Providing nomadic people with health care
The Kenyan government and medical charities are
fighting hard to deliver good health care to the people of Kenya. Deborah Cohen looks
at the particular difficulties involved in providing care to the nomadic
people of Turkana, in the north west of the country
The Turkana are nomadic
pastoralists in northwest Kenya who raise camels, cattle, sheep, goats, and
donkeys to provide milk, meat, and blood for nourishment. Under British
rule the Turkana district was virtually cut off from outside contact; the
government had declared it a “closed district” and restricted
movement.
Overview
When the region experienced famine in 1961,
missionaries were granted access by the British to provide support for the
population, and missionaries are still a large presence there.
Andrew Aitchison
A child receives his “Plumpy Nut” from
Merlin in Longech
According to Gezaghen Kebede, Oxfam’s country
programme manager for Kenya, this political and social isolation from the
mainstream still exists today. The Turkana are barely represented in the
political system, nor have they benefited from programmes implemented to
aid development. Moreover, pastoralists have come under pressure from
governments and development agencies to become sedentary and adapt to the
more manageable urban way of life.
Inwani Malweyi, Merlin’s (a UK medical relief
and healthcare charity) emergency medical coordinator in Kenya, says that
the pastoralists’ lifestyle poses challenges to healthcare
delivery—their mobility and resulting difficulties in getting and
maintaining treatment, the harsh environment, political and socioeconomic
marginalisation, and their proximity to animals. Generally, ill people use
western medicine and traditional medicine. Sometimes they adhere to one,
changing only if the treatment fails to relieve physical discomfort or
emotional distress.1
The Turkana region is arid and semi-arid—the
rains are scarce and erratic. Malaria and nutritional status are also
seasonal—after the rains there’s water and more pasture so the
animals are fatter and more productive. A 1992 survey from the Africa
Medical Research Foundation found that the number of people attending one
of their mobile units fell away in August as people retreated into the
hills for pasture and water.2 But the recent increase in the frequency of droughts
has taken its toll on the Turkana and has resulted in widespread poverty
and malnutrition. Last year, an Oxfam internal survey showed that the
levels of acute malnutrition were 35% in northern Turkana, with rates this
year falling to 22% after interventions. The high levels are a result of
poor access to, and availability of, food, and are also exacerbated by poor
access to basic health services.
Poor infrastructure
Turkana covers an area of 77000 km2; paved roads are
few and far between. Away from the main roads, access to larger settlements
requires a four wheel drive and the journey passes over lake and riverbeds.
It’s bumpy and slow in the dry season, and almost impassable in the
wet. The poor infrastructure prohibits both public and emergency transport
access, and the provisions vary between settlements.
In Kaeris, if hospital referral is needed and the
patient is mobile they will walk more than 30 kilometres to the main road
to hitch a lift to the nearest hospital in Lodwar, the Turkana district
capital, 150 kilometres away. If not, a family member makes the trip and
tries to get transport. There are no telephone or mobile networks in the
majority of Turkana, and when asked if there was one thing that would make
his job easier, John Ateyo, a Ministry of Health nurse replied, “A
radio.”
But for non-governmental organisations (NGOs) and the
government, the poor infrastructure stretches the amount of time and money
spent in delivering health and development programmes. Conflict between
neighbouring ethnic groups, insecurity because of bandit activity, and the
presence of a burgeoning small arms trade add to the cost; armed security
is essential for travel in some areas.
Andrew Aitchison
A borehole in Kanukurudio funded by a Catholic
mission
Health care
It is important to adapt the provision of health care
to the lives of pastoralists, who might fall outside the scope of everyday
services. If western medicine is incompatible with indigenous health
seeking behaviour, it can compromise its effectiveness.3 This has meant
making services mobile, and implementing community care schemes where
practical. One outreach scheme, which according to a Merlin internal audit
has been successful, is their immunisation scheme. The scheme was initially
piggybacked on to food distributions by Oxfam after the 1994 drought; a
team now drive to visit the villages to give the vaccinations. In the
regions where Merlin operates, immunisations for measles have risen from
40% to 78%, but as mobile communities move, some children are lost to
follow-up.
Where there are larger settled communities, it’s
economically viable for the Ministry of Health to provide a nurse, a
dispensary, and a health centre, which may have space for a few patients to
stay. Nurses are the backbone of health care—they perform the duties
of doctors, pharmacists, and midwives—and the broad based training in
the nursing college in Lodwar reflects this. Increasingly, NGOs are turning
to training patient attendants in each village on how to recognise illness
and when to refer.
Nevertheless, healthcare planning in Kenya is
centralised. Drugs and medical supplies sent to the local dispensaries are
made centrally in Nairobi and don’t always reflect the needs of the
area. Packs normally contain a range of antibiotics, analgesics,
antimalarials, and worming medication. Some packs contain drugs for
hypertension and diabetes—illnesses rarely seen in Turkana—but
most of them fail to contain eyedrops for eye infections, iodine as an
antiseptic, and hydrocortisone for bites. John Ateyo says you have to be
very selective about what you use as you can’t guarantee the date of
the next delivery.
NGOs in the field
When driving through the region, it’s clear that
the Turkana have been on the receiving end of NGO interventions.
There’s a Catholic mission funded borehole here, and a Merlin
subsidised health centre there. The activity of different NGOs in different
areas means there hasn’t been a consistent approach to tackling
health needs.
Oxfam and World Vision offer training in sanitation
and hygiene to different influential members of the community, who, in
turn, impart their knowledge to the rest of the community.
