key: cord-0762162-cvi0ga8t
authors: Lodge, Mark
title: The role of the Commonwealth in the wider cancer control agenda
date: 2020-06-29
journal: Lancet Oncol
DOI: 10.1016/s1470-2045(20)30222-9
sha: bed1b636e64baeee652bdc76be439feedbeb0099
doc_id: 762162
cord_uid: cvi0ga8t

nan

The core purpose of the Commonwealth was affirmed by the Commonwealth Heads of Government Meeting (Port of Spain, Trinidad and Tobago) in November, 2009: "We reaffirm our belief in the Commonwealth as a voluntary association of sovereign independent states whose pursuit of common principles continues to influence international society to the benefit of all." 2 It has long been the view of the Head of the Commonwealth that "The Commonwealth is not an organisation with a mission. It is rather an opportunity for its people to work together to achieve practical solutions to problems." 3 Where does this view leave population health care? Traditionally, this issue is low on the Commonwealth's list of priorities. Access to health and education was ranked 10th of 12 core values listed in the 2009 affirmation. 2 The influential 2011 report by the Commonwealth Eminent Persons Group to the Commonwealth heads of government provides further discouragement. 3 References to non-communicable diseases in this report are so brief that they can be quoted in full: "Health Ministers have rightly acknowledged the rise of noncommunicable diseases in the Commonwealth and the importance of programmes to address this growing problem. We support fully this heightened attention. However, a disturbing report compiled by the United Nations Development Programme (UNDP) in respect of HIV/AIDS was presented to us. This report points out that many of the countries of the Commonwealth are facing acute and urgent challenges from the HIV epidemic, making it a very specific Commonwealth problem… This should not minimise the many other valid health priorities of member governments, notably child health, maternal mortality, and the impact of other communicable and non-communicable diseases." Unsurprisingly, all five recommendations (R57-R61) that concluded the health section of the report related solely to HIV or AIDS. The contest here is not between advocacy based on eminence or on evidence (although more could be said on that account) but between the response displayed by governments to the acute threat presented to their health security by outbreaks of communicable disease, compared with that of chronic non-communicable disease.

Not all cancers fit into the non-communicable disease category: 25% of cancers in low-income and middleincome countries are linked to infection or parasites. 4 In 2018, more than 425 000 women in the Commonwealth were living with cervical cancer, which is closely linked to infection by the human papillomavirus, and 13 women died from the disease every hour. By 2030, annually, the Commonwealth will have 265 627 new cases of cervical cancer (representing 38% of the projected global incidence) and 168 012 deaths from the disease (42% of predicted global mortality). 1 Since 2016, the Commonwealth Secretariat has been under increasing pressure to bring the issue of the rising incidence and mortality from cervical cancer to the attention of Commonwealth ministers. 5 Simultaneous with the call from the WHO Director-General for the elimination of cervical cancer as a public health problem, the case for collective Commonwealth action on cervical cancer was discussed at the Commonwealth Health Ministers Meeting in May, 2018. 6 Since 2018, under the supervision of the Commonwealth Secretary-General, Baroness Scotland, the Commonwealth's Secretariat has worked to build a database of information about vaccine costs and availability that will enable the Commonwealth to use pooled procurement to make these lifesaving drugs more affordable to its member countries. However, facilitating access to vaccines and screening will not be sufficient. Community education and social mobilisation are essential components of the comprehensive approach to prevention of cervical cancer recommended by WHO. 7 90% of deaths from cervical cancer occur in low-income and middle-income countries, 7 where ignorance, superstition, and stigma (particularly relating to women with cancer) are major drivers for late presentation. The Commonwealth represents potentially the world's richest source of research evidence in terms of genomic and topographical heterogeneity. The construction of an accessible online knowledge base of the cancer control research conducted within the Commonwealth is under active consideration by the Commonwealth Secretariat. Gathering up this crucial information and making it more accessible to health professionals, community groups, and the media will be as important to the campaign to eliminate cervical cancer as providing access to human papillomavirus vaccines. Until this information becomes accessible, ignorance about cancer and the forms of cancer care that are available will continue to prevail in low-income and middleincome countries. It is sobering to find the alarming and hypocritical reality of so-called prayer camps and other centres run for profit in a Commonwealth country, where the faith of people with cancer is taken advantage of and people with mental illness are kept in chains. 8 Traditional beliefs often ignore research and can be a source of female oppression and exploitation, which the Commonwealth is yet to address.

