Primary health care was put forward thirty years ago as a set of values, rinciples and approaches aimed at raising the level of health in deprived populations. In all countries, it offered a way to improve fairness in access to health care and efficiency in the way resources were used. Primary health care embraced a holistic view of health that went well beyond a narrow medical model. It recognized that many root causes of ill health and disease lie beyond the control of the health sector and thus must be tackled through a broad whole-of-society approach. Doing so would meet several objectives: better health, less disease, greater equity, and vast improvements in the performance of health systems.
Today, health systems, even in the most developed countries, are falling short of these objectives. Although remarkable strides have been made to improve health, combat disease and lengthen life spans, people worldwide are dissatisfied with existing health systems. One of the greatest worries is about the cost of health care. This is a realistic concern since 100 million people fall into poverty each year paying for health care. Millions more are unable to access any health care.
The source of the problem is that health systems and health development agendas have evolved into a patchwork of components. This is evident in the excessive specialization in rich countries and donor-driven, single disease focused programmes in poor ones. A vast proportion of resources are spent on curative services, neglecting prevention and health promotion that could cut 70% of global disease burden. In short, health systems are unfair, disjointed, inefficient and less effective than they could be. Moreover, without substantial reorienting, today’s struggling health systems are likely to be overwhelmed by the growing challenges of aging populations, pandemics of chronic diseases, new emerging diseases such as SARS, and the impacts of climate change.
“Rather than improving their response capacity and anticipating new challenges, health systems seem to be drifting from one short-term priority to another, increasingly fragmented and without a clear sense of direction,” says World Health Report 2008 entitled Primary Health Care – Now More Than Ever.
With the publication of the report on 14 October, WHO hopes to start a global conversation on the effectiveness of primary health care as a way of reorienting national health systems. WHO Director-General, Margaret Chan, wrote in a recent editorial in the journal The Lancet: “Above all, primary health care offer(s) a way to organize the full range of health care, from households to hospitals, with prevention equally important as cure, and with resources invested rationally in the different levels of care.”
Actually, WHO hopes to revive the conversation. Primary health care was officially launched in 1978, when WHO member states signed the Alma Ata Declaration. That was 30 years ago. A few countries pursued the ideal. But, says Dr Chan: “The approach was almost immediately misunderstood.”
Primary health care was misconstrued as poor care for poor people. It was also seen as having an exclusive focus on first-level care. Some dismissed it as utopian and others thought it a threat to the medical establishment.
In the World Health Report, WHO proposes that countries make health system and health development decisions guided by four broad, interlinked policy directions. These four represent core primary health care principles.
Universal coverage: For fair and efficient systems, all people must have access to health care according to need and regardless of ability to pay. If they do not have access, health inequities produce decades of differences in life expectancies not only between countries but within countries. These inequities raise risks, especially of disease outbreaks, for all. Providing coverage to all is a financial challenge, but most systems now rely on out-of-pocket payments which is the least fair and effective method. WHO recommends financial pooling and pre-payment, such as insurance schemes. Brazil began working towards universal coverage in 1988 and now reaches 70% of its population.
People-centred services: Health systems can be reoriented to better respond to people’s needs through delivery points embedded in communities. The Islamic Republic of Iran’s 17 000 “health houses” each serve about 1500 people and are responsible for a sharp drop in mortality over the last two decades, with life expectancy increasing to 71 years in 2006 from 63 years in 1990. New Zealand’s Primary Health Care Strategy, launched in 2001, has as part of its core strategy an emphasis on prevention and management of chronic diseases. Cuba’s “polyclinics” have helped give Cubans one of the longest life expectancies (78 years) of any developing country in the world. Brazil’s Family Health Programme provides quality care to families in their homes, at clinics and in hospitals.
Healthy Public Policies: Biology alone does not explain many gaps in longevity, such as the 27-year difference in Glasgow’s rich and poor neighborhoods. In fact, much of what impacts health broadly lies outside the influence of the health sector. Ministries of trade, environment, education and others all have their impact on health, and yet little attention is generally paid to decisions in these ministries that have health impacts. WHO believes they should all be part of deliberations and that a “health in all policies” approach needs to be integrated broadly throughout governments. This will require a shift in political calculations since some of the greatest health impacts can be achieved through early childhood development programmes and education of women, but those benefits are unlikely to be seen during a single politician’s term or terms in office.
