Thursday, December 15, 2011

Male Circumcision and the Path to an AIDS-Free Generation: My Washington Post Op-Ed

On Tuesday, 14 December 2011, I published an opinion column about scaling up non-surgical voluntary male circumcision in the Washington Post, an American newspaper based in Washington DC. You can read my column below or here at the newspaper's website.

Male circumcision and the path to an AIDS-free generation

Agnes Binagwaho is the Minister of Health of the Republic of Rwanda and recipient of an honorary PhD in sciences from Dartmouth College for her lifetime achievement in treating and preventing AIDS.

We have an opportunity to lay the foundation for an AIDS-free generation, as Secretary of State Hillary Clinton declared on Nov. 8. Unfortunately, we’re trying to dig that foundation with a spoon when we have a shovel at our disposal.

We have the capacity to save nearly 4 million lives in sub-Saharan Africa, the hardest hit region in the world, by scaling up voluntary medical male circumcision — the best tool we have for HIV prevention. But the only method widely approved for funding is the surgical method, which is expensive and impractical for countries lacking physicians and surgical infrastructure.

Rwanda’s national goal is to decrease HIV incidence by 50 percent for boys ages 10 to 19 and 30 percent among men age 20 and older. It would take more than 12 years for Rwanda to achieve its national goal to offer voluntary medical male circumcision to the nation’s male population using formal, surgical procedures. We need to reach 2 million men in two years to benefit from the protective effect of the procedure in order to achieve this as part of a comprehensive, combination HIV prevention strategy.

We have clinically studied and approved PrePex, non-surgical device for voluntary adult male circumcision that requires no injected anesthesia. Over 50 percent of nearly 1,100 Rapid Male Circumcision (RMC) procedures were conducted by low-cadre nurses. Using this device, the out-patient circumcision procedure is safe, fast, bloodless and virtually painless. This device aligns with our national policy change, allowing for task-shifting of circumcision way from surgeons and family physicians to nurses and possibly even community health workers.

What’s more, whereas a surgical circumcision can take as long as 20 minutes per patient, this device reduces procedure time to a total of 1.5 minutes to place the device and 1.5 minutes to remove it, meaning we can circumcise more men faster and without compromising their safety or the device’s effectiveness. In fact, in our comparison study between the device and the surgical method, audited on site by WHO and USAID delegates, we found that this device is in fact safer than the surgical method.

Such simple solutions can be game-changers in the fight against HIV/AIDS. Public health officials set a goal to reach nearly 20 million men ages 15 to 49 by 2015, but in four years, Africa has reached less than 3 percent of its target goal. Research consistently proves that circumcised men reduce their risk of HIV infection by 60 percent. By scaling up circumcision to reach the at-risk population of adult men, we could avert millions of new infections and save billions of dollars in donor funds.

It is time to reinvent the vocabulary for what is possible, and I propose to start talking about RMC, Rapid Male Circumcision, because the device we studied can revolutionize our prevention toolkit in Africa. RMC is not a silver bullet but an extremely powerful tool when promoted in combination with other proven prevention strategies.

We need to be able to use every HIV prevention tool at our disposal, and I call on the international community to effectively support the scale up of Rapid Male Circumcision, through the more efficient non-surgical devices that will make the procedure possible in countries with fewer skilled health-care professionals and surgical infrastructure.

Such scalable solutions provide the clearest path to reaching short-term prevention goals, allowing us to continue efforts toward longer-term efforts to abolish the spread of HIV/AIDS for generations to come.


Mondays with the Minister #3: Malnutrition in Rwanda

On Monday 12 December 2011, I hosted the third consecutive “Mondays with the Minister” Twitter chat on the topic of malnutrition in Rwanda. For the first time, SMS was used in addition to Twitter. I recently partnered with a local company, Nyaruka, to integrate SMS into the bi-weekly discussions. Nyaruka moved fast to design a superb web platform where I can receive, respond to, and publicly display SMS messages. During this first Twitter/SMS Mondays with the Minister, approximately 40 people participated on Twitter, asking questions from across Rwanda and other countries in the region. Students and researchers interested in global health also joined from Europe and North America. 

We will be improving the publicity on the SMS portion of the discussion in coming weeks. Radio announcements and a Ministry of Health press release will help to publicize it more widely for future chats, allowing Rwandans across the country to contribute questions or comments about the chosen topic in the language of their choice (Kinyarwanda, English, or French) during the time frame of the discussion. Five total questions were contributed by SMS in English and Kinyarwanda this past Monday, and I look forward to seeing many more in future weeks.

