AMREF – Responding to crisis: Lessons from Kenya’s silent emergency

Responding to crisis: Lessons from Kenya’s silent emergency


AMREF’s Deputy-Director General, Dr Florence Muli-Musiime has warned that emergency institutions, both local and international, risk misdirecting their humanitarian crisis response if they are not sensitive to community dynamics that are not always visible in times of upheaval. In a powerful message to hundreds of delegates at the 35th Global Health Council Conference taking place in Washington DC, Dr Muli-Musiime described a ‘silent emergency’ that nobody spoke about following the post-election violence in Kenya, whose implications for healing and recovery has more serious implications for post-conflict health and social development than the more widely publicised plight of internally displaced people in the country.

‘When the crisis broke out,’ she said, ‘the focus of the health system was to mitigate the physical injuries, while that of the donor community and emergency institutions was on the Internally Displaced People. But we realised that there was a silent emergency which none of the two groups was looking at – that of thousands of people who were caught up in their own homes, unable to go to IDP camps because they would have had to go through hostile territory to get there, and unable to access health or any other basic services. To make matters worse, they were physically assaulted and sexually abused in their own homes.’

Dr Muli-Musiime one of four panelists in a discussion on how current affairs affect health care in the community, with a specific focus on the recent crisis in Kenya. The others were Dr Sylvester Kimaiyo, Programme Director for AMPATH; MAP International’s Senior Director for was Health and HIV/AIDS Policy, Dr Peter Okaalet; and Dr. Salvador de la Torre, Country Director for the Catholic Medical Missions Board, all based in Kenya.

The purpose of the session, according to moderator Sheila Mitchell, Senior Vice-President at the Institute for HIV/AIDS, Family Health International, was to draw lessons from the experiences of organisations that were working on the ground at the time of the crisis in Kenya and come up with recommendations for what to do in similar situations.

AMREF has worked for many years in one of the areas most affected by the violence and attendant humanitarian crisis – Kibera, a vast informal settlement that is home to close to a million people.

‘Our northern-based partners focused on only a fraction of people in need,’ said Dr Muli-Musiime. ‘For example, only 5,000 of Kibera’s 750,000 people were in the camps. Very few organisations – AMREF, MSF and some faith-based institutions – stayed where the majority of people were. Here, we observed the emergence of significant new health challenges. One of these was gender-based violence, which was systematically used as a tool to promote the political violence. Then there was a total breakdown of the health system, and disruption of household life. People were unable to cross from one section of Kibera to another to access even the most basic of health services.’ This scenario was repeated in all the regions where the violence was intense; the Rift Valley, Nyanza and Western provinces.

‘A very scary phenomenon that is difficult to explain was the psyche of the violence – it had no restraint. In Kibera, when a mob descended on a house, sexual violence was unprecedented and unrestrained: everyone – men, children and women – was raped. In Africa, it is not usual for men to admit that they raped other men, but it happened during this violence. The most frightening aspect was that it was all so silent, a silence that was perpetrated by the media, which was more interested in the bleeding, not where there was hurting and the bleeding was in secret. This was extremely sad.’

HIV and TB programmes were severely affected. Systems that had been established to monitor and track patients collapsed. In Kibera for example, where AMREF had established an efficient monitoring system for TB and HIV patients, the organisation lost track, within the first two weeks, of 70 per cent of AIDS patients and 30 per cent of TB patients registered at the AMREF clinic and with community support groups for drug adherance and household support. Dr Muli-Musiime warned that the fallout from this disruption was certain to erupt in coming months as the effects of missing critical dosages took effect on hundreds of patients across the country.

Countrywide, the crisis had a heavy impact on the health system. Supply was affected between the two groups. Initially, when the crisis broke out, the health system was very quick to react, thanks to the 1998 bomb blast that hit Nairobi, leading to the creation of an emergency response plan. The plan immediately kicked in when the crisis broke out last December. Those affected were quickly evacuated and moved to hospitals, although this was hampered by the fact that medical personnel could not move about freely due to ethnic animosities. Hospitals were also able to respond to the crisis adequately for the first two weeks, but as the fighting continued, they began to run out of supplies, especially surgical equipment and drugs. People were disconnected from the services because of inability to access certain areas, because of being displaced, and the inability of service providers to move into the communities as they had been doing before. This was further complicated by the fact that the health workforce was also a target of the violence depending on their ethnic origin.

‘Our response was to work on both sides,’ said Dr Muli-Musiime of AMREF’s activities. ‘We went into the IDP camps and stepped in to do the things that emergency organisations were not doing, such as water and sanitation – building bathrooms and latrines, providing clean water and keeping the camps clean – as well as providing laboratory services. Within the communities, we responded by reaching out and going where the communities were trapped and unable to get out. This required serious dialogue and negotiation with all the actors, working with households, and creating a presence on the ground. Instead of waiting for the people to come to us, we went to them. We set up mobile clinics in each village, as people were unwilling to seek services in sections of Kibera inhabited by different communities. We also had to negotiate with the communities to allow our staff and government workers to move through Kibera to provide services.

The role of the media

Dr Muli-Musiime expressed great disappointment in the media’s handling of the crisis and of the victims. ‘I was deeply saddened that journalists could be so insensitive to the people they were reporting about. The media needs to report painful incidents in a manner that does not magnify the pain and trauma as a result of exposure, repetition of clips showing wanton violence, or blatant insensitivity, particularly when reporting about sexual violence. When you ask a woman whether she was raped and she is surrounded by her family, she will not tell you the truth because of shame and fear of ostracisation, but they told us in private what they had been through.’

With the increased incidence of violence and aggression in communities, she suggested integration of mental health and gender-based violence into whatever work an organisation is doing. ‘The underlying principle is integration. Let us not create silos – we need to ensure that we look at the spiritual and mental, as well as physical health of the people. Similarly, we need to move away from verticalising the various responses within a crisis based on the interests of different intervention partners including donors. This only ends up creating many parallel, segregated systems within the same communities. The international community is involved in patchwork; we want to create a mosaic.’

The healing process

Dr Muli-Musiime suggested that civil society has a huge role to play in the country’s healing process. ‘We need to reach out to politicians, interact with them, and create avenues for dialogue. We may not always agree with them, but at least we will be talking. We must also learn as Africans to appreciate our diversity, because the friction created by diversity is necessary and is needed to drive social change. We must recognise, promote and celebrate the strengths of different communities. The onus is also on each one of us as individuals. We need to change our actions and attitudes. We cannot wait for the politicians or the government to reconcile us. We need to empower communities to be conscious of the issues that cause misunderstanding, to address them and to find solutions for themselves. AMREF believes that there can be no progress in a community, whether in health or any other field, if the people themselves are not fully involved.’

The panelists emphasised the importance of putting emergency plans in place regardless of a country’s past experiences. ‘Kenya has been a haven of peace in a volatile region, and a refuge for many exiled people from troubled countries in the Horn of Africa and central Africa. Nobody expected anything like this would happen there. It taught us that we must always be prepared, and that we must have a plan in collaboration with other players on the ground.’

The need for coordination, honesty and integrity were also emphasised, as many organisations and individuals were involved in the humanitarian efforts, but there was a lot of duplication of activities, and even exploitation of victims of the crisis.

ReliefWeb

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