John Prine (1946-2020)

By the the mid sixties singer/song writers had replaced most instrumental music and had even nudged crooners off center stage. It seems like every high school musician had became intent on trying his or her hand at the genre. Not many of them were successful. In fact most of their efforts are gone and forgotten. To this day when a young performer gets up on stage and introduces their latest effort as a song they wrote I go into a mental cringe. Most juvenile efforts are just not up to the mark. However, in the post Gordon Lightfoot / Bob Dylan era there are standouts. In Canada there was Stan Rogers and David Francy; In Australia there was Eric Bogle and probably the most successful in North America was John Prine. Stan Rogers is dead off course, David Francy and Eric Bogle are retired and now, unfortunately, John Prine has passed away. What all these writers had in common was a deep attachment to their cultural roots and abilities to make the ordinary extraordinary. In doing so they painted mental images that are immediate and tell a story. There maybe sub-texts in and behind the songs but on first listening their songs are immediately decipherable. In fact there is no need to search for the meaning of their songs. They are clear and immediate portrayals of the human conditions. There is no Psychoanalysis  required. There is nothing else that needs to be added. The songs speak for themselves. Listen to John Prine’s Souvenirs……

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Celebrated Singer-Songwriter John Prine dies at 73 – New York Times Obituary, April 7, 2020

John Prine, the ingenious singer-songwriter who explored the heartbreaks, indignities and absurdities of everyday life in “Angel from Montgomery,” “Sam Stone,” “Hello in There” and scores of other indelible tunes, died Tuesday at the age of 73. Prine died of complications from the coronavirus at Vanderbilt University Medical Center in Nashville, Tennessee, his wife said Wednesday. Despite “the incredible skill and care of his medical team,” she said, “he could not overcome the damage this virus inflicted on his body.” Fiona Whelan Prine said last month that she had tested positive for COVID-19 and she has since recovered, but her husband was hospitalized on March 26 with coronavirus symptoms and had to be put on a ventilator before he died.

Winner of a lifetime achievement Grammy earlier this year, Prine was a virtuoso of the soul, if not the body. He sang his conversational lyrics in a voice so rough that even he didn’t like the sound all that much, until it was softened by the throat cancer surgery that disfigured his jaw late in life. He joked that he fumbled so often on the guitar, taught to him as a teenager by his older brother, that people thought he was inventing a new style. But his open-heartedness, eye for detail and sharp and surreal humor brought him the highest admiration from critics, from such peers as Bob Dylan and Kris Kristofferson, and from such younger stars as Jason Isbell and Kacey Musgraves, who even named a song after him.

In 2017, Rolling Stone proclaimed him “The Mark Twain of American songwriting.”

Prine began playing as a young Army veteran who invented songs to fight boredom while delivering the U.S. mail in Maywood, Illinois. He and his friend, folk singer Steve Goodman, were still polishing their skills at the Old Town School of Folk Music when Kristofferson, a rising star at the time, heard them sing one night in Chicago, and invited them to share his stage in New York City. The late film critic Roger Ebert, then with the Chicago Sun-Times, also saw one of his shows and declared him an “extraordinary new composer.” Suddenly noticed by America’s most popular folk, rock and country singers, Prine signed with Atlantic Records and released his first album in 1971. “I was really into writing about characters, givin’ ‘em names,” Prine said, reminiscing about his long career in a January 2016 public television interview that was posted on his website.

“You just sit and look around you. You don’t have to make up stuff. If you just try to take down the bare description of what’s going on, and not try to over-describe something, then it leaves space for the reader or the listener to fill in their experience with it, and they become part of it.”

He was among the many promoted as a “New Dylan” and among the few to survive it and find his own way. Few songwriters could equal his wordplay, his empathy or his imagination. “I try to look through someone else’s eyes,” he told Ebert in 1970. His characters were common people and confirmed eccentrics, facing the frustrations and pleasures anyone could relate to. “Sam Stone” traces the decline of a drug-addicted Vietnam veteran through the eyes of his little girl. “Donald and Lydia” tells of a tryst between a shy Army private and small-town girl, both vainly searching for “love hidden deep in your heart:”

They made love in the mountains, they made love in the streams / they made love in the valleys, they made love in their dreams / But when they were finished, there was nothing to say, / ‘cause mostly they made love from ten miles away.

“He writes beautiful songs,” Dylan once told MTV producer Bill Flanagan. “I remember when Kris Kristofferson first brought him on the scene. All that stuff about Sam Stone the soldier-junkie-daddy, and Donald and Lydia, where people make love from ten miles away — nobody but Prine could write like that.” Prine’s mischief shined in songs like “Illegal Smile,” which he swore wasn’t about marijuana; “Spanish Pipedream,” about a topless waitress with “something up her sleeve;” and “Dear Abby,” in which Prine imagines the advice columnist getting fed up with whiners and hypochondriacs.

You have no complaint,” his Abby writes back / You are what you are and you ain’t what you ain’t / so listen up Buster, and listen up good / stop wishin’ for bad luck and knocking on wood!”