This week’s discussion on malnutrition in Rwanda touched on current chronic malnutrition and anemia statistics in Rwanda, which remain very high. We discussed the state of the Ministry of Health’s response to malnutrition, and many Rwandans were interested in behavioral change communication efforts underway to promote balanced diets in addition to structural anti-poverty interventions (such as One Cow per Family, kitchen gardens, milk for students at school, and ubudehe) that seek to combat food insecurity at the community level. Others were interested in institutional collaborations to address malnutrition, public-private partnerships in Government programs, the linkages between nutrition and care for chronic diseases such as HIV and tuberculosis, oversight of UNHCR refugee camps, and the prevention of obesity as Rwanda’s economic growth continues. I asked what participants thought was the weakest part of the Ministry of Health’s response, and this led to an exchange about meeting the needs of vulnerable youth – particularly “street kids.”

All in all, the discussion was very interesting and informative for me as Minister of Health. As is the case with Rwanda’s Umushyikirano (National Day of Dialogue), it is so important for Rwandans to be able to communicate with their Government. In the Ministry of Health and throughout the central Government, we strive for transparency, accountability, and accessibility.

I’d like to thank again Nyaruka’s staff, especially Nic, Eugene, and Eric, for their hard work on creating this new platform. I appreciate this partnership and highly recommend them for other ICT for health initiatives. For all those interested, you can visit their company’s website at

My next “Mondays with the Minister” discussion on Twitter and SMS will be held on 9 January 2012 (time TBD). The topic will be vaccinations, and we will discuss the impact, delivery, and sustainability of vaccines in Rwanda. As a reminder, you can follow the discussion through my Twitter account @agnesbinagwaho and by searching for #MinisterMondays. You can also send a question or comment in Kinyarwanda, English, or French by SMS to 0788 38 66 55. SMS questions and my answers can be viewed online at I greatly look forward to our next discussion.

Sunday, December 11, 2011

Bringing Mondays with the Minister to Communities

As previously discussed on my blog, I recently began a series of online discussions through Twitter to allow Rwandans, colleagues, and partners around the world to discuss issues related to health policy. These chats, held on Monday afternoons twice per month, are entitled “Mondays with the Minister.” 

I believe that equitable access to information and participation in debates around public health issues is a right of all citizens of the world, and I particularly avail myself for my fellow Rwandan citizens. I find this access important in all aspects of the Ministry of Health’s work. I am grateful to the owner of the ICT company Nyaruka, who leads by the same principles and worked at no cost with me on this project in order to allow Rwandans to send questions and comments by SMS for the discussion. Because cell phone coverage in Rwanda is over 60%, and because each of the three community health workers per village have cell phones, all Rwandans should be able to contribute a question or comment if they wish. The owner of the ICT company Nyaruka also graciously proposed to make this access free forever, as far as it is for a program that shares the same goals of open communication for improving health. 

Mondays with the Minister discussions will be held every two weeks. The time of may change, but they will always last for two hours duration. 

The next Mondays with the Minister chat will be Monday, 12 December from 3:00 p.m. to 5:00 p.m. The topic for discussion and debate will be malnutrition in Rwanda and what the Ministry of Health is doing to address the problem. 

To join on Twitter, follow me on Twitter at @agnesbinagwaho. To join by SMS, send a message to 0788 38 66 55 between 3:00 p.m. and 5:00 p.m. And, if dialing from outside of Rwanda, please dial: +250 788 38 66 55. You can also see the questions submitted by SMS and their answers at I consider this and the Twitter forum to be a great opportunity for improving service delivery by incorporating the direct suggestions of the population, who are at the center of all decisions made by the Ministry of Health. I welcome your questions and look forward to productive and inclusive discussions!

Twitter: @agnesbinagwaho
SMS: 0788 38 66 55


Health, Human Rights, and Democracy in Rwanda

Below is my piece in the New Times published on 11 December 2011. You can click here to read the article on the New Times website

Health, Human Rights, and Democracy in Rwanda
By Dr. Agnes Binagwaho

Success in Rwanda’s health sector is due to the fact that the Government works as one in pursuit of an integrated and community-driven development process. This past year, I have read and listened to many great newspaper articles and speeches about Rwanda’s social and economic progress since 1994 that highlight the country’s unprecedented achievements but conclude with a single sentence or two that intends to make the reader or listener doubt all of these achievements.