Leah Nachere, a traditional birth attendant and town
councillor in Kaikor, points out the bins (holes in the ground) and
draining racks in the village. “We’ve also had training in the
importance of showering, washing clothes and utensils, and drying
them,” she says.
But although some health messages are filtering
through, a concrete solution doesn’t always materialise. Financial
constraints mean that communities are asked by NGOs to prioritise according
to their main needs. Access to food and water for people and livestock
might understandably trump other requirements. Well versed in the hygienic
benefits of using latrines, several village leaders pleaded for help in
building them. “We really need the equipment to build pit latrines
here,” Moses Lopeyok, chief of Longech says. “The ground simply
doesn’t support hand dug pit latrines—it collapses.”
Not all health improving measures need to be
sophisticated high cost interventions in order to make a difference. For
example, Oxfam has provided the traditional birthing assistants with kits
to aid their work. They’re simple, yet contain basic equipment that
is essential for improving hygiene. Oxfam also provides training to spot
complications in the mother and child, antenatally and postnatally, and
when to refer to the nurse. But Leah Nachere says that one-day training is
not enough. “People need to be monitored and have reminder
trainings,” she says.
Health problems
Although animals provide the mainstay of food and
nutrition, the Turkana’s proximity to them poses health
problems—hydatidosis (Echinococcus)—spread by the close contact between humans and dogs,
which affects the liver and spleen. Brucellosis, pneumonia, and
tuberculosis (TB) are also particularly prevalent.
Tuberculosis
Malweyi Inwani says the follow-up of TB patients who
lead a nomadic lifestyle has always challenged Kenyan doctors. Directly
observed treatment short courses were difficult to maintain because
patients would start treatment only to abandon it, after the community
moved to a different area.
To deal with TB among nomadic groups, the national
tuberculosis and leprosy programme introduced the “TB manyatta”
approach. These are treatment centres attached to hospitals. Inside the
manyattas, patients receive four months of intensive TB treatment under
constant medical supervision, and the rest of the drugs are given in a
package so that patients can move on. Treatment for TB is given free of
charge through the health ministry as directed by government policy and
WHO. The current rise in TB has caused a strain on the government’s
budget for medication, however, making it difficult for hospitals to
provide treatment free of charge. Some hospital management boards
introduced limited cost sharing for TB drugs—the government and the patient shares the cost of the
drug. But, according to Inwani Malweyi, the introduction of cost sharing
charges for TB treatment poses a threat to treatment and control of the
disease. The Turkana are poor, and paying for health care might come second
to buying food or they may not have the cash to hand and have to wait until
they are able to sell some livestock.
Malnutrition
Because of the high levels of malnutrition, specialist
nutrition programmes to treat the moderately and severely malnourished
children are needed. Attached to the dispensaries in the larger settlements
are therapeutic feeding centres, where children with a a height to weight
ratio of less than 80% of the median receive fortified dry skimmed milk
products provided by different organisations.
Like directly observed treatment short course schemes,
therapeutic feeding centres have their problems fitting in around the
Turkana lifestyle. According to Isaac Ekeru, field project officer for
Merlin, mothers sometimes have to be persuaded to leave their other
children. Admission also further undermines economic productivity and food
security.4 This has prompted the arrival of home based care with ready to
use therapeutic food—if there are no other medical
complications—where children receive nutrition as outpatients.
HIV on the rise
For a long time, NGOs were under the erroneous
impression that HIV was not a problem among pastoralists—their
isolation protected them from the spread of the disease. Although there are
no basic data about the prevalence of HIV, the suspicion is that it’s
increasing. As a tarred road was built through the region to connect Lodwar
with Lokichoggio, the UN base for Operation Lifeline Sudan, the number of
truckers and public transport increased. These routes attract impoverished
women who turn to prostitution for food.
Merlin has started to offer a voluntary counselling
and testing service in the bigger settlements. Volunteers get thorough
pretest counselling, are offered the option for on the spot testing with
immediate results, and then get post-test counselling. Judging by the queue
outside, it’s a popular service.
Although mobile clinics and NGOs seem to be plugging
the gaps in the healthcare system, they have high running and maintenance
costs and it’s questionable how sustainable they are in the long
term. As Isaac Ekeru says, “No one has completely addressed health
care in Turkana.”
Deborah Cohen, assistant editor, affiliation
Email: BMJ dcohen@bmj.com
studentBMJ 2005;13:397- 440 November ISSN 0966-6494
- Duba H, Mur-Veeman I, van Raak A. Pastoralist health care in Kenya. Int J Integrated Care 2001.www.ijic.org/publish/articles/000019/index.html (accessed 15 Oct 2005).
- Africa Medical Research Foundation. 1991 Annual report. Nairobi: AMREF, 1992.
- Harragin S. Health and healthcare provision in Northwest Turkana, Kenya. London: Overseas Development Institute, 1994.
www.odi.org.uk/pdn/papers/36c.pdf (accessed 15 Oct 2005).
- Collins S. Community-based therapeutic care: a new paradigm for selective feeding in nutritional crises. London: Humanitarian Practice Network, Overseas Development Institute.[WHAT YEAR WAS THIS PUBLISHED? Please give URL]
- African Studies Quarterly. The online journal for African studies.
www.africa.ufl.edu/asq/v7/v7i1a2.htm (accessed 16 Oct 2005). [WHERE SHOULD THIS BE CITED?]
