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    How Access to the HPV Vaccine Entrenches China’s Health Care Gap

    Cervical cancer rates are higher among poor, rural women, while middle-class ‘medical tourists’ head to overseas private clinics to get their shots.

    On April 29, China’s State Drug Administration announced that it had conditionally approved the 9-valent human papillomavirus (HPV) vaccine. Usually marketed under the name Gardasil 9, the vaccine protects against nine strains of HPV — a virus best known for causing cervical, vaginal, anal, and vulvar cancers. HPV is the world’s most common sexually transmitted infection, although many people merely carry the virus and show no symptoms.

    The entire approval process took just eight days, and clinical trials took less than half a year. That contrasts dramatically with the eight years of trials that took place before the government approved the 2-valent HPV vaccine in July 2016. Indeed, by the time China rolled out the 2-valent and 4-valent HPV vaccines — both of which protect against fewer diseases than Gardasil 9 — the United States had already begun to phase them out in favor of the 9-valent version.

    China’s slow approval system for new medicines has left the country lagging far behind the rest of the world in access to innovative treatments. From 2004 to 2014, the U.S. approved 291 new molecular entities — the official term for new medicines — but just 79 of them received Chinese approval. Even when medicines are approved, they often take an inordinate length of time before they arrive in hospitals.

    Thankfully, a recent round of medical reforms resulted in Gardasil 9 being fast-tracked for approval. In October last year, the State Council — China’s cabinet — directed the health authorities to speed up the approval process for medications and medical devices, especially in the treatment of rare diseases and those for which there is an urgent clinical need. Then, in April of this year, the State Council decided that, as of May 1, imported cancer medications would be exempt from import duties. In addition, businesses, not customs officers, will assume greater legal liability for testing imported precursor chemicals for manufacturing medicines.

    The three years since the HPV vaccines entered the mainland Chinese market have revealed how regional and social inequalities continue to limit access to medical resources and health rights. First, China’s underdeveloped medical sector has left it incapable of meeting the needs of all the country’s residents. This, in turn, has led to the rise of cross-border markets for medical treatment. Prior to the Gardasil 9 rollout, many middle- and upper-class Chinese traveled abroad to buy it. Furthermore, the 2016 vaccine scandal, which revealed that various medical companies had sold 25 illegally stored vaccines to both children and adults across the country, deepened the public’s lack of confidence in the country’s medical sector.

    Most so-called medical tourists booked vaccinations in Hong Kong, which runs a separate health care system from the Chinese mainland but allows nonresidents to get shots at private clinics. Hong Kong’s private vaccination clinics are quietly growing in number, as are the prices of vaccination itself — from 4,000 Hong Kong dollars ($500) for three shots of the 9-valent HPV vaccine in early 2017, to approximately HK$7,500 today.

    International students are another main source of clients for the cross-border vaccine industry. In countries where the HPV vaccine is covered by national health care systems — for example, the U.S. and Canada — many Chinese students get vaccinated via doctors’ referrals. In other places, international students buy their shots at so-called student discounts. For example, several universities in Hong Kong hold campus-wide HPV vaccination events each year, where students, teachers, and even family members can sign up for cut-price vaccinations at campus medical centers.

    When I conducted interviews for this article in Hong Kong earlier this year, the young women I spoke to who said they were from mainland Chinese cities explained that they mainly came to Hong Kong to avoid the shortcomings of the mainland medical system. Indeed, their consumer patterns carry a hint of activism, as women embrace cross-border medical services to practice self-care they cannot achieve in their hometowns.

    On the mainland, the HPV vaccine continues to be a scarce resource. Limited supplies and vaccination appointments, high prices, and ineffective public health campaigns combine to keep China’s HPV vaccination rate low and concentrated among young, urban, middle-class women.

    Due to low import quotas, even those living in China’s largest cities who are willing to pay for the vaccine often have trouble making appointments to get it. According to a May 2 report from the Chengdu Economic Daily, waiting lists at some of the southwestern Chinese city’s locations now exceed 1,000 people, with some women waiting since December. And that’s in Chengdu — a major city with a comparatively developed medical sector.

    Regional and social inequalities in HPV vaccination mainly come down to the fact that China’s somewhat spotty universal health coverage does not currently include these shots. In an interview with state news agency Xinhua last year, Zhao Fanghui, a doctor at the Chinese Academy of Medical Sciences’ Cancer Hospital, stated that only after more domestically produced vaccines enter the market and competition drives prices down will it be possible to cover HPV vaccines on national health insurance. But this stage is a long way off, and we cannot rely solely on market mechanisms to bring down prices.

    Chinese public health campaigns do a poor job of teaching people about HPV. According to the World Health Organization, more than 85 percent of the estimated 270,000 deaths from cervical cancer worldwide every year occur in less developed regions. In China, cervical cancer is the third most common form of cancer affecting women between the ages of 15 and 44; 100,000 new cases and 30,000 deaths from the disease occur every year. However, only 15 percent of women on the Chinese mainland have heard of the vaccines, and their high cost puts off many low-income patients, according to Sui Long, chief gynecologist at Shanghai’s foremost obstetrics and gynecology hospital.

    People living in less developed regions are less likely to undergo HPV screenings or inoculations, allowing the virus to spread more easily. Between 2004 to 2016, incidences of cervical cancer were mostly concentrated in central and western China. Of the nearly 25,000 cases of cervical cancer studied during that time, 65 percent of patients were from the countryside. (Only 41 percent of Chinese people lived in the countryside by the end of 2017.)

    Other developing regions have handled the issue better, relying on the government or international groups to help increase vaccination rates. According to a report from news outlet Caixin, six out of every seven Latin American girls in the recommended age range have received their HPV shots. In Africa, the Vaccine Alliance has helped many low-income countries add HPV to their national immunization plans.

    Similar campaigns exist in developed health care systems, too. Beginning in April of this year, the Hong Kong Community Care Fund invested HK$99 million to provide the HPV vaccine to the city’s poorer residents, thereby reducing some of the health inequality that besets the region.

    Finally, HPV vaccinations are highly gendered. Many people don’t realize that the vaccine is recommended for men as well as women. But media outlets habitually refer to it as the “cervical cancer vaccine,” which does little to encourage men to get vaccinated. In reality, men are also at risk of HPV, which can cause rectal cancer, prostate cancer, and penile cancer. HPV can also cause genital warts and is a leading cause of oropharyngeal cancer, even more so than smoking and alcohol consumption. The U.S. Centers for Disease Control and Prevention estimate that 70 percent of oropharyngeal cancers are caused by HPV, and 12,600 men contract the disease every year.

    In China, too, many women are being priced out of essential HPV vaccines or denied access to them altogether. Accelerating the approval of imported vaccines is a good first step, but if we want to get serious about ensuring public health rights, we need to step up the provision of vaccines in remote areas and teach disadvantaged groups that those three little shots can be the gateway to a longer, healthier life.

    Translator: Kilian O’Donnell; editors: Zhang Bo and Matthew Walsh.

    (Header image: A woman receives a 4-valent HPV vaccination at a community health center in Shanghai, China, March 8, 2018. Si Hong/IC)