Wanderlust: Botswana, where cancer is the new AIDS

Illustration by Antler.</p>

Illustration by Antler.

Editor's note: Wanderlust is a regular GlobalPost series on global sex and relationship issues written by Iva Skoch, who is now traveling the world writing a book on the subject.

GABORONE, Botswana – In a small trailer, a nurse applies vinegar – the cheapest kind they sell in local supermarkets – on her patient’s genitals.

Because tissue harboring precancerous lesions turns white when exposed to acetic acid, she waits for white spots to appear on her patient's cervix.

Once she sees them, she isn't sure whether they are actual lesions or scar tissue. So she snaps a photo of the cervix using her phone camera. She then forwards it to a doctor’s phone with the text message: “39-year-old patient. I think there’s a distant lesion at 2 o’clock. Do you agree?”

Some 200 miles away, Dr. Doreen Ramogola-Masire opens the message, zooms in on the lesion’s borders and agrees. She recommends cryotheraphy, a treatment that freezes part of a woman’s cervix to destroy abnormal cells that may lead to cancer.

A few minutes later in the trailer, the nurse freezes the patient’s cervix using liquid nitrogen.

According to Dr. Masire, even a one-time cryo treatment decreases a woman’s lifelong chances to develop cervical cancer by 25 percent. But most women in Botswana don’t get screened or treated at all because they don’t have easy access — or the resources — to see a doctor. Distant consultations, such as this one, have potential to change that.

“The future with cell phones is huge, especially in rural areas,” said Dr. Masire, head of the Women’s Health Initiative Botswana that partners with University of Pennsylvania for clinical care, research and funding, who helped introduce the telemedicine pilot program to help battle an epidemic of cervical cancer that’s sweeping sub-Saharan Africa.

“Cervical cancer is a disease of inequity,” she said. “Those who can afford it get the screening.” According to research done in neighboring South Africa, black women are 26 times more likely to develop cervical cancer than white women.

Cervical cancer represents about 25 percent of all cancer cases in females in Botswana, while, for example, in the United Kingdom, it accounts for 2 percent. Although the disease is considered one of the more preventable cancers in the West, ranking as the eighth most-common cancer in women in the U.S. – with mortality rates lagging far behind breast cancer, lung cancer and colon cancer – it’s the leading cancer killer of women in the developing world. About 300,000 women die of cervical cancer every year, most of them in the poorest areas of Africa, South America and Asia.

Nobody knows exactly why the incidence of cervical cancer is so high in Botswana, one of Africa’s richest countries because of its diamond wealth.

But anecdotal evidence suggests cervical cancer runs rampant due to lack of mass screening, a lack of education and sexual behavior that would be considered licentious in the West. Also, because of extremely high HIV rates in this area of the world, available resources typically go to tackle AIDS research rather than cancer.

People often assume there’s no cancer in Africa, said Dr. Masire. “But the truth is we have no data on cancer in Africa,” she said. And without data, it’s almost impossible to provide help and to get help from abroad.

“Data is king,” she said.

That’s one of the reasons her organization began collecting cancer data. It's also providing cervical cancer screening to local women who are HIV-positive.

About one-third of Botswana’s adult population is estimated to carry the HIV virus and HIV-positive women are, in turn, five times more likely to contract the human papillomavirus (HPV). HPV, which triggers cell alterations of the cervix, can lead to cervical cancer, as well as cancers of the vulva, vagina and anus.

In the last two years Dr. Masire and her team have screened 2,200 local women. Only half had a healthy cervix. Of the rest, 354 had mild precancerous lesions and were given cryotherapy. The remaining 700 or so had abnormalities of the cervix that required more treatment, surgery, or even radiation, and were invited for further consultations in the referral clinic run by Dr. Masire and her team.

Prevention is essential, since there’s only one oncology ward with 20 beds – 10 for men, 10 for women – in this country of 2 million people. It’s a modest ward, without the equipment to handle advanced cases. For radiation, patients are typically sent to hospitals in South Africa.

In developed countries, cervical screening programs, such as PAP smears, have significantly reduced the incidence of invasive cervical cancer. But in sub-Saharan Africa, PAP smears aren’t readily available and if they are, results take months, sometimes years. Often, they get lost.

“The PAP smear test is good, but it requires a sophisticated infrastructure,” said Dr. Masire. In remote areas of Africa, the infrastructure is poor and clinics typically don’t have the slides, the sprays and most importantly, qualified personnel to do these tests or read the slides. When women finally make it to one of the clinics, they often have symptoms too advanced to help them.

A decade ago, in the midst of the HIV epidemic, so many people in Botswana were dying of AIDS the country feared its population would be decimated by the disease. So in 2001, the government made a widely applauded – and in Africa a quite unprecedented – decision to provide antiretroviral drugs to all citizens who needed them. Today, more than 90 percent of patients in Botswana who need HIV treatment receive it. The disease that used to be a death sentence has gradually become a chronic disease.

But there is bad news, too. A decade ago, HIV patients would have almost no chance to die of cervical cancer. They would have died of tuberculosis or meningitis or one of the more common symptoms that are considered complications of AIDS long before they would die of cancer, which is much more costly to treat.

“Now, people are living longer and pre-cancers have a chance to develop into cancers,” said Dr. Masire.

Improvement in the patients’ quality of life has also made them enjoy sex more once again. Dr. Masire speculates that when there were no HIV meds, people looked ill, had no energy and were probably not having too much sex.

Nowadays, with antriretroviral drugs, nobody can tell who has AIDS and who doesn’t. People look healthy and feel good, which might also affect how they interact sexually, she said.

Crystal Mhone, a 27-year-old patient, whose name was changed to protect her privacy, tested positive for cervical cancer and had surgery on her cervix last month. She has been HIV-positive since 2007 and because here, cervical cancer is classified as one of the AIDS-defining illnesses, she is no longer considered an HIV patient. Because of her cervical cancer diagnosis, she is an AIDS patient now. She doesn’t remember where she got infected or by whom.

When she was asked how many sexual partners she’s had – a routine question during gynecological visits – she replies with a disarming, “You mean in total? Or now?”

Dr. Mimi Raesima, one of the medical officers working with Dr. Masire, said that multiple partners, especially the prevalence of concurrent partners, as well as inter-generational sex, is a huge obstacle in their efforts to curb the cervical cancer epidemic.

“If my husband has several girlfriends and I have several boyfriends at the same time, and all of them have multiple lovers, the number of lovers we are effectively sleeping with is staggering,” she said.

In Botswana, such arrangements are quite common. Men often claim that the shortage of male population here requires local men to have more than one girlfriend. Otherwise, there would be a lot of lonely women. Because most of Africa still doesn’t provide a lot of professional opportunities for women, especially “lonely” ones, a woman is often forced into transactional relationships with multiple men, who in turn help cover her household expenses – from her mobile phone bills to her often distant and expensive doctor visits.

Dr. Raesima said that many patients think that if they already have the HPV virus, they don’t have to worry about it anymore. “Once you have it, you haven’t won. You can always get reinfected by other strains,” she said.

Some 40 different strains of HPV are transmitted through sexual contact and unlike HIV, condoms are only 70 percent effective in preventing HPV transmission. Vast majority of cervical cancers in the West are caused by the HPV virus 16 and 18. Not surprisingly, the HPV vaccines, available in the developed world, prevent infection with the HPV types 16 and 18.

The vaccine isn’t readily available in Botswana yet because it’s expensive and because there’s no definitive research proving that strains 16 and 18 are the most common types of HPV in Africa, too.

“Data is king,” repeats Dr. Masire.