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Health for All: A Reflection on the Current State of Healthcare in Kenya

15 min read.

The goal of universal healthcare must take into account how Kenyans access and pay for health services, and eschew the concept of “world class” as a standard for what good quality care should be. By NJOKI NGUMI

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Health for All: A Reflection on the Current State of Healthcare in Kenya
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There are three main concerns Kenyans from all walks of life have during illness or any manner of health crisis: 1) Who is going to take care of me, and where do I have to go to access that care? 2) Will all the options I need for full care be available to me, and are they the best ones there are? 3) Who is going to pay for the options I take? Is it going to have to be me, and what does that mean for my budget and my life?

These are obviously very valid and important questions, and it is a challenge to separate them because they weave so intractably into each other. Where we go and who we see when ill are dictated by who we are. Our age, gender, religion, socio-economic class, employment status, tribe, and proximity to an urban area or hub dictate the options available, and all these rest on the bedrock of the available funds to create and maintain a system of administration, equipment and skilled workers that avail healthcare services. All that considered, let us unpack each of these questions to see much more clearly where we sit in this often confusing and scary place.

Becoming a patient

The first thing we need to remember is that nobody plans for illness, and in that African cultural and spiritual way, we actively assume full wellness in anyone until they are on the verge of collapse. This is rooted in a commonly understood and yet completely unsaid superstition that if we summon illness it will come to stay; so we deny it until we cannot any longer. Kenyans are much less likely to be hypochondriacs than they are to sit uncomfortably on a symptom until it is alarmingly close to its worst possible manifestations.

The first thing we need to remember is that nobody plans for illness, and in that African cultural and spiritual way, we actively assume full wellness in anyone until they are on the verge of collapse. This is rooted in a commonly understood and yet completely unsaid superstition that if we summon illness it will come to stay; so we deny it until we cannot any longer.

A lot of this is linked to the roles we play in society: many people have hostile employers who view illness as a way to chicken out of work. Additionally, there are things we cannot opt out of, even while ill: parenting, especially by mothers of small children, is an example of a 24-hour shift regardless of our state of health. Many doctors will actually make a decision to admit and keep a mother who needs bed rest in hospital because sending her back home is a guarantee that nobody will let her stay in bed longer than five minutes. Many mothers cannot even have a short call in peace when in a house with a small and active child, let alone have a quiet meal or a full night’s sleep.

The idea of who is going to take care of a sick person, therefore, has to begin with who is available to take over or cover for the tasks they have, because this helps them on the path to acknowledging lack of wellness that is severe enough to need intervention from an outside source. Women again tend to draw the short straw and take on a third shift of minder to the sick and frail in a household. Predictably, another woman will likely be destabilised from other roles to come and hold fort for a woman if she herself is sick. Women therefore end up trading their time (as it is seen as less valuable) to take sick relatives to hospital and to assist recuperation there and at home.

Where we go to find help

When seeking help for illness, we prefer to play our cards as close to our chests as possible, and as Kenyans we cannot really blame ourselves for this. In a society where trust metrics have been in active decline for a while now, we are used to being scammed. We watch liars every day on our news channels and listen to them every Sunday at church. Choosing the devils we know, however inefficient they may be, is an easier option emotionally for a people weary of untruths.

One option is to go straight to a chemist, because most people end up at one, one way or another, to buy medicine. They relay the group of symptoms to the person behind the counter, whose only claim to care is a white coat. This person listens to the symptom list: to be fair, it is usually pain, stomach problems, or something respiratory, the majority of which are not too serious, and these things can mostly be managed over the counter. There is definitely room for one-stop interventions and medications, but one key issue is that a single quick public exchange often reduces the quality of the questions and the depth of the answers given. It is thus very easy to miss the subtle nuances between a series of self-limiting symptoms which need instant calming for quick relief, and an unfolding disease process which would need a more intensive treatment plan, as mapped out by lab and image investigations.

Another key locus in an honest healthcare analysis in Kenya is the traditional practitioner, who can be a herbalist, spiritualist, medium or even a medicine man or woman. Often the holders of cultural knowledge and trust, and able to speak to us deeply in language we can understand, using a frame of reference we are instantly familiar with, they have often been much more affordable and much easier to access, sparing us the long queues on hard chairs which end with cold, uniformed people using hard words that nobody understands.