Listening to such reflections on my country has caused me to reflect on a number of trends since my return to Rwanda in 1996. Still much needs to be done and as a nation and as a people, we have pursued with fierce urgency the integration of participatory democratic principles and equitable social policy to ensure that all Rwandans benefit from the process of development. We promote and strengthen our democracy by always engaging our people – Rwanda’s true wealth – in the formulation and implementation of policies for health, education, gender, youth, decentralization, financing, infrastructure and other.

In order to do so, the Government must apply an integrated and collaborative approach across all sectors. His Excellency Paul Kagame, the President of Rwanda, makes this quite clear when responding to a new policy proposal from a member of his Cabinet, asking first without fail: “What will this mean for the people, and how does it link to our poverty reduction and economic development strategy?” The evidence and results of such an approach can be seen at all levels, exemplified by a number of uniquely Rwandan approaches to the empowerment of our citizens.

One fine example of communities working together for national development is the monthly day ofUmuganda, a voluntary work day on the final Saturday of each month. Community members in villages, towns, and cities across Rwanda collaborate on various service projects. Activities are identified and selected through a participatory process, and often include building schools or health centres, planting trees, or clearing areas for the construction of new homes for the community’s most vulnerable families. Umuganda creates momentum for the development of all sectors, as public sector agencies often choose to contribute resources to these projects (and Ministry officials often join in the work around the country). All of these initiatives serve the pursuit of health; even the construction of a school will facilitate increased uptake of health services in the next generation because a well-educated woman is a highly valued member of a family who is well taken care of.

Other national programs similarly fight poverty and promote economic growth in ways that amplify the work of the health sector. For instance, the Ubudehe process of village-level community decision-making that includes “poverty-mapping” (or communal categorization of households into socio-economic categories based on income and needs) allows for better targeting of social services and pro-poor subsidies for items such as our community-based health insurance program, Mutuelles de Santé. In the Ministry of Health, we use Ubudehe and district level data to proportionally allocate our malnutrition interventions (such as the One Cow per Family and kitchen garden programs) towards the most affected areas of the country.

In order to catalyze economic development at the community level, our Government undertakes massive sensitization campaigns around financial savings. Umurenge Savings and Credit Cooperatives (SACCO) were established across Rwanda to increase access to financial services among the rural poor. Today, all of the country’s sectors manage their own SACCO with technical assistance from the central government. These cooperatives are voluntary, and they allow each citizen to contribute what they want to the communal savings pool. With these savings, the community can provide loans (same amount as invested by the citizen) to individuals who agree to reimburse the cooperative for the amount. One district I visited two weeks ago, Burera, has a savings pool of over one billion Rwanda francs. Umurenge SACCO is a very successful program for economic empowerment through the creation of community-owned and directed capital.

The Ministry of Health also uses cooperative savings mechanisms to compensate our 45,000 clinical services providers the community health workers (CHWs) through performance-based financing. Each community elects the CHWs in a participatory and open manner, after which they are trained by the Ministry of Health in prevention, care, and referral of the most common causes of diseases and mortality among communities in Rwanda. As I have written about elsewhere, our massive team of CHWs has contribute to dramatic improvements in health outcomes over the past five years, including a 50% decline in child mortality, a 70% decline in malaria incidence, a 52% increase in the proportion of mothers delivering at health facilities, and a 450% increase in the uptake of modern family planning methods. They serve as the first line of defence against the biggest killers, addressing 80% of the burden of disease through home-based care, but also stand ready to link patients to health centres or district hospitals via ambulances that they contact with their cell phone.

Economic development at the community level is crucial to Rwanda’s long-term vision for the health sector, because we want every Rwandan to be capable of contributing premiums to the Mutuelle de Santé program. When visiting officials from our partners in the United States or Europe ask how we plan to make this vision sustainable, I like to show them a graph of Rwanda’s recent economic growth – about 8% for the past several years, which has contributed to the expansion and flourishing of our poverty reduction programs.

Rwanda has the vision of becoming a middle-income country that is able to self-finance our pro-poor social interventions and guarantee equitable access to high-quality medical care. When I join in for Umuganda or visit a SACCO and see our people’s unwavering commitment to our nation’s vision, I have no doubts that we will make it. To empower Rwandan citizens economically, we promote a spirit of independence to make the best choices for themselves. This is the basis of democracy; when you are dependent and begging, you cannot direct your life.

