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Thursday, March 24, 2016

Is Bad Luck the Cause of Most Cancers in Nigeria?

The recent study in the journal Science, which suggested that most cancers are due to bad luck rather than lifestyle or environmental factors, generated massive media ripples. To summarize, authors Tomasetti and Vogelstein of Johns Hopkins University say the "majority [of cancers] are due to "bad luck," that is, random mutations arising during DNA replication in normal, noncancerous stem cells".

Even though Nigerian media outlets joined the rest of the world in reporting a finding that the publishers called 'remarkable', Nigerians have known long before now that cancer is the result of a rotten luck.

Bad luck in Nigeria



In traditional Nigerian societies, perceptions about the causes of illness and disease were rooted in mischance and misfortune. A survey conducted by Imelda Nwoga among the Igbo speaking people of southern Nigeria revealed an interesting list of what traditional healers believe to be the cause of cancer. These include evil curses, magic, incestuous acts and adultery. Stepping on poison and crossing an evil line were considered the two major causes of cancer.

The acceptance of bad luck as the major etiological factor for cancer is not limited to the south. Another survey conducted among the Hausa and Fulani of northern Nigeria found that cancers are thought to be due to contact by the victim with evil spirits in the forest.

Magical Medicine



As such, when ill, the average traditional Nigerian consults a traditional healer. Traditional healers often play three roles in patient care. Many are simultaneously herbalists, diviners and occultists. They are also the custodians of the community's religious life. With the increasing acceptance of Christianity and Islam, many traditional healers have also become leaders of these faiths. As Pew Research found, many [Nigerians] who indicate they are deeply committed to the practice of Christianity or Islam also incorporate elements of African traditional religions into their daily lives.

The persistence of traditional beliefs in health care is evident in the fact that many Nigerians still turn to alternative medicine even when receiving orthodox care for cancer and other chronic diseases. One study in southeastern Nigeria showed that 65% of cancer patients interviewed at a Nigerian tertiary hospital utilized complementary and alternative medicine (CAM) at some time during their current cancer illness. The use of CAM was not affected by age, marital status, level of education, religious affiliation, or socioeconomic status. Another study conducted in the southwest of the country highlighted the fact that a majority of patients use CAM while seeking care at orthodox clinics. In this Lagos study, 84% of the parents interviewed admitted to using CAMs to treat their children with epilepsy, asthma and sickle-cell anemia.

In my own practice as a physician, I quickly found the belief in metaphysical explanations for ill-health to be one of the reasons why many traditional Nigerians see a visit to an orthodox medical clinic or hospital as a last resort. Such patients show up in a Westernized clinic or emergency room only when all hope is lost. Many die before a diagnosis can be made.

Cancer in Nigeria



Yet, available data suggests that the numbers of newly diagnosed cases of cancer in Nigeria have steadily increased in recent times. This increase may be due a combination of factors not limited to an improvement in diagnostic capacity, better acceptance of orthodox medicine and better general population awareness of cancer. In any case, there is no doubt that cancer is a growing problem for Nigeria.

Even then there is still reason to believe that the incidence of cancer in Nigeria is grossly under-estimated. For one, a large proportion of the population never seeks orthodox medical care, and so cancers among them are not recorded. Fatimah Abdulkareem, a Nigerian professor of Anatomic Pathology, also reports that inaccurate population statistics, inadequate diagnostic facilities, limited access to care, inadequate technical manpower and infrastructure as well as [the poor] quality of cancer data systems all contribute to inaccurate data on the cancer burden in Nigeria.

Given that Nigeria is the richest nation in Africa, it is reasonable to think that the state of cancer research is probably at its best in Nigeria as far as the region is concerned. But with the reality described above, there is little wonder that a study of cancer registry literature updated from all over the world, found that only 1% of the literature emanated from Africa compared to 34% and 42% from Europe and Asia respectively.

Bad luck for real



So how do we deal with a problem without a good knowledge of its magnitude? Well, we can't! That, for me, is the real bad luck in this case. The rotten luck of a poor understanding of the true state of our population health is certainly impeding our ability to prevent the development of many cancers. In reality, the bad luck of ignorance is the cause of many cases of cancer in Nigeria.

There is therefore an urgent need to enlighten the Nigerian people about the reality of cancer. Nigeria's academic and political leaders are also in acute need of accurate knowledge about who is affected, how, where, when and why. We need to accumulate reliable local data on the sorts of cancer that our people are dealing with and, in order to manage them appropriately, we must establish their etiologies and/or risk factors as best as we can. The era of adapting the results of research conducted in foreign lands to our population must come to an end. The increasing incidence of diagnosed cancer may be an indication that the 'adaptation' model has not worked.

Reasons for hope



But there is hope. In the summer of 2013, Popoola and colleagues reported that there were only 11 cancer registries in Nigeria, all located in tertiary hospitals. They all produce hospital-based data and most of them were poorly funded. Now the number of cancer registries in Nigeria has increased to 21 and it is reasonable to believe that the state of their funding has improved. The establishment of the Nigerian Institute of Medical Research and the Data Inventory and Documentation Initiative of the Federal Ministry of Health are other steps in the right direction.

Many questions, few answers



Yet beyond the creation of cancer registries there is the need to ensure that cancers are diagnosed as early as possible. This calls for an improvement in cancer screening. Are there any national cancer screening guidelines in Nigeria? Must we continue to apply standards generated in other populations to our people?

When cancers are suspected or diagnosed, do we have the capacity to readily do genomic testing in order to identify causative factors and determine risk? What is being done about well-defined cancer risk factors such as cigarette smoking, alcoholism, air pollution, poor water quality, Westernized diets and chronic infections?

Ultimately, for many Nigerians, the issue of luck and cancer boils down to the state of the health system. Only a strong health system that respects traditional values and incorporates all providers at the grass root can create the mass awareness that is needed to defeat cancer. To strengthen our health system we will need manpower, materials and money.

A role for the Nigerian diaspora



In terms of technical manpower, it is gratifying to note that many Nigerians, both at home and in the diaspora, are conducting world-class groundbreaking cancer research. Fortunately, those highly skilled Nigerians in the diaspora are willing to collaborate with researchers on the ground in Nigeria. Most importantly, personal communication with several Nigerian scientists currently living abroad indicates that many of them would happily return home to strengthen the system if they were assured of a supportive environment - an environment that can only be created by good policies.

Policies and politics



Good governance also holds the key to the infrastructural development and research funding that is needed to strengthen the Nigerian health system. Strong regulatory policies that are well executed are also needed to prevent the environmental pollution known to cause cancer and other diseases.

Hopefully, this year's general elections in Nigeria will usher in the political leadership necessary to bring forth the health system of our dreams. This is a chance to reverse our luck.





This article was originally published by the University of Michigan Risk Science Center

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