Leadership: Existing health systems will not naturally gravitate towards more fair, efficient (those that work better) and effective (those that achieve their goals) models. So, rather than command and control, leadership has to negotiate and steer. All components of society – including those not traditionally involved in health – have to be engaged, including civil society, the private sector, communities and the business sector. Health leaders need to ensure that vulnerable groups have a platform to express their needs and that these pleas are heeded. There is enormous potential to be tapped. In half of the world’s countries, health issues are the greatest personal concern for a third of the population. Wise leadership requires knowledge of what works. Yet health systems research is an area that is often severely under funded. In the United States of America, for example, health systems research claims only 0.1% of the nation’s health budget expenditure. Yet research is needed to generate the best evidence as a basis for health decision.
By aiming at these four primary health care goals, national health systems can become more coherent, more efficient, more fair and vastly more effective.
Progress is possible, in all countries. Now, more than ever, there are opportunities to start changing health systems towards primary health care in all countries. The challenges are different for countries with different income levels, but there are commonalities. There is more money being spent on health than ever before and more knowledge to address global health challenges, including better medical technology. There is also now recognition that threats and opportunities in health are shared across the world. Aid is important for some countries, but the vast majority of health spending comes from domestic sources. Even today, in Africa, 70% of all resources for health come from domestic funds. Thus most countries have the ability to start moving towards and enjoying the benefits of primary health care.
Monday, October 20, 2008
Wednesday, October 15, 2008
Reflections on Primary Health Care 30 years after Alma Ata and the Challenges Ahead
The recently released World Health Report on PHC (WHO Oct 2008) is an attempt to bring PHC again to the forefront of our priorities in global health. Good for that!
But the world has changed in these 30 years.
In 1978, we did not have:
· Neoliberal globalization.
· Selective, vertical health programs (many of them aggressively pushed by public-private partnerships -- PPPs that started, because they did not trust WHO…).
· A big health manpower crisis (only in part due to the AIDS pandemic).
· The magnitude of economic impediments to access to health by poor people with increasing inequities and disparities between the haves and the have nots.
· Increasing privatization and commercialization/commoditization of health services as a result of globalization *.
· Intellectual property issues (patent issues) used against the interest of poor countries and poor patients.
We also did not have:
· An energetic and active civil society.
· The People's Health Movement (PHM) and its global network.
Therefore, as a PHM member, on top of seeing PHC and Alma Ata as still alive, I think PHC-in-2008-and-beyond needs to address these (and other unmentioned) "did not have" issues as challenges at local, national and global level.
For this to happen, WHO is to recuperate its moral and political leadership in PHC, in health overall, and in proactively addressing the social determinants of health as per the recommendations of the ad-hoc WHO Commission that just released its report.
To go beyond well-meaning pronouncements, this will clearly need some internal reorganization in this UN agency. The question is whether its leadership plans such a reorientation.
PHM does not shy away from a political approach to PHC and is not really fighting its opponents; it is rather bringing the level of the discussion to a higher level. Therefore, it has published an alternative report to the World Health Report of 2008 --the Global Health Watch 2 (being released today, see www.phmovement.org ).
PHM challenges the concept that good health is an imperative for increased economic productivity: Instead, it insists and departs from the premise that health is an inalienable Human Right.
Health is not either a technical or a political issue: it is both…and pro-poor health interventions mean nothing if not concomitantly accompanied by poverty reduction actions that are pro-health.
Based on patients registers at health facilities, statistics want to make us believe that 50% of the poor choose to seek private health care. Such a fallacy hides the real fact that 50% of the poor do not seek any care (and thus escape facility-based statistics!). So, let us stop using the slogan "those who can pay should pay" without carefully weighing its meaning.
I am a perennial optimist. I hope recent developments mean a real new window of opportunity for PHC. But WHO/member states/civil society interactions will have to become more of a 'two-way street'. I am sure PHM will play its role in achieving this.
Claudio Schuftan, Ho Chi Minh City
cschuftan@phmovement.org
______________
*: The myth that private health providers are more efficient has to be broken once and for all. Without trying to generalize, it is still true that, in the private sector, the following facts are prevalent:
· An irrational use of drugs, of polypharmacy and an overuse of antibiotics, vitamins and steroids.
· An overuse of injectables.
