Journal of Obstetrics and Gynaecology, April 2008; 28(3): 333 – 335

Poverty eradication and decreased human papilloma virus related

cancer of the penis and vulva in Jamaica

H. M. FLETCHER1 & B. HANCHARD2

Departments of 1Obstetrics and Gynaecology and 2Pathology, University of the West Indies Mona, Kingston, Jamaica

Summary
Human papilloma virus causes genital cancers. Decreases in cervical cancer have been reported to be due to comprehensive
screening programmes difficult to replicate in poorer countries. HPV cancer may be related to poverty. In Jamaica, we have
seen decreases in cancer of the penis and vulva and there has also been a decrease in poverty. The decrease cannot be
attributed to screening. We believe elimination of poverty has decreased HPV persistence and decreased cancer rates.

Keywords
Poverty reduction, HPV cancer, penis, vulva, Jamaica

Introduction Registry, of the Pathology Department, University of the

Human papilloma virus (HPV) infection of the genital tract
is the most common sexually transmitted disease. This is so
in many countries of the world. In the USA, it has been
estimated that 80% of sexually active women will acquire
HPV infection by the age of 50 years (CDC 2004). There are
now about 200 known HPV serotypes and the high risk types
are associated with cancer of the ano-genital tract in men
and women. The virus although common, is only proble-
matic if it persists in the host overcoming host defences,
resulting in neoplasia in about 1% of patients who test
positive. The host’s defence is very important and is
determined by innate immunity as well as the nutritional
status of the person. It has been demonstrated in one study
that elevated plasma homocysteine (a marker for folate
deficiency) was found to be a risk factor for cervical dysplasia
and also that this enhances the effects of other risk factors
(Thomson et al. 2000).
While the marked difference in rates of HPV-associated
cancer in poor communities and poor countries, compared
with affluent countries, have often been attributed to
promiscuity and poor medical care (lack of comprehensive
screening and treatment of early disease), it is now
becoming apparent that other social factors may play a part
in the persistence of HPV and the resulting disparity of
disease burden apparent in poorer parts of the world as seen
in parts of Africa, China, India, Melanesia, Central America
and the Caribbean. We therefore undertook a review of
HPV genital cancers in Jamaica over the last 40 years. We
concentrated on cancer of the penis and vulva where no
screening programmes exist.
West Indies from the first report in 1958 to the last in 2002.
The registry is a population-based registry which uses the
population of Kingston and Saint Andrew as its base.
These combined, predominantly urban parishes account
for more than one-third of the population of Jamaica.
Data for people living below the poverty line in Jamaica
was obtained from the yearly survey of living conditions by
the Statistical Institute of Jamaica, in place since 1990, as
well as data obtained from papers written about poverty
before that period. It was only possible to obtain
fragmented data for the earlier period.
Results
We found that the rates of cancer of the penis and vulva for
Jamaica have fallen significantly over the years without
improvement in screening or treatment. The highest
incidence of cancer of the penis was 6/100,000 in the
period 1958 to 1962, falling to 1.8/100,000 in the period
1998–2002. Cancer in the vulva showed an incidence of
2/100,000 in 1958–1962 and 1/100,000 in 1998–2002
(Figure 1). This is even more dramatic if we look at
reported cases per year. The highest number of cases of
cancer of the penis was 44 in 1968 compared with three
cases in 2001. The highest recorded number of cases
of cancer of the vulva was 16 in 1964, with three cases in
2001. We also found that the percentage of people living
below the poverty line has also decreased significantly
during the period reviewed, from a high of 55% in 1958 to
16.9% in 2001 (King 1997; Downes and Le Franc 2001)
(Figure 2).

