Disease Prevention Requires Social Change

The World Health Organization has determined that most of the world's premature deaths, including those caused by cervical cancer, can be prevented with established, available interventions. What is not clear is how to make available interventions more widely available to the people who most need them. Before Papanicolaou cytologic screening (which is usually referred to as "Pap screening") became widely available in the United States, cervical cancer was the leading cause of cancer-related death among American women. Developing countries have for the past several decades focused on health programs targeting communicable diseases of childhood and reproductive health. Developing countries have only recently started to introduce programs targeting the health problems of adulthood, such as heart disease, mental illness, and cancer. Because Pap screening is therefore not yet widely available in the developing world, cervical cancer remains the leading cause of cancer-related death among women in developing countries, including Vietnam. On a global scale, cervical cancer and lung cancer are the most preventable forms of cancer-related death among women.  

Pap screening, like tobacco abstinence, is an extraordinarily powerful tool for disease prevention. Pap screening, like screening mammography, results in the detection of existing cases of cancer at earlier, more curable stages of disease progression. However, Pap screening also detects precursor lesions to cancer. Detection and treatment of these important precursor lesions halts their progression to cervical cancer. Pap screening thereby dramatically reduces the numbers of new cases of cervical cancer that occur among women who are screened. The U.S. Agency for Healthcare Research and Quality has determined that Pap screening, when fully effective, reduces cervical cancer rates by 60% to 90% within 3 years of its distribution to women who have never before been screened, and that these reductions in suffering and mortality are consistent and dramatic across populations.

Official Vietnamese government statistics indicate that cervical cancer rates in Ho Chi Minh City (the largest city in Vietnam; population ~9 million) have fallen from 29.2 cases among every 100,000 women in 1998 to 16 cases among every 100,000 women in 2003. For reasons outlined in our Quality Management Wiki, measurements of cervical cancer rates in developing countries are inherently inaccurate, and tracking cervical cancer rates over time is therefore not an entirely appropriate method by which to measure the successes or the failures of cervical cancer prevention efforts in developing countries. Nevertheless, it appears that Vietnam has now joined a growing group of developing countries, including Argentina, Brazil, Chile, Costa Rica, Ecuador, Mexico, Nicaragua, and South Africa, which have started to successfully turn the tide against this life-threatening disease by making Pap screening services available to the women who most need them. 

The U.S. Agency for Healthcare Research and Quality has determined that cervical cancer rates in the United States have fallen approximately 100% since the introduction of Pap screening in the 1950s. It is correspondingly unlikely that innovative technologies for cervical cancer prevention (such as human papillomavirus (HPV) testing or HPV vaccines) will substantially improve on the performance of Pap screening for the prevention of cervical cancer. Because all females who receive HPV vaccines must also be screened, any eventual added benefit of HPV vaccination for the prevention of cervical cancer is uncertain. And, as we explain on our webpage about HPV vaccines, the possibility remains that HPV vaccination, even when implemented flawlessly, may eventually prove to be completely ineffective for cervical cancer prevention.

Cervical Cancer in Developing Countries: An Important Problem with a Clear and Present Solution

The Viet/American Cervical Cancer Prevention Project (VACCPP) has proposed that Pap screening in developing countries is an idea whose time has come, for the following reasons:

Pap screening is feasible anywhere cervical screening is appropriate; no other options for cervical cancer prevention are currently affordable and/or appropriate for all women in developing countries such as Vietnam (click here for details); all future prevention strategies will require at least a small component of Pap "triage" confirmatory testing to function properly; and it is unlikely that less-progressive public health leaders who are unwilling to implement Pap screening (which is an inexpensive, generic, "open-source," home-grown intervention) will be any more willing to implement expensive, proprietary, imported interventions such as HPV screening.

At the heart of the matter is the inescapable conundrum that, in any region of any country, progress is optional. The status quo is always beneficial for some people, no matter how dreadful it may be for others. The central theme of this website is that successful cervical cancer prevention requires social change.

Improved technology is plainly desirable but is not required, because real-world obstacles to successful cervical cancer prevention involve people (and apathy) far more than technology. Political leaders, global health organizations, health care providers, and at-risk women must learn to think and act in manners that may be unfamiliar in order to achieve goals that everyone agrees are worthwhile. As we outline in our Quality Management Wiki, laboratory data constitute an indispensable yet often overlooked fulcrum against which to leverage the social change required to preserve life.

What We Do: Patient-Centered Quality Management

The gap between the health interventions that should be delivered and the health interventions that are actually delivered is referred to as the "quality chasm" and is addressed in a landmark 2001 report by the American Institute of Medicine. The critical skill set for "crossing the quality chasm" resides in the field of health quality management, which was pioneered during the 20th century largely by managed care organizations such as Kaiser Permanente. Health quality management efforts achieve remarkable success by making available health interventions more widely available to the people who most need them. For example, in California, heart disease mortality is 30% lower among Kaiser Permanente health plan members than among members of health plans other than Kaiser Permanente.

