Cervical cancer silently claims lives
In a patriarchal society, where women’s reproductive health is a hushed affair, the secondary socialisation of young women encourages them to silently endure the suffering that comes with having a womb since physical pain is considered a normal aspect of womanhood. Abiding by this unspoken expectation of stoicism, adolescent girls enduring severe menstrual cramping might miss out on a few days of school; however, for women unknowingly battling cervical cancer, the decision to choose shame over survival often costs them their lives.
According to the World Health Organisation (WHO), cervical cancer, which develops at the cervix or entrance to the uterus, is the fourth most common cancer among women. The primary cause of cervical cancer is persistent infection from the high-risk variants of the human papillomavirus (HPV) transmitted through sexual contact. In 2022, an estimated 660,000 women were diagnosed with cervical cancer worldwide, while nearly 350,000 women died from the disease.
The situation in Pakistan is even more worrisome. Data obtained from the HPV Information Centre revealed that cervical cancer is the second most common cancer among women between 15 and 44 years of age in the country. Each year, more than 5,000 women are diagnosed with cervical cancer in Pakistan, out of which at least 3,000 succumb to the disease. Alarmingly, the mortality rate for cervical cancer is between 60 to 85 per cent in Pakistan, which is significantly higher than the expected mortality rate of 45 per cent.
According to the Cancer Council, precancerous changes in cervical cells rarely cause symptoms; therefore, cervical screenings are the only way to identify abnormal cells. In case the malignant cells escape timely diagnosis, they may develop into cervical cancer, causing the patient to experience a myriad of symptoms, including bleeding between periods, heavy menstrual bleeding, pain or bleeding during intercourse, bleeding after menopause, pelvic pain, or unusual discharge.
“At least 80 per cent of cases of cervical cancer are caused by HPV, which is a sexually transmitted virus. Sexually active reproductive-aged women should undergo cervical cancer screenings once every three years. However, in our country, neither the female patients nor the healthcare providers know their importance. Since the detection of HPV does not happen in time through regular pap smears, women battling cervical cancer succumb to the illness,” explained Dr Malahat Mansoor, Head of Obstetrics and Gynaecology at the Sahara Medical College.
Culture of neglect
A factory supplying a few hundred loaves of bread would judiciously invest in regularly maintaining its ovens even when the baking apparatus is not operational. Ironically, in a country with an annual birth rate of millions, women’s bodies have less value than commercial machinery.
From puberty to menopause, women’s child-bearing phase lasts nearly four to five decades. However, when society extensively views women as little more than vessels for carrying life, the female reproductive organs are deemed worthy of receiving medical attention only during the nine-odd months when they are serving their “true” purpose. The vessel may crack, bleed, or shatter in the remaining years, yet nobody would ever know since objects cannot convey pain. Given such unabashed objectification of the womb, perhaps it is no surprise that cervical cancer continues to silently claim the lives of thousands of women across the country.
“Most women only visit the gynaecologist during pregnancy since that is the only time families prioritise their health. However, the detection of cervical cancer during pregnancy is difficult. Even today, women do not visit a gynaecologist for regular checkups, while general practitioners and gynecologists do not emphasize the importance of cervical screening. Hence, doctors have no data or records available on cervical cancer and its actual prevalence,” noted Dr Mansoor.
According to the results of a study published by the Pakistan Development Review, nearly 50 to 80 per cent of married women between the ages of 15-49 years refrain from seeking medical help for a variety of reproductive tract issues, including abnormal discharge, lower pelvic pain, irregular or painful menstruation, painful urination, and discomfort or bleeding during intercourse. Shockingly, of all the women who ignored their gynecological complaints, a significant percentage felt that the symptoms, especially those involving pain, which are often associated with cervical cancer, were a “normal” part of womanhood.
In their book titled “Outrageous Practices: How Gender Bias Threatens Women’s Health,” Leslie Laurence and Beth Weinhouse highlighted the subtle ways in which the cultural disregard of women’s suffering during various life stages, including menstruation, pregnancy, and childbirth desensitised them to the point where they no longer identified pain as a sign of a serious physical ailment. Hence, as compared to men, women were more likely to ignore severe pain and wait for it to go away.
