她力量｜一位中国妇科医生的故事：只愿草原再无宫颈癌

内蒙古鄂尔多斯市的准格尔旗是中国第一个免费提供HPV疫苗接种服务的地方。这个名不见经传的小县城能超越北上广成为“中国第一”并非偶然，这一成就的背后是国家级宫颈癌防治专家段仙芝几十年如一日的努力。她为防治宫颈癌奋斗一生，哪怕家里还有两个孩子嗷嗷待哺，哪怕一次出诊往返路程上千公里，哪怕她已经69岁。段仙芝说：“我选择了这个职业就意味着奉献，什么都很完美是不可能的，能帮助到家乡50多万名妇女，我一生很满足。”

1952年，一个女孩在内蒙古鄂尔多斯市准格尔旗的农村呱呱落地，她就是段仙芝。谁也不会想到正是这个平凡的蒙古族小女孩让这座偏远的县城超越北上广，成为了中国第一个免费提供HPV疫苗接种服务的地方。

在那个年代的准格尔旗，女孩子上学是很少见的事。在大部分人的观念中，女孩长大了是要相夫教子、干农活的，男孩才需要读书。段仙芝的妈妈和奶奶也不例外。段仙芝却对读书很感兴趣，她总觉得读了书路才宽。段仙芝回忆道：“从小学二年级开始，我就是班里唯一的女生。为了上学，我总是在清晨偷偷溜出家门，从草垛里扒出昨天藏好的书包，独自跑7公里的泥路去学校。”

Duan Xianzhi was the only girl in her class from second grade in elementary school. /courtesy of Duan Xianzhi

经过不懈努力，她成了村里少有的知识分子，更是通过进修成为了一名妇产科医生。当她成为医生之后，她发现原来村里老人们总说的“倒开花”，其实就是宫颈癌，只是农村女性因为缺乏相应的知识，把这种绝经之后又流血的现象打趣成了“倒开花”，殊不知这是一只夺命之手。因为童年的成长经历，段仙芝对中国农村女性的处境有深刻的体会。她下定决心要把自己的技术学好了，让自己有能力为家乡这些被病痛折磨的老百姓解除痛苦。

段仙芝从2005年开始在当地推广宫颈癌筛查项目，仅那一年她在参与项目的400名女性中就筛查出了4位宫颈癌患者和28位癌前病变患者。2011年这个项目推广到了鄂尔多斯全市范围，她惊讶地发现鄂尔多斯的宫颈癌发病率竟然接近全国平均水平的两倍。

贫穷、受教育水平低、自然环境恶劣、妇产科医生稀缺等诸多因素导致了这个结果。段仙芝说：“草原上缺水，女人们不会经常洗澡。而且她们社会经济地位相对较低，如果有身体不适，也不愿意说出来。”她还发现，因为妇科疾病通常让人想到性生活不检点，这种污名化也让女性在发现身体异样的时候产生羞耻感，更不用说去医院看病了。即便有了免费的筛查项目，也有很多人不愿意接受检查。段仙芝解释说：“一方面她们没有钱，另一方面她们因为缺乏这方面的知识而感到羞耻和恐惧。”在这种情况下，为了说服农村女性来做筛查，她几乎走遍了鄂尔多斯各个旗县。

The only health center in Shi'erliancheng Village, Jungar Banner under Ordos City, north China's Inner Mongolia Autonomous Region, September 4, 2021. Yang Shengjie/CGTN

This is the story of a female gynecologist, rural women and pervasive cervical cancer in a remote, obscure town nestled in north China's Inner Mongolia Autonomous Region. 

In the late 1950s, Duan Xianzhi, an ethnic Mongolian girl, sneaked out of her house every morning to run seven kilometers to school on dirt country roads. Her mother and grandmother wouldn't let her go to school since a girl was supposed to stay home doing chores and working the farmland. But she persisted, believing education would give a woman more choices in life.

Fifty years later, she traveled across the crescent-shaped Inner Mongolia Autonomous Region in north China to understand why the incidence rates of cervical cancer were so high along with the state of disease prevention and control. She started an early detection and treatment program for cervical cancer in 2005 when leading the Department of Gynecology and Obstetrics at Inner Mongolia People's Hospital. Among the 400 women she screened that year, she found four with cancer and 28 with precancerous lesions. These figures were disconcerting.