Prine was never a major commercial success, but performed for more than four decades, often selling his records at club appearances where he mentored rising country and bluegrass musicians. “I felt like I was going door to door meeting the people and cleaning their carpets and selling them a record,” he joked in a 1995 Associated Press interview. Many others adopted his songs. Bonnie Raitt made a signature tune out of “Angel from Montgomery,” about the stifled dreams of a lonely housewife, and performed it at the 2020 Grammys ceremony. Bette Midler recorded “Hello in There,” Prine’s poignant take on old age. Prine wrote “Unwed Fathers” for Tammy Wynette, and “Love Is on a Roll” for Don Williams.

Others who covered Prine’s music included Joan Baez, Johnny Cash, John Denver, the Everly Brothers, Carly Simon, George Strait, Miranda Lambert, Norah Jones and Old Crow Medicine Show. Prine himself regarded Dylan and Cash as key influences, bridges between folk and country whose duet on Dylan’s country rock album “Nashville Skyline” made Prine feel there was a place for him in contemporary music. Though mostly raised in Maywood, he spent summers in Paradise, Kentucky, and felt so great an affinity to his family’s roots there he would call himself “pure Kentuckian.”

Prine was married three times, and appreciated a relationship that lasted. In 1999, he and Iris DeMent shared vocals on the classic title track of his album “In Spite of Ourselves,” a ribald tribute to an old married couple.

In spite of ourselves we’ll end up a-sittin’ on a rainbow / Against all odds, honey we’re the big door-prize / We’re gonna spite our noses right off of our faces / There won’t be nothin’ but big ol’ hearts dancin’ in our eyes

Prine preferred songs about feelings to topical music, but he did respond at times to the day’s headlines. Prine’s parents had moved to suburban Chicago from Paradise, a coal town ravaged by strip mining that inspired one of his most cutting protest songs, “Paradise.” It appeared on his first album, along with “Your Flag Decal Won’t Get You Into Heaven Anymore,” which criticized what he saw as false patriotism surrounding the Vietnam War. Many years later, as President George W. Bush sent soldiers to war, Prine had a song for that, too. In “Some Humans Ain’t Human,” he wrote: “You’re feeling your freedom, and the world’s off your back, some cowboy from Texas, starts his own war in Iraq.”

Prine’s off-hand charisma made him a natural for movies. He appeared in the John Mellencamp film “Falling From Grace,” and in Billy Bob Thornton’s “Daddy and Them.” His other Grammy Awards include Best Contemporary Folk Recording for his 1991 album “The Missing Years,” with guest vocalists including Raitt, Tom Petty, Bruce Springsteen and Phil Everly. He won Best Traditional Folk Album in 2004 for “Beautiful Dreamer.” Prine didn’t let illness stop him from performing or recording. In 2013, long after surviving throat cancer, he was diagnosed with an unrelated and operable form of lung cancer, but he bounced back from that, too, often sharing the stage with DeMent and other younger artists. On the playful talking blues “When I Get to Heaven,” from the 2018 album “The Tree of Forgiveness,” he vowed to have the last laugh for all eternity.

When I get to heaven, I’m gonna shake God’s hand / Thank him for more blessings than one man can stand / Then I’m gonna get a guitar and start a rock-n-roll band / Check into a swell hotel; ain’t the afterlife grand?

His survived by his wife, Fiona, two sons Jack and Tommy, his stepson Jody and three grandchildren.

Bob Brown/Richmond Times-Dispatch, via Associated Press

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Read any Good Books lately? (#16) – A novel for our times .

The Quarantine Station by Michelle Montbello ($3.99- Kindle)

The book spans two time frames. In the present era a woman is trying to come to terms with personal issues and a family history associated with the great “Spanish Flu” Pandemic of 1918-1920.

“When Rose Porter arrives on the shores of Sydney with little money, she must take a job as a parlour maid at the mysterious North Head Quarantine Station. It’s a place of turmoil, segregated classes and strict rules concerning employee relationships. But as Rose learns, some rules were made to be broken and Rose proceeds to break them all. 2019 … Over a century later, Emma Wilcott lives a secluded life in Sydney where her one-hundred-year-old grandmother, Gwendoline, is all she has. Gwendoline is suffering dementia and her long-term memories take her wandering at night. Emma realizes she is searching for someone from her past. Emma’s investigation leads her to the Quarantine Station where she meets Matt, the station carpenter, and together they unravel a mystery so compelling it has the power to change lives, the power to change everything Emma ever knew about herself.”

