The country with the world’s highest cervical cancer rate – and why its women are needlessly dying

Zeione Satheka grimaces and shifts uncomfortably as her pain medication starts to wear off.

The 38-year-old mother of three is largely bedridden now and tended to by her own mother. She has cervical cancer and the disease was too advanced to be treated by the time it was spotted. Nurses can only give painkillers and try to soothe her symptoms. Friends from church come and pray with her when she cannot make it to services.

Mrs Satheka is far from alone in her suffering – Malawi has the highest cervical cancer mortality rate in the world, with thousands of women dying from the condition every year, estimates suggest. They are deaths that are entirely avoidable.

At the nearby Queen Elizabeth Central Hospital in the city of Blantyre, a doctor examines another woman, Febbie Felix. Her biopsy and ultrasound show she too has cervical cancer. She had not been screened for the disease before and she only came to be tested when she felt pain in her lower abdomen and had bleeding.

Now, the tumour is already too large for surgery, and she is prescribed chemotherapy to see if it will shrink enough for a hysterectomy. If nothing can be done, she too will be prescribed palliative care.

“That’s the nature of the problem,” explains Dr Sam Meja after examining her. “People are not screened early enough.

“We miss a lot of opportunities for screening. By the time we pick them up, they already have symptoms. We should have picked them up much, much earlier.”

Half of the women diagnosed with cervical cancer at this centre run by the medical charity Doctors without Borders are already too late to be treated.

Malawi reports around 51.5 cervical cancer deaths per 100,000 people each year. That rate is twice that of the surrounding region and seven times the global rate. Cervical cancer is the most common type among women in the country, accounting for around four in 10 cancers.

Stalled vaccinations

The tragedy of Malawi’s experience with cervical cancer is that it is easily preventable if girls are vaccinated at a young age.

More than 95 per cent of cervical cancer worldwide is due to persistent infection with the sexually-transmitted human papillomavirus (HPV), which most sexually active women and men will pick up at some point in their lives.

When offered at an early age to girls, typically 12 to 13, the HPV vaccine dramatically reduces cervical cancer rates later in life by almost 90 per cent, research suggests.

The scope to prevent the disease has been demonstrated in England, where nationwide vaccination against HPV began in 2008. A 2021 study in the Lancet journal estimated the programme had “successfully almost eliminated cervical cancer in women born since Sept 1, 1995”. Today, just 850 women die from the disease each year in the UK.

Malawi is lagging far behind with its own immunisation programme, which is hindered by a shortage of doses. HPV vaccine coverage sits at around 60 per cent in Blantyre, the country’s second largest city, and lower elsewhere.

Screening of those who have been vaccinated, usually carried out between the ages of 35 and 45, is also of poor quality.

Malawi’s alarming cervical cancer mortality rate is further explained by the high prevalence of HIV within the population, with nearly 10 per cent of adults infected by the virus.

HIV weakens a patient’s immune system, meaning they are less likely to clear a HPV infection, which then lingers in the body and, over decades, can lead to precancerous lesions. If these are not identified and treated, cervical cancer will eventually develop.

Indeed, women living with HIV are six times more likely to develop cervical cancer than those without. Cervical cancer normally takes 15 to 20 years to develop in women with normal immune systems, but only five to 10 years in women with weakened immune systems.

Some of the key tools used against the disease in richer nations, beyond vaccines, are also not available in Malawi. Pap smear tests used for screening cannot be conducted because of a lack of labs and staff, while radiotherapy is not available, even though it is considered the “gold standard” for treatment in Europe.

Inadequate health services are similarly hindering efforts to tackle cervical cancer. Women who do go to doctors with symptoms are often misdiagnosed with STDs.

Médecins Sans Frontières (MSF), also known as Doctors Without Borders, treats cervical cancer patients living across southern Malawi, as well as running screening services.

Such cancer treatment is rarely conducted by aid agencies, but that is likely to change in the future, MSF predicts. 

As poorer countries make progress against childhood and infectious diseases and life expectancies and living standards increase, they are likely to need more help treating chronic degenerative and lifestyle diseases, such as cancer.

Marion Péchayre, MSF’s Malawi chief, says: “Cancer is going to become a major problem, even in countries like Malawi.

“Cancer care is highly technical, so it means these countries won't have access to a good level of care, so the gap between these countries and others will be massive.”

The Malawian surgeons at Blantyre hospital’s cervical cancer unit must conduct so many hysterectomies that their skills have now surpassed those of the French doctors who trained them, says MSF.

Part of the charity’s plan is to improve screening.

Outside Blantyre, a white lorry rocks and jolts down a dirt road before coming to a halt outside an austere health centre.

As some nurses set up a consultation room in the back of the lorry, others crank up the pop music and begin hailing residents on a loud speaker.

Little by little, women arrive out of the maize fields and forest with babies bound to their backs.

Soon a couple of dozen are waiting to be checked in the mobile screening lorry, but the young women are obviously hesitant. They admit they have heard rumours that the screening will be painful, or intrusive. The screening team reassures the women and jokes with them to help overcome their misconceptions.

With pap smears not available, screening relies on visual inspections by trained health workers. Acetic acid is placed on the uterus and after a minute or so, lesions become visible. Yet, the technique is far from perfect.

“It has a very low sensitivity, so it means it's very operator dependent,” explains Sylvie Goossens, a cervical cancer project coordinator for MSF. “One nurse will say it’s positive, another nurse will say it’s negative. So it’s not a very good test.”

A new study being conducted from May will try to improve the accuracy. Firstly women will be tested to see if they have HPV infection. Health workers will also be given a smartphone app which will use artificial intelligence and machine learning from a database of thousands of cases and images to help them better identify precancerous lesions.

The technique should enable screening teams to spot more cancers in their early stages.

The Word Health Organization's three-part strategy for eliminating cervical cancer aims to make sure 90 per cent of girls are given HPV vaccine before they are 15. Then, 70 per cent of women are given good quality screening at the ages of 35 and 45, and finally 90 per cent of women with cancer get treatment.

Hitting those targets would avert 74 million cases and 62 million deaths in low and middle income countries, the WHO calculates.

Yet even if such benchmarks are reached, modelling has predicted that while millions of lives would soon be saved, it would still take a century for the disease to be eradicated from the global population.

In the meantime, MSF field workers, such as Wilfred Khhambule, try to provide comfort and pain relief to women like Mrs Satheka who are beyond treatment.

“For many of these women it’s no longer about drugs,” he says, “it’s about giving our time so that they can talk and that's a relief for them.”

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