· A veritable 'ultrasound epidemic'.
· An excessive numbers of cesarean sections and tonsillectomies performed.
· Private insurance companies cherry picking the healthier patients and leaving the others for the public sector to care for (or offering minimum coverage packages to the poor that end up in 1st, 2nd and 3rd class medicine).
· A penetration of transnational health corporations in developing countries using GATS provisions (that PHM denounces).
· Public hospitals opening private wards 'that will (allegedly) generate income to subsidize the public wards', but most of the times ending up being subsidized by the public sector since they undercharge private patients.
· Health tourism springing up in many countries with the consequent internal brain drain.
· A conspicuous absence of private practitioners in remote and poor areas.
· A very limited role of this sector in preventive and promotive health actions and a minimal role in TB and in AIDS, and
· A resistance of medical associations to any measures directed at regulating private practice.
---
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Wednesday, October 08, 2008
Social Determinants of Health
By Alberto G. Romualdez, M.D.
Malaya, Tuesday, 7 October 2008
In 2005, the late Director-General of the World Health Organization, Dr. Lee Jun-Wok, set up the Commission on the Social Determinants of Health. Its job was to marshal evidence on what could be done to promote health equity. Last month, after working for three years, the Commission issued its final report entitled “Closing the Gap in a Generation – Health Equity through Action on the Social Determinants of Health”.
Chaired by a well-respected epidemiologist, Professor Michael Marmot of the United Kingdom, the Commission’s members were a diverse group ranging from a former president of Chile to health ministers and health experts to a Nobel laureate in economics. But despite their different backgrounds, the Chairman noted that “everyone connected to the Commission were united in three concerns: a passion for social justice, a respect for evidence, and a frustration that there appeared to be far too little action on the social determinants of health.”
“Closing the Gap” did not reveal any startlingly new findings about the relationships between social status and health. However, its methodical exposition of the evidence on these relationships and how widespread they were across the globe provides documentation that should initiate action by responsible authorities not only in the health sector but at all levels and areas.
For the Philippines, the findings of the Commission underscored the fact that, as repeatedly asserted in past forums, our country situation mirrors the global situation in almost all aspects especially in the disgraceful health inequities between the rich minority and the poor majority of Filipinos.
The recommendations on the approaches to reducing health inequities are also very much applicable to our situation. These approaches are based on an all-encompassing concern for social justice which, the report asserts, “is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death.”
The Commission proposes three overarching recommendations for dealing with inequities in health. It is obvious from these that reforming the health sector to deal with inequality cannot be the business of the health sector alone because not all the factors that promote inequity are within its sphere.
The first of these is to improve living conditions for all because “the inequities in how society is organized mean that the freedom to lead a flourishing life and to enjoy good health is unequally distributed between and within societies. This inequity is seen in the conditions of early childhood and schooling, the nature of employment and working conditions, the physical form of the built environment, and the quality of the natural environment.”
The second overarching recommendation is to tackle the inequitable distribution of power, money, and resources because “inequity in the conditions of daily living is shaped by deeper social structures and processes. The inequity is systematic, produced by social norms, policies, and practices that tolerate or actually promote unfair distribution of and access to power, wealth, and other necessary social resources.”
The third recommendation is to measure and understand the problem and to assess the impact of action because “the world is changing fast and often it is unclear the impact that social, economic, and political change will have on health in general and on health inequities in particular. Action on the social determinants of health will be more effective if basic data systems, including vital registration and routine monitoring of health inequity and the social determinants of health are in place.”
“Closing the Gap in a Generation” is a very important document that will help to understand the underpinnings of health inequity. It should be required reading for individuals who have any interest in trying to remedy the problem of inequity in the Philippine health system. The document provides materials to support the argument that it is time to elevate the level of politicization of health from that of parochial self-interests and petty patronage to a national issue of common concern.
Unfortunately, despite the fact that polls show that health is a priority issue for most Filipinos, politicians’ have for the most part shown a rather shallow appreciation of the issues. It is for this reason that political campaigns for any post always feature medical missions and distributions of medicines (mostly unnecessary). The most common promise of politicians to their constituents is to build yet another hospital or health center or health station.
