rushed to the same hospital where I was being managed. This time, I saw another doctor who asked me to carry out some tests. About three weeks later, I received a diagnosis — I had stage 2 cervical cancer. The doctor said that the pain I felt in my waist and legs was due to the pressure of the enlarging tumor. I was told that I needed to start chemotherapy immediately and I was referred to National Hospital in Abuja for further treatment.”
The diagnosis disrupted Alice’s life in unimaginable ways. She had taken too many days off at work and was eventually let go. She moved from her home in Imane, Kogi State to Abuja — leaving behind her husband and six children — to access the recommended treatment. Her husband started seeing another woman. “He barely cares about me nor supports me with funds for treatment. I am now left alone to bear the financial, emotional and psychological burden of treating cervical cancer, to stay alive.”
A treatable cancer
Cervical cancer develops in a woman’s cervix and is the second most common cancer among women between the ages of 15 and 44 in Nigeria. However, if diagnosed early and managed effectively, it is one of the most successfully treatable forms of cancer.
If cervical cancer is one of the most treatable forms of cancer, why then does it have such a high mortality rate? The answer can be summarised in one word — access. Women like Alice do not have access to testing facilities; therefore the cancer often goes undetected — if ever — until it has advanced, and symptoms develop. If diagnosed, due to economic and other factors, they have limited or no access to treatment options like surgery, radiotherapy and chemotherapy. In addition, they have little or no access to preventive measures like vaccines and education.
The human papillomavirus
Most cervical cancer cases are caused by the human papillomavirus (HPV) and according to the World Health Organization (WHO), HPV vaccination could prevent at least one-third of all HPV-related cancers in Africa. A key objective of Nigeria’s National Cancer Control plan is to attain 90% HPV vaccine coverage among children aged 9–13yrs in Nigeria, on or before 2022. One way to achieve this objective is by including HPV vaccination in the National immunisation programme.
However, despite the government’s commitment to providing free immunisation services for all vaccine preventable diseases (VPDs), Nigeria’s National Immunisation Programme (NIP) does not cover the cost of HPV vaccinations; where available, recipients must pay out-of-pocket. This means that affordability will continue to be a major obstacle to vaccination uptake, particularly for low-income populations. Governments at all levels must prioritise funding of the HPV vaccine to guarantee vaccine access, particularly in rural communities.
According to Runcie C.W Chidebe, Executive Director, Project PINK BLUE, the HPV vaccine is more expensive in Nigeria than in many countries across the world, including Europe.” It is so expensive because it is not accessible. Individuals may buy the HPV vaccine for as high as 16, 000 or 20,000 Naira, depending on where they are buying from. Hospitals and pharmaceutical companies also face a lot of hurdles importing it”.
In Nigeria, Kebbi State is one of the states working to ensure that cervical cancer is eliminated. Between February and July 2020, a pilot vaccination programme targeting adolescent girls in Yauri, a rural community in Kebbi State was conducted by Medicaid Cancer Foundation (MCF), in partnership with the Kebbi State Ministry of Health and Jaiz Charity and Development Foundation (JCDF). Six months after implementation, a study was carried out in the community to examine contextual factors and challenges to vaccine delivery in a low-resource, rural setting.
The one-billion-naira cancer fund
Following her referral, Alice began receiving treatment at the National Hospital, Abuja. “I have had 6 chemotherapy sessions with various tests and scans, which so far have cost me close to 2 million Naira. It was difficult to raise the money. I borrowed some and sold some of my property to make the money available and it’s still not enough”. Many cancer patients in Nigeria can barely afford the cost of care. Some sell all they own and are left bankrupt by the end of the treatment. Some simply stop accessing care when the money runs out and others resort to traditional means.
The Cancer Health Fund (CHF) Initiative is a one-billion-naira fund created by the Federal Government to reduce the burden of the treatment of breast, cervical and prostate cancer, on Nigerians who cannot afford the cost of treatment. The Federal Ministry of Health (FMoH) is responsible for implementing this Fund which was piloted in six Federal Teaching Hospitals across Nigeria. However, there have been calls to the government to move the Fund from the FMoH to the National Health Insurance Authority (NHIA).
The National Health Insurance Authority (NHIA) is mandated to ensure provision of health insurance for all Nigerians through a mandatory mechanism, in collaboration with state health insurance agencies. To tackle the high incidence of poverty and deaths caused by out-of-pocket expenses for cancer management, it is pertinent that health financing for cancer patients should be strengthened, this will bring Nigeria a step closer to achieving universal health coverage.
Sadly, Alice is grappling with more than just finances. At the time of publication, the radiotherapy machine in the hospital had stopped working, halting Alice’s treatment which for her is very disturbing. “I had my last chemotherapy session four months ago and since then, I haven’t received any treatment. Even after paying 600,000 Naira for it.” Alice’s only other option is to travel to Lagos where radiotherapy costs about 1.3 million Naira.
The Federal Government recently announced that over 2,000 indigent cancer patients have registered to receive treatment in 17 hospitals, under the CHF Initiative. Nigeria’s cancer burden is high. The statistics for cervical cancer alone are a cause for concern. The CHF initiative and by extension, the National Cancer Control programme must be implemented with more urgency if more lives are to be saved.
Global Strategy for cervical cancer elimination
The global cervical cancer burden is projected to rise to 700 000 cases and 400 000 deaths in 2030. To reverse this trend, the World Health Assembly adopted the Global Strategy for cervical cancer elimination outlining a 90–70–90 target that must be met by 2030 for countries to be on track to eliminating cervical cancer.
Prior to her diagnosis, Alice was barely educated about cervical cancer and how it could have been prevented. She has four daughters — ages 20, 23, 27 and 29. For these ones and for the many other young women and men who may well be unaware of the risks of this and other cancers, state and local governments must take responsibility for their people’s health and bring cervical cancer checks, treatment and vaccines closer to the people.
Strategic steps must be taken to raise public awareness, increase workforce capacity, strengthen health systems, reduce the cost of cancer treatment, hasten the integration of affordable technology into screening and treatment systems, and scale up organised, population-based prevention and treatment platforms will be necessary to get on track to reduce the national cancer burden.
In line with the objectives of the National Cancer Control Plan, government at National, State and Local levels should,
- Provide easy access to cervical cancer screening and HPV tests to women in urban and rural areas
- Improve access to quality, cost effective and equitable diagnostic and treatment services for cancer care,
- Ensure the availability of drugs, consumables, and functional equipment for cancer care in Nigeria
- Increase cancer awareness and advocate for cancer control amongst the populace.
- Ensure effective coordination and adequate resources for cancer control and care in Nigeria
Waiting in hope
Alice’s prognosis is good. At least, this is what her doctors said 10 months ago. They were confident that she could fight the disease as with chemotherapy and radiotherapy, the cells will begin to shrink. However, this was given at the beginning of her treatment. It’s been four months since she has had any treatment and so, it is hard to know what the prognosis might be now. While Alice waits — with a long line of other patients, for the hospital to fix the radiotherapy machine, she chooses to wait in hope, believing that she will beat this.
*Not her real name.
Every cancer patient tells us a common story story of constant struggle between hope and hopelessness, yet with unique experience as they navigate the continuum of care. We owe them the responsibility to support them to maintain hope amidst the mountains of challenges. One factor that is common to all the survivor’s stories that I have listened to is that they remained hopeful despite the daunting challenges. While we continue to encourage Alice and thousands of hopeful cancer patients out there to hang on there and continue to look forward to tomorrow with hope, we plead with relevant authorities to please act on the challenges outlined in good faith rather than adopting a defensive mode.