Lecture 2
Cancer as a Mirror of Society: Health Inequities and the Policy Challenge of the “Last Mile”

Zainab Shinkafi BAGUDU is a distinguished pediatrician and global health leader with a profound commitment to women’s health and cancer care. A pioneer in Nigerian healthcare, she established Medicaid Radio-Diagnostics & Clinics, the first comprehensive diagnostic center in Abuja, addressing a critical gap in medical services.

Recognizing the urgent need for cancer care, she also founded the Medicaid Cancer Foundation, driving awareness, prevention, and improved access to treatment. The foundation has raised over $2 million to address gaps in cancer care.

As the former First Lady of Kebbi State, Dr Bagudu leveraged her position to spearhead transformative healthcare initiatives, including the development of a comprehensive cancer control plan and the expansion of HPV vaccination for girls. Her advocacy extends globally through her roles with UICC and First Ladies Against Cancer.

With a relentless dedication to improving lives, Dr Bagudu continues to be a driving force in the action against cancer, empowering communities, and shaping healthcare policies in Nigeria and beyond.

(1) Introduction to the lecture

Norie KAWAHARA opened the second lecture of the Spring 2026 semester of the Surviving Cancer in Asia: Cross-boundary Cancer Studies lecture series by reflecting on the previous week’s lecture. Dr. Kawahara recalled that, as discussed in the previous session, the lecture series is an interdisciplinary educational program that began in 2011, inspired by the late Professor Hideyuki Akaza’s concept of “cancer as a mirror of society.” From its foundation, the program has approached cancer not only as a medical issue but as a social challenge that must be examined across multiple dimensions of society. The UICC Asia Regional Office (UICC-ARO) has supported the program in many ways since its inception, including through financial support.

Dr. Kawahara recalled that in the previous week’s lecture, Shinjiro NOZAKI had set out the structural foundation for thinking about prevention in Asia. Two points had emerged with particular force. First, with rapid population aging and the growing burden of non-communicable diseases, active treatment alone is no longer sufficient to overcome challenges. Second, prevention should be understood not simply as an individual choice but as a social investment that protects families, sustains the workforce, and supports society as a whole.

Dr. Kawahara then introduced her own team’s work as a concrete illustration of how these ideas can be put into practice, referring to a recent UICC news story featuring the BEAUTY Project in Malaysia, supported by Astellas Pharma (https://www.uicc.org/news-and-updates/news/26-m3-community-prevention-and-hope-taking-root-malaysia). The project is important not simply because it raises awareness, but because it demonstrates how cancer prevention can be socially implemented by being embedded into the ordinary pathways of everyday life.

In Malaysia, the team does not begin from the hospital side but from the spaces used by people in their everyday lives. Beauty salons and barbershops are places that people visit regularly; they are trusted spaces where people feel comfortable, conversations happen naturally, and health can become part of everyday life. These settings help connect awareness to action — not only to learning, but also to screening, consultation, and early detection. 

Because Malaysia is a multilingual and multicultural society, educational materials have been prepared in English, Malay, Chinese, and Tamil, and smartphones and digital tools are used so that participants can stay connected and continue learning. This work is now being extended into the workplace, which is a very important next step. Dr. Kawahara indicated that, later in the lecture series, she hoped students would have an opportunity to hear directly from practitioners operating in Malaysia about how this social model of prevention continues to grow in practice.

Dr. Kawahara explained that the BEAUTY Project has its roots in a much earlier experience, in a rural area outside Harbin, China, beginning in 2005. At that time, rapid changes in diet and lifestyle were reshaping people’s lives, and many villagers were developing lifestyle-related diseases, yet they had very little knowledge about cancer. Even when the government offered cancer screening, almost no one came forward. The team visited the village many times with medical experts, but lectures and direct encouragement had little effect.

The turning point came unexpectedly, when the owner of a local beauty salon — a close friend of the village leader’s wife — began to help the team, sharing information through social media and supporting their activities on the ground. Rather than continuing with medical lectures alone, the team redesigned its approach around beauty workshops for the women of the village. Through these sessions, one central message was conveyed: cancer does not have to mean death; if it is detected early, people can return to their lives. The team also went into elementary schools, teaching children that their daily habits are linked to their bodies and to their future health, setting them the homework of observing and recording their own diets, and — most importantly — seeking to instill a sense that they themselves are the ones who will shape the future of their community.

