This week on PLOS blog Translational Global Health, two emerging health leaders from Kenya lend their voices on the topic of cancer control and care.
Meet Mary, a 43 year-old mother of 5 children and a poor peasant farmer from rural Kenya, who has been battling breast cancer for 7 years. In denial of her condition, Mary has held the firm belief that her breast lump is a result of witchcraft against her. She received her initial diagnosis at a rural health facility 7 years ago, but declined the advised mastectomy.
After her diagnosis, Mary went 5 years without any medical follow-up until she finally visited the health facility again. At this time her breast was ulcerated and oozing, but she still did not agree to a mastectomy. Earlier this year, Mary was sent to Kenya’s main public referral hospital in Nairobi, Kenyatta National Hospital, where specialists found that her breast cancer had metastasized to her spinal cord. An aggressive treatment regimen was initiated, but radiotherapy could not reverse the complications. Unfortunately, the only remaining option is to manage her pain, although her breast cancer could have been manageable had it been detected sooner. Sadly, Mary is a prime example of the many people struggling with cancer in Kenya.
The issues and barriers to cancer control
Cancer accounts for approximately 18,000 deaths annually in Kenya, with up to 60% of fatalities occurring among people who are in the most productive years of their life [1, 2]. Men are most commonly diagnosed with prostate or esophageal cancer, and women are most frequently affected by breast and cervical cancer .
A huge disparity exists in patient outcomes between low-income countries like Kenya and high-income countries like Canada. Take cervical cancer as an example: due to pap testing, cervical cancer is rare in Canada or the US; however, it is the number one cause of cancer deaths in Kenyan women . Prevention and screening has just not been available or accessible to most people in Kenya. Most cases are often undiagnosed or misdiagnosed, which is partly due to inadequate healthcare infrastructure.
The issue is exacerbated further by a faulty national health insurance plan that doesn’t allow patients to afford medical services . The health system is inadequately designed and resourced – particularly for people with cancer – with poorly equipped hospitals, a low doctor to patient ratio, and a lack of access to affordable drugs. These factors lead to late presentation, complications and meager patient follow-up .
Widespread lack of awareness and accurate information about cancer is another reason why screening is rare and many cancers are detected when it is too late to treat effectively. Several cultural myths exist regarding cancer, which are critical obstacles to expanded cancer control and care in Kenya, especially when it comes to early detection . One popular myth, as demonstrated by Mary’s case, is that cancer is caused by curses from ancestors and elders. In such cases, people even believe that you can ‘catch’ the disease from those who have it.
Although developing countries bear 80% of the cancer burden, only about 5% of global resources devoted to cancer are found in these countries . Most cancer care services in Kenya are concentrated within a 5 km radius of each other in Nairobi, making it difficult for most Kenyans to access necessary care. The public national hospital hosts most of Kenya’s oncology expertise and technology. About 78% of Kenyans live in rural areas, which mean that many patients requiring care may travel up to 600 km to access cancer services . The wait time for treatment at Kenyatta National Hospital is extremely long, and this is a problem, as there is a narrow window of opportunity to treat cancer effectively.
The other option of private cancer care, is not actually an option for the majority of Kenyans, as treatment costs in these hospitals are so astronomical that many patients travel to India for cancer treatment instead. More effort and resources are needed to make treatment more widely available and accessible.
Action required to reduce barriers to cancer prevention and care
Prevention efforts, both on a personal and policy level, must be scaled up for cancers that are amenable to prevention such as cervical cancer.
Non-communicable diseases (NCDs), which include cancer and other chronic conditions, share common behavioural risk factors that must be reduced to facilitate disease prevention: physical inactivity, tobacco use, harmful use of alcohol, and unhealthy diet [1, 2]. Smoking and alcohol abuse are on the rise in Kenya, air pollution is potent in urban areas, schools do not prioritize physical activity, obesity is on the rise, and the list goes on .
Reduction of these NCD risk factors is not addressed sufficiently by the Ministry of Health and other policymakers. Only 5% of the Kenyan budget is spent on health – instead of the recommended 15%, and much of the cost is on treatment rather than prevention . Robust prevention policies will result not only in lives saved in the long term, but also in long-term economic gains.
Some community awareness campaigns are happening at the grassroots level, but these must be scaled up nationally to affect sustainable change. Additionally, the many people currently struggling with cancer, and those to be diagnosed with the disease in the coming years, should not be deprived of cancer care due to their geography or inability to pay. These patients have a right to receive treatment, and it is time that this right is recognized with investment in better cancer care in Kenya.
Progress is on the horizon
In 2012, Kenya established a National Cancer Prevention and Control Act, making it one of the few countries in Africa with legislation for cancer . The Act, which stipulates the establishment of a National Cancer Institute among other important advances to counter this disease in Kenya, has yet to be operationalized .
During a launch of 2013 breast cancer awareness and screening month (October), the Kenyan Ministry of Health called for revenue allocation for cancer control in the government budget. The presence of the First Lady, Margaret Kenyatta, and other government officials at the cancer-screening launch ignited hope for high-level commitment in reducing the cancer burden. The First Lady declared that she and President Uhuru Kenyatta had been screened for cancer, encouraging the public to follow suit – potentially lifting some of the public’s stigmatization of cancer.
Kenya is currently undergoing decentralization of government functions, including healthcare, which means that there is a renewed opportunity to integrate cancer care into other regions of the country and build an overall healthier Kenya. As 47 counties of Kenya absorb the healthcare mandate, it is expected that greater community involvement will result in tailored healthcare for each region. Devolution will facilitate more straightforward avenues for advocacy on NCDs at the county-level, as the decision-makers in government will be more localized and have so far demonstrated themselves as easier to communicate with. County health policymakers are usually also native to the communities that they serve and have a more vested interest in improved health outcomes in their designated regions, than the previous national level decision-makers.
For both healthcare devolution and expanded care for cancer, there is a push to build private-public partnerships. Both public and private healthcare providers must have a seat at the policy table and work together, as multi-sectoral action will have the biggest impact within communities. Yet, the need to safeguard public health must be emphasized and the terms of such partnerships critically evaluated and monitored.
- World Health Organisation. Non Communicable Diseases: An overview of Africa’s New Silent Killers. Available from: http://www.afro.who.int/en/kenya/kenya-publications/1236-non-communicable-diseases-an-overview-of-africas-new-silent-killers.html [Accessed 9 Nov 2013].
- Baldwin W, Amato L. Fact Sheet: Global Burden of Non-communicable Diseases. Available from: http://www.prb.org/Publications/Datasheets/2012/world-population-data-sheet/fact-sheet-ncds.aspx [Accessed 9 Nov 2013].
- Yonga G. Case Kenya Study: NCD Situation http://iom.edu/~/media/Files/Activity%20Files/Global/ControlChronicDiseases/Sess2Sp2Yonga.pdf [Accessed 9 Oct 2013]
- The Conversation. Shining a Light on world’s biggest killer: non-communicable diseases. March 2013. Available from: http://theconversation.com/shining-a-light-on-developing-worlds-biggest-killer-non-communicable-diseases-12925 [Accessed 9 Nov 2013].
- Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380: 2095128.
- Kenya National Cancer Prevention and Control Act http://www.ipcrc.net/pdfs/Kenya-National-Cancer-Control-strategy.pdf [Accessed 1 Dec 2013]