Traditional practitioners can also seamlessly weave in spiritual ideology around healing, which can be a challenge for Western-trained caregivers. Several schools of thought would seek to corral or erase the traditional practitioner, but if anything, they are becoming increasingly popular in light of the limits current care has in seeing the person as a whole being as opposed to a concatenation of symptoms that need solving. Additionally, with the rise of Eastern practices, we are seeing more of Chinese medicine and Ayurvedic methods being explored in academic spaces. A reasonable strategist can project that the diverse African healthcare methods are the next frontier for Big Pharma. This is a conversation that is going on globally, not just in Kenya, and we would do well to take the brief headstart we have to explore some of these areas to whatever advantage we can.

The list of formal facilities available to Kenyans includes public hospitals, clinics and dispensaries, known mostly for understaffing, overcrowding, and subsequent inefficiency. Though many Kenyans go in and out of them daily without too many issues, they boast few stories of consistently stellar service. Faith-based and mission spaces have had many successes, but the vast majority of them are small operations and the footprint of their impact, even cumulatively, is thus limited. Private facilities close out the ranks; they are known for better quality amenities and offerings, but with the price tag we have learned to expect from all private suppliers of goods that should be publicly available—including transport, education and security. They are mitigated by market forces alone, and not subsidised by our taxes or regulated by public policy.

The list of formal facilities available to Kenyans includes public hospitals, clinics and dispensaries, known mostly for understaffing, overcrowding, and subsequent inefficiency. Though many Kenyans go in and out of them daily without too many issues, they boast few stories of consistently stellar service.

The case against being “world class”

We should really worry about the concept of “world class” as an abstract standard permeating our ideas of what good quality should be, especially with a sector as vast as healthcare. First of all, the idea of urbanness and urban contexts is intractably tied to the availability of specialist caregivers and facilities all over the world. Attracting and keeping certain cadres of healthcare providers necessitates certain amenities and access to a lifestyle associated with upward social mobility. However, rural contexts have human beings who are just as much in need of these exact services, but “world class” escapes an association with village life and small scale. There is nothing inclusive about it. It is not a term that was designed to make room for people who fall outside its reach.

Secondly, the trappings of “world class” care are almost, blow by blow, things that can be associated with luxury and availability of high budgets to afford the comforts over and above the basics. In the mostly capitalist context of the Kenyan economy, dignity is one of those things, because in many senses people have to pay to matter. The speed at which people will rush to the bedside of a VIP will tell you that even though the value system of care argues that all people are equal, the Orwellian situation where some are more equal than others, as detailed in the classic literary work Animal Farm, can most often be trusted to prevail. A “world class” situation where people who pay and people who don’t pay are getting the same quality of service can create conflicts, and we therefore find that we have to create discomfort for people who pay less in order to justify the comfort of those who are paying more. A practical example of that is the ever-shrinking size of economy class seats in most airliners.

Thirdly, “world class” in resource-limited contexts like these has tended to focus, rather dangerously, on flashiness of equipment and an array of available specialties, rather than on how the people feel about how they are being treated and guided on the path back to health. We have seen billboards with photos of futuristic diagnostic machines, but heard horrifying stories of patients suffering in the same hospitals where the sci-fi imagers sit. In many ways, we like the idea of a hospital that looks like one abroad but haven’t thought beyond that to a hospital where Kenyans are treated as though they matter.

But even as regards care, we must focus on the caregivers, and the situation with them in this country has been tenuous for a while. The line between public healthcare workers and private ones is very thin because most of them receive their education in the same institutions. The labour issues of the healthcare sector have been known for a while, with strikes rocking the nation at different points, causing unfathomable gaps in direct patient care and public health interventions for vulnerable populations, such as children under the age of 5, people living with HIV, pregnant mothers, the elderly etc. For many reasons, top among which are understaffing, overwork and underpayment, many caregivers are burned out and unable to engage humanely in the lives of their patients, and this humane engagement is the bedrock of what the intention of the word “care” is. Professor David Ndetei et al published a preliminary sample study in 2014 that found that over 95 percent of caregivers at Kenyatta Hospital, Kenya’s largest teaching and referral hospital, were showing clinical signs of burnout. As such, we can have all the best machines in the world, but if we do not also ensure that our caregivers are at their best, we are already running a losing race. The same can be said of healthcare support and administrative staff.

A fourth element of “world class”, which we may have been phased out due to unfocused policy, is matching the disease burden and health needs of the people with the opportunities for training new specialists. This country is only just coming to terms with its prevalence of cancer and many non-communicable diseases, for instance. Our previous leaning on tropical medicine and infectious diseases without keeping a sharp eye on the peripheries has allowed this to feel like it snuck up on us when in reality people have always been suffering: it is just us who didn’t take notice.