 This “book” has been sitting in my Kindle stockpile since October. Now, during this current pandemic it seemed like a good time to read it.  The book had instant appeal for me because of the setting …….. The North Head Quarantine Station in Sydney Harbor. The Quarantine Station was in operation from 1832 to 1984 and it was the Australian equivalent of the Canadian Grosse Isle quarantine station off Quebec and as such it had a rather grim history. It is situated just inside the entrance to Sydney Harbor in a very pretty spot that over looks the harbor. It no longer functions as a quarantine station and has been turned into an historical site. It is just down the road from where I used to live. I even remember a sailing trip on Sydney Harbor with a group of friends that included anchoring off the beach below the station for a picnic.  The setting, to the best of my memory is authentic, and to some extent for me it was a trip down memory lane. Of course the pandemic history is before my time but, given our current situation, it is very easy to slip into the history of the era and relate to the trials and tribulations of the Spanish Flu pandemic of 1918. “The story is an exquisitely told and beautifully realized historical tale that weaves history and fiction together.The story is a beautifully realized historical tale that I highly recommend. If you have ever lived or visited Sydney this book is a must read.

 

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Foot Notes:

  • The “Spanish Flu” was not Spanish in origin. It originally came to life during World War I in the military camps of the American Mid-West. American troops spread the infection when deployed to Europe in the latter stages of the war.
  • The historic Quarantine Station is located in Manly on Sydney’s North Head, an area which has important cultural and spiritual significance to the land’s traditional owners. The site is part of the rich history of Aboriginal occupation of the Sydney area.

    Chosen in 1832 as the ideal site for the development of a quarantine facility, due to its isolation, deep anchorage options, fresh water spring and proximity to the entrance to Sydney Harbor, the site reflects the evolving cultural landscape of colonial Australia, as well as demonstrating the impact of changing social attitudes and scientific and medical developments.

    The small but comprehensive museum relays the historical, material. social, cultural, and political influences in the evolution of the site. The site’s 65 heritage buildings reflect a rich history. The diverse character of the buildings occurred  through changing practices of use and expansions when the site’s facilities were in high demand due to larger disease outbreaks – Wikipedia

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Rick Parsons – In Memory

Obituary of Richard “Rick” Douglas Parsons

May 5, 1947 – March 16, 2020

It is with great sadness that we announce the passing of Richard Douglas Parsons on Monday, March 16, 2020 in Cranbrook, BC.

Rick was born on Salt Spring Island on May 5, 1947. After graduation, he went to Vancouver to work for BC Tel. He worked for BC Tel/Telus for 35 years. He transferred to Cranbrook (his favourite hunting grounds) in the fall of 1993. He loved the fall when he would try to get that elk. “Deer Camp” was formed in 2010, when good friends from Chilliwack would come and experience Kootenay hunting and in turn Rick would go out there and share in the Fraser River fishing.

As a young boy, Rick took piano lessons and got as far as Grade Two with the Royal Conservatory, but then came “Rock and Roll” and he ditched the piano and taught himself to play the drums. At the age of 14, he was playing at school, local dances and off island gigs. He even played for his graduation! In his 20’s he started playing organ again but then took off about 10 years to get married and raise his daughters. In 1985, after his marriage ended, he got back into playing again.

After moving to Cranbrook, Rick joined bands such as the Home Brew, Eragone, Loose Change, Diamond Forever, Little Sand Creek, East West Connections, The Choice and Resisting A Rest. He had recently debuted with Brass Monkey, just after finding out his liver was in failure.

Rick has been diagnosed with a rare form of PNET cancer 3 years ago. In 2018/2019. Rick took part in a trial treatment in Quebec. The treatment had shrunk the tumors for 6 ½ months but then the cancer rapidly took over.

Rick is predeceased by Doug Parsons and Barb Parsons.

He leaves behind his partner and soulmate; Paula Bedford, 2 daughters; Stacy, Kelly (Sean), stepdaughter; Lynn (Clint), stepson; Jason (Livi), 7 grandchildren; Mason, Callie, Micheal & Jordy, Declan & Soraya, and the newest addition Tyler.

We are going to miss his keyboards.

In lieu of flowers, Rick and his family ask that donations be made to the BC Cancer Society (PNET)

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A note from fellow musician James Neve:

Friends,

Before his passing, Rick Parsons asked me to assist Paula in parting with his musical gear, and as a long time performer and collector, there is quite a bit of gear. So, Rather than advertise directly I thought I would pull together a list, and send it out to those performers and players I know to see if you might be interested in some of the items. I did an internet search to try and find fair prices – now some of the gear is Vintage and other stuff newer and like new. So I did my best to try and set these prices. Even if you are not interested perhaps you know someone who might be so by all means pass on the attached list with my contact information.
A few items that have sold were cleaned/disinfected by me or have been stored for many weeks without human contact.
Thank you for your interest and help.
Jamie Neve
familyneve@gmail.com
250-427-4882
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Read any Good Books lately? (#15) – Afghanistan ….. with a twist.