Hopefully, the publication of “Closing the Gap in a Generation” coupled with the promotion of the attainment of the millennium development goals will encourage deeper thinking about the situation of health in the Philippines. Perhaps a true concern for the health of poor Filipinos will also convince some of the more conservative religious groups to reconsider their stance on reproductive health, information and services which will empower poor couples to become responsible couples, allow them to pay more attention to their family needs, and avoid the many health risks associated with reproductive ignorance.
***
The initial confusion and delays in the response of Philippine health authorities to the melamine contaminated food products from China reflects the inherent weaknesses of the food and drug regulatory system now in place. It turns out that this problem came at a very awkward time for the Bureau of Food and Drugs. Its Deputy Director, who was effectively the agency’s main trouble-shooter, had just resigned. There had just been a reshuffle of division chiefs that had cause a level of demoralization because it had been done to appease a powerful multinational food company at the behest of the Department of Trade and Industry. Hopefully, after things settle back to normal following this melamine affair, the story behind the turmoil of the country’s food and drug safety agency can be told as one of the basis for reforms of food and drug regulations expected with the passage of a pending BFAD strengthening law.
(Dr. Romualdez’ e-mail address is: alberto.romualdez@gmail.com)
Malaya, Tuesday, 7 October 2008
In 2005, the late Director-General of the World Health Organization, Dr. Lee Jun-Wok, set up the Commission on the Social Determinants of Health. Its job was to marshal evidence on what could be done to promote health equity. Last month, after working for three years, the Commission issued its final report entitled “Closing the Gap in a Generation – Health Equity through Action on the Social Determinants of Health”.
Chaired by a well-respected epidemiologist, Professor Michael Marmot of the United Kingdom, the Commission’s members were a diverse group ranging from a former president of Chile to health ministers and health experts to a Nobel laureate in economics. But despite their different backgrounds, the Chairman noted that “everyone connected to the Commission were united in three concerns: a passion for social justice, a respect for evidence, and a frustration that there appeared to be far too little action on the social determinants of health.”
“Closing the Gap” did not reveal any startlingly new findings about the relationships between social status and health. However, its methodical exposition of the evidence on these relationships and how widespread they were across the globe provides documentation that should initiate action by responsible authorities not only in the health sector but at all levels and areas.
For the Philippines, the findings of the Commission underscored the fact that, as repeatedly asserted in past forums, our country situation mirrors the global situation in almost all aspects especially in the disgraceful health inequities between the rich minority and the poor majority of Filipinos.
The recommendations on the approaches to reducing health inequities are also very much applicable to our situation. These approaches are based on an all-encompassing concern for social justice which, the report asserts, “is a matter of life and death. It affects the way people live, their consequent chance of illness, and their risk of premature death.”
The Commission proposes three overarching recommendations for dealing with inequities in health. It is obvious from these that reforming the health sector to deal with inequality cannot be the business of the health sector alone because not all the factors that promote inequity are within its sphere.
The first of these is to improve living conditions for all because “the inequities in how society is organized mean that the freedom to lead a flourishing life and to enjoy good health is unequally distributed between and within societies. This inequity is seen in the conditions of early childhood and schooling, the nature of employment and working conditions, the physical form of the built environment, and the quality of the natural environment.”
The second overarching recommendation is to tackle the inequitable distribution of power, money, and resources because “inequity in the conditions of daily living is shaped by deeper social structures and processes. The inequity is systematic, produced by social norms, policies, and practices that tolerate or actually promote unfair distribution of and access to power, wealth, and other necessary social resources.”
The third recommendation is to measure and understand the problem and to assess the impact of action because “the world is changing fast and often it is unclear the impact that social, economic, and political change will have on health in general and on health inequities in particular. Action on the social determinants of health will be more effective if basic data systems, including vital registration and routine monitoring of health inequity and the social determinants of health are in place.”
“Closing the Gap in a Generation” is a very important document that will help to understand the underpinnings of health inequity. It should be required reading for individuals who have any interest in trying to remedy the problem of inequity in the Philippine health system. The document provides materials to support the argument that it is time to elevate the level of politicization of health from that of parochial self-interests and petty patronage to a national issue of common concern.
Unfortunately, despite the fact that polls show that health is a priority issue for most Filipinos, politicians’ have for the most part shown a rather shallow appreciation of the issues. It is for this reason that political campaigns for any post always feature medical missions and distributions of medicines (mostly unnecessary). The most common promise of politicians to their constituents is to build yet another hospital or health center or health station.