Full civil and political rights are essential to human development and are highly valued in Rwanda, but we can never forget that these must be built upon a foundation of social and economic rights. If a woman fears that her child may die of malaria for want of a 500 Rwandan franc treatment, being able to vote will not serve her in the short term if it is not link with economic growth; if a man does not have enough money to feed his family or send his children to school, the ability to nonviolently express grievances will not fill stomachs or pay school fees. Civil and political rights and social and economic rights can and must be mutually reinforcing; neither is sufficient alone – we must assure them all. This understanding is woven into the very fabric of our nation’s Constitution and each of our major social sector policies; we must never forget it.

I am truly delighted that more and more high-level officials from the Governments of our long-time development partner countries are coming to see firsthand what we are doing in Rwanda. I have the feeling that we are all truly contributing to a revolution that will bring more health and wealth to our people. Our partners deserve to see how we are using the investment in the health and wealth of our population. In the global humanitarian market, the value of money invested in Rwanda is incredibly high due to lack of corruption, our dedication to participatory processes, and our reliance on integrated cross-sectorial approaches to tackling policy challenges. As a public servant, I am so proud to belong to Rwanda, a country that has pro-poor human-focused policies in practice, and to its population, who are the most valuable resource our country will ever have.


Saturday, December 10, 2011

Press Release: MoH appreciates support from USG

Below is the press release I published in the New Times on 10 December 2011. Click here to read the article on the New Times website.

Press Release: MoH appreciates support from USG

Kigali - The Ministry of Health would like to clarify a story published in the Chronicles Newspaper issue no. 008/5th-11th Dec 2011 titled, “US responds to Minister Binagwaho’s criticism,’ which was captured in a wrong context.

The Author of the story plays around with figures and creates a false impression of discontent on the part of the Government of Rwanda, and the Health sector in particular, regarding the US Government’s support.

This is wrong.

The U.S. Government is a great friend of Rwanda and the major supporter of our Health sector. U.S. Government support has saved thousands of lives in Rwanda and strengthened our health system. By implying that we do not understand how the global economic crisis has impacted the global flow of aid—and U.S. Government support included —the article misleads your readers.

We commend Washington’s flexibility during this period of economic difficulties, having agreed to reorient funds to support some of our major strategies for sustainable health sector development. For example, the PEPFAR transition process allows all clinical services to be managed directly by the national system, which serves to strengthen district hospitals and support our decentralization efforts.

The article does not recognize our appreciation for this thoughtful and innovative support.

Friends may not agree 100% of the time, but we know that the U.S. Government is committed to working closely with us through this challenging period and will keep supporting us more with less, as President Obama said months ago.

The article ignores the tremendous achievements that we have made together, and the important discussions that are ongoing in order to sustain our success in the health sector, and embrace change to make more sustainable investments for better health. We all understand this, and Rwanda is up to the task.

MOH management
Minister of Health


Leadership and the fight against HIV/AIDS

Panel on leadership in Africa in the fight against HIV/AIDS, ICASA 2011. (Photo credit: UNAIDS/J. Ose)
Last Monday, December 5 - 2011, I had the great honor the speak on behalf of His Excellency, Paul Kagame, President of the Republic of Rwanda, at the International Conference on AIDS and STIs in Africa (ICASA 2011). I spoke on a panel with esteemed representatives of institutions and national health sectors, alongside Festus Gontebanye Mogae, Eric Goosby, Abune Paulos, Michel Sidibe, Oueld Zbel Yastahel Kadad, Madeleine Ba Diallo, and Bience Gawanas.

We were asked to speak about how African leaders can advance the agenda of addressing the burden of HIV/AIDS around the world. As we all now face financial challenges, such a question is vital as leadership will be the key to ensuring Africa does not backtrack on the progress made over the past decade.

When it was my turn to speak I stated that it is our duty to stand up for our people, as Africans are the most affected, especially in the Sub-Sahara region which accounts for more than 70% of all those living with HIV worldwide.

There is no doubt that a lot has been accomplished. The majority of African Governments have made the fight against HIV a top priority for the past 10 years since the Abuja declaration, leading to UNGASS 2001. Much more need to be doe as too many African are still dying due to AIDS.

Today the global economic crisis is a threat to the fight against HIV in Africa as it has impacted the global flow of foreign aid. The challenge we face today is the proof that overall national development (economic growth, self-sufficiency, etc.) is the key for sustainable success in the fight against HIV. I illustrated this point during the panel – taking my country, Rwanda as an example – and elaborated on our fight against HIV as a cross-cutting pillar of Rwanda’s Vision 2020, and our Economic Development and Poverty Reduction Strategy. From the outset, we made the multi-sectorial national HIV response a cross-cutting issue, which strengthened our health system as a whole and supported our national development. Our HIV response included prevention, treatment and the mitigation of the social burden mitigation of disease, as expressed in the National HIV&AIDS Strategic Plan.