Over many years of effort this work came to be supported by the Japan International Cooperation Agency (JICA). Something remarkable then happened: in a village where no one had previously come forward, screening attendance began to grow, and two women were diagnosed with early-stage cervical cancer and treated in time. Astellas Pharma subsequently decided to support the work, and today they are supporting the Malaysia BEAUTY and Health Project as part of a larger sustainability initiative.

Dr. Kawahara noted that through her work she has always been deeply inspired by the vision of the UICC. It was therefore a great honor to welcome as the week’s speaker a leader who truly represents that vision. Dr. Zainab Shinkafi Bagudu is an outstanding clinician and advocate, and the President-elect of the UICC. Her work has focused on equity, access, and reaching the “last mile.” 

(2)  Cancer as a Mirror of Society: Health Inequities and the Policy Challenge of the “Last Mile”

Zainab Shinkafi BAGUDU greeted participants from Abuja, the federal capital territory of Nigeria. She explained that, as President-elect of UICC, she would speak from a place of practical experience, drawing on her work as a clinician and advocate in a low- and middle-income country (LMIC) setting, and on her earlier experience as First Lady of Kebbi State in northwestern Nigeria. Dr. Bagudu said she had been inspired by Dr. Kawahara’s earlier presentation on the BEAUTY and Health Project in Malaysia, and indicated that the lecture would move through three stages: first, an overview of the cancer burden in LMIC environments; second, an examination of why such inequities persist; and third, practical solutions for closing the gap.

Cancer as a Mirror of Society

Dr. Bagudu explained that in Nigeria, and across much of Africa, cancer is still surrounded by fear, misunderstanding, and a significant gap between the haves and the have-nots; those with access to education and better jobs on the one hand, and those without on the other. That divide is reflected in outcomes, and is equally visible when comparing high-income countries such as Japan with LMICs in Africa. The global map of cancer is itself a reflection of the fact that there are diseases that the Global South continues to suffer disproportionately. Cervical cancer is the clearest example: from prevention through diagnosis, treatment and palliative care, the outcomes are starkly different between high- and low-income settings. Most LMICs have National Cancer Control Plans on paper, but for a range of reasons these remain largely unimplemented.

A mirror is a tool that a person looks into to see themselves and their image. Looking into the ecosystem of an LMIC reveals the broader societal failures that shape cancer outcomes. Many people must seek health care out of pocket because universal health insurance is not available; informal-sector work is common; insecurity and, increasingly, climate change are disrupting daily life. 

Climate change is often framed as a concern of high-income countries, but in northern Nigeria it manifests as flooding that makes it physically difficult for cancer patients to reach hospitals. Data weakness is another dimension of that same mirror: if the scope of the problem is not recorded, it cannot be solved. Although efforts are under way to strengthen the cancer registration system, these remain fragile. Funding is a closely related challenge, with the call always being about “inadequate funding,” but without a clear picture of the problem, resources are often spread across parallel programs pursuing the same objectives in uncoordinated ways.

Human resources represent a further dimension of the mirror. There has been a very high outflow of specialized healthcare professionals across the African continent, including oncologists, specialized nurses, and general doctors responsible for cancer care. The most common pathway for this “brain drain” begins when a student or a new graduate travels to the Global North, ostensibly to further their education, and ends with settling there permanently. Although diaspora remittances partially offset the loss, the weakening of healthcare systems is severe. Training itself compounds the problem: curricula follow a Eurocentric model in which students learn ideal protocols, including radiotherapy and brachytherapy, etc., but the infrastructure to deliver those treatments does not exist in most LMICs. Practitioners therefore graduate into a reality that bears little resemblance to what they were taught.

The Global Cancer Burden and the “Last Mile”

Cancer currently accounts for approximately 17% of all deaths globally, with one in six cancer patients being lost to the disease. The burden is rising sharply: from an estimated 20 million new cases in 2022, projections indicate a rise to around 35 million cases by 2050, an increase of roughly 77%. Despite the combined efforts of UICC, WHO, researchers, clinicians and advocates, Dr. Bagudu noted that “we are not catching up.”

