Project:Screen South AfricaBryan Knight, M.B., Ch.B., M.Med.(Path.), Ph.D., F.I.A.C.

In South Africa, carcinoma of the cervix affects 1 in 29 women.A national screening programme to address the problem hasbeen implemented. The programme faces serious challengesincluding shortage of funds, a lack of trained laboratory person-nel and the HIV epidemic. Diagn. Cytopathol. 2005;33:356–358. ' 2005 Wiley-Liss, Inc.

Key Words: carcinoma; cervix; screening; South Africa

‘‘South Africa, a world in one country’’ was the slogan

used by SATOUR, a paragovernmental organization that

promoted tourism in South Africa for many years, and

quite right they were. However, this magnificent country

with huge potential faces health issues of monumental

proportion. This seminar expresses the very personal

views of a cytopathologist who until recently worked in

South Africa.

Cervical Carcinoma in South Africa

The National Cancer Registry in South Africa reports the

incidence of histologically proven malignancies. In 2003,

the registry compared the incidence of squamous carci-

noma of the uterine cervix in women of different races,

as reported in 1997.1 The incidence in white women was

about 18 per 100,000. For many years, white women have

been generally well screened for carcinoma by means of

Pap smears. On the other hand, black women, who as a

group have not been adequately screened, suffer a much

higher incidence of carcinoma, 37 per 100,000. Overall,

in South Africa about 30 per 100,000 women present with

invasive squamous carcinoma, and 1 of 29 women (up to

74 yr) run a lifetime risk of developing cervical carci-

noma.1 These figures are compared with the incidence of

cervical carcinoma in women in the USA of 8 per

100,000.1

The South African National CancerControl Programme 1999

In 1999, the South African government announced a

national cancer control programme as part of the new

national health policy. A national cervical screening pro-

gramme was launched in 2001, as part of the cancer control

programme. After years of debate and soul searching, a

panel of local experts advised the government to take a

compromise position setting aside the ideal screening pro-

gramme and accepting the best possible affordable and

practical solution (the author’s personal observation). Most

of the panelists recognized that the final proposal fell short

of the standards and norms set in the western world.

The aim of the programme was to screen asymptomatic

women over the age of 30 yr three times in their lifetime,

at intervals of 10 yr. It was hoped to achieve a 70% pene-

tration of the target population. Symptomatic women

would be treated as appropriate and would not be part of

the screening programme. The proposal was based largely

on the recommendations of the International Agency for

Research on Cancer (1986).2 This report noted that organ-

ized mass screening reduces the incidence of, and mortal-

ity due to, carcinoma of the cervix. In the report, calcula-

tions showed that the incidence of cervical cancer could

be reduced by 65%, if 100% of women were screened at

intervals of 10 yr between 35 and 65 yr. The report con-

tended that the target age of the population to be screened

was a more important factor than the frequency of screen-

ing. Research in South Africa showed that the prevalence

of precursor squamous intra-epithelial lesions (SIL) was

highest in women in their late 30s.3,4

The Implementation of a National CervicalScreening Programme: Are South AfricanCytology Laboratories up to the Challenge?

In South Africa, most women present in the late stages

of the disease. However, the intention of the screening

programme would be to find women with precursor

lesions, reducing the cost of medical management and

improving morbidity and mortality. However, of the nine

provinces in South Africa, only one (Gauteng) has so far

found the resources to introduce a limited screening pro-

gramme.5 A study to assess the capacity of the public

health sector laboratories has shown that there are signifi-

356 Diagnostic Cytopathology, Vol 33, No 5 # 2005 WILEY-LISS, INC.

University of Alberta, Edmonton, Alberta, CanadaDynacare Kasper Medical Laboratories, Edmonton, Alberta, CanadaCorrespondence to: Bryan Knight, M.B., Ch.B., M.Med.(Path.), Ph.D.,

F.I.A.C., Dynacare Kasper Medical Laboratories, 10150–102 Street,Edmonton, Alberta T5J 5E2, Canada. E-mail: donna.schuurman@dkml.com

Received 28 July 2004; Accepted 26 August 2004DOI 10.1002/dc.20295Published online in Wiley InterScience (www.interscience.wiley.com)

cant requirements for more cytology-trained personnel, a

uniform reporting system with proper implementation of

the Bethesda System, and a computerized laboratory

information system to enable adequate record keeping,

follow-up of patients, and stringent quality assurance

mechanisms to monitor outcomes.5

Getting the Priorities Right: Other Health Problemsin South Africa

A visit to the web site of the South African Govern-

ment Department of Health (www.doh.gov.za) provides a

shattering perspective of the health issues facing the coun-

try. For example, the problem of HIV infection in South-

ern Africa is terrifying. Statistics from this web site reveal

that there are an estimated 2.2–2.4 million persons

infected with HIV in Sub-Saharan Africa6 (Fig. 1). The

same article estimates the number of HIV-infected per-

sons as follows: North America, 12,000–18,000; Carib-

bean, 30,000–50,000; Latin America, 49,000–70,000;