Her program of providing free cervical cancer screenings to female residents aged between 35 and 64 expanded to Jungar Banner under the Inner Mongolia city of Ordos in 2011. Afterward, she found that the incidence of cervical cancer was twice as high as the national average, and the mortality rate was unusually high because most women never got screenings until the cancer became terminal.

Multiple factors contributed to this sordid state of affairs. Poverty, low literacy rates, a harsh physical environment and lack of experienced gynecologists were all culprits. "Households on the plateau face acute water scarcity so that women wouldn't take showers often. What's more, a relatively low socioeconomic status makes them reluctant to speak out about their pain," Duan told us with concern in her voice. The structural barriers are longstanding and hard to break.

We met the 69-year-old veteran gynecologist for the first time in July in her humble, tidy office at Beijing Tongren Hospital, a prestigious public hospital founded in the Chinese capital city in 1886. When we arrived, she had just completed five operations but showed no signs of exhaustion. She walks lightly and speaks fast, looking much younger than her age.

"When I was little, I often heard elderly neighbors murmuring that someone was having postmenopausal bleeding. And people died from it," she recalled. She did not learn that it was actually cervical cancer and that it's primarily caused by infection from the human papillomavirus (HPV) until she became a medical student many years later. She also found that most women in Inner Mongolia would put up with problems regarding the cervix because gynecological diseases were usually associated with promiscuity or other activities that were stigmatized.

The shame attached to the disease prevented them from seeing a doctor, let alone get screened. Duan went from door to door, persuading the women to get tested. "Penury is one thing; the feeling of shame or fear due to poor information is another."

Duan and her team have screened 120,000 women over the years, and according to their findings, Ordos had the highest detection rate for cervical cancer, standing at 9.87 percent. "That means one in every 10 women with positive HPV test results in Ordos is likely to develop cervical cancer."

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“沉默的杀手”

The 'silent killer'

作为全球女性第四大常见癌症，仅2020年就有34万女性因患宫颈癌而死亡，即每分钟就有一名患者被确诊，每两分钟就有一名患者因此去世。宫颈癌在早期阶段通常没有任何症状，如果没有定期筛查，很难被发现。因此，宫颈癌也被称为“沉默的杀手”。

这种疾病对发展中国家的女性来说更为致命。根据世界卫生组织 (WHO) 的数据，因患宫颈癌而死亡的女性中大约 80% 至 90% 来自中低收入国家。因为缺乏预防知识、治疗手段和资金支持等原因，这些国家的宫颈癌死亡率极高。

中国的情况同样严峻。2020年全球超过34万人死于宫颈癌，其中近6万人在中国。而中国农村女性的宫颈癌死亡率是城市的两倍，内蒙古等偏远农村地区的数据最是骇人。

然而，如果及早发现，这一对女性生命造成威胁的癌症是可以被消除的。在所有类型的人类癌症中，宫颈癌是唯一一种已知病因、可以防治的癌症。患者一定是因为感染了某些高危型 HPV病毒才会患上宫颈癌，所以宫颈癌筛查和HPV疫苗接种对于女性至关重要。这些措施的落实与否决定着全世界几十万人的生与死。

段仙芝坚定地认为：“女性不应该死于宫颈癌，特别是现在我们除了筛查之外还有疫苗。”HPV疫苗接种是感染的一级预防。第一种HPV疫苗于2006年面世，而2019年底，中国国内首支HPV疫苗也问世了。

2020年11月17日，世界卫生组织（WHO）启动了加速消除宫颈癌的全球战略，包括中国在内的所有194个成员国首次一致承诺消除宫颈癌。该战略旨在推动全球到2030年实现下列目标，将使所有国家走上消除宫颈癌的道路: 90%的女孩在15岁之前完成人乳头状瘤病毒疫苗接种；70%的妇女在35岁和45岁之前接受高效检测方法筛查；90%确诊宫颈疾病的妇女得到治疗（90%癌前病变阳性妇女得到治疗，90%浸润性癌病例得到管理）。

Cervical cancer is the fourth most common cancer in women worldwide. It kills more than 300,000 women per year, with one woman diagnosed every minute and dying of the disease every two minutes.

It's called the "silent killer" because it typically presents no symptoms in its early stages and develops slowly. Without regular screening and timely treatment, cervical cancer, in most cases, can't be identified until it's too late.

The disease is even deadlier for women in the developing world. Some 80-90 percent of those who die from cervical cancer are from middle- and low-income countries, according to the World Health Organization (WHO). Lack of access to prevention and treatment means, including screening, surgery, chemotherapy or radiotherapy, have resulted in alarming death rates.

