Where Kenya gets it wrong in the treatment of cancer

His interest in oncology was sparked by a forbidden book he read after A-levels.

Cancer Ward, the novel by Russian author Aleksandr Solzhenitsyn, was banned in the Soviet Union in 1967, a year after its publication.

The author had used fictitious patients in a cancer ward to condemn the “Great Purge” by Soviet dictator Joseph Stalin, where millions of people were killed in efforts to eliminate rebels within the Communist Party.

Aleksandr used cancer to show there would be no healing after this purge, only periods of remission.

Nicholas Othieno-Abinya, now known as Prof Nicholas Abinya, received a copy of the book in 1973, as a prize for excelling in A-level biology. He says this book inspired him to become an oncologist.

Now aged 70, Kenya’s first certified medical oncologist has published his own version of Cancer Ward.

Shadow in Perpetuity: The Hard Journey with Cancer, is a semi-autobiographical novel that uses the experiences of real and fictional patients and medics in Kenya.

Prof Abinya explains the latest cancer treatment is available in Kenya, which also boasts some of the best-trained oncologists in Africa.

However, he says, Kenyans are filled with a fear of cancer, leading to a state of panic, which demands that cancer treatment centres must be established anywhere.

The book condemns the increased trafficking of cancer patients to India, and the mushrooming cancer centres in Kenya, which the author labels ‘death centres’.

Prof Abinya is also miffed by the unrealistic promises of cure, which rogue doctors sell to patients and take them through unending cycles of treatment.

“Patients need help, and as long as there is still some hope for altering the disease course, a doctor must pursue all realistic leads. When all is done, a doctor should scale down the interventions and prevent waste that only impoverishes families,” he says.

“Hospitals should be institutions where the sick are cared for, not stolen from as happens in almost all our private hospitals.”

The book, he says, will make readers appreciate the efforts of doctors treating cancer “while understanding that we are indeed chasing a shadow in perpetuity”.

He spoke with Star’s John Muchangi and Michael Muma.

The Star: You appear quite stingy with the word “cure”. Which word would you rather use?

Prof Abinya: The concept of cure can be very tricky. When you cheat people you have been cured, sometimes you really are not telling the truth. All you can say is that we have treated your cancer very well in the standard way. And chances are this percentage or that percentage that it will not come back again.

When I was doing my fellowship in the UK, we use to wrestle with the professor in charge of the department over the word a cure. He would talk maybe of a five-year cure. We would ask why not just cure, cancer will probably never come back again? And over this, he would drag you down into a fight. Cancer being cancer, it can be very tricky. You may think you've done everything and the thing is gone and a few years later, you'll find the same cancer is back.

Is this more common with some forms of cancer?

Yes. And so you see, some actually don't need to be treated. For instance, in malignant lymphomas, there are some types that are called indolent B-cell types.

If you find them very early, you treat them vigorously with the hope of finding a cure. If you find them advanced, if they are asymptomatic, you don't treat them.

Just let them be because they can go for years without causing any trouble. If you're over-enthusiastic with the treatment, you may kill the patient even before that lymphoma does.

So you can just follow up for five years, six years, seven years, without doing anything. But when they start misbehaving, you start treatment.

The overall survival will not be improved by you treating it as opposed to waiting to treat it when it begins to be violent.

But then there are some of those lymphomas which are highly aggressive, and if not treated in good time they will cause death within months. Those ones we treat and those are curable.

Then there are other cases where the patient has advanced cancer, their organs are not functioning very well, and the patient is not strong. Here, you don't treat, you just do symptom control, what is called best supportive care.

So if they are in pain, you control pain, if they can't walk, you find out why they can't walk, you give them some support. If they are vomiting, you control vomiting. If they're not sleeping, make sure they are sedated, they are relaxed, they are not in pain. That is what we call end-of-life care.

In your book, you also mention how some dishonest doctors or health facilities steal from patients through unnecessary tests and treatment. Please explain. 

If we work like in the United Kingdom, the National Health Services ensures there's nothing wasted through the system. If they know that you are going to administer a treatment that will not translate into any form of benefit to the patient, they will not accept it and an oncologist may be barred from practise for prescribing that kind of treatment because it's going to be wasteful.

So once they know there is nothing more than can be done, they will put you straight on the best supportive care (palliative care without any other anticancer therapies).

