He had knowing, radiant eyes despite the obvious agony gnawing at his entire being. His body was relegated to cachexia; one year of difficulty swallowing and unimaginable weight loss has robbed his muscles of any tone they might have had. His eyes smiled at me as I stepped up as the third surgeon to examine him, talking over him in a partly foreign language. He started to have trouble swallowing a year ago he told me, offering no explanation on why he had waited so long to come to a hospital. It was only when he started having stridor, audible upper airway obstruction with a whistle accompanying every exhale that was impossible to miss, that his relatives brought him to seek medical care. He had bulky lymph nodes on both sides of his neck, protruding from his fragile skeleton like golf balls. There was a palpable mass protruding from his neck that had been slowly robbing him of his twenty year old life.
I have found myself at a missionary hospital in the mountains of Kijabe, Kenya, a long-established facility known throughout the region for its surgical expertise and care for the marginalized. The overwhelmingly prevalent diagnosis I have cared for during my time in Kenya has been gasroesophageal cancer. Kenyans well versed in the matter will tell you that it’s the deadliest of cancers in Kenya, claiming more lives among both men and women than any other. Even more baffling is the stage at presentation. Patients present with months to years of advancing symptoms—difficulty swallowing and worsening pain leading to persistent vomiting, dehydration and inability to tolerate even their own secretions. It is then that they present to be seen in an outpatient department and get funneled into the surgery outpatient clinic where up to 200 people a day wait from early morning into the evening to be seen and scheduled for an Oesophagogastroduodenoscopy to biopsy the fungating lesion that has been allowed to grow in the dark for all this time. Rarely are patients candidates for resection by the time we see them due to adherence of the mass to surrounding organs or advanced spread to other parts of the body. We offer palliative procedures that may temporarily relieve their symptoms and talk to them about chemotherapy and radiation, something they must be referred to Nairobi to discuss. Many lack both the finances and the physical wellbeing to make neoadjuvant therapy a feasible option.
Medical decisions are made differently in Kenya. I have been told by multiple providers that Kenyans do not go to a hospital unless they think they have no other option. Primary care and prevention is a rarity and geographic and financial barriers keep patients from seeking adequate medical attention. There is a reality of pending financial ruin that faces families making decisions about their health care. Kenya only recently rolled out a national health insurance, available at a monthly cost. The majority of patients haven’t signed up due to lack of knowledge or funds or a feeling of lack of necessity. Catastrophic healthcare costs discourage families from seeking medical attention until they are certain no other options exist. The economics of health care do not incentivize patient wellbeing so much so that they tolerate great discomfort before coming to search for answers or relief.
I am a small and temporary piece in this puzzle, caring for those with advanced, life-threatening problems in high volumes and magnitudes that can often seem overwhelming. This however, is the reality in which many individuals live. Addressing the burden of this disease in this country will require efforts not only from facilities like this but all levels of government and culture, making this a public health problem that requires national attention. The eyes of many must be forced to see this deep suffering.