The situation is equally grave in China. Among the more than 340,000 deaths from cervical cancer in 2020 worldwide, nearly 60,000 were in China. The incidence and death rates vary widely among regions. The annual mortality rate in rural China is twice as high as among urban women, as shown by cervical cancer studies.

Remote, desolate rural regions such as Inner Mongolia report the most disturbing figures. In the 1990s, cervical cancer mortality in Inner Mongolia was 7.6 per 100,000 people, which remained distressing despite a decline from 14.4 in the 1970s, according to estimates. Morbidity also posts a concerning annual growth rate of over 25 percent in the region, twice as high as the national average.

However, the threat to women's lives is preventable and even curable if detected early.

Out of all types of human cancers, cervical cancer is the only one with a known cause – infection with certain high-risk types of HPV. The virus is primarily transmitted through sexual activity. After transmission, it depends on the person – for those who are fortunate or have strong immune systems, the virus is purged from their bodies. A weakened immune system could give HPV the chance to integrate with the DNA in the cells, to which the virus could then cause changes that may eventually give rise to cervical cancer.

It's the only curable cancer in human history. Screening and getting an early diagnosis are crucial to preventing infections and precancers. These measures can make a real difference – a difference between life and death.

"Women should not be dying from cervical cancer," Duan said. "Especially now that we have vaccines in addition to screening."

HPV vaccination is the primary prevention of infection. The first HPV vaccine became available in 2006, and a decade later, it entered China. By the end of 2019, the first domestic HPV vaccine was introduced after rigorous review over the course of 18 years. 

The World Health Organization (WHO) launched the Global Strategy to Accelerate the Elimination of Cervical Cancer last November, proposing 90-70-90 targets by 2030 – that is, 90 percent of girls fully vaccinated with the HPV vaccine by 15 years of age, 70 percent of women screened using a high-performance test by age 35 and again by 45, and 90 percent of women identified with cervical disease receiving treatment. The initiative points out that vaccination, screening and treatment, if properly implemented, could reduce more than 40 percent of new cases and 5 million related deaths by 2050. It was the first time that 194 countries committed to a goal, marking a historic collective effort in tackling the disease.

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段仙芝的努力

Make it happen

CGTN新媒体记者到达准格尔旗十二连城乡进行拍摄时，段仙芝已经在当地的乡镇医院筛查了一周了。虽然从2008年开始，段仙芝就因为工作调动定居在了北京，但因为宫颈癌筛查项目，她每个月至少会回鄂尔多斯一次，除了给病人进行筛查，她还要给病情棘手的患者做手术。去年，她在准格尔旗的时间有128天。段仙芝谦虚地说：“准格尔是我的家乡，我只是想为家乡的百姓做点什么”。

Women queue at the door of the screening room in the health center of Shi'erliancheng Village, Jungar Banner under Ordos City, Inner Mongolia, September 4, 2021. Du Junzhi/CGTN

段仙芝筛查室外的走廊上挤满了人。其中一位中年女性兴奋地说：“听说段医生回来了，在亲自做筛查，我赶紧带着我妈妈过来了。”像她一样，走廊里很多人都是从数百公里外赶来的。如今，当地已经有超过 84% 的女性居民主动接受宫颈癌筛查，这在几年前是不可想象的。

结束筛查后，段仙芝立刻赶往准格尔旗另一家医院给疑难杂症患者们做手术。刚一到医院，她就遇到坐了五个小时长途汽车匆忙赶来的36 岁患者郭艳芳。郭艳芳说：“我听说段医生今天会来，所以我马上就来了。”因为被查出高度病变，郭艳芳迫不及待地想要接受手术。因为当天已经安排了11台手术，郭艳芳只能安排到第二天，段仙芝决定为这个焦急的患者多待一天。

除了提供免费的宫颈癌筛查外，准格尔还从2020年8月开始为13-18 岁的女孩提供免费 HPV 疫苗接种，并因此而受到广泛关注。一位来接种第三针HPV疫苗的女孩告诉CGTN：“我记得当时还上了微博热搜，因为是免费接种疫苗，其他地区都要花几千块钱预约这个事情，我感到很自豪。”

Lu Jia, a local senior high student, receives her third shot of the HPV vaccine at the Jungar Banner Women and Children's Hospital, Ordos City, Inner Mongolia, September 6, 2021. Wang Xiaonan/CGTN