Today the global fight against HIV does face constraints, but we also have many solutions that have not been explored widely in other countries. As such, even if many believe that nothing can be done without the money to make it happen, we do not believe this is totally true. There are many ways we can continue to advance.

For example we can use effective decentralization to break geographic barriers and scale-up HIV interventions at the district level. In addition, the Community Health Workers can sensitize Rwandans at the village level about issues of HIV/AIDS at almost no cost. This also goes for politicians, as well as community and administrative leaders who can take upon themselves the task of major sensitization campaigns on the radio, or newspaper, or internet. HIV sensitization could be included in every interaction with the population or in major speeches. It is not costly and it is effective and it creates a sense of national responsibility and solidarity.

We can improve the performance and quality of services as well as the retention of personnel in remote areas using a Performance Based Financing (PBF) framework.  This framework helps district health teams to ensure the availability of qualified health personnel, and to ensure that utilization in rural areas is commensurate with health needs by providing financial incentives to health workers. We can integrate HIV in all curricula in our formal education, aiming to break geographic barriers to access information about HIV/AIDS.

We can also shift the proportion of our national budget that is given to health financing, which would benefit the fight against HIV. Financial barriers can also been reduce by creating a health insurance program. This will enable people’s access to health services, and will prevent PLWHA from dying of common diseases. In Rwanda we developed the community-based health insurance (CBHI) scheme called Mutuelles de Santé. It is one of our key governmental programs, which addresses issues of equity, accessibility and utilization of services, including HIV.

If we use all of these strategies and continue to innovate to find new ones, we will make the money work, save lives, and increase equity in access to prevention, care, and treatment. In Rwanda we have implemented these strategies in order to leave no group out of the benefits of our health services and national development.

Our inclusion principle is largely based on age and gender equity. Children are a priority in service delivery; while we have improvements to make, we know that healthy and educated children are the path to a healthy, peaceful future for Rwanda. Women are equally prioritized, and we have more women on ARVs than men (more women are infected than men) and as a result we have now 80% of women accessing PMTCT, 94% of eligible HIV infected people on ARVs: children, women and men.

These gains are important as they allow us to provide better general services. In many hospitals, beds previously occupied by PLWHA are now free for people coming in with other diseases. This was certainly not the case 10 years ago, when many people were dying outside the hospital due to curable diseases because people with HIV/AIDS occupied many beds.

We are facing a global budget cut in different programs to fight HIV/AIDS and we know that if we don’t increase the proportion of PLWHA on treatment (who need treatment) the disease that is now largely under control will spread again and the world will lose its current gain. Some countries are facing that reality already.

We need to react by making our development partners fulfill their promises, but we need also to have smarter public health approaches as aforementioned. The integration of services is also key. HIV is a chronic disease and must be integrated into our service delivery for other chronic diseases and stop vertical programs. In Rwanda, integration is a policy we adhere to. We have started to tackle non-communicable diseases building on the success of our HIV program.

In this time of crisis, it is also imperative to be more innovative. We have created an Internet clinical based reporting system called TRAC-Net for all people on ARVs. It gives us monthly reports of the clinical, biological and immunological status of our patients and the status of drugs storage across the country. Building on our experience fighting HIV, we are now creating an Electronic Medical Record system for all Rwandan citizens, to be used in all health facilities, thus moving away from paper based medical recording.

In Rwanda, we have put in place an HIV evidence-based operational monitoring and evaluation system, and a Web-based resource-tracking mechanism for all finances in the health sector. It allows us to better plan and to align all actions of all stakeholders to our overall national development plan. But we still have a long way to go.

In 2011, Africa must have zero-tolerance for partners who do not respect the critical importance of country ownership. It is a matter of sustainability. We need better plans and to truly work hand in hand with our national partners and our development partners. But for sustainable success we need to reinforce the structure wth which we we coordinate everyone around our national plan. All of this will bring an economy of scale and will allow us to reach the imperative dictated by the diminution of aid: doing more with either the same or less investment.