It seems like Afghanistan is a bottomless pit of war and violence. It has been that way “forever”. The locals have fought and killed each other in tribal disputes for centuries. In the 19th century they fought the British to a standstill in the wars of the North West Frontier. In the 20th they defeated the Russians before renewing their own inter tribal conflicts. Following the expulsion of the Russians the Taliban rose to the top of heap and ruled with a religious ferocity. Following the terrorist attack on the “Twin Towers” in New York the country caught the interest of the USA and were perceived to be a haven for Islamic terrorists. Rightly or wrongly, in the American world view they needed to be eradicated. To that end the US embarked on a military adventure to win “the war on terror”. By invading the country there was a hope of pacifying the country and ushering in an era of democratic peace. Under US patronage and with the  help of an international military force the occupation has lasted eighteen years. Think about it! Eighteen years. During that time attempts have been made to introduce democracy into the country and protect the rights women and, despite the best of intentions, that seems to have failed. Like the British and the Russians before them the US is now preparing to leave. The golden rule of any occupation is that the occupiers eventually have to go home. The other part of the golden rule is that all insurgents know this. They just have to keep up the pressure and wait until the time is right for the occupying force to come up with some face saving pretext to leave the country honorably. The only occupying force to achieve a measure of success against insurgents has been the British in Malaya in their fight against the communists in the 1950s.

Like any war there have been a multitude of novels, war stories  and pages and pages of political analysis. In most publications the context has been one with an American perspective. The Americans were perceived as the only allied heroes, and villains, fighting the Taliban.  This is despite the fact that the allied partners from many counties have participated in the “war on terror” and suffered significant casualties. One of the partners in the “adventure” is Denmark. Danish, Canadian, German, French etc soldiers have fought and died in Afghanistan and their stories need to be told. One of the partners in the “adventure” is Denmark and this is an Afghan story with a  Danish perspective.

Carsten Jensen is a leading literary figure in his native Denmark. He is the author of the international bestseller We, the Drowned, which has sold more than half a million copies in twenty languages. As well as being an acclaimed novelist, essayist, newspaper columnist, and political commentator, Jensen has reported from war zones in the Balkans and Afghanistan. He has been awarded many prizes for fiction and nonfiction, including Denmark’s coveted Golden Laurel for the travelogue I Have Seen the World Begin, and Sweden’s prestigious Olof Palme Prize for his “work, in words and deed, to defend the weak and vulnerable in his own country as well as around the world.”

 

Read any Good Books lately? (#14) – It’s an Italian Thing

THE WALLS OF LUCCA by Steve Physioc
“An award-winning tale of love, life and forgiveness in World War I Italy”
Kindle edition $3.98
ABOVE THE WALLS by Steve Physioc
“Riveting World War II family saga with a heart-stopping ending”
Kindle edition $5.31

Remembering John Renbourn

John Renbourn. Not exactly a household name in 2019 but back in the day (mid-1960s), his name was synonymous with the innovations in Acoustic Finger Picking guitar styles. That era was a hot bed of musical innovation for acoustic guitar players.  In the UK and Ireland the “folk music revival” of that time fostered interest in the American acoustic finger picking styles of the Rev. Gary Davis, Doc Watson, Mississippi John Hurt, Elizabeth Cotten, Dave Van Ronk, Joseph Spence, Blind Lemon Jefferson, Merle Travis and many more “roots” musician. Guitarists of today probably do not realize the extent of the volatility of the acoustic guitar scene of that era. Memories of that scene have been somewhat over shadowed by the explosive growth of the “British Rock and Roll” phenomenon and the electric guitar scene that followed shortly after. At that time acoustic guitarists were very fortunate to be exposed to the increased availability of recorded material, a huge number of touring folk musician legends, and a steady improvement in the quality of acoustic instruments. The acceptance of the guitar into the traditional folk scene was not immediate. The guitar was then considered foreign to the unaccompanied vocal traditions that were prevalent in the British folk clubs. However, a number of acoustic guitarists adapted the imported styles and created blends of techniques and musical styles to create new, unique ways of playing “folk music”. Innovators of the day included Davey Graham (the inventor of DADGAD tuning), Nic Jones, Martin Carthy, Bert Jansch and of course John Renbourn. Most of the innovators have gone and the only one still playing at the peak of his powers is probably Martin Carthy. Nic Jones is till alive but still suffering the effects of a catastrophic car accident. On March 26, 2015 at the age of 70 years John Renbourn passed away.

I was very fortunate to be in Banff on Thursday, September 26, 2001. I was coming off a back packing trip to Mount Assiniboine when I spotted a poster for a concert by John Renbourn at the Banff Centre. I was fortunate enough to land a seat no more than six feet away from John. I had smuggled in my camera and I managed to snap some illegal photos right at the end of the show. That was just before I was nailed by the usher. It was a small price to pay for the opportunity. Apart from the music the thing that struck me most about this master musician was how old looked. He must have been only in his late 50’s but he looked more like eighty. He did have a reputation for living hard and it showed when he shuffled on stage, sat down and had to physically hoist his one leg across his knee to support his guitar. That didn’t seem to impair his technical ability or his musicianship. It was a memorable concert and one that has come flooding back after viewing this attached video.

I think the video speaks for itself. There are some interesting anecdotes as well as demonstrations of John’s playing. Clive Carroll is a name that is new to me but obviously one deserving of attention. His playing ranks right up there with other modern masters and I am looking forward to hearing more of his work.