Progress in cancer control has generally been slow in many of the low-income and middle-income Commonwealth countries and there are many rumours as to the reason why the Commonwealth has hitherto not acted in a collective fashion to address the growing threat of the disease. Historically, there have been concerns that its Secretariat risked duplicating work done elsewhere; in this case, by WHO. 3 However, this fear is unfounded: WHO's principal role is to inform, to extol, and to warn, whereas the Commonwealth's role is to encourage and facilitate. Whereas work has been published by the Commonwealth on the challenge of sustainable development in an era of climate change (most notably in the small island states 9 ), at the same time the Commonwealth Secretariat's establishment for health and education has been drastically downsized and the resources diverted into concept programmes. Such a revision is antithetical to the Commonwealth's core values and harmful to its populations. Few things are more dangerous to democracy and to human rights than a poorly educated electorate. Cervical cancer, although widely regarded as the easiest cancer to prevent, cannot be eliminated through the means of sport, youth, and gender initiatives, which have taken priority over health and education initiatives.

Health is a human right and governments are responsible for the health of their populations. 10 More than 7 million Commonwealth citizens are living with cancer and a new case of the disease occurs somewhere in the Commonwealth every 10 seconds. 1 The prevention and downstaging of cervical cancers by vaccination, early detection (through screening), excision of premalignant lesions, and the early diagnosis and treatment of tumours are achievable goals for the Commonwealth. In countries transitioning from mostly communicable disease to mostly non-communicable diseases, cancer prevention and treatment will require buy-in from, and political oversight at, the top levels of government. The time has come for the Commonwealth to elevate the issue of Commonwealth collective action against cervical cancer to the agenda of the Commonwealth Heads of Government Meeting. However, even then, the outcome will be uncertain. The preparations for the postponed Commonwealth Heads of Government Meeting will be made in the shadow of the ongoing threat of 2019 novel coronavirus disease (COVID-19). There is a depressing possibility that, once the COVID-19 pandemic has abated, noncommunicable diseases will still be waiting in the office in-trays of Commonwealth ministers of health, rather than on the desks of their prime ministers, where they belong.

The Commonwealth is wise not to have tied itself to a fixed mission statement. Kamalesh Sharma, a previous Commonwealth Secretary, observed that "By adopting a pragmatic and responsive approach rather than a prescriptive or rigid one, it is able to adapt to the rapidly changing context in which it operates." 3 In the past, such flexibility has provided resilience. Now, the challenges of the 21st century require the Commonwealth to reassess its priority values. Populations, linked closely by social media, are increasingly expecting their governments to be both caring and competent. The values of access to affordable health care and universal education, and the careful stewardship of the planet and its resources, need to be placed on an equal footing with the patrician values of democracy, rule of law, and respect for human rights, as eligibility criteria for Commonwealth membership.

Commonwealth prime ministers should note that cancer has a way of affecting everyone at some point in their lives. The question of how to respond to the global call to eliminate cervical cancer represents a crossroads for both the Commonwealth Heads of Government Meeting attendees and for the Commonwealth as an association. Just as much as COVID-19, the elimination of cervical cancer will require an informed response by all of government, albeit of a different nature. The Commonwealth has an important role to play by supporting its member governments through facilitating pooled procurement and knowledge transfer, and by encouraging training partnerships in cancer control between countries within its association. I report personal fees from the Commonwealth Secretariat, outside of the submitted work.

International Network for Cancer Treatment and Research, Oxford OX2 7HT, UK

Global cancer observatory: cancer tomorrow. Lyon: International Agency for Research on Cancer

A Commonwealth of the people: time for urgent reform. The report of the Eminent Persons Group to Commonwealth heads of government

Open letter to Lady Scotland

A sustainable future for small states: Pacific 2050. London: Commonwealth Secretariat

International Conference on Primary Health Care. Declaration of Alma-Ata

Commonwealth Heads of Government Meeting, Port of Spain, Trinidad and Tobago: declarations and statements

Ghana's mental health patients confined to prayer camps