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South Africa
South Africa has a population of approximately 49 million people and is geographically divided into 9 provinces. Often referred to as ‘the rainbow nation’, its people come from a diverse range of cultures and ethnic groups. The country boasts 11 official languages, the most widely spoken languages being Zulu and Xhosa, followed by English and Afrikaans.
In South Africa, cervical cancer mostly affects black women – currently 1 in 26 will be affected. Complex challenges the country faces continue to predispose black women to a low socio-economic status: access to good education, health facilities, and resources is limited and the likelihood of ‘inheriting’ an unhealthy lifestyle is increased.
History
South Africa’s diversity originates in its heritage of the Xhosa and Khoi-San tribes occupying the land at the time when European traders began sailing around the tip of Africa. Dutch traders landed at the southern tip of modern day South Africa in 1652, setting up a stopover point on the spice route between the Netherlands and the East.
After the British took control of the Cape of Good Hope in 1806, many of the Dutch settlers left the Cape, encountering other native tribes further north. Later, the discovery of diamonds and gold attracted settlers and labourers from European and Asian nations
Economy
South Africa is regarded as a middle-income, emerging market with a rich supply of natural resources. It enjoys sturdy financial, legal, tourism, communications, energy, and transport sectors; has a stock exchange that is 17th largest in the world; and has modern infrastructure that supports an efficient distribution of goods to its major cities. A highly successful mining industry has placed South Africa as the world’s largest producer of platinum and gold.
High-quality medical research units exist in several cities, which are often paired with the academic and clinical health faculties of local universities. The clinical facilities service the local public, while highly specialised services often attract patients from the rest of Africa.
However, despite SA’s strengths and development, unemployment sits at approximately 24%, with an estimated 50% of the country’s inhabitants living below the poverty line. Many of the challenges the country faces mostly affect previously disadvantaged groups from the apartheid era.
The Female Cancer Program South Africa
FCP South Africa is overseen by the Cervical Cancer Prevention Trust, which was established in 2007 in Cape Town towards prudent administration of the project. The Trust is managed by three non-executive trustees who either belong to the medical profession or have considerable experience in business.
FCP South Africa has established its operations in a township called Mdantsane in the Eastern Cape Province in partnership with local government (the Eastern Cape Department of Health) and the Cancer Association of South Africa.
Mdantsane is known to be the second largest township in South Africa. Population size and the province’s very high incidence of pre-cancerous lesions of the cervix, cervical cancer and HIV are the reasons for this site being chosen.
Thirty-two clinics service the residents of Mdantsane. The FCP cervical cancer prevention project was initially set up in two major clinics in the area with intentions to roll out the project in selected clinics in 2009 and 2010.
Female Cancer Program South Africa Team
From Left to right: Nomfusi Nkonyeni, Lisa Aspeling, Dr Robbert Soeters, Sandy Ferreira.
Dr Robbert Soeters heads up the Gynaecology Oncology Unit at Groote Schuur Hospital in Cape Town. As the National Coordinator, Dr Soeters provides oversight and steering for the project.
Lisa Aspeling studied at the University of Cape Town and the Cape Peninsula University of Technology. As National Liaison Officer, she manages the project as a whole, liaising with various stakeholders and managing the organisation’s PR.
Sandy Ferreira is one of the project’s Training Facilitators and oversees the project from Mdantsane. She manages the training of local government nurses in VIA and cryotherapy, also ensuring the smooth implementation of daily activities.
Nomfusi Nkonyeni is also a Training Facilitator. Known for her activism in education around health issues, she is a respected member of the community. She trains government nurses and community workers, and heads up the areas of local awareness and networking.
See & Treat: VIA and Cryotherapy
“The launch of the project in the Eastern Cape heralds a new era of cervical screening in South Africa,” says Dr Soeters. The project is based on See and Treat (a single visit approach) which makes it cost- and time-efficient. It is cost-efficient since no lab technicians are required as with
the Pap smear.