Also here is a video of John performing one of his iconic master pieces – SWEET POTATO

After viewing the videos I went looking for the photos I took on that night to add to this blog. They are buried deep in the masses of photos I have taken over the years and I have not been able to find them. But all was not lost. I did a search on the internet and lo and behold I came up with a link to my original article written at the time. So here are the photos ……

 

All in all it has been a nice reminder that there is more to guitar playing than strumming three chords.

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File under Wonderful – The possible eradication of Cervical Cancer

https://mosaicscience.com/story/rwanda-cervical-cancer-hpv-vaccine-gardasil-cervarix/

The East African country’s campaign to end cervical cancer through the HPV vaccine has had to overcome cultural taboos and rumours about infertility – but it’s saving lives.

Girls began queuing at their local school with their friends, waiting for their names to be called. Many were apprehensive. After all, most of them had not had a vaccination since they were babies. It was 2013 and a new vaccine had arrived in Kanyirabanyana, a village in the Gakenke district of Rwanda. Reached by a reddened earth road, the village is surrounded by rolling hills and plantations growing crops from bananas to potatoes. Unlike the 10 vaccines already offered to young children as part of the country’s immunisation programme, this vaccine was different: it was being offered to older girls, age 11–12, in the final year of primary school.

Three years before, Rwanda had decided to make preventing cervical cancer a health priority. The government agreed a partnership with pharmaceutical company Merck to offer Rwandan girls the opportunity to be vaccinated against human papillomavirus (HPV), which causes cervical cancer.

This was the first time an African country had embarked on a national prevention programme for cervical cancer. Could Rwanda become the first country in Africa to eliminate it?

It was an ambitious goal. Cervical cancer is the most common cancer in Rwandan women, and there were considerable cultural barriers to the vaccination programme – HPV is a sexually transmitted infection and talking about sex is taboo in Rwanda. Added to this, rumours that the vaccine could cause infertility made some parents reluctant to allow their daughters to be vaccinated.

Rwanda’s economy and history also made it seem an improbable candidate for achieving high HPV vaccination coverage. After the 1994 genocide, it was ranked as one of the poorest countries in the world. High-income countries had only achieved moderate coverage of the HPV vaccine; if the United States and France couldn’t achieve high coverage, how could Rwanda?

Worldwide, cervical cancer is the fourth most common cancer in women. There were an estimated 570,000 new cases in 2018 – and over 310,000 deaths, the vast majority in low- and middle-income countries. Sub-Saharan Africa has lagged behind the rest of the world in introducing the HPV vaccine and routine screening, which means the cancer often isn’t identified and treated until it has reached an advanced stage.

Almost all cases of cervical cancer are caused by HPV. It is one of the commonest sexually transmitted infections globally, and most of us are infected with at least one type of genital HPV at some point in our lives – usually as teenagers or young adults. In most cases the virus is harmless and resolves spontaneously without causing any symptoms such as genital warts.

There are more than 100 strains of HPV, at least 14 of which can cause cervical cancer and a range of less common cancers, including of the penis, vagina and anus. Persistent infection with two strains of HPV, 16 and 18, is responsible for 70 per cent of cervical cancer cases.

The first vaccine against HPV became available in 2006. This was the culmination of decades of work, notably by scientists in Germany, who in 1983 discovered the link between HPV infection and cervical cancer.

Ian Frazer and Jian Zhou at the University of Queensland, Australia, then jointly developed the technology that enabled the HPV vaccine. Using recombinant DNA technology, they built the shell of the virus from scratch and made an ‘empty’ human papillomavirus in the lab.

“This was something nobody had achieved before,” Frazer says. They realised this empty, non-infectious HPV could be used as a vaccine to prevent HPV and cervical cancer.

The news that there was a new vaccine which could drastically reduce the number of women getting cervical cancer went around the world. But with the excitement about the new vaccine came the realization that not all girls would have the same opportunity to receive it. It was likely that at least a decade would pass between its introduction in high-income countries and in low-income countries.

Today there are three HPV vaccines – Gardasil and Gardasil 9, made by Merck, and Cervarix, made by GSK. All are highly effective at preventing infection with virus types 16 and 18. The newest – Gardasil 9 – was licensed in 2014 and protects against nine types of HPV, which between them cause around 90 per cent of cervical cancers.

More than 800,000 people died in the Rwandan genocide, and its widespread destruction left the country devastated. Coverage of most World Health Organization-recommended childhood vaccinations plummeted to below 25 per cent. But within 20 years, the number of babies in Rwanda receiving all recommended vaccinations, such as polio, measles and rubella, had increased to around 95 per cent. Rwandans’ life expectancy more than doubled between 1995 and 2011. The Rwandan government had demonstrated the determination and thoroughness of its approach to vaccinations. Could it now have the same success with HPV?

Before the HPV vaccine arrived in Kanyirabanyana, 63-year-old Michel Ntuyahaga, a community health worker, spent weeks canvassing his village, going to each of the 127 mud-brick houses to inform parents about the upcoming vaccination campaign.

Joined by a nurse, he explained to parents that if they had an adolescent daughter, they had an opportunity for her to be vaccinated against a deadly women’s disease – cervical cancer.