Hopefully, the publication of “Closing the Gap in a Generation” coupled with the promotion of the attainment of the millennium development goals will encourage deeper thinking about the situation of health in the Philippines. Perhaps a true concern for the health of poor Filipinos will also convince some of the more conservative religious groups to reconsider their stance on reproductive health, information and services which will empower poor couples to become responsible couples, allow them to pay more attention to their family needs, and avoid the many health risks associated with reproductive ignorance.
***
The initial confusion and delays in the response of Philippine health authorities to the melamine contaminated food products from China reflects the inherent weaknesses of the food and drug regulatory system now in place. It turns out that this problem came at a very awkward time for the Bureau of Food and Drugs. Its Deputy Director, who was effectively the agency’s main trouble-shooter, had just resigned. There had just been a reshuffle of division chiefs that had cause a level of demoralization because it had been done to appease a powerful multinational food company at the behest of the Department of Trade and Industry. Hopefully, after things settle back to normal following this melamine affair, the story behind the turmoil of the country’s food and drug safety agency can be told as one of the basis for reforms of food and drug regulations expected with the passage of a pending BFAD strengthening law.
(Dr. Romualdez’ e-mail address is: alberto.romualdez@gmail.com)
Thursday, October 02, 2008
Cervical Cancer and Human Papillomavirus
Reading through The Philippine Star, I bumped into an advertisement which presents a husband lying in bed and trying to feel the presence of his deceased wife. What makes this interesting is the question flashed below which goes Naisip mo na ba kung gaano kasakit matulog at gumising na mga-isa?. Apparently, this seeks to inform readers that a woman has an eighty percent chance of already being infected with human papillomavirus (HPV) when she reaches fifty and that there are ten women who die of cervical cancer hence, ten new widowers everyday.
This advertisement brought me back to an article entitled A survivor’s battle with cervical cancer by Annie A. Jambora which was released last August fifth in Philippine Daily Inquirer. This highlights the experience of Josefina de la Cruz with cervical cancer, country’s second leading cause of death among Filipino women. Other than her menstrual period which takes much longer than usual, sometimes going for full ten days, she was feeling fine. In August 2001, exactly ten years after her mother succumbed to the same disease, she was diagnosed with multiple myoma.
Although the diagnosis is not a life-threatening condition, she nevertheless pushed through with all the necessary medical procedures. However, it was just last year when she figured out that the cancer was actually caused by HPV which she, unknowingly, had acquired from her husband.
Cervical Cancer
The Harvard Guide to Women’s Health defines cervical cancer as a disease that develops gradually starting with abnormal cell changes called preinvasive lesions (also called low-grade squamous intraepithelial lesions, or SIL; or dysplasia). These sometimes revert to normal cells. Nevertheless, these cell changes are considered a precancerous condition. In time (sometimes a full decade), some precancerous cells may develop into localized cancer, called carcinoma in situ, which affects the outer surface of the cervix (Carlson, Eisenstat, Ziporyn, 1996, p. 130).
World Health Organization states, in its website, that all cervical cancer cases (99%) are linked to genital infection with HPV, which is the most common viral infection of the reproductive tract.
Human Papillomavirus (HPV)
Cervical cancer, human papillomavirus (HPV), and HVP vaccines-Key points for policy makers and health professionals provides main points on this virus.
HPVs are a family of viruses that are extremely common worldwide. There are more than 100 types.
They are deoxyribonucleic acid (DNA) viruses that infect skin or mucosal cells.
At least 13 of these types are oncogenic (cancer-causing).
HPV is estimated to cause
-100% of cancer cases,
-90% of anal cancer cases,
-40% of cases of cancers of the external genitalia (vulva, vagina and penis),
-at least 12% of oropharyngeal cancer cases, and
-at least 3% of oral cancer cases.
HPV types 16 and 18 cause approximately 70% of all cervical cancers worldwide.
Almost 500 000 cases of cervical cancer and 274 000 cervical cancer deaths occurred in 2002.
About 80% of cervical cancer deaths occur in developing countries.
In the article which was mentioned earlier, it is stated that HPV, affecting both men and women, can be acquired only through skin contact. Men are generally spared from the deadly virus and only serve as carriers even if they use condoms. These do not protect a woman from contacting the said virus since the scrotum is still exposed.