Western Europe, 2,600–3,400; North Africa and Middle

East, 35,000–50,000; Eastern Europe and Central Asia,

23,000–37,000; East Asia and Pacific, 32,000–58,000;

South and Southeast Asia, 330,000–590,000, and Aus-

tralia and New Zealand, less than 100.6

A matter of huge concern is the rising incidence of

HIV positivity in pregnant women in South Africa. The

South African Department of Health Statistics show that

in 1971 less than 1% of pregnant women were HIV-posi-

tive (Fig. 2). In 2002, 15% of pregnant women less than

20 yr, 29% of pregnant women aged 20–24, and 35% of

pregnant women aged 25–30 were HIV-positive. The inci-

dence in pregnant women older than this dropped slightly:

28% of pregnant women aged 30–34, 20% of pregnant

women aged 35–40, and 18% of pregnant women over 40

were HIV-positive. The incidence of tuberculosis in South

Africa is at higher levels in some communities than those

recorded ever before.7

Stop Arguing and Save Lives Exhorts ArchbishopTutu!

A report from the Cape Times newspaper7 in South

Africa recently ran the headline ‘‘Stop arguing and save

lives exhorts Archbishop Tutu!’’ In the report, the news-

paper quoted Archbishop Tutu as saying ‘‘Let’s get on

with the business of saving people’s lives.’’ The article

continues as follows: ‘‘This was the message from Angli-

can Archbishop Emeritus Desmond Tutu at a recent AIDS

panel discussion on Monday (2nd December 2003).

Speaking at the University of Cape Town on World AIDS

Day, Tutu lashed out at the government’s AIDS policy

before it (recently) changed to include a national antire-

troviral drug rollout.’’

The newspaper quotes the Archbishop further: ‘‘We

were engaging in futile discussions on what might cause

AIDS, while our people were dying like flies. A consider-

able amount of energy was dissipated in scoring points

against each other, which was contrary to the spirit of the

antiapartheid struggle.’’

At the same seminar, the Cape Times reports that the

Assistant Director-General at the World Health Organisa-

tion, Joy Phumaphi, said ‘‘The challenge is huge but it is

time to embrace it. Treatment is no longer an option. It is

part of prevention, of caring and support. It will help

break the stigma around HIV/AIDS as more people will

come forward to receive antiretrovirals, giving them the

opportunity to live.’’

In the same newspaper, a photograph shows a patient

receiving his free HIV medication for the first time at

Mitchell’s Plein Medical Centre, Cape Town, South Africa.

The life and times in South Africa are constantly changing.

Conclusion

South Africa presents a stark contrast between its mod-

ern sophisticated communities on one hand and the pov-

Fig. 1. The incidence of HIV infection in Africa (www.doh.gov.za).

Fig. 2. Incidence of HIV positivity in pregnant women attending antena-tal clinics in South Africa (www.doh.gov.za).

CERVICAL SCREENING PROGRAMME IN SOUTH AFRICA

Diagnostic Cytopathology, Vol 33, No 5 357

erty-stricken and uneducated masses on the other: a stark

contrast between the rich and the unscreened! These are

the personal observations of the author.

Acknowledgments

The author acknowledges Dr. Pam Michelow in Johannes-

burg, South Africa, and Professor Gladwyn Leiman in

Burlington, Vermont, USA, for their valuable input and

sharing some insights.

References

1. Mqoqi N, Kellett P, Madhoo J, Sitas F. SA Institute for MedicalResearch, National Cancer Registry of South Africa, Johannesburg, 2002.

2. Report of the International Agency for Research on Cancer, (WHO),New York, 1986.

3. Michelow PM, Wright CA, Mayer NT, Leiman G. Evaluation of theinterim cervical screening programme in the greater Johannesburgmetropolitan area. S Afr J Epidemiol Infect 1999;14:36–39.

4. Learmonth GM, Durcan CM, Beck JD. The changing incidence ofcervical intraepithelial neoplasia. S Afr Med J 1990;77:637–639.

5. Michelow P, Dubb M. ‘‘The implementation of a National CervicalScreening Programme: are South African Cytology Laboratories up tothe Challenge?’’ S Afr J Epidemiol Infect 2003;18:38–41.

6. ‘‘HIV Infection in Africa’’ and ‘‘HIV prevalence in pregnant womenat antenatal clinics in South Africa, by age group: 1991–2002.’’Available at www.doh.gov.za/facts/index.html

7. ‘‘Stop arguing and save lives exhorts Archbishop Tutu!’’ and ‘‘Thechallenge is huge but let’s embrace it.’’ The Cape Times, SouthAfrica, Dec 2, 2003.

KNIGHT

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