“I explained to parents that the cancer is a disease and that the one measure to prevent it is vaccination,” he says.

Ntuyahaga wasn’t the only person educating the community about the vaccination campaign.

Constantine Nyiransengiyera has been a primary school teacher in Kanyirabanyana for the past 13 years. In addition to teaching maths, science, French and English, she was – and continues to be – responsible for gathering all the 12-year-old girls at the local school to educate them about the HPV vaccine.

Silas Berinyuma, a leader in Kanyirabanyana’s Anglican church for the past 24 years, preached about the importance of the vaccine for weeks before it arrived in the village. The church used drama to depict scenes of cervical cancer’s devastating impact. This continues today.

The same awareness campaign was taking place around the country – Rwanda has a network of 45,000 community health workers, volunteers who are present in every village. Bugesera is a district in the Eastern Province, not far from the border with Burundi. Billboards line roads through the district, advertising soft drinks alongside public health messages. One says: “Talk to your children about sex, it may save their lives.”

Not far off the main road is Karambi, a village surrounded by banana plantations. Toddlers roll tyres down the red-earth roads, teenagers carry handfuls of firewood on their heads, and adults herd cows and goats.

In 2013, the then 12-year-old Ernestine Muhoza was vaccinated against HPV at her school. “The teachers called just girls for assembly and told us that there was a rise of a specific cancer among girls aged 12 and that it was time for us to get vaccinated,” she says.

The Rwandan government had demonstrated the determination and thoroughness of its approach to vaccinations. Could it now have the same success with HPV?

When she went home to tell her parents about the vaccination, they’d already heard about it on the radio and via community health workers.

Muhoza’s parents readily agreed. But not every parent did. Some were sceptical. Why, they wondered, would their girls be getting vaccinated now, at this age? Why couldn’t all girls and women receive the vaccine? And rumour had it that the vaccine would make girls infertile.

Community health worker Odette Mukarumongi worked tirelessly in Karambi to counteract the rumours. “I told parents that a girl will go into constant menstruation – like endless bleeding – if she gets cervical cancer,” she says.

Mukarumongi says parents eventually “surrendered” and allowed their daughters to be vaccinated. Today, she says, parents rarely refuse, now that they can see the widespread acceptance of it in the community.

In Kanyirabanyana, Ntuyahaga worked similarly hard to convince parents that the vaccine wouldn’t stop their daughters from being able to conceive.

“Parents had heard that the vaccine made girls infertile. We struggled to explain to them it wasn’t true – that it was better to vaccinate their daughters against the cancer because if they got it they would become infertile,” he says.

Community health workers and nurses visited homes with posters of women’s reproductive organs to show parents the damage cervical cancer could do to their daughters.

Felix Sayinzoga, manager of the maternal, child and community health division at the Ministry of Health, says: “Rwandans are really afraid about cancer so it was easy [to roll the vaccine out]. It was also about the trust the community has in the government. That was really important – the community knows that we do not bring things that are not good for them.”

The current health minister, Diane Gashumba, agrees that trust in the government has been critical in supporting the vaccine’s uptake, but admits that the rumours surrounding it were difficult to quash.

“The rumours were not anticipated. But, of course, as the HPV vaccine was a new vaccine for a new target group there were many questions.” She adds that church and village leaders, community health workers and radio programmes played an integral role in dispelling myths about the vaccine.

Despite the vaccine’s potential to save lives – millions of them – HPV vaccination has been mired in controversy and hostility, and this has heightened in recent years.

The vaccine is recommended for girls, and in some countries for boys aged 12 to 13 too, because this is before sexual activity begins, bringing the risk of exposure to HPV. This has resulted in the vaccine being linked with promiscuity – a belief that vaccinating young girls against an STI sexualises them and encourages sexual activity. There is no evidence that boys or girls who receive the vaccine have sex earlier than those who do not have the vaccine. But this concern is one of the reasons that India – a country where more than 67,000 women die from cervical cancer every year – has refused to introduce HPV vaccine into its routine immunisation programme.

Leela Visaria, social researcher and honorary professor at the Gujarat Institute of Development Research in India, says: “The underlying reason why people don’t want it [the vaccine] is the fact it’s given to adolescent girls. They fear that girls will become promiscuous.”

Parents’ concerns about the HPV vaccine have been further fuelled by false claims about its safety. This misinformation has spread rapidly, worldwide, on social media. Japan’s take-up rate has plunged from more than 70 per cent to less than 1 per cent. Coverage has also dropped in parts of Europe, such as Denmark. In Ireland, conversely, a targeted social media campaign is reversing a sharp decline in the HPV vaccination rate.

Peter Hotez, a vaccine scientist and dean of the National School of Tropical Medicine at Baylor College of Medicine in Texas, agrees that there is a problem in the fears that the vaccine sexualises young girls. “The other problem is that the anti-vax movement has been making false assertions about it – claims that it leads to autoimmune diseases and paralysis.

