Waiting to die: Cervical cancer in America

Newly available HPV vaccines help prevent against cervical cancer in women [GALLO/GETTY]
New York, NY - Cervical cancer is a hotly-debated political topic in the United States right now - a debate fuelled largely by Republican presidential contenders. The cancer is caused by strains of the human papillomavirus (HPV), which is sexually transmitted. As a result, discourse on cervical cancer centres around whether or not newly available vaccines to prevent the disease encourage promiscuity.

This argument entirely misses the most scandalous fact about cervical cancer in the US: its geography. Where a woman lives in the US largely determines whether she will suffer from the disease - and whether she will die from it.

Every year 4,000 American women die from cervical cancer, most of them in the South.

Cervical cancer is extraordinarily slow-growing, taking 10-15 years for invasive cells to develop. Even without the vaccine, the cancer is completely preventable. Routine Pap tests that cost between $25 and $40 detect abnormal cells, and these cells can then be removed during a visit to a doctor's office. If all American women had these tests and received follow-up care as recommended, cervical cancer would go the way of small pox and polio in the US - eradicated.

But every year 4,000 American women die from the disease, most of them in the South. For instance, a woman in Mississippi is nearly twice as likely to die from cervical cancer as an average American woman.

Why?

The seemingly obvious answer is that Mississippi is the poorest state in the US, and therefore must have a lot of residents without health insurance. But when Mississippi is compared to a state like California, which has a similar rate of uninsured people, Mississippi's death rate from cervical cancer remains extraordinary: 75 per cent higher than that in California.

Again, why?

Safety net

The answer lies in where uninsured residents obtain their health care. About 15 per cent of Americans aren't poor enough to qualify for government-provided Medicaid health insurance, but aren't rich enough to buy private health insurance, which costs nearly $20,000 per year for a family of four. The federal government provides money to states to create a safety net to support the wellness of people who fall in these "holes" between health insurance programmes. The size of the holes largely depend on how wisely states and regions use their federal dollars.

A 41-year-old federal programme called Title X provides comprehensive family planning and other related preventative health services, largely for the uninsured. This year, the US is spending about $327m on Title X, which operates clinics in 75 per cent of US counties.

But these clinics do not provide uniform services for uniform prices in the way, for instance, McDonald's provides standard products at all of its locations around the world. Instead, the system is quite convoluted: 91 regional grantees contract some 4,400 local entities to operate Title X-funded clinics.

The only grantee in the state of Mississippi is the Mississippi State Department of Health, which uses most of its Title X funds to operate clinics. On the other hand, California's three Title X grantees are each privately-run non-profit organisations, by far the largest of which is Planned Parenthood.

I called 10 clinics in each state seeking cervical cancer screening. Not one of the Mississippi Health Clinic receptionists knew if her facility offered cervical cancer screening. They transferred me to the family planning sections of their clinics, where eventually I was told that each one did offer Pap tests. However, at all of the clinics, the first available appointments were at least three months away - one clinic explained that it was because their doctor only came on Tuesdays and the first and last Friday of each month.

When I asked about the cost of the test, all of the Mississippi clinics told me it would be based upon my income. I said I earned $16,000 a year, the approximate per-capita income in the state. Still, no one with whom I spoke in Mississippi could tell me the cost of the appointment, because "the computer figures it out when you come in".

"So I have to make an appointment for a test I might not be able to pay for?" I asked.

"Yes, ma'am," was the answer - over and over again.

The receptionist at every California clinic I called not only knew that his or her clinic offered cervical cancer screening, but at seven of the 10 clinics asked if I were experiencing "discharge or discomfort" - a symptom of pelvic infection or cancer. The longest wait for a non-emergency appointment was two weeks. As in Mississippi, when I asked how much the appointment would cost, I was told it would be based on my income. I told the California clinics that I earned $23,000 a year, the approximate per-capita income in that state. Every clinic told me that my appointment would be free.

Planned Parenthood is the only effective primary healthcare provider for the United States' 17 million uninsured women.

There are understandable reasons that the Mississippi Department of Health offers relatively poor cervical cancer screening services to their residents. The main one is that it is so busy doing so many other things, such as ensure safe drinking water, oversee the state's emergency medical services, monitor disease prevention, and maintain the state's birth, marriage, divorce and death records.

On the other hand, Planned Parenthood's primary focus is women’s health care. In fact, it is the US' largest provider of women's healthcare. It provides birth control, emergency contraception, pregnancy testing, sexually-transmitted infection treatment, breast exams and cervical cancer screening. One in five American women use Planned Parenthood at some point during their lifetime.

The reason I suspect that the organisation's service is good (most of the centres get a rating of four of five stars on the user-review site Yelp) is that, like most successful organisations, it focusses its time, energy and resources on a core business. Think Apple, Google and McDonald's.

So why don't all grantees in all states hire Planned Parenthood to provide their Title X services?

Because in addition to being the US' largest women's healthcare provider, Planned Parenthood is also America's largest abortion provider. In 2009, Planned Parenthood facilities terminated 332,278 pregnancies, accounting for about a quarter of all abortions in the US. So pro-life lawmakers will often not allow the organisation to offer Title X services in their states.

Planned Parenthood supporters point out that federal law has always required that no government funds be used to provide abortions. Opponents of the procedure counter that any money given to Planned Parenthood from Title X frees up more nonfederal funds to be used to perform abortions. Either way, what's indisputable is that Planned Parenthood is the only effective primary healthcare provider for the United States' 17 million uninsured women.

In February 2011, the US House of Representatives successfully passed a bill introduced by Congressman Mike Pence (R-Indiana) to completely eliminate Title X - and offered nothing in its place. Early next year, when the president releases his proposed budget for 2013, the same is expected to happen again - except that this time, in this campaign season of cost-cutting one-upmanship, the Senate might go along and really end the programme.

Americans have been mired in a literally murderous debate about abortion for more than a generation. The issue rends the country. As far into the future as anyone can imagine, there will be bills to restrict access, to redefine personhood and trials to establish permissible harassment of physicians and patients.

But no one, on either side of that issue, can possibly believe that the collateral damage should be the lives of innocent women who just need routine healthcare. Title X must continue to be funded and either Planned Parenthood clinics must open in the areas of the country that lack them, or other providers that specialise in high-quality, comprehensive women's healthcare need to step in. Immediately.

In the US, living among pro-life politicians should not be a death sentence.