Benson A. Mulemi

 

A bed capacity of thirty in the adult cancer ward in Kenyatta National Hospital (KNH) - Kenya’s main public referral hospital in the capital Nairobi - belies the magnitude of the cancer crisis. Incidence of the disease is rapidly increasing, with over 82 000 new cases reported annually in Kenya. The cancer clinic is often full, with long queues of desperate patients seeking admission and routine out-patient treatment. Some of the patients travel up to 600 kilometres to the only public hospital that hosts most of the oncology expertise and technology in Kenya. Only a few get the admission or out-patient treatment, because they can either afford it or physically endure therapies. A patient’s relative noted:

 

They [peripheral hospitals] just keep them [patients] there (...) they eventually refer them here, when ‘the disease has already eaten someone’. Another patient came with a cheek with so many terrible wounds covered with a piece of cloth…I thought, is it not better for them to tell him to go to another hospital instead of dying in the queue?

 

Crisis

Cancer ranks third among the main causes of death in Kenya after infections and cardiovascular diseases. It accounts for up to 18 000 deaths annually, and up to 60% of those who die are in the most productive years of their lives. The five most common malignancies among men in Kenya are oesophagus cancer, prostate cancer, non-Hodgkin lymphoma, liver and stomach cancer. HIV/AIDS is worsening the epidemic, particularly by increasing the incidence of Kaposi’s sarcoma. In addition, a major cancer epidemic may unfold among patients benefiting from antiretroviral therapies. While patients may survive AIDS, viral associated malignancies that thrive on immunosuppression pose a serious threat.

 

Breast and cervical cancer are the most common cancers among women, with incidence rates of about 19% and 10% respectively. Oesophagus, stomach, ovarian, and non-Hodgkin cancers have an incidence rate of about 4.5% each. Head and neck cancers constitute a significant proportion of all cancers afflicting both men and women. Data at the adult oncology ward and treatment centre clinic at KNH indicate an alarming doubling tendency of new cases. This trend reflects unique ethno-regional distribution patterns coinciding with the socioeconomic structure of Kenya related to its history and politics; the epidemiology of cancer thus manifests inequalities in the Kenyan society.

 

Cancer as a politically invisible disease

Malignancies have hardly been a public health concern in Kenya and in the rest of Africa since colonial times. Public health experts assumed that cancer was rare among both the white population of European origin in African countries and indigenous Africans. This partly concealed insufficient efforts for research and registration in Kenya and other African countries. Cancer as a public health problem emerged in late 1940s, coinciding with a steady flow of information about the disease in Africa after World War II. However little attention was paid to the disease even when changing lifestyles, environmental hazards and increased life expectancy accelerated the incidence.

 

 

We are not given the resources and facilities we are supposed to receive in this department. We are just seen as a ka-peripheral (diminutively peripheral) unit compared to other departments.

Cancer is not a politically visible disease that attracts African governments to allocate adequate budgetary resources for research and policy making. In 1997, the National Cancer Control Programme established by Kenya’s Ministry of Health finally emphasized that cancer and other non-communicable diseases, which health providers once believed to be diseases of the Western world, threatened the well being of many Kenyans.

 

The first full-scale cancer research study was conducted about ten years after the KNH clinic begun consistent treatment of the disease in the 1960s. Since then studies have been reiterating the effect of late presentation for medical treatment and poor socio-economics. However, there is a scarcity of comprehensive accounts of patients’ subjective experiences of the disease and treatment processes. In addition, available studies give little attention to the limitations of hospital budgetary expenditure on cancer management in Kenya.  Policy on prevention and comprehensive management of the disease is yet to be clearly formulated and implemented.

 

Treatment challenges and ambiguity

Governmental and private hospitals, missionaries and non-governmental organizations provide health care in Kenya. Ill-equipped health centres, dispensaries, and maternity homes serve the majority of the poor people at the community level in rural and urban areas. District hospitals constitute the second, and provincial or secondary hospitals form the third level of the public health care sector and referral system. However, only a few medical oncologists are available for cancer management and they are all based in Nairobi. Besides, frequent shortage of medicines and other resources characterize the public hospitals.

 

Cancer treatment is protracted and expensive, especially due to the intensive procedures required for the advanced cancer cases. Delayed and futile multiple referrals pave the way for the most intensive and expensive hospital treatment, which entail catastrophic disruption of the livelihood. Hospital treatment is therefore a process of hope, fraught with daily life struggles. These negate the hope in oncology and medical technology as the sources of reassurance.

 

Implications for the future

To improve the diagnostic facilities and treatment of cancer, there is a need for more pathologists and oncologists in peripheral hospitals to facilitate early detection and prompt treatment of cancer. In addition, government, public and private teaching hospitals should commit themselves to widening the scope of learning about cancer in basic medical and nursing training programmes. Thirdly, policy guidelines would help in preventing cancer and minimising treatment interventions and hospital stays that increase individual suffering. Finally, governmental and non-governmental organisations should collaborate in drug dispensing, distribution and payment mechanisms and support for poor patients.

 

About the author

Benson Mulemi is a medical anthropologist from Kenya and received his PhD at the University of Amsterdam on the topic Coping with cancer and adversity: Hospital ethnography in Kenya.

 

Further Reading

• Mulemi, B A. Coping with cancer and adversity: Hospital ethnography in Kenya. 2010. Leiden: African Studies Centre.
• Roth, J.A. The necessity and control of hospitalisation. Social Science and  Medicine 1972 66: 425-446.