“I think the movement is attempting to draw a line in the sand and say, ‘no more vaccines’ and when something like HPV comes along they are throwing everything they can at it. It’s having a devastating impact. I worry that we will start to export this garbage and it will impact vaccine uptake in Africa.”

“Initially, when the HPV vaccine was introduced in different countries, there were differences of opinion on whether to focus on HPV and how it’s transmitted, or to focus on the fact that HPV leads to cancer and this vaccine will prevent cancer,” says Mark Feinberg. He is the former chief public health and science officer at Merck who was involved with the Rwanda programme.

“Rwanda emphasised cancer prevention. It sought to communicate that the vaccine is here to protect young women from cervical cancer.”

Sayinzoga, from the Ministry of Health, agrees that policy makers made a conscious decision not to link the vaccine with sex. “For us, we didn’t associate the vaccine with sex. We rather focused on the side-effects of cervical cancer: that it can cause infertility. Sex wasn’t part of the campaign,” he says.

It’s a decision that is widely accepted by public health experts as the right one.

Ian Frazer, the immunologist who co-invented the first HPV vaccine, says: “The HPV vaccine has had a negative association. It has turned cervical cancer into an STI, which it is, of course, but we have to be careful. There is a right messaging for every country. Now we just talk about it as a vaccine to prevent cervical cancer. I think that’s the right strategy.”

In Karambi, Muhoza, who is now 17 years old, says: “You know, there are some things that cannot be talked about openly, especially when they relate to sex.”

When Rwanda and Merck signed their agreement, it meant that from 2011 the pharmaceutical company would supply the country with HPV vaccinations for three years at no cost.

As one of the world’s largest pharmaceutical companies, Merck wanted to demonstrate that it was feasible to introduce the vaccine in low-income countries in the hope that Gavi – a global health alliance to increase access to vaccination in these countries – would take note and get on board.

“Yes, Merck is a for-profit company, but our motivation was to maximize the impact of the vaccine. We wanted to find ways of enabling its innovations to be more broadly available,” says Feinberg, who is now president and CEO of the International AIDS Vaccine Initiative.

“You quickly recognise that you have a vaccine that can have such a major impact in preventing cervical cancer, and the greatest disease burden is concentrated in the world’s poorest communities. You cannot with any conscience not come forward and make the vaccine affordable and create a sustainable vaccination programme.

“The programme in Rwanda had two purposes: to get the vaccine to a population who could benefit, but also to demonstrate what was possible. Rwanda is an incredible country in its commitment to national health. If it wasn’t possible in Rwanda, we knew it wouldn’t be possible anywhere else.”

Rwanda’s decision to partner with Merck wasn’t without its critics. In a scathing letter to the Lancet, German public health researchers voiced “serious doubts” that the HPV programme was “in the best interest of the people”. A major issue, they contended, was that while the burden of cervical cancer in the region was substantial, there were far more pressing diseases to vaccinate against, such as tetanus and measles.

If it wasn’t possible in Rwanda, we knew it wouldn’t be possible anywhere else

Rwanda’s then Minister of Health, Agnes Binagwaho, replied publicly in a letter co-signed by two US researchers. They said that Rwanda already had very high vaccination rates for tetanus and measles, and asked: “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’?”

Drawing an analogy with earlier opposition to antiretroviral therapy in Africa, they said that such objections were “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.”

Binagwaho, now vice-chancellor at the University of Global Health Equity in Rwanda, is still scathing about the critics of the decision to rollout the HPV vaccine. “The people who have created a backlash haven’t done their homework – they don’t know our country, they don’t know that our kids are well vaccinated with other vaccines available. [The HPV vaccine is] a great tool to prevent one of the most ravaging women’s cancers. It is less costly to prevent cervical cancer and all its suffering.”

Rwanda has proved to the world that it can achieve excellent HPV vaccination coverage. The Ministry of Health reports that 93 per cent of girls now receive the vaccine.

Almost all Rwandan girls attend school, and the systematic inclusion of local and religious leaders, community health workers and teachers in the vaccine delivery strategy has proved highly effective in spreading the message about the benefits of the vaccine and combating myths.

“I think some of the biggest reasons why Rwanda has been so successful is, first and foremost, the political will and national mobilisation, and secondly, that they decided to do a school-based programme,” says Claire Wagner, a student at Harvard Medical School who formerly worked as research assistant to Binagwaho.

The success in getting girls vaccinated has boosted confidence that the country is making rapid progress towards eliminating the disease. “We are working on our goal. We put our people first,” says health minister Gashumba.

Since 2006, over 80 countries have introduced the HPV vaccine into their routine immunization programmes. The majority are high-income, from Australia to the United Kingdom to Finland. These countries also have screening programmes for HPV and are moving from the pap smear test to a more advanced test, taken every five years, that detects high-risk HPV infections before cancer develops.