Expanding on the culture of neglect prevalent among women in Pakistan, Dr Uzma Ashiq Khan, Assistant Professor of Gender Studies at the Lahore College for Women University (LCWU), felt that although lack of awareness and affordability contributed significantly to women’s poor access to reproductive healthcare, the stigma attached to women’s health led families to ignore reproductive issues intentionally. “As a result, women often turn to traditional medicine or hearsay for addressing gynecological issues, which can lead to further complications,” noted Dr Khan.
Tabooed transmission
Being a sexually transmitted disease, the human papillomavirus (HPV) can transfer between people through a range of sexual contacts. However, regardless of whether a woman herself was involved in an illicit union or was ill-fatedly married to an unfaithful partner, the brunt of the encounter is borne single-handedly by the partner with a cervix.
“In my locality, I have observed that a significant percentage of men who work overseas are involved in extramarital affairs. When they return home, they transmit the HPV infection to their wives, who end up with cervical cancer,” revealed Dr Mansoor.
On the other hand, Dr Basmaa Ali, Resident Scientist at the Lahore University of Management Sciences (LUMS), revealed that premarital sex, too, had become very common in Pakistan. “Given the tabooed nature of the topic, unmarried women engaged in sexual activity are often unaware of sexually transmitted diseases and the need for barrier protection. The spread of HPV is a concern, particularly among women between the age they become sexually active and the age of 35,” noted Dr Ali.
However, according to research published by the Annals of Medicine and Surgery, testing for cervical cancer is relatively low among women in Pakistan due to a lack of awareness, fear and embarrassment, misconceptions about screening, stigma around sexual health, and lack of family support.
Interestingly, although premarital sex, despite its stigmatised nature, has increasingly emerged as a social concern, cervical cancer screening, recommended for all sexually active women, is reserved for married women only. As a result, single women engaged in sexual activity, who are perhaps most prone to acquiring HPV, are systemically denied screening.
“In our society, we normally conflate sexual activity with marriage. Therefore, pap smears are not offered to unmarried women since, in our culture, doctors find it offensive to inquire a never-married woman about her sexual history. Unless the patient herself talks to the doctor, we never ask,” explained Dr Mansoor.
In light of such cultural biases, Dr Ali felt that to curtail the incidence of cervical cancer, disseminating information on safe sex was the need of the hour. “We need to engage young women in conversations highlighting the benefits of abstinence, which will save them from a bunch of trouble, including unwanted pregnancy and HPV. All you need to get HPV is one unprotected sexual encounter with a partner who simultaneously has had many other sexual partners,” informed Dr Ali.
Global action, local inaction
According to the WHO’s Global Action Plan for the elimination of cervical cancer as a public health problem, low to middle-income countries (LMICs) must follow the 90-70-90 target to reduce the incidence of cervical cancer by 2030.
Under this target, 90 per cent of girls must be fully vaccinated with the HPV vaccine by the age of 15, 70 per cent of women should be screened with a high-performance test by the age of 35 and 45, and 90 per cent of women identified with cervical disease, including those with precancer and invasive cancer, must receive treatment.
While developed countries have nearly eliminated cervical cancer, several developing countries across the economic spectrum have announced comprehensive national plans to combat cervical cancer among their local populations.
For instance, in the United Arab Emirates, the Ministry of Health and Prevention (MoHAP) has aimed to vaccinate 90 per cent of girls aged 13-14 by 2030 while ensuring early screening for cervical cancer starting at age 25 and international standard treatment for diagnosed patients. In 2018, the UAE became the first country in the Eastern Mediterranean region to introduce the HPV vaccine in its national immunisation programme. In 2022, neighbouring India, which currently reports one cervical cancer death every seven minutes, manufactured its vaccine against HPV, known as Cervavac. India, too, plans to introduce the vaccine in its immunisation programme.