It is wonderful knowing that newsprint media have started realizing the importance of writing on cervical cancer and human papillomavirus (HPV) as one of its causes. Untold stories of women, we can now finally conclude, are beginning to be told.
Citations:
• “Naisip mo na ba kung gaano kasakit matulog at gumising na mga-isa?”. The Philippine Star: September 24, 2008, page 13.
• Jambora, Annie A. “A survivor’s battle with cervical cancer”. Philippine Daily Inquirer: August 05, 2008, page C1.
• Carlson, Karen J., Eisenstat, Stephanie A., Ziporyn, Terra. The Harvard Guide to Women’s Health. Cambridge, Massachusetts: Harvard University Press, 1996.
• World Health Organization. September 29, 2008.
• “Cervical cancer, human papillomavirus (HPV), and HVP vaccines-Key points for policy makers and health professionals”. September 29, 2008.
Original article by Amanh B Lao, research associate, HAIN.
This advertisement brought me back to an article entitled A survivor’s battle with cervical cancer by Annie A. Jambora which was released last August fifth in Philippine Daily Inquirer. This highlights the experience of Josefina de la Cruz with cervical cancer, country’s second leading cause of death among Filipino women. Other than her menstrual period which takes much longer than usual, sometimes going for full ten days, she was feeling fine. In August 2001, exactly ten years after her mother succumbed to the same disease, she was diagnosed with multiple myoma.
Although the diagnosis is not a life-threatening condition, she nevertheless pushed through with all the necessary medical procedures. However, it was just last year when she figured out that the cancer was actually caused by HPV which she, unknowingly, had acquired from her husband.
Cervical Cancer
The Harvard Guide to Women’s Health defines cervical cancer as a disease that develops gradually starting with abnormal cell changes called preinvasive lesions (also called low-grade squamous intraepithelial lesions, or SIL; or dysplasia). These sometimes revert to normal cells. Nevertheless, these cell changes are considered a precancerous condition. In time (sometimes a full decade), some precancerous cells may develop into localized cancer, called carcinoma in situ, which affects the outer surface of the cervix (Carlson, Eisenstat, Ziporyn, 1996, p. 130).
World Health Organization states, in its website, that all cervical cancer cases (99%) are linked to genital infection with HPV, which is the most common viral infection of the reproductive tract.
Human Papillomavirus (HPV)
Cervical cancer, human papillomavirus (HPV), and HVP vaccines-Key points for policy makers and health professionals provides main points on this virus.
HPVs are a family of viruses that are extremely common worldwide. There are more than 100 types.
They are deoxyribonucleic acid (DNA) viruses that infect skin or mucosal cells.
At least 13 of these types are oncogenic (cancer-causing).
HPV is estimated to cause
-100% of cancer cases,
-90% of anal cancer cases,
-40% of cases of cancers of the external genitalia (vulva, vagina and penis),
-at least 12% of oropharyngeal cancer cases, and
-at least 3% of oral cancer cases.
HPV types 16 and 18 cause approximately 70% of all cervical cancers worldwide.
Almost 500 000 cases of cervical cancer and 274 000 cervical cancer deaths occurred in 2002.
About 80% of cervical cancer deaths occur in developing countries.
In the article which was mentioned earlier, it is stated that HPV, affecting both men and women, can be acquired only through skin contact. Men are generally spared from the deadly virus and only serve as carriers even if they use condoms. These do not protect a woman from contacting the said virus since the scrotum is still exposed.
It is wonderful knowing that newsprint media have started realizing the importance of writing on cervical cancer and human papillomavirus (HPV) as one of its causes. Untold stories of women, we can now finally conclude, are beginning to be told.
Citations:
• “Naisip mo na ba kung gaano kasakit matulog at gumising na mga-isa?”. The Philippine Star: September 24, 2008, page 13.
• Jambora, Annie A. “A survivor’s battle with cervical cancer”. Philippine Daily Inquirer: August 05, 2008, page C1.
• Carlson, Karen J., Eisenstat, Stephanie A., Ziporyn, Terra. The Harvard Guide to Women’s Health. Cambridge, Massachusetts: Harvard University Press, 1996.
• World Health Organization. September 29, 2008
• “Cervical cancer, human papillomavirus (HPV), and HVP vaccines-Key points for policy makers and health professionals”. September 29, 2008
Original article by Amanh B Lao, research associate, HAIN.