HPV疫苗成本高昂，但供不应求，几年前许多女孩甚至特地去香港接种。目前，中国部分城市都有了充足的供应，但价格依然比较昂贵。接种疫苗的护士骄傲地说：“在这个偏远的乡镇，能免费接种HPV疫苗，几乎是一个奇迹。”没有段仙芝和她在协和医院的朋友乔友林的努力，这个奇迹就不会发生。

乔友林是全国知名癌症专家，20世纪90年代他放弃约翰霍普金斯大学的理想职位，回到北京，从零开始在中国推广宫颈癌防治。段仙芝听说乔友林有更准确、更低廉的检测方法，便赶忙前往拜访。两位拥有共同理想的医生很快一拍即合，他们开始在准格尔用这种新的检测方法进行大规模筛查。随着当地对宫颈筛查的接受度越来越高，免费的HPV疫苗接种项目也得到了越来越多政府、机构和个人的支持，众人拾柴火焰高，就这样准格尔成为了中国第一个提供免费接种HPV疫苗服务的地方。乔友林高兴地告诉记者：“第一个月疫苗接种率就达到了84.5%，虽然中国在HPV疫苗接种方面是后来者，但我们正在迅速赶上。”

Duan Xianzhi (6th L) and Qiao Youlin (7th L) at the 2021 APEC Women Leadership Forum in Chengdu, southwest China's Sichuan Province, September 25, 2021. /courtesy of Qiao Youlin

截至 2021 年 9 月，准格尔旗已经为约85%的适龄女孩接种了第一针疫苗。段仙芝笑着说：“因此，我们将在 2023 年之前完成世卫组织 2030 年的目标。”

在过去的 40 多年里，段仙芝治疗了超过 50万名患者，并进行了 2万多台手术。人的精力总是有限的，工作上全力付出难免导致在照顾家庭上做得不足。她虽然育有两个孩子，但陪伴孩子的时间却十分有限。孩子小的时候，她做手术忙不开，甚至只能让病人的家属帮忙照看一会儿。段仙芝告诉记者：“既然我选择了这个职业，就意味着奉献。什么都很完美是不可能的。我作为一个妇产科医生，我能够走到现在我很开心，我一生中是很充实的。”

Duan Xianzhi in her office at Tongren Hospital in Beijing, China, September 30, 2021. Wang Xiaonan/CGTN

We arrived in Jungar on a breezy September day, in the middle of Duan's trip as part of the cervical cancer prevention and treatment program. Since her transfer to Beijing Tongren Hospital in 2008, she's been making such trips once or twice a month, carrying out screenings during the summer months and performing operations on those diagnosed with precancerous lesions or cancers during the previous year's screenings. Last year, she spent 128 days working here.

Though perched on what's known as tourist idylls, Jungar, quietly lying along the Yellow River, possesses no beautiful grasslands and pastures. "This is my hometown. I want to do something for the women here – the mothers and the daughters who have lived on this land for generations."

In the public health center of Shi'erliancheng Village under Jungar, the only hospital in the village, we saw women gathering in the hallways in clusters, waiting to get screened. "I heard Dr Duan came back to do the screenings in person, so I brought my mother here, and we can both get checked together," a young woman said excitedly. Like her, a lot of women came from hundreds of miles away with their mothers or mothers-in-law. Nowadays, over 84 percent of female residents would accept cervical screenings, something unimaginable just a few years ago.

For the past week, Duan screened some 200 women every day. After finishing this screening round, she rushed to another hospital in a local economic development zone to perform surgeries for a dozen women diagnosed with different kinds of precancers or invasive cancers.

Guo Yanfang, 36, arrived at the hospital late in the night after a five-hour coach trip. "I heard Dr Duan would be here today, so I came immediately," she said, fidgeting. She was diagnosed with three precancerous lesions and couldn't wait to get the operation. After a day of 11 operations, Duan decided to stay in town for another day to accommodate this anxious woman.

Besides pioneering free cervical screenings, Jungar shot to fame in August 2020 with the initiative to offer free HPV vaccination for girls aged 13-18.

"I remember when Ordos became the first Chinese city to offer free HPV vaccination last summer, it became one of the top trending Weibo searches," Lu Jia recalled. She was one of the girls that were receiving their third shots of HPV vaccine at the banner's women and children's hospital on the day we went. "I'm very proud of my hometown," said the 17-year-old girl. Entering the final year of senior high, she hopes to study at a medical school and become a cardiologist. "I want to save people's lives, just as now we can get vaccinated against HPV."