Methods Discussion
Incidence data for cancer of the vulva and the penis were Human papilloma virus infections are very common. It has
extracted from the 5-yearly reports of the Jamaica Cancer been said that HPV is the most common cause of sexually

Correspondence: H. M. Fletcher, Department of Obstetrics and Gynaecology University of the West Indies Mona, Kingston, Jamaica.
E-mail: horace.fletcher@uwimona.edu.jm
ISSN 0144-3615 print/ISSN 1364-6893 online Ó 2008 Informa UK Ltd.
DOI: 10.1080/01443610802044981
334 H. M. Fletcher & B. Hanchard
transmitted disease. This is so in many countries of the
world. There are now about 200 serotypes and the high risk
types are associated with cancer of the ano-genital tract in
men and women. The virus, although common, is only
problematic if it persists in the host overcoming host
defences, resulting in neoplasia in about 1% of patients
exposed to HPV. In most countries, prevalence of HPV in
young people is very high and this decreases with age,
however in the poorest study areas in Asia (Shanxi, China
and Dindigul, India), and in Nigeria, HPV prevalence was
high across all age groups (Franceschi et al. 2006). In these
same areas, the rate of cervical cancer is the highest in the
world. The decrease in rates of cancer of the cervix in rich
countries is often attributed to the introduction of
comprehensive screening and treatment programmes.
However, no such programmes exist for other genital
cancers, such as cancer of the vulva and penis. These have
also shown dramatic decreases as in affluent countries
where social conditions have improved for most people
(Pukkala and Weiderpass 2002). It is noteworthy however,
that in these rich countries, a high prevalence of HPV
cancers is still found in poor communities (Schwartz et al.
Figure 1. Jamaica (Kingston and St Andrew) Cancer Registry
Reports 1958–2001 (incidence data each 5 years per 100,000) for
penis cancer and vulva cancer.
Figure 2. Percentage of people living below the poverty line in Jamaica 1958–2002. Modified from King (1997) and Downes and Le Franc
(2001).
2003) and even in very rich countries where the social
differences are not great, disparities are still evident
(Pukkala and Weiderpass 1999). In another study, it was
found that the racial disparity in prevalence of cancer cervix
disappeared in a population of uniform economic status
(Sung et al. 1997).
As found with cancer of the penis and vulva, cancer of
the cervix in Jamaica has also shown a decrease although
less dramatic, from 30/100,000 cases in the 1960s to 19/
100,000 at present. This is also without a comprehensive
screening programme. Screening in Jamaica, at time of
writing, is still opportunistic. It is also well documented
that the transformation zone of the adolescent cervix may
have increased susceptibility to HPV infection compared
with the rest of the genital tract and this may explain the
less dramatic decrease for cervix than is found with
the other two genital cancers. While some may argue that
the decrease in poverty may result in an increase in health
seeking behaviour and hence an increase in screening, this
may be true for cervix but not for the other genital cancers,
since no screening is done for these.
The marked decrease in cancer of the penis is not
matched by as dramatic a fall in vulval or cervical cancer
and it has been noted in Jamaica from the survey of living
conditions for 1998 posits that 66.1% of single parent
households living in poverty are headed by females, while
only 33.9% are headed by males (Osei 2001). This
unfortunately, is a worldwide problem in poor countries
and this gender inequality is also, we believe apparent in
the greater burden of HPV-related cancer in women.
It is also important to note that the two cancer incidence
graphs (Figure 1) show a similar trend with an early fall
followed by a period of stability in the turbulent 1970s, a
period in Jamaica’s history when there was much social
discord and economic downturn. This was followed by a
sustained fall, which is mimicked by the poverty alleviation
graph (Figure 2).
The introduction of the HPV vaccines is also expected to
show dramatic decreases in these cancers; however as in the
case with the screening programmes, the cost may be too
much to bear for the people who need it most. Poor
countries may need to implement other strategies to
 Poverty eradication and decrease in cancer in Jamaica
combat these diseases and one area which may be
beneficial is poverty eradication and improved nutrition,
especially of young women, to prevent HPV persistence
and disease. This is critical information in poor countries
because while we recognise the importance of screening
programmes and the introduction of vaccines, we cannot
ignore the fact that poverty eradication is also an important
step for governments to consider.
Declaration of interest: The authors report no conflicts
of interest. The authors alone are responsible for the
content and writing of the paper.
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