Is cancer the leading killer? What is killing Kenyans?

Last week, the headlines in my favorite paper was about a health crisis that had hit Kenya. The two radiotherapy machines in the country had broken down and patients suffering from cancer where being turned away. The ‘Daily Nation’ newspaper pushed the story and got a response from the government which ensured that one of the two radiotherapy machines was fixed. This showed the effect the media has in pushing for change in the health sector and also exposed our vulnerability when it comes to cancer care.

http://www.nation.co.ke/news/Repair-the-machines-for-others-patient/-/1056/2659870/-/omn6qh/-/index.html
http://www.nation.co.ke/news/Cancer-Treatment-Kenyatta-National-Hospital/-/1056/2658368/-/mqh32gz/-/index.html
http://www.nation.co.ke/news/Cancer-Radiotherapy-Machines-Kenyatta-National-Hospital/-/1056/2661720/-/tayvlwz/-/index.html
http://www.nation.co.ke/news/Radiotherapy-Machine-Kenyatta-National-Hospital-Cancer/-/1056/2660768/-/10x1rkhz/-/index.html
http://www.nation.co.ke/news/KNH-to-resume-radiotherapy-Monday/-/1056/2660544/-/1cpfiqz/-/index.html

I was extremely pleased by the impact of the stories and many ‘hongera’s’ to the Nation Media Group for pushing this. I am a johny-come-lately that wants to split hairs a bit. One of the headline pages alleged that cancer is killing 27,000 a year and there are 40,000 new cancer cases each year in Kenya.

Cancer, the headline page said, was killing more people in Kenya than malaria and pneumonia. I was rather surprised by that statement and wondered to myself about the truth of that statement. You may think this is splitting hairs but I am a public health person and I could not stop asking myself – what really is the biggest killer in Kenya?
A good place to look for an idea of what is killing Kenyans is the Kenya health policy 2014

This document can be downloaded free … you find that cancer is not among the top 10 killers in Kenya.

Whether in terms of death and disability, cancer does not make it to the top ten.

I was however keen to know how many people are dying of malaria in Kenya. Feeling too lazy to go through all the documents I have on this topic, I decided to email two great epidemiologists who have spent years answering this very question. My malaria epidemiology buddy Prof Abdisalan Noor and my former Phd supervisor Prof Bob Snow.

Prof Noor said to me, ‘We do not know how many people die from malaria and we do not know how many people die from cancer in Kenya’.

Prof Snow alluding to the same, directed me to a paper he recently published in BMC Medicine in 2014 titled ‘Sixty years trying to define the malaria burden in Africa: have we made any progress?’

http://www.biomedcentral.com/1741-7015/12/227

I quote Prof Snow ‘ …yet it remains impossible to provide a single figure of the number of deaths or clinical event resulting from P.falciparum infection, or more importantly, how many of these events have been averted since the launch of unprecedented overseas assistance since 2000. It is a tragedy that, despite billions of health dollars spent on the control of malaria in Africa since 2000, we remain uncertain about the health impact of this funding in 2014.”

This coming from a man who has spent decades quantifying malaria is interesting. If anyone should be able to tell you how much malaria there is in Kenya, it would be these two great brains in Nairobi – yet they don’t.

It should not be surprising though as many people in Kenya die at home and these deaths are not recorded so we don’t really know for sure what people are dying from.

A study was conducted by Ndila and colleagues and published in the journal Global Health Action in 2014 – looked at the causes of death in a community in Kilifi that has regular census as part of the research work by KEMRI- Welcome Trust Research Program. According to Dr Bauni, a demographer in KEMRI-WTRP, about 60% of the deaths among this population occur at home and so there are no records on the cause of death.

In lieu of this, Ndila used verbal autopsies for 4,460 deaths that occurred in this population, among all age groups, between 2008 and 2011. Verbal autopsies is where questions are asked to family of the deceased and the likely cause of death assigned through analysis of clinical symptoms and signs displayed by the deceased. Many verbal autopsies rely on physicians interpreting the data but Ndila’s group used WHO-compliant, InterVA-4 model to determine the cause of death from the verbal autopsies.

Cancer appears among the leading causes of death in the 15 to 49 year bracket – causing 6-10% of all deaths and is the 4th leading cause of death in that age group. Cancer is the number one cause of death in those over 50 years of age, both female and male leading to between 15-18% of all deaths.

Verbal autopsies have their own peculiar complexities as questions are asked of the deceased family to ascertain death. Verbal autopsies are also a huge investment of resources – how much easier it would be if all deaths were registered.

Even for those deaths that occur in a hospital setting – the cause of death recorded can be tricky. If a child died with malaria, pneumonia and underlying malnutrition – either of these 3 could be written as the cause of death. Malaria parasites in the blood are not indicative of malaria disease, so the death may be attributed to malaria because the child had parasites while actually pneumonia is what killed the child. Epidemiologists like neat entries, but these aren’t necessary correct.

Even where the death may be more obvious, the cause of death may be recorded differently. For example, a person is admitted for an AIDS related ailment but because the heart stops beating before death – the death is recorded as heart failure. So that death is reported as due to cardiovascular failure. This is not a made up story – I have seen this in reality.

Until Kenya has a good vital registration system – where each and every death is recorded – we shall be making our health policy based on the best guess – estimates of what we imagine would be the biggest killers. Unless we know what is killing us- it will be difficult to invest our money wisely and the nation will rise and respond to the next biggest whim.

Cancer is a particularly sensitive issue that needs careful planning ahead for. We are having a crisis of treatment now, yet the numbers are set to rise for sure as our life expectancy rises. Globally, among the countries with good vital registration systems, the ones with the highest rates of cancer are the countries who are doing well

http://www.wcrf.org/int/cancer-facts-figures/comparing-more-less-developed-countries

Populations in rich countries are living longer and with a long life, comes the increased likelihood of cancer.

Life expectancy in Kenya is on the rise. We are living longer, our bodies are being exposed to all manner of carcinogens. When it comes to cancer, we desperately need good vital registration systems in order to monitor the trends and plan ahead.

The newspaper talked about 40,000 new cancer cases a year resulting in 27,000 deaths. This is what you would call a best guess estimate – what we like to call – guestimates. No one knows how many cancer deaths occur in Kenya and no one knows the number of new cases we have – we can only make guesses.

The only way to know for sure what is killing us – is to step up a vital registration system. In the same way that a child will not be allowed to sit their primary exams without a birth certificate – no one should be buried without a death certificate. Every death should be certified so that we can know what the numbers are and plan ahead. We need to plan from fact, not guesses.