Written by Matt Fisher
Announced in mid-September at the “Summit to Save Lives,” hosted by the George W. Bush Institute1, the Pink Ribbon Red Ribbon (PRRR) initiative aims to leverage the public health infrastructure established through the President’s Emergency Plan for AIDS Relief (PEPFAR) with new public and private investments to make progress in the early detection and treatment of cervical and breast cancer in the developing world. The initiative’s name highlights its linkage of cancer and HIV/AIDS programs: pink ribbons have traditionally denoted support for breast cancer research and awareness, and red ribbons have signified support for HIV/AIDS research and awareness.
A Bipartisan, Public-Private Effort
PRRR is the first large-scale proposal launched by the Bush Institute, and the first major post-presidential initiative of the institute’s namesake. Building on the PEPFAR’s success in reducing HIV/AIDS in Africa, PRRR is driven by the recognition that “it’s not enough to save a woman from AIDS, if she is then left to die of another very preventable disease.”
The effort involves a variety of partners: the Office of the U.S. Global AIDS Coordinator, the Susan G. Komen for the Cure Foundation, the Joint United Nations Program on HIV/AIDS (UNAIDS), and corporate donors Merck, Becton Dickinson, Bristol-Myers Squibb, QIAGEN, Caris Foundation, GlaxoSmithKline, and IBM. With initial commitments of $75 million over five years – $30 million in new PEPFAR funds and $45 million in corporate donations – the initiative aims to save hundreds of thousands of women in the developing world from premature deaths each year.
This initiative is groundbreaking in several respects: it spans the Bush and Obama administrations; links HIV and maternal and child health priorities with non-communicable disease priorities; creatively combines public and private resources; and signals growing consensus that concerted action must be taken to address cervical and breast cancer in low-income countries. As global health priorities confront fiscal realities in the U.S., PRRR’s public-private model may serve as a useful template for future health initiatives.
Addressing an Urgent Need
Although the number of deaths from breast and cervical cancer has declined in the U.S. in recent decades partly due to enhanced screening and treatment efforts, the number of deaths from these cancers is increasing in the developing world. This situation requires action; “today the majority of women in Sub-Saharan Africa do not have access to critical breast and cervical cancer screening and treatment services,” according to Amb. Nancy G. Brinker, founder and CEO of Susan G. Komen for the Cure. Many breast and cervical cancer cases are detected too late, after the cancers have developed past the point where treatment options are available.
At the “Summit to Save Lives,” former President George W. Bush, Secretary of State Hillary Clinton, and former Secretary of State Condoleezza Rice all argued that it is morally unacceptable for the U.S. to stand-by in the face of on-going, preventable suffering. Former Secretary of State Rice elaborated on this theme in her keynote address, noting that U.S. policy should recognize that “every life is precious, that every individual has potential, and that any person left without the access to education, to health care, and to freedom, is a world that we, as Americans, cannot tolerate.”
The speakers also made the strategic case for these investments. As noted by former first lady Laura Bush, “it’s important for our national security to make sure that people don’t think we’re just standing by while everyone across Africa is dying of something that is treatable or is preventable.” Secretary Clinton highlighted the critical role that women play in ensuring the healthy functioning of their families, communities, and societies more broadly. Former Secretary Rice urged Americans to “never forget the premise that our own security is linked to the well-being of others, and let us never forget, too, that out of chaos comes danger.”
Responding to Cervical Cancer
Cervical cancer is responsible for over 242,000 deaths annually in the developing world. Infection with genital human papillomavirus (HPV) is the “most common cause of cervical cancer.” Women who are HIV-positive are uniquely susceptible to contracting cervical cancer; HIV-weakened immune systems increase the risk of infection from HPV.
PEPFAR has already made tremendous strides in improving public health systems in focal partner countries and expanding care and prevention services for HIV/AIDS. Some PEPFAR funds have already been devoted to cervical cancer screening and treatment efforts, as PEPFAR “began setting up clinics to screen and treat women for cervical cancer in 2005, and the services are now offered at about 250 sites in 11 countries... $4 million of the AIDS-relief plan's annual budget goes to fund the effort.”