In Rwanda, before the HPV vaccine was introduced in 2011, there was no cervical cancer screening available in public health facilities – a few private clinics and NGOs offered it sporadically. Along with the vaccination programme, Rwanda also launched a national strategic plan for the prevention, control and management of cervical lesions and cancer. Women are meant to undergo visual inspection of cervix with acetic acid (VIA) at their local health centre or district hospital. Done by nurses and doctors, the screening is available to women with HIV aged 30 to 50, and other women aged 35 to 45. It’s unclear how effective and widespread this screening is.

“The problem with VIA is that one in five women will be positive but only 5 per cent need to be treated. That is an enormous cost to the healthcare system,” Frazer says. “If we want quick results we need to have some type of screening programme, but there’s a lot of debate about what that should look like in the developing world and how feasible it is.”

In Bugesera, community health worker Odette Mukarumongi says the closest health centre doesn’t do cervical cancer screening. Instead, she tells girls and women that if they experience any symptoms, like pelvic pain or constant menstruation, they should go to the health centre for a check-up.

Given that most cervical cancer cases occur in women in their 40s and 50s, if Rwanda is going to eliminate cervical cancer it will need a robust screening programme that reaches all women – women who have not benefited from the vaccine.

Countries across sub-Saharan Africa and Asia have struggled to implement cervical screening programmes. Given geographical challenges, lack of funding, and competing health issues such as HIV and malaria, cervical cancer hasn’t been a priority for most policy makers. While it accounts for less than 1 per cent of all cancers in women in high-income countries, in low- and middle-income countries it’s almost 12 per cent. This is why the HPV vaccine is so critical: for girls and women in these countries it is their best – and often only – line of defence against the disease.

Another factor in the success of Rwanda’s campaign to end cervical cancer will be its ability to sustain the HPV vaccination programme. In 2014, Merck’s donation of Gardasil ended. As Feinberg had hoped, the Gavi alliance announced it would support Rwanda’s HPV programme through a co-financing model. Rwanda pays 20 cents per dose of the vaccine, and Gavi covers the remainder of the $4.50 cost. As the country’s economy continues to grow, its co-financing obligations will rise until it reaches a threshold after which Gavi support will phase out over a five-year period. Eventually, Rwanda will fully finance its HPV vaccine.

Will the country be able to afford this?

Sayinzoga from the Ministry of Health admits he’s concerned about the country’s ability to pay for the vaccine in future. “The HPV vaccine is very expensive. What we are doing annually is looking at how we can plan for the next three years. We were in need and we accepted Merck’s help. We need to invest in the life of our people,” he says.

Gashumba says the Ministry is exploring options to make the vaccination programme sustainable, such as including the vaccine in health insurance.

Whatever the challenges in the future, Rwanda has today achieved remarkably high coverage of the HPV vaccine for girls – an extraordinary public health achievement that should inspire countries around the world.

As Rwanda gears up for a new round of vaccinations later this year, the immunologist responsible for the vaccine that has saved so many women’s lives believes the world cannot be complacent. “You can’t be happy until everyone has been vaccinated,” Frazer says.

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“Human papilloma virus (HPV) vaccines are vaccines that prevent infection by certain types of human papillomavirus.[1] Available vaccines protect against either two, four, or nine types of HPV.[1][2] All vaccines protect against at least HPV type 16 and 18 that cause the greatest risk of cervical cancer.[1] It is estimated that they may prevent 70% of cervical cancer, 80% of anal cancer, 60% of vaginal cancer, 40% of vulvar cancer, and possibly some mouth cancer.[3][4][5] They additionally prevent some genital warts with the vaccines against 4 and 9 HPV types providing greater protection.[1]

The World Health Organization (WHO) recommends HPV vaccines as part of routine vaccinations in all countries, along with other prevention measures.[1] The vaccines require two or three doses depending on a person’s age and immune status.[1] Vaccinating girls around the ages of nine to thirteen is typically recommended.[1] The vaccines provide protection for at least 5 to 10 years.[1] Cervical cancer screening is still required following vaccination.[1] Vaccinating a large portion of the population may also benefit the unvaccinated.[6] In those already infected the vaccines are not effective.[1]

HPV vaccines are very safe.[1] Pain at the site of injection occurs in about 80% of people.[1] Redness and swelling at the site and fever may also occur.[1] No link to Guillain–Barré syndrome has been found.[1]

The first HPV vaccine became available in 2006.[1][7] As of 2017, 71 countries include it in their routine vaccinations, at least for girls.[1] They are on the World Health Organization’s List of Essential Medicines, the most effective and safe medicines needed in a health system.[8] The wholesale cost in the developing world is about US$47 a dose as of 2014.[9] In the United States it costs more than US$200.[10] Vaccination may be cost effective in the developing world.[11] —–   Wikipedia

 

“Research studies have shown early signs of the vaccine’s success including: a 77% reduction in HPV types responsible for almost 75% of cervical cancer. almost 50% reduction in the incidence of high-grade cervical abnormalities in Victorian girls under 18 years of age.”

“How effective is the HPV vaccine? The HPV vaccine provides almost 100% protection from nine HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58), if all doses are received at the correct intervals, and if it is given before you have an infection with these types.”   —–   Wikipedia

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