Once the vaccine hit the shores of China, the demand far exceeded the supply despite high costs, with many girls even going to Hong Kong to get it. Eventually, big cities on the Chinese mainland had ample supply, but one may have to wait several months to get the vaccine at public hospitals.

"It seems like a miracle that such a rare luxury could happen in this backward, scarcely populated township," the head nurse said. This miracle wouldn't have happened without Duan and her colleague Qiao Youlin, a cancer epidemiologist at Peking Union Medical College.

In the '90s, Qiao gave up a desired research post at John Hopkins and returned to Beijing to start from scratch in China's cervical cancer prevention and treatment. After launching screenings in an impoverished county in northern Shanxi Province, he went on to look for other rural areas to continue the work, which was difficult because he had few connections with local hospitals.

On the other side, upon hearing that Qiao had a more accurate and cost-effective testing method, Duan rushed to visit him. The two doctors, both compassionate workaholics, hit it off – they started to launch massive screenings with the new method in Jungar. Things fell into place rapidly. As people became more accepting of cervical screenings, it was easy to carry out free HPV vaccination. "For the first month, the vaccination rate achieved 84.5 percent," Qiao said, looking radiant. 

Though 65, he's still leading the campaign to eliminate cervical cancer in a multitude of Chinese cities. "Besides using your expertise, you have to ensure women book their screening tests (once every five years), and then you need to get more girls to receive vaccines," he noted. 

He once lamented that China is a latecomer to HPV vaccination but now is happy to see the progress, "We're quickly catching up." The local government was very supportive of this endeavor when no other city in China had ever tried. Zhang Yinyin, deputy county head of Jungar, pledged 4.8 million yuan ($750,000) for the vaccination project, despite the risk of being the first mover. "She's a young ethnic Mongolian. She knew the pain of the women on the plateau."

As of September 2021, Jungar has given the first shots of HPV vaccination to some 85 percent of girls aged 13-18. "As such, we'll complete the WHO's 2030 goal by 2023," said Duan, smiling proudly. 

A difficult childhood

As a little girl, Duan craved knowledge. But half a century ago, few girls in rural China had access to education. "From the second grade in elementary school, I was the only girl in class. My mother and grandma used to object to me going to school. So when I came back from school, I just hid my bag in a stack of firewood outside my home and my dog looked after it every night. The next morning I told my mother I needed to use the toilet [At the time, toilets were built outside the house in villages] and ran to take my bag and headed to school," Duan described for us. She ran a dozen kilometers every day, practiced calligraphy in the soil, and sold eggs to buy books.

Her efforts paid off. In 1965, she became the only student in her village to be admitted to Jungar's sole middle school. Her graduation from high school coincided with the pandemonium of the Cultural Revolution. Like millions of youths in the country, she couldn't take the entrance exams to enter university, but she didn't want to return home either to toil the land. With a childhood dream of being a doctor, she chose to do simple jobs for the banner's health center such as planting vegetables. "When I was six, I saw a family relative die of tuberculosis. I was determined to become a doctor so that I could save people's lives."

The hospital recognized her diligence and determination, so it trained her to become a nurse and then gave her a quota to study at the Inner Mongolia Medical University. She chose to be an obstetrician-gynecologist at the Jungar Banner Hospital upon graduation as the hospital had no trained doctor in this arena. Given her childhood experience, Duan has a keen understanding of the plight facing women residing in rural China.

At a training program in Hohhot, capital of Inner Mongolia, in 1985, she found many rural women diagnosed with cervical cancer were too poor to get any treatment. "I felt sorry for them, but my teacher Wang Enyu said, 'Feeling sorry changes nothing. You need to hone your skills. Only when you become a good surgeon can you serve these women from your hometown."

Duan is undoubtedly very accomplished and passionate about her mission, but her dedication has not been without sacrifices. Her time devoted to helping women and girls across Inner Mongolia made her miss out on much of her children's lives.

"There's always a limit in one's time and energy. For a certain period of time when I was on the night shift doing operations, I had to ask the patient's family members to look after my kids," she recalled.

Over the past more than 40 years, she treated over 500,000 women and did more than 20,000 operations.

As she keeps dedicating her life to helping the women and girls of her native region stay away from cervical cancer, she continues to raise awareness while being self-effacing, preferring instead to bring attention to the many people she's treated, their families, and those who continue to be shackled by the stigma of a culture she knows deeply. One day, she hopes to see her hometown and beyond free of the plight of cervical cancer.

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