In-depth: Another Kenya - The humanitarian cost of under-development

KENYA: Where life can be brutal and short

Poor healthcare means preventable and curable diseases are more deadly in Northern Kenya than elsewhere in the country
GARISSA, 18 December 2009 (IRIN) - In remote northeastern Kenya, poor healthcare, a harsh climate and an ever-growing influx of refugees conspire to make preventable and treatable diseases more deadly than elsewhere in the country.

"You must either prepare to mourn or celebrate when your wife gets pregnant," Mohamed Geley, a truck driver in Isiolo, told IRIN.

Geley's wife died in October as he was taking her to a hospital in Isiolo Town in the east, from the area of Modogashe (about 200km away) for a caesarean.

An under-developed health system characterizes the northeastern and upper-eastern region. "These are areas which do not attract [health] staff as they are hardship places. There is a chronic shortage of staff," Argata Guracha, of the World Health Organization's (WHO) Emergency Humanitarian Action (EHA) programme, told IRIN.

The poor infrastructure does not help. "Facilities that can do a basic C-[Caesarean] section are just available at the district level. Yet getting there is a problem.

"There are few options [available] so you have to depend on a health facility, which is often very far [away]," said Guracha.

Nomadic lifestyles in the predominantly pastoralist region, as well as female illiteracy, are factors limiting access to antenatal care. “As the mother’s educational level rises, so does the likelihood that she will see a health professional for care during pregnancy,” noted the 2008-2009 Kenya Demographic and Health Survey (KDHS) – Preliminary Report.

KDHS results showed that 72 percent of women with no education received antenatal care compared with 91 percent of those with incomplete primary education.

More mobile clinics and maternal shelters would help, said Guracha as "most interventions that work well in a static community do not work well here". Maternal shelters, located close to the hospitals, which accommodate expectant women so they can access full health services, are being piloted in the northern region.

Northeastern has the lowest percentage of women who deliver in a health facility nationally at 17.3, according to the KDHS. In Nairobi Province, the percentage is 89.4, and 44.2 in Nyanza Province. Northeastern also has the lowest percentage of women who receive antenatal care from a health professional (doctor, nurse or midwife).

Challenges

Poverty, persistent conflict, and culture - for example, the insistence on obtaining a husband's consent before a woman can give birth in a clinic - are also barriers to health service delivery and access.


Photo: Ann Weru/IRIN
Children play at a shallow well: Most of the wells are uncovered exposing residents to the risk of using contaminated water
Guracha said: "A poor system of referring those with complications to health centres is also a challenge.”

Poor roads make transporting medical supplies difficult. "You may have so much in Nairobi but there are cost implications," he said.

Most of the roads are poor and often get cut off during the rains due to the largely flat terrain, rendering some parts inaccessible. Even in dry times, roads remain tortuous. The area is characterized by cyclical drought and flooding.

Cholera risk

According to an October alert by the UN Office for the Coordination of Humanitarian Affairs (OCHA), "Diarrhoeal diseases are a permanent feature in Africa’s Horn mainly due to recurrent natural disasters such as floods and droughts, which reduce the availability of safe water."

The absence or deterioration of social service delivery in health, water and sanitation sectors only serves to exacerbate recurrent diarrhoeal-related outbreaks, it added.

Several districts in the northeast and upper eastern region were also affected in a cholera outbreak, including the upper eastern town of Moyale, bordering Ethiopia.

"Those affected were using contaminated water as there was a drought," Rashid Osman, the assistant chief of the Odda Location of Moyale, told IRIN.

First reported on the Ethiopian side, population movement along the porous border was said to have fuelled the spread.

"When there’s no water, sanitation issues follow," noted Mutuku Kimeu, Isiolo District drought management officer (DMO). The Kipsing area, north of Isiolo, was also affected by cholera early this year.

Cholera resurgence has been reported in Turkana District, in the northwest, according to OCHA, adding that the Kakuma refugee camp in the district had recorded about 144 cases.

Already, more than 500 water wells have been contaminated, according to OCHA, after latrines were submerged in El Wak, in the northeastern Mandera area, which borders Ethiopia and Somalia.

Refugees at risk

According to OCHA, poor sanitation and overcrowding in refugee camps are additional causes of epidemics.

''You must either prepare to mourn or celebrate when your wife gets pregnant''
For example, the Northeastern Province capital of Garissa borders Africa's largest refugee camp, Dadaab, which as of 13 November was housing 267,525 refugees – more than three times its capacity.   

Arriving at an overwhelming rate of 6,400 a month, the mainly Somali refugees are adding more pressure to the already overstretched facilities and resources in Dadaab, according to the UN Refugee Agency (UNHCR).
 
But the effects of the influx are far-reaching, with the lack of a general medical screening centre for new refugees increasing the risk of disease spread.

In October, the International Rescue Committee (IRC) reported that 21 H1N1/A cases had been confirmed in two Dadaab camps. Measles and polio have also been reported.

Cross-border disease importation remains a threat. For example, a recent polio outbreak in Turkana originated in neighbouring Southern Sudan, according to the public health and sanitation ministry. Kenya had been polio free for about 20 years.

This calls for strengthened cross-border surveillance, Guracha added.

Despite both polio and measles being preventable, immunization coverage remains low at only 48 percent compared with almost 86 percent in Central and 85 percent for Rift Valley Province, according to the KDHS, due to infrastructural and livelihood challenges.  

"Because of low immunization coverage, a poor health system and porous borders with a flow of a homogenous population, there are bound to be major disease outbreaks," he said.

Threat of kala-azar

The northern region also sporadically reports cases of neglected tropical diseases, such as visceral leishmaniasis, also known as kala-azar or black fever. Kala-azar is endemic in northern Kenya and outbreaks are common during drought.

According to Guracha, such diseases are neglected as "in routine budgets, much is not allocated to them as they are not among the top causes of mortality".


Photo: Allan Gichigi/IRIN
Young girls go in search of water in Dadaab refugee camp, Kenya (file photo)
He said there had been a resurgence of kala-azar in the larger Wajir District and in Isiolo. The areas reported a kala-azar outbreak in 2008, which mainly affected malnourished children.

The Kenya Red Cross Society (KRCS) is implementing an integrated health outreach programme in the region to improve healthcare access, KRCS Eastern Regional Coordinator, Liban Mohamed, told IRIN.

Mohamed said KRCS-recruited scouts were helping to mobilize communities in areas such as Isiolo and Marsabit to seek preventive health services.

"Immunization coverage in Garbatulla [140km from Isiolo], has increased from 65 percent to almost 100 [percent]," he said.

Meanwhile, many families are still struggling to access medical services in the region.

"I know of a family who sold all their livestock in Marsabit to take their daughter to hospital in Meru [about 300km away] last month, but she died; it was a double tragedy," Cosmas Adow, of the local Pastoralists Information and Research Organisation, told IRIN.

Communities that are far from health centres sometimes end up using traditional herbs when sick, which may be risky, said Ibrahim Kosi of the Sericho Development Initiative.  

According to a recent report by the International Federation of the Red Cross and Red Crescent societies, infectious diseases and weak national health systems in developing nations are among the two greatest international health challenges.

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[This article is part of a special package "Another Kenya". For more reports: http://www.irinnews.org/IndepthMain.aspx?InDepthID=83&ReportID=87469 ]