Like in Indonesia, the SA project uses VIA to test cervical cells for the presence of HPV. Taking minutes to perform, VIA eliminates the waiting period for test results, saving time for medical personnel and patients. If the VIA result is positive, the patient is treated immediately with cryotherapy in order to prevent cancer. Dr Soeters is optimistic about the use of cryotherapy, “ This is truly an easy and safe approach with very good published results. The main advantage is that electricity is not required because the equipment runs on nitrous oxide. This is great for rural areas where electricity supply is not guaranteed.”
For women, the advantage of See and Treat is that they don’t have to return to the clinic for results and treatment. Joyce Matebese, Director of Maternal Child Women’s Health, is very supportive of the single visit approach: “One of our biggest struggles, from a health service provider’s perspective, is that often women do not return to get their Pap smear results and are sometimes not contactable by phone.” She continues, “This means that if there is a problem we are less able to help that woman, who is often the bread winner for her family.” Many women cannot afford multiple visits to the clinic, especially when they have to travel long distances.
Challenges
Challenges the project faces in this area lie around government nurses, who are already straining under their heavy loads due to staffing shortages. We must constantly find ways to motivate and encourage them in their partnership with us, despite difficult circumstances.
Vaccines
HPV vaccines are available in South Africa, but are presently too expensive for the high-risk group who would benefit most. It will be some time before government can offer vaccinations to the public. A concern about this vaccine is that it may promote promiscuity instead of discouraging it. In the South African context it would be more acceptable to endorse the vaccine as protection against cervical cancer instead of an STI.
HIV/Aids and HPV
Over recent years, HIV/Aids infections in the country have reached epidemic proportions. South Africa has one of the highest infection rates in the world, as well as one of the highest numbers of people living with HIV.
Problems surrounding the Aids epidemic include: shortened life expectancies and increased medical costs; a dramatic increase in the number of children being orphaned; and human resources shortages across industries.
Myths and beliefs in some cultures hinder the work of health professionals in the area of HIV. A heavy stigma around being HIV positive sometimes exists, and misperceptions – often despite education – sometimes cause people to avoid being tested, and even ignore the call to practice safe sex.
HIV, as well as cervical cancer, especially affect South Africa’s most economically active group of women. The effect of HIV on the economy has become measurable, as more women playing a central role in achieving economic progress for the country get sick.
Nurses report that many people are becoming less responsive to HIV education due to ‘over-exposure’ in some cases. A huge advantage in education around HPV is that it is perceived as being ‘new’ information. Women are currently responding well to the information being provided.
Raising Awareness
Like HIV/Aids, the battle in preventing cervical cancer falls heavily on education. Women need to be informed about HPV, health-seeking behaviour and cervical screening methods before they will participate in the program.
The slogan for our awareness campaign is:
“Value your family, value your community, value yourself!”
This slogan is meant to empower women – a key element to overcoming cervical cancer. In many instances, women need their husbands’ consent with regard to health issues. The awareness campaign encourages the community to recognise that women are essential to their well-being and need to be released to look after themselves and one another.
Awareness Tools:
Research
A study measuring the impact and effectiveness of some of these tools will run in 2009. A comparative analysis will be carried out, measuring women’s perceptions around cervical cancer and their self-reported health-seeking behaviours before and after being exposed to awareness materials.
It is important that the awareness messages hit their targets, because awareness is the long-term key to preventing cervical cancer.
Sustainability
Planning and implementation is being done in consultation with several interested groups. These include the Eastern Cape Department of Health (local government), the Cancer Association of South Africa, local community leaders, traditional healers and the managers and staff of day clinics.
Dr Soeters comments, “This consultative approach is needed to get the assistance and collaboration of all these role-players. We often refer to it as a ‘bottom-up’ approach. In contrast to the traditional ‘top-down’ approach, it’s probably a better recipe for success here. We hope to elicit support and participation from our partners to reap long-term benefits from the project.”
In thinking about the future, we anticipate that no further international funding is likely to be available after 2010. World markets will be attempting to recover from massive recessions in 2008, thus promoting social responsibility spending decreases.
Since South Africa has been largely sheltered from the financial turmoil, it is hoped and expected that local government will implement a similar program, taking ownership of the project’s vision.
Dr Soeters says, “We are delighted that the role players in the Eastern Cape are very keen to make the See and Treat program a success and have recognised its intrinsic value. ”