Why India's HPV Vaccine Costs a Fifth of Gardasil

We use ICG dye and do the procedure robotically or laparoscopically with a 4K camera using the Firefly technique. We always open the retroperitoneal spaces first and get everything ready before injecting, because if there's bleeding during dissection after injecting, you won't be able to locate the sentinel node properly. If you're implementing this for the first time, do a pilot study of at least 25 cases each for endometrial and cervical cancer before using it as your standard method.

The most common complication is urinary issues, in about one or two out of every hundred patients we operate on, because we try carefully to identify and spare the inferior hypogastric nerve. Unlike axillary lymph node dissection, we don't see lymphoedema with the same frequency after pelvic lymph node dissection. We also follow the ERAS protocol, enhanced recovery after surgery, ambulating the patient the same day and starting oral intake within hours.

PCOS is a lifestyle disease. If you correct the lifestyle, your hormones should be under control. We explain to patients what's causing the imbalance rather than putting them on hormonal pills upfront, and give them 3 to 4 months to work on diet, exercise, stress management and sleep, alongside antioxidant medications. 60 to 70 percent of our patients come back at the end of 3 months saying they're having regular cycles.

Fertility-sparing treatment is done only if the lady desires fertility, the disease is early, confined to one single ovary, with no peritoneal deposits and no malignant cells in the ascites. Even at stage 1B we'd do a diagnostic laparoscopy to check the other ovary, because imaging might miss small deposits. For germ cell tumours we always do fertility-sparing surgery because they're highly chemosensitive; for other tumours the decision has to be tailor-made.

If it's an advanced stage, stage 3 or 4, treatment is usually chemotherapy with radiation therapy. Squamous cell carcinomas are radiosensitive, and chemotherapy is given as a radiosensitiser to get a better response. If there's stage 4 disease with distant metastasis, systemic therapy is needed. Even after this, if there's residual disease and the patient's performance status is good, we'd still go back and remove the residual disease.

India's own quadrivalent HPV vaccine sells for around 2,000 rupees, roughly 22 US dollars, against approximately 10,000 rupees, about 110 dollars, for Gardasil 9, about a fifth of the price.

It's roughly 90 percent effective against cervical cancer, 80 to 85 percent against vaginal, anal, vulvar and penile cancers, and 93 percent against oropharyngeal cancers. It also reduces benign genital warts by 90 percent.

Australia began vaccinating 14-year-old girls in its national immunisation programme, then added boys in 2013 once it recognised they were spreading the virus into adulthood. It's now on track to become the first country to eliminate cervical cancer by 2030.

Not the vaccine's cost or effectiveness, but scale and stigma: not enough people attend awareness sessions, and making vaccination a national default requires a collective decision by government, society, and advocacy groups.