Past and current failures of cervical cancer prevention programs are not attributable to factors specific to the Pap test, but to failures of political will and quality management to which all preventive interventions are vulnerable. Dr. William Foege, a former Director of the U.S. Centers for Disease Control and Prevention, has observed that a lack of management skills, rather than a lack of appropriate technology, appears to be the single most important barrier to improving health throughout the world. VACCPP concurs with Dr. Foege's assessment in the context of cervical cancer prevention for developing countries. VACCPP participants therefore include physicians with specific expertise in the field of cervical cancer quality management, the goal of which is to assure that women at high risk for developing cervical cancer are screened and receive appropriate follow-up care. Our efforts are centered on improving health outcomes as rapidly as possible among as many women as possible, rather than on improving corporate profits or on academic career advancement.

Distribution vs. Innovation: An Appeal for Patient-Centered Balance Between Complementary Humanitarian Impulses

Opportunity costs, borne most gravely by those least privileged, are associated with prioritizing research on innovative health interventions in any setting where established interventions are feasible but unavailable. Understandably, progressive political and public health leaders throughout Asia, Africa, and the Americas, including countries as diverse as Vietnam, South Africa, and Argentina, have judged Pap screening to be the appropriate method for cervical cancer control in these countries. However, because powerful research and commercial interests often benefit from the humanitarian impulse toward innovation, Pap screening for developing countries such as Vietnam is currently an ethical imperative lacking a substantial political constituency in the global health community. 

The Alliance for Cervical Cancer Prevention, for example, was established in 1999 with a gift of $50 million from the Gates Foundation. The extraordinary, tragically well-intentioned founding assumption of the Alliance is that innovative technologies, rather than Pap screening, are the most likely solution to the problem of cervical cancer in developing countries. The creation of the Alliance was announced within months after progressive Vietnamese health leaders in Ho Chi Minh City, Hue, and Hanoi had agreed, for the reasons outlined above, that Pap screening is the appropriate solution for the problem of cervical cancer in Vietnam. In contrast, Alliance leaders at the International Agency for Research on Cancer (Lyon, France) are on record as being "loathe" to recommend the implementation of Pap screening services for settings where no cervical cancer prevention services currently exist. Alliance leaders at the Program for Appropriate Technology in Health (Seattle, Washington) persistently deny all evidence for the success of Pap screening in developing countries, further empowering apologists for the status quo and further undermining more-progressive public health leaders in their efforts to implement strategically essential Pap screening services in these settings. Alliance leaders who had previously assumed that new screening technologies, rather than Pap screening, constituted the most likely solution to the problem of cervical cancer in developing countries, now maintain that the most promising new strategy for the prevention of cervical cancer in developing countries is HPV vaccination. The scientific shortcomings of these well-intentioned beliefs are outlined on our webpage about HPV vaccines.

Our Mission and the Goal of this Website 

Progress is optional in any setting, and Vietnamese define the meaning of progress in Vietnam. VACCPP's mission is to help more-progressive political and health leaders in Vietnam in their efforts to distribute Pap screening services to Vietnamese women. 

Physicians have known for decades that war is a risk factor for the development of cervical cancer, and an added dimension of our mission stems from the finding that the problem of cervical cancer in contemporary Vietnam is, in part, a legacy of the Vietnam War. We delayed publication of scientific evidence linking the Vietnam War to cervical cancer for 8 years while we worked to establish a nationwide cervical cancer prevention program in Vietnam and to publish a framework for its completion endorsed by appropriate Vietnamese authorities. Our hope was to ease the process of reconciliation by presenting what most would acknowledge to be a remedy in advance of what some will perceive to be an accusation.

We continue to study the fears, costs, and benefits associated with discussing the relationship between war and disease, and to examine perceptions regarding Vietnamese, American, and multilateral responsibilities for controlling the problem of cervical cancer in Vietnam. Our published policy is that the complexities of guilt and responsibility can only truthfully be discussed in the context of a loving struggle among individuals who maintain solidarity with one another.

The goal of this website is to help clarify health policies by sharing lessons we have learned during the past 16 years. We also invite you to consider making an online donation in order to sustain our efforts in Vietnam. With your support, we will continue to help Vietnam develop Pap screening services while we study the relationship between the Vietnam War and cervical cancer.

Thank you for your interest in these issues.

Eric J. Suba M.D.
President and Executive Director 
The Viet/American Cervical Cancer Prevention Project   

Stephen S. Raab M.D.
Vice-President and Director
The Viet/American Cervical Cancer Prevention Project