And that should be the same here. We have the National Hospital Insurance Fund [now the National Health Insurance Fund]. If they also did that, nothing will be wasted or stolen. You can go back and scrutinise the practitioners. You prescribed ABCD for this patient, is he going to benefit because it's going to cost NHIF maybe Sh100,000? Some patients may need such a shot every two weeks. I have a patient today on a drug that costs Sh500,000 a shot. They're supposed to do it every two weeks.

I was discussing this with them yesterday. Should we do it, or should we not do it? You see, these are the equations. Now NHIF should come in and find out through the hospital pharmacist if the drugs prescribed are going to change anything. If we're using expensive treatment to extend somebody's survival by a month, it is probably not worth the waste. Specialists who understand oncology will not prescribe, but there are those who don't understand, who will just give.

Chemotherapy given in Africa leads to more death than abroad. This is because many of these centres lack the facilities to monitor the blood cells and kidney and liver functions. So you're just pumping in drugs and people are dying

You describe the many upcoming cancer centres in Kenya as death centres. Why?

Well, this is what I mean by that. Something like chemotherapy, if not well applied, will lead to more deaths. In fact, there was a study where we showed that chemotherapy given in Africa leads to more death than chemotherapy abroad. This is because many of these centres lack the facilities to monitor the blood cells and kidney and liver functions.

So you're just pumping in drugs and people are dying. A lot of hospitals, believe me, don't have those laboratories. They will not even monitor for you simple haemoglobin or a simple kidney function.

So if you are going to get chemotherapy through side centres, you are finished. Luckily, radiation is not widespread. But chemotherapy applied just anyhow is death. So these centres need to be supported by very good laboratories.

They also need good hygiene, leave alone the laboratory. If you go to a cancer centre and it’s filthy, just forget about it. I'll give you an example. Take acute leukaemia, which we treat in very few centres in the country.

We use the same drugs as used in Europe or North America, but the outcomes are far inferior to the outcomes in Europe and North America. Our cure rates are much lower.

The death rates in Africa are much higher because of our filthy environment, nothing else. It is not the know-how of the practitioner. This is because cancers can weaken the immune system and patients may be more susceptible to illness. They make not even fight off things like a cold.

What makes cancer treatment so expensive?

Well, I give you an example of acute leukaemia. When your white blood cells go down, you need the best of antibiotics. Some of those antibiotics are very costly. The antifungal treatment is also very expensive. They might cost you, let's say, Sh20,000 per day, or Sh30,000 per day.

Then they will be pumping in platelets. One unit, if it is irradiated, is going to be Sh50,000 per unit. By two to three weeks, we are talking about Sh2 million.

If a doctor cares about the economy of the country, then he or she will only refer those who need to be referred, you can't justify everybody. Because you are just taking money away from the country to build another country and you leave your country poor

You write that “rogue and runaway medical tourism threatens to cripple the economies of many countries in the entire sub-Saharan Africa region”. In fact, you call it peaceful robbery. Do you still write referral letters?

I’m very hesitant and only write when I feel it will benefit somebody. Only about five per cent of cancer cases will need to be referred out.

If it goes high, I don't think it reaches 10 per cent. Some of them are things like bone marrow transplants, which we don't have locally. Or some very complicated surgeries.

If a doctor cares about the economy of the country, then he or she will only refer those who need to be referred, you can't justify everybody. Because what are you doing? You are just taking money away from the country to another country to build that country and you leave your country poor. People say oh, there are few oncologists, there are few centres. Yes, there are few centres. But if you look at these centres, they are underutilised.

If you take, let's say, the cancer centre [here at Nairobi Hospital], my roster is not running at full capacity. If you take Aga Khan, it is not running at full capacity. If you take a MP Shah, they're not running at full capacity.

The ones that are running at more than full capacity are public hospitals. Because of affordability, being a public institution. But when you look at the private ones, which are well-equipped, they are not running at full capacity because people are running away to go to India to get the same treatment.

And the Indians have perfected the art of cheating people that oh, no, they can't do this in Kenya. Come, we can do it better. Then they will tell you, you have been cured. Well, the cancer is just this waiting to bounce back on you.

If you are referring a patient to the US or to the UK, they will ask you, what do you want us to do that you cannot do in your country? They don't want too many people just running there.

Edited by T Jalio