We can add to this list the conditions that are considered “rare” and therefore possible to ignore because their sufferers have not reached a number large enough to make macroeconomic investment worthwhile. As such, those with the means are able to get treatment and management in other countries which, whether for free market reasons, solid national planning, or both, enabled spaces where this is available. Often we hear of VIPs who manage public resources having the additional perks of opting out of the care available here, which is almost as though, when it is convenient, they get to stop being the Kenyans they are happy for the rest of us to be. This is not an indictment on everyone who has had the privilege of getting on a plane to places like the UK, India or South Africa to access treatment: it is, however, a recognition of the tragedy in the lives we have lost because so many were not able to access the same options. It becomes pricklier when we consider that sometimes there is room for our national public insurer to pay for people to get care abroad, which is obviously wonderful, but why do we remain unable to do what it would take to avail those options here to all Kenyans? How can we ensure that all lives are viewed as equally valuable?

Often we hear of VIPs who manage public resources having the additional perks of opting out of the care available here, which is almost as though, when it is convenient, they get to stop being the Kenyans they are happy for the rest of us to be. This is not an indictment on everyone who has had the privilege of getting on a plane to places like the UK, India or South Africa to access treatment: it is, however, a recognition of the tragedy in the lives we have lost because so many were not able to access the same options.

A general issue with accessing care abroad is that the great equaliser of persons as regards quality of care becomes emergency services. Regardless of who we are, if we are involved in a road traffic accident or suffer some other acute trauma, we are bound to the nearest facility, wherever it may be, to get the interventions that we need in order to make sure that we buy time and avoid death. During such moments, it is not how much we can pay that matters as much as the assurance that wherever we go, the people in both private and public spaces can give us the exact care we need to keep us alive. Currently that is a difficult assurance to give Kenyans, and so these aspirations towards world-class care are more distractions than they are honest analyses of what is actually possible for us.

Who pays for universal healthcare?

The organic segue when discussing value of life in healthcare is to ask ourselves a few rather philosophical questions. How much are states willing to invest in the life and wellbeing of their citizens? A quantification of the amounts of money a nation’s citizens pay out of pocket for healthcare would be one way to understand that. Understanding where citizens have to plug in from their own net income—and why—may be a more qualitative way to map out any gaps in a country’s healthcare spend.

We have to negotiate the practicalities of actively rolling out what we call universal healthcare. It cannot qualify as universal if citizens cannot access it, or if they are paying a significant part of its cost from their own pockets. It bears explaining that once rolled out, Kenyans may not pay for it, but it is far from free: What it means is that everyone’s care is averaged out and charged to each citizen via the varied taxes we already pay, as well as from the net incomes of a nation from the items it offers for sale to the global market. Basically, we put money in Caesar’s pocket, and it is added to whatever Caesar already has coming in, and then Caesar pays for everyone. The reliance on a central source of funds for our healthcare can be worrying if we consider our rising national debt, and our known tendencies to make monies intended for public expenditure disappear. Furthermore, it has been a long time since Kenya even pretended to spend 15% of its total budget on healthcare, as it pledged in the 2001 Abuja Declaration, so how we move from blatant disregard to even just toeing the minimum will be a matter of the ideal sustained political will that is known to elude us on many other matters of public interest.

The other source of money for healthcare spend is medical insurance, and because of the relatively tiny percentage of people who are privately insured in this country, most of whom access this as a benefit of formal employment. Comprehensive comparisons and analyses have also been hard to come by, but it is the rare client who has not been blindsided or left in the financial lurch by the sudden onset of red tape and small print. Additionally, it is notable that the list of exclusions are not a fair reflection of the disease burden of this population: the alarming number of services that women are unable to easily access as part of comprehensive reproductive health are testament to that. By and large, it is understandable that insurance companies would want to keep a tight handle on spending and payouts, especially when having to work with a relatively small number of customers. It has, however, been disappointing that for professionals who are well versed in betting on the macroeconomics of health and profiting off savvy investments, the clear advantages of a demographic youth boom such as Kenya’s has not created a space in which to partner with the state in more scalable ways to make healthcare available for more people.

It is impossible to consider healthcare without considering the effects of harambee, ubuntu or community contributions. Many Kenyans have reaped the benefits of belonging to a culture that values, for many reasons, coming together to help a person in need. The person does not even have to belong directly to our tribe, religion or family: we will sacrificially find coins to help someone who has been visited by the misfortune of an illness whose treatment surpassed their ability to pay.