The concept of the “last mile” describes the final leg of the journey from prevention, data, technology and new medicines to the rural communities where most of the people who need them live. There is a very wide gap between what is globally available and what reaches rural patients. 

Closing that gap is the core policy challenge, and it is where the social value of prevention becomes most visible. At present, most cancer funding flows to the research end of the pipeline, which is legitimate and necessary, but there is a great deal to be gained from investing in the LMIC settings where awareness and education remain weak, the workforce is thin, and financial toxicity is the norm.

Dr. Bagudu highlighted several persistent barriers. Data systems are weak. Electricity, something that may be easily taken for granted, is a binding constraint on prevention, because cold chains for vaccines cannot be maintained without reliable power, and on diagnosis, because constant power surges damage the machines that are brought into the country. Cultural fatalism, namely the belief that a cancer diagnosis is simply the end, continues to deter people from seeking care. Displaced populations, particularly in Nigeria’s northeast and parts of the northwest and north-central regions, face even more acute difficulties in reaching healthcare.

The Economic Case for Prevention

The economic argument for investing in prevention is strong, even if it is not always the argument that political leaders respond to most readily. Dr. Bagudu cited the widely reported figure that for every US$1 invested in the elimination of cervical cancer through 2050, an average of US$3.20 is returned to the economy, rising to around US$26 once wider societal benefits and the impact on families are taken into account.

In effect, a dollar invested today can return $15 to $26 in value over time. The same logic applies to hepatitis B vaccination as a preventive intervention against liver cancer. However, when a government is weighing a dollar for prevention against the need to pay salaries, build roads, and settle insurance obligations, future benefits do not always carry weight. For that reason, the case must be made, and remade, by advocates, researchers, clinicians and nurses across the cancer care continuum.

Dr. Bagudu framed the return on prevention as the preservation of a “triple asset”: productivity, by avoiding the loss of skilled workers in their prime years (ages 30–50); education, by ensuring that children stay in school rather than dropping out to become caregivers or laborers for sick parents; and family stability, by preventing the “medical impoverishment” that forces families to sell homes and land to pay for late-stage chemotherapy. Cancer causes severe financial toxicity even for mid- and high-income families without insurance, and innovative financing mechanisms are therefore urgently needed to avoid reliance on out-of-pocket payments, which damage the national economy as well as individual households.

There is also a case for a gender-inclusive prevention strategy. Hepatitis B causes the majority of primary liver cancer and disproportionately affects the male workforce, so vaccinating men protects the primary income of millions of households. HPV vaccines prevent cervical cancer, protecting the women who form the “bedrock of the informal economy.” Most HPV vaccination programs concentrate on girls, for the obvious clinical reason that cervical cancer affects those with a cervix, but there is considerable value in vaccinating boys as well, since bi-gender vaccination creates the herd immunity needed to slow HPV transmission across both sexes. Adoption of bi-gender vaccination has, however, been slow.

These economic arguments sit against a backdrop of stark inequality in cancer service access: on some measures, high-income countries have four to seven times greater access to cancer services than low-income countries, which directly shapes survival outcomes.

Interventions: Building from the Community Upwards

Dr. Bagudu turned to the interventions that have worked in her own practice, anchored in what she referred to as the “Kebbi State model.” The guiding principle is that it is not enough to train healthcare workers in hospitals: the general community must also be engaged, and engagement must run through the gatekeepers that communities actually listen to, including traditional leaders and religious leaders. Medicaid Cancer Foundation, together with partners, has run capacity-building programs for these leaders, equipping them to explain cancer in terms their communities trust and to advocate for the right care pathways.

Technology has been a growing asset. Artificial intelligence (AI) is now being used for cervical cancer screening and other conditions. In Nigeria, E-wallets are being used to channel funding from the national Cancer Health Fund  to patients who can then access care at the seven major tertiary hospitals that host comprehensive cancer centers. Community awareness has been raised through the use of influencers drawn from the movie and music industries, whose presence alone draws a crowd in ways that a clinical lecture cannot. Educational materials are produced in local dialects rather than English only, which greatly increases their reach in communities where literacy in English is limited.

