522 deaths during Kenya’s nurses’ strike: What do we actually know about the figure?

Kenya’s nurses are returning to work after a 43-day nationwide strike, but an alarming number is now dominating discussion about the human cost of the industrial action: 522 deaths.

The Standard reported on Thursday that 522 deaths were recorded during the strike, including 63 women who died while giving birth and 69 babies who died shortly after birth.

The figures are disturbing. But there is an important question that risks being lost in the headline:

Did 522 people die because of the nurses’ strike, or were 522 deaths recorded during the period of the strike?

Those are not medically or statistically the same claim.

And the evidence publicly available so far does not establish that every one of the 522 deaths was caused by the absence of nurses.

What do we know?

The nationwide strike began on July 29 and ended on September 9 after the Kenya National Union of Nurses and Midwives (KNUNM) reached a return-to-work agreement with the Council of Governors.

KNUNM Secretary-General Seth Panyako directed nurses to return immediately, or within 24 hours. The agreement gives the parties another 45 days to conclude negotiations over implementation of the 2017 Collective Bargaining Agreement.

During those 43 days, disruption across public hospitals was severe.

Some dispensaries and services were closed, doctors complained of being overwhelmed, and patients faced reduced services and delays. The Kenya Medical Practitioners, Pharmacists and Dentists Union had threatened to join the strike, saying doctors could not indefinitely absorb nursing duties.

There is also credible evidence that significant numbers of maternal, neonatal and perinatal deaths were being recorded during the disruption.

On September 3, for example, the National Nurses Association of Kenya said eight maternal deaths, 16 neonatal deaths and 55 perinatal deaths had been recorded nationally between Monday and Wednesday of that week.

It also reported 22 maternal, 44 neonatal and 130 perinatal deaths in the preceding week.

Earlier reporting by The Standard put the cumulative figures during the strike at 83 maternal deaths and 513 perinatal deaths by September 4.

But those figures themselves demonstrate why caution is necessary when interpreting the final toll.

‘Recorded during’ does not necessarily mean ‘caused by’

People die in hospitals every day, including mothers and newborn babies, even when the health system is operating normally.

To establish the actual mortality impact of the strike, researchers would need to do more than count deaths occurring between July 29 and September 9.

One useful comparison would be the number of maternal, neonatal and other relevant deaths during the same 43-day period in previous years.

Another would compare affected public hospitals with facilities where services remained relatively normal.

Individual cases would also have to be examined to establish whether delayed treatment, unavailable nurses, closed services, referral problems or other strike-related disruptions contributed to a patient's death.

That distinction was explicitly recognised by the Kenya National Commission on Human Rights.

When KNCHR raised alarm over 79 reported deaths between August 31 and September 2, it said the figures needed to be independently verified before conclusions were reached about their causes or circumstances.

That caveat remains important now.

So where does the 522 figure come from?

The Standard reported the figure as the number of deaths recorded by the end of the strike, including maternal and newborn deaths.

However, other publicly available reporting reviewed by LiveNow Africa does not yet provide an independent national audit establishing that 522 deaths were directly attributable to the strike.

The Associated Press, reporting internationally on the end of the industrial action, said the Senate had discussed increased deaths and the closure of some dispensaries during the crisis, but it did not report an independently verified strike-attributable death toll of 522.

This does not mean the deaths are unrelated to the strike.

The disruption clearly created serious risks to patients.

It means something narrower but important: the available evidence does not yet allow all 522 deaths to be described confidently as people “killed by the nurses’ strike.”

Doctors were warning about the danger

Long before the strike ended, doctors had warned that the health system was approaching a dangerous point.

KMPDU Secretary-General Davji Atellah said doctors were carrying additional responsibilities because nurses were absent and warned that the situation could not continue indefinitely.

After the agreement was reached, KMPDU said the nurses’ return would ease the “immense pressure” placed on doctors and other healthcare workers during the dispute.

The disruption was particularly consequential because nurses are involved throughout hospital care, from maternity wards and emergency departments to theatres, inpatient wards, clinics and community health services.

Their absence cannot simply be compensated for by asking doctors to perform nursing duties.

Who should establish the real death toll?

Now that the strike is over, one of the most important questions is whether the government will conduct a formal mortality review.

The Ministry of Health and county governments hold much of the information required to answer it.

Hospital records could establish how many patients died during the strike, where the deaths occurred, which services were unavailable and whether mortality increased compared with normal periods.

Maternal and perinatal deaths should be particularly amenable to review because Kenya already has systems for reporting and investigating such deaths.

A credible assessment would also need to distinguish between correlation and causation.

If, for example, maternal mortality increased substantially during the strike compared with comparable periods, that would be important evidence of its impact. But establishing whether an individual death resulted from the industrial action would still require examination of the circumstances.

The strike is over, but the dispute isn't

The nurses have not returned to work because all their grievances have been resolved.

The return-to-work formula creates a 45-day window for the union and government to conclude outstanding negotiations over the 2017 CBA.

The agreement also commits counties to work on career guidelines for nurses and addresses the employment of Universal Health Coverage workers on permanent and pensionable terms. Nurses who participated in the strike are not supposed to be victimised.

That makes the next 45 days important.

Kenya has restored nursing services before resolving the underlying dispute that removed thousands of nurses from hospitals for six weeks.

For patients and their families, however, another question deserves an answer.

If hundreds of additional or potentially preventable deaths occurred while negotiations dragged on, who will establish exactly what happened, and will anyone be held accountable?

That investigation may ultimately tell Kenya far more about the real cost of the 43-day strike than a single headline number ever could.