PRRR aims to expand upon these cervical cancer prevention efforts by dedicating more resources to them. As explained by Eric Bing, director of global health at the George W. Bush Institute, PRRR’s “goal is to reduce deaths from cervical cancer by an estimated 25% among women vaccinated, screened and treated through the initiative, significantly increase access to cervical cancer prevention, diagnosis and treatment … and create innovative models that can be scaled up and used globally.” Simple, cost-effective procedures for screening and treating cervical cancer are available. One such procedure involves a health worker using vinegar to make pre-cancerous lesions visible and then, if any lesions are found, using liquid nitrogen to freeze the cancerous cells off. By requiring a single visit for screening and treatment, this approach can overcome various obstacles to treatment in low-income countries that methods that necessitate a follow-up visit present: a woman’s inability to spend extended periods of time away from home and the lack of transportation to health clinics.
Beyond these efforts, corporate partners committed to providing vaccines – Gardasil (from Merck) and Cervarix (from GlaxoSmithKline) – to help protect young girls from contracting HPV. Merck’s commitment to provide vaccines to low-income nations is similar to an earlier pledge that the company made; in 2011, Merck drastically reduced the price of Gardasil in advance of the Global Alliance for Vaccines and Immunization (GAVI) Pledging Conference. That said, PRRR “doesn't call for vaccination yet, but instead will focus on screening and treatment.”
Increasing Breast Cancer Awareness
PRRR also aims to deal with breast cancer in developing nations, which is responsible for over 269,000 deaths annually. To that end, PRRR will implement programs to increase breast cancer awareness and education. This effort complements breast cancer awareness programs that were launched during the Bush administration: the U.S.-Middle East Partnership for Breast Cancer Awareness and Research and the Partnership for Breast Cancer Awareness and Research of the Americas. The effort also builds on the 2008 and 2011 Breast Cancer Global Congresses, which were designed to bring together public health experts and breast cancer advocates from throughout the world to share best practices for treating, screening, and raising awareness of the cancer. The congresses were organized, in part, by the State Department.
State Department participation in the breast cancer component of PRRR will be more limited than its participation in activities to reduce cervical cancer rates. No PEPFAR funds will be used to directly support breast cancer reduction initiatives; the cancer has not been linked to HIV, and therefore falls outside of PEPFAR’s mandate. Despite this limitation, PRRR partners will be able to utilize PEPFAR platforms to train health workers to raise breast cancer awareness and educate women about the importance of giving themselves regular breast exams.
U.S. global health initiatives have traditionally concentrated on women during their childbearing age by supporting reproductive health and family planning programs. This may negatively impact the participation rate of older women in cervical cancer screenings, as the outreach effort may not target them. Successfully targeting older women for cervical cancer screening is vital to ensuring the PRRR initiative reaches its goals; although HPV is often contracted by sexually active women during their teenage years and in their early 20s, “the risk of precursor lesions is highest among women in their thirties and forties, cervical cancer itself occurs most commonly among women in their forties and fifties.” A WHO study on cervical cancer screening participation confirms that older women have been found to be less responsive to cervical cancer outreach than younger populations. This suggests that the PRRR should incorporate messages that are targeted at older women.” In addition, the stigma associated with gynecologic examinations and cervical cancer’s link to sexual activity may impede screening efforts in low-income countries.
In the event that PRRR makes substantial gains in detecting cases of cervical cancer, it remains to be seen what treatment options could be provided for women with advanced cases of the disease. Moreover, “Clinicians in the developing world will be able to do less for patients at risk for breast cancer,” as “the infrastructure [for treatment] isn’t there.” Specifically, “breast cancer treatment such as chemotherapy and surgery… capabilities are not widely available.” Therefore, while PRRR may effectively raise awareness of the need for early detection of breast and cervical cancer, women with advanced cases of these diseases may not have sufficient treatment options available.
Aware of the challenges, Liz Thompson, president of Susan G. Komen for the Cure, emphasized that, “we have to start somewhere—we can't wait until we have all the pieces together.” Pink Ribbon Red Ribbon has the potential to dramatically advance the health of women in the developing world, and, for that, the initiative deserves praise.
1.The George W. Bush Institute aims at being an “action-oriented think tank ” that is connected to the George W. Bush Presidential Center.