Task shifting, while rarely labeled as such, is already pervasive in African health systems. A single community health worker may serve a primary healthcare center responsible for an entire village of three to five thousand people, and nurses routinely perform functions that would be reserved for physicians in higher-income settings. Medicaid Cancer Foundation and its partners have sought to formalize this reality by offering community health workers better training, capacity building and remuneration, although sustainability is difficult given competing demands on national funding.

Innovative funding mechanisms include the Cancer Health Fund, which pools national insurance resources with other contributions, and a newly established pooled-procurement organization currently focused on maternal health and selected non-communicable disease commodities such as hypertension medicines. Integration of services is another important lever: rather than running a separate laboratory for HIV, for example, GeneXpert platforms used for HIV can also be used for HPV analysis. 

Universal Health Coverage (UHC) remains aspirational in most African contexts, although employer-funded insurance schemes are gradually expanding the base. The elimination of user fees has helped in specific instances but is not, on its own, a sustainable solution. Workforce training and supply-chain strengthening round out the set of interventions; Dr. Bagudu noted the importance of GAVI, The Vaccine Alliance support, which had provided both training and solar-powered refrigerators for vaccine storage, significantly boosting vaccination rates in the states concerned.

Dr. Bagudu shared images of the nursing-student training and community outreach activities that she continues to lead personally, and of a large-scale screening program supported by WHO, CHAI and UNITAID, through which 40,000 women were screened for cervical cancer and started on treatment where required.

The UICC and the Medicaid Cancer Foundation

Dr. Bagudu then moved from the national context of Nigeria to the global context and the work of UICC, which is the largest cancer umbrella body in the world, with more than 1,150 members across more than 170 countries. 

Its mission is to unite the cancer community to reduce the global burden of cancer while promoting equity. Its greatest strength is the breadth of its membership. The UICC delivers its mission through convening (including the World Cancer Congress, to be held in Hong Kong later in 2026), advocacy, evidence-based capacity building and education (including online training for generalists and specialists), and awareness and mobilization campaigns.

Having been elected to lead the board of the UICC, Dr. Bagudu outlined her priorities as incoming president-elect: closing the care gap, with a focus on LMICs; pursuing sustainable financing for cancer care in developing economies; strengthening health systems by investing in human resources and education; and ensuring that the lived experience of patients is not pushed to the back of policy conversations. She also noted that she intends to foster South–South and North–South collaboration, advocate for UHC to reduce out-of-pocket costs, build capacity for community health workers, and champion childhood cancer to reduce pediatric cancer mortality in Africa and other LMIC settings.

Alongside her UICC work, Dr. Bagudu introduced her own organization, Medicaid Cancer Foundation, founded on 17 October 2009. Its mission is to eradicate cancer and enhance quality of life for people living with the disease through collective and sustained support systems, and its vision is to reduce cancer mortality rates through awareness, early detection and preventive measures. The foundation funds screening and treatment (including mammograms and chemotherapy) for underserved populations, runs awareness campaigns such as the #WalkAwayCancer initiative to reduce stigma, trains healthcare workers, advocates at national and global level, and supports clinical oncology research and data collation in African populations. Community outreach programs include childhood cancer campaigns that also reach mothers, and screenings that are combined with food packs, clothing or medication. A forthcoming outreach in Kebbi State will distribute ready-to-use therapeutic foods for childhood nutrition.

Dr. Bagudu closed with the image that framed her lecture: if cancer mirrors our society, let that reflection be one of reality, because access to care should move beyond who a person is or where they live. Solutions and outcomes today, she noted, are still too often determined by identity, profession, age, or geographical location. The task for the cancer community is to move beyond that.

(3) Assignment

Dr. Bagudu set students a two-part assignment designed to make them think practically about closing the care gap and reaching the last mile.

Part A: Case Study – Closing the Access Gap

You are appointed as a consultant for a UICC-backed project in a resource-limited setting where 70% of women have never heard of cervical cancer screening. Although funding is available and services are free, uptake remains extremely low.

Task 1

a) Identify one key barrier to cancer prevention or screening in your community.

b) Propose one non-medical partnership 

c) Explain the social value and how your solution reaches the “last mile” population

d) What role can you play as a future health professional in addressing these gaps?