The best example for Pakistan to study is Rwanda, which was one of the first developing countries to launch an HPV vaccination drive for female adolescents under the age of 15 back in 2011. Interestingly, despite its status as a low-income country (LIC), good governance and a strong commitment to public health have allowed the government to maintain the ideal 90 per cent coverage. As a result of its timely action, just this year, Rwanda announced its aim to eliminate cervical cancer by 2027, three years ahead of the WHO target. Experts predict that Rwanda might be on its way to becoming the first country in the world to eliminate cervical cancer.
Pakistan, however, is far from reaching these goals even in the next one hundred years. According to a study published by the Journal of Clinical Laboratory Analysis, eight different subtypes of HPV have been identified among cervical cancer patients in Pakistan, with HPV 16 accounting for 80 per cent of all cases. However, the state has failed to address the serious need for widespread screening and vaccination.
Although the government has decided to launch a cervical cancer vaccination drive for girls aged 9 to 14 in September 2025, public health experts are not too optimistic about the success of the initiative, given the current abysmal state of the public healthcare system.
According to Dr Basmaa Ali, a Clinical Instructor in Internal Medicine at Harvard Medical School, the data on the HPV vaccine, also known as Gardasil, show that it works on the HPV variant present in the Western population.
“From a scientific perspective, introducing the vaccine makes sense. However, realistically speaking, to date, we have failed to offer mammography to women in the country and even administer the polio vaccine to a sizeable population. Therefore, it is unreasonable to think that in the current situation, without improving the existing healthcare system, the government can administer the Gardasil vaccine to a sizeable population of young girls to the extent that pap smears are no longer required,” opined Dr Ali.
On the other hand, Dr Mansoor revealed that even in the private sector, the availability and affordability of the HPV vaccine were significant hindrances. “First of all, the availability of the HPV vaccine is a challenge since import and export barriers have halted the supply of several vaccines. Even when the vaccine is available in Pakistan, its cost is between Rs12,000 and Rs17,000, which is not affordable for the local population. Moreover, the majority of doctors do not have knowledge or information regarding the cervical cancer vaccine. Most importantly, the HPV vaccine only offers protection against a few strains of HPV; hence, it does not guarantee 100 per cent protection. Therefore, screening is still mandatory for battling cervical cancer,” urged Dr Mansoor.
The way forward
Although the elimination of cervical cancer is not possible without developing a national long-term strategy for achieving the vaccination and treatment targets, the current strain on the country’s public healthcare system necessitates the adoption of a short-term plan for curtailing the spread of HPV by raising awareness on safe sex and abstinence.
“Even though condoms can offer a barrier, they are not 100 percent safe; therefore, young women should abstain from premarital sex. While premarital sex has increased among the youth, cultural and religious principles that discourage the practice and emphasise its negative consequences still hold. Therefore, the government must adopt a holistic approach to tackling cervical cancer by creating accessible content on body literacy, which can talk about abstinence, safe sex, and sexually transmitted diseases in a very gentle manner. Simultaneously, pap smears should be encouraged among women, and introducing the vaccine could also be a good decision,” noted Dr Ali.
On the other hand, Dr Khan stressed the importance of educating men on women’s health issues since she believed this could have a positive impact on reducing cases of cervical cancer. “Whenever you want to bring about change in a patriarchal society, you have to sensitize the dominant gender, which is in power. Therefore, society should include men in these discussions as facilitators to encourage a positive development of masculinity. Furthermore, the government should mobilize the media and influential figures like celebrities and bloggers to spread awareness on such issues,” implored Dr Khan.
Similarly, Dr Mansoor also felt that the mainstream media, as well as social media, could play a part in spreading awareness of cervical cancer. “The government should also use television programs and short-form content through social media reels to disseminate information. People should know that cervical cancer is a preventable cancer. If we as a society work on tackling its spread and facilitating its diagnosis, we can save our women’s lives,” urged Dr Mansoor.
All facts and information are the sole responsibility of the writer