We also need to center our fight against HIV in our development plan. We need to build pharmaceutical manufacturing companies on our continent, and continue to fight counterfeits to assure the quality of drugs. Building these companies here is necessary because although the cost of ARVs has declined dramatically, only 47% of all those eligible to receive ARVs in low- and middle-income countries are actually receiving it.

So, if we need to make our partners in the North, and in the West fulfill their promises in funding support, we may call upon them to reduce their overhead and inject that money into the fight against HIV. Let us all, together, commit to investing in a sustainable fight against HIV. We should commit ourselves to focus our fight against HIV on improved decentralization, better integration, more participation of our people and a stronger link between HIV/AIDS services and national development agendas.

Wednesday, December 7, 2011

Video for Harvard Course: Case Studies in Global Health

This video was recorded for the Harvard College course SW25: "Case Studies in Global Health: Biosocial Perspectives." In this video, I presents the linkages between health, social justice and Rwanda's national vision.

You can also watch this video by clicking here.

Friday, December 2, 2011

HPV Vaccine in Rwanda: Different Disease, Same Double Standard

On December 2, a Correspondence letter that I co-authored was published in The Lancet regarding debates about using and paying for the Human Papillomavirus vaccine in low-income countries: “HPV Vaccine in Rwanda: Different Disease, Same Double Standard.” The text of the letter is copied below, and you can click here to read it on The Lancet website. This Youtube Video was recorded to complement the Letter in the Lancet.

We respond to a group of public health researchers who wrote a piece in July that was critical of Rwanda's program and made several claims which have been echoed in other corners of the international community. We draw parallel between this resistance and that of many debates about providing antiretroviral therapy in Africa last decade.

We have detailed articles on strategy, delivery, and outcomes of Rwanda’s program underway, and will post on my blog once they are published.

Published in The Lancet on 2 Dec 2011

HPV vaccine in Rwanda: different disease, same double standard

Agnes Binagwaho, Claire M Wagner, Cameron T Nutt

In a Correspondence letter (July 23, p 315) [1] regarding Rwanda's human papillomavirus (HPV) vaccine roll-out, Nobila Ouedraogo and colleagues express “serious doubts that [a national HPV immunisation programme] is in the best interest of the people”. Are the 330 000 Rwandan girls who will be vaccinated against a highly prevalent, oncogenic virus for free during the first phase of this programme not regarded as “the people”?

Ouedraogo and colleagues argue that cervical cancer ranks behind other vaccine-preventable diseases in resource-constrained settings. But for the diseases cited (measles and tetanus), Rwanda has 95% and 96·8% vaccination coverage rates, respectively [2]. Second, Ouedraogo and colleagues state that HPV vaccine effectiveness is unknown. Many studies say otherwise [3]. Third, the cost-effectiveness analysis cited does not account for vaccine market dynamics by presenting assumptions as immutable facts. The initial price of the pneumococcal vaccine provides a helpful lesson, and Merck announced a two-thirds reduction in the price of Gardasil for GAVI-eligible countries (to US$5 per dose) [4] more than a month before Ouedraogo and colleagues published their Correspondence letter. Finally, Ouedraogo and colleagues accuse Merck and Rwanda of conflicts of interest regarding connections to the GAVI Alliance. Actually, Merck representatives are non-voting GAVI observers, and GAVI's website clearly shows Rwanda's board membership terminating on Dec 31, 2011 [5]. GAVI will have no role in the HPV vaccine programme before 2014.

Ouedraogo and colleagues' argument reminds us of nihilistic claims against provision of antiretroviral therapy in Africa. Their argument constitutes but the latest backlash against progressive health policies by African countries. When the possibility of prevention exists, writing off women to die of cancer solely because of where they are born is a violation of human rights.

The opinions expressed in this Correspondence are entirely those of the authors and should not be attributed to Harvard Medical School or Dartmouth College. We declare that we have no conflicts of interest.


1) Ouedraogo N, Müller O, Jahn A, Gerhardus A. Human papillomavirus vaccination in Africa. Lancet 2011; 377: 315-316. PubMed
2) Ministry of Health of Rwanda. Demographic and health survey 2010: preliminary report. Kigali: National Institute of Statistics of Rwanda, 2011.
3) Schiffman M, Wacholder S. Success of HPV vaccination is now a matter of coverage. Lancet Oncol 201110.1016/S1470-2045(11)70324-2. published online Nov 9. PubMed
4) Merck . Merck offers further commitment to sustainable vaccine access. (accessed Aug 9, 2011).
5) GAVI Alliance. Board members. (accessed Aug 9, 2011).