Part B: Reaching the “Last Mile” in Displaced Populations

“Reflecting on a recent clinical outreach in the rural provinces of Vietnam, where the 'mirror of society' reveals that deep-seated mistrust of government institutions and the cultural stigma of a diagnosis often keep the most vulnerable away, suggest  possible solutions that strategically leverage non-medical partners to bridge the gap from the mere availability of cancer screening to actual, life-saving utilization for the most marginalized 'last mile' populations.  

(4) Discussion

Dr. Kawahara thanked Dr. Bagudu for an inspiring lecture, observing that the “last mile” is shaped not only by systems and services but also by trust, and by the culture through which people accept prevention. She noted that the Asia Cancer Forum’s ongoing research with partner institutions seeks to understand cross-country differences in what might be characterized as the “culture of prevention.” If that idea is to be translated into a practical indicator for policy and implementation, she asked, what is the single most important thing that societies should measure?

Dr. Bagudu answered that the question must be placed in context: in an African setting, a great deal depends on the cultural and geographical background of the community. The first task is a reality check on what the healthcare system currently offers the general population; solutions cannot be so high-end that even nurses in a teaching hospital cannot understand or deliver them. Standardizing what is offered is therefore crucial, and partnerships must be formed at every level — from community-based organizations through to cross-continental collaborations such as that between the Asia Cancer Forum and Medicaid Cancer Foundation. The flow of knowledge should be bi-directional, and the voice of lived experience — people who have had cancer and overcome it, or who are living with it — must be part of every solution.

Dr. Kawahara then invited Kosuke MATSUI of Yakult, who was joining from the Netherlands and is currently working with her team on well-being research, to contribute, noting that Yakult’s community-based “Yakult Lady” model is closely connected to the theme of the “last mile.”

Mr. Matsui noted that Dr. Bagudu’s lecture had been deeply inspiring, and that the student assignment was a genuinely difficult task, one that was more complex than many questions that arise in his own business-related tasks. 

He then offered a short introduction to Yakult, which was founded in 1935 in Japan as a probiotic beverage company at a time when no one in Japan believed that good bacteria could live in the human gut and bacteria were assumed to be germs and therefore harmful. The company’s original challenge was, in effect, to create a new habit, namely to normalize the idea of consuming good bacteria for health maintenance. The structural problem, he suggested, was similar to the one that Dr. Bagudu and Dr. Kawahara are working on today.

The company’s response, devised by its founder Dr. Minoru Shirota, was to build a local community network around housewives. Before the 1980s, housewives in Japan typically made the household’s food-choice decisions, and so Dr. Shirota intentionally recruited them as “Yakult Ladies,” training them as messengers of the new probiotic concept as they delivered the product to neighbors in their communities. The key lesson from the Yakult Lady model, Mr. Matsui said, is the importance of careful observation of local habits, and of adjusting the delivery mechanism to those habits, which echoes Dr. Bagudu’s point about working in local dialects in Nigeria. 

Yakult is now sold in forty countries, and where the Yakult Lady system does not fit the local context, the company works through local kiosks or “papa and mama” stores, which perform the equivalent function in those communities. Such adaptation is what allows the core concept underpinning the “Yakult Lady” to expand.

Dr. Bagudu noted that Mr. Matsui had, in the course of his explanation, supplied the answer to Dr. Kawahara’s initial question: Yakult’s approach used housewives — non-medical community members who are central to both the problem and the solution — as the conduit for spreading a message about health. That is precisely the kind of non-medical partnership she had asked her students to propose. She added that lifestyle and diet are themselves critical dimensions of cancer care, both for patients in treatment and for prevention, and noted that Yakult is not yet widely sold in Nigeria — something she suggested may be worth addressing.

Mr. Matsui added that the shared challenge is how to spread an understanding of prevention, and that this varies with religion, culture and nationality. In Japan or China, the word “health” is typically associated with nutrition, sport and physical activity; in Muslim communities, it is often more closely tied to ideas of discipline and sanitary practice. Understanding each community’s underlying sense of value is therefore essential. He referred to an ongoing collaboration with Dr. Kawahara’s team in Malaysia in which Yakult has found that its product is very popular in the Chinese community but not in the Muslim community, and invited Dr. Bagudu’s reflections.

Dr. Bagudu agreed, noting that in some Muslim communities in Nigeria, a male health worker, no matter how knowledgeable, would not be given access to women, regardless of the intervention he was offering, and so the messenger must be matched to the community. 

Religious leaders, both imams and pastors, have proven invaluable allies and they have received targeted capacity-building training and then use their own language and scriptural references to carry prevention messages to their congregations, including guidance on diet. Culture, religion, language and lifestyle therefore have a profound impact on health-seeking behavior and on the allocation of funding. Dr. Bagudu observed, however, that UN resolutions on tobacco, antimicrobial resistance or UHC are too often formulated as single, uniform solutions that do not make space for this diversity.

Dr. Kawahara reflected that language and culture are not merely obstacles but are themselves the means by which people understand health, build trust in information, and make sound decisions — making them both a barrier and an essential resource for engagement in any “health for all” agenda.

A student from Afghanistan thanked Dr. Bagudu and said that the framing of cancer as a mirror of society had struck him deeply, capturing the way cancer outcomes reveal underlying inequalities: the Global North is moving towards the elimination of cervical cancer, while the Global South continues to bear 90% of the mortality burden, driven by policy gaps, poverty, conflict and other structural factors. He noted that the economic return of up to $26 per dollar invested makes prevention a matter of societal, not only medical, concern, and said the lecture had motivated him to channel his own interest in global health towards underserved settings like Afghanistan, where conflict, migration and poverty create last-mile barriers similar to those Dr. Bagudu had described. He asked for further detail on the Kebbi State model for improving community-level screening.

Dr. Bagudu explained that Kebbi is a predominantly Muslim state in northwestern Nigeria with a population of approximately seven million. Its cervical cancer control program rested on three pillars: political will, funding, and education and awareness. Political will mobilized resources from inside and outside the state, in partnership with WHO, CHAI and the state government’s own counterpart funding. Persistent advocacy highlighted both the scale of the problem and the fact that solutions exist. WHO supplied the screening toolkits and models; CHAI supplied the cryotherapy machines for the treatment of pre-cancerous lesions. Outreach was delivered in partnership between Medicaid Cancer Foundation, the state Ministry of Health, local (regional) governments, and community-based organizations, using traditional and religious leaders as gatekeepers. 

A student asked how the case for investing in cancer prevention and control could be made more persuasively in LMICs, where policymakers tend to prioritize immediate treatment results and where infectious diseases such as HIV and tuberculosis remain widespread.

Dr. Bagudu advised that effective advocacy begins with strong partnerships with community-based organizations, and rests on a well-researched economic case tailored to the shorter time horizons that political leaders actually operate on, for example, three years rather than ten years. A clear needs assessment of the target population is essential, as is a concrete proposition for how available resources will be used. She emphasized the value of training lawmakers themselves through capacity-building sessions tied to events such as Women’s Day or World Health Day, noting that many legislators still view cancer as a death sentence and are unaware that many cancers can be prevented. Advocates must genuinely believe in the cause; where one person cannot carry the argument alone, partnerships should be built to do so.

Mr. Matsui asked Dr. Bagudu how the return on investment in prevention could be made visible in monetary terms. This is a particularly pressing issue for the health-food industry, where companies offering products such as Yakult are routinely asked to quantify the return on investment.

Dr. Bagudu replied that Medicaid Cancer Foundation does not currently run a dedicated project that examines return on investment, but that the data generated through its screenings, treatments and outreach activities contribute to the accumulation of a wider evidence base. For a health-product company, she recommended investing in pilot studies and prospective research tracking defined populations over time to document outcomes. She observed that probiotics research is already well established scientifically and noted that the rapid growth in the use of semaglutide for weight loss and diabetes is now commonly accompanied by probiotic prescriptions, often in capsule form, for which a palatable alternative such as Yakult offers a clear advantage.

Dr. Kawahara closed the discussion by thanking Dr. Bagudu for a particularly meaningful lecture, which had reminded students that prevention is not only about avoiding disease but about protecting family life, sustaining the dignity and productivity of working people, and supporting society as a whole. Real solutions are built not only in hospitals but in communities, through trust, partnership and practical action.