However, the intervention of the many is suited to a one-time issue which will hopefully go into remission forever. The burdens of a chronic condition can quickly elicit compassion fatigue in even the most charitable people. Additionally, personal finances are finite, especially in shaky economic times, and the same person who could be generous at one moment can find his circumstances changed radically during a subsequent request. Because of the unpredictable nature of misfortune and the opaque nature of healthcare costs, someone can so easily come from contributing to another’s issue only to find himself the next victim of these particular debts that can so easily impoverish. Moreover, healthcare costs are unrelenting: they don’t care whether the person is working (and in the case of some illnesses and conditions, the sufferer’s ability to do so is actually taken away) or able to pay for them; they just continue to rack up. It is a terrible and cruel thing for any person to have to contemplate whether it is fair that they cannot raise the amount of money they need in order to guarantee healing and well-being in this life.

It is impossible to consider healthcare without considering the effects of harambee, ubuntu or community contributions. Many Kenyans have reaped the benefits of belonging to a culture that values, for many reasons, coming together to help a person in need.

Light at the end of the tunnel

Despite the fact that it would be easy for cynicism to set in, there are actually several things to be optimistic about as regards healthcare in this country. First among these is that we can always hope that the seemingly renewed state commitment to health for all can be a multipartisan agenda whose achievement can transcend the short-term possibilities of political gain for a few. We may, for many reasons, actually get the high political will and follow-through with this that would not only make it a success but also be a shining light for the failures in provision of other public goods for Kenyan citizens. The massive strides forward we are seeing in Makueni County, helmed by its determined governor, Kivutha Kibwana, are practical attempts at universal healthcare that redefine it as possible, not merely as an ambitious pipe dream.

Secondly, the labour conflicts in this sector have illuminated and mapped out the gaps faced by the civil servants who work in it. Because of this, we have a much clearer picture when we look at the issues raised by both them and the patients or service consumers about what is wrong, and are thus in a much better position to look for solutions, with the great advantage of a multidimensional approach.

The presence of devolution is a mixed bag. Many argue that the complexities of healthcare service provision meant that Counties were prematurely bequeathed this responsibility, especially without a data-driven approach to truly understanding the direct concerns of each county. Others had hoped that because each county has such distinctly different needs, the room for and success of innovative solutions that have been created by this separation from national overview can outperform the wide blanket of country-wide strategy by far. Again Makueni County’s innovative methods stand out significantly. All agree, however, that we need a much slower, more deliberate plan to tease out the relationship between the state and the county as regards the healthcare for citizens, especially along the lines of who pays for what.

A fourth advantage is the position of Kenya regionally and continentally as a hub for quality and ambition as regards healthcare policy and practice. Kenya’s public sector is known across the continent for its progressive, almost radical HIV care, treatment and prevention policies. Kenya was the second country in Africa and is still among a minority in the world to roll out pre-exposure prophylaxis to the masses and is deeply involved in research and experimentation towards both a cure and a vaccine.

Another example is our no-nonsense approach to maternal mortality, most recently elaborated as the Beyond Zero campaign led by the Country’s First Lady, Margaret Kenyatta. This campaign has been highly praised globally and is being studied to map out how its implementation can be replicated in other spaces. We’re currently debating and drafting legislature on fertility treatment and surrogacy, and despite our societal and religious conservatism, have been able to shift sexual and reproductive health conversations, especially as part of women’s rights, in very significant ways. The private sector has not been left behind; for many of the region’s citizens, Kenya, and Nairobi in particular, are destinations for quality specialist care and access to services that are not available to them at home. There are definitely ethical concerns in turning a country into a medical tourism hub offering services that are not available for the majority of its own citizens. It is, however, a comfort to note that the ingredients for success are already here.

Kenya’s public sector is known across the continent for its progressive, almost radical HIV care, treatment and prevention policies. Kenya was the second country in Africa and is still among a minority in the world to roll out pre-exposure prophylaxis to the masses, and is deeply involved in research and experimentation towards both a cure and a vaccine.

A follow-up to this is the rising numbers of both facilities and care workers in training. Again, we remain aware that tertiary institutions in this country, and the wider education sector, have also had their struggles with labour tensions, privatisation, underemployment and reduced funding from central government, but that is a whole other article. On the bright side regarding health, there are many more training opportunities available, but the vast majority of these are for first certificates, diplomas and degrees. Specialist training programmes for all cadres of healthcare givers are still inordinately expensive, and the government-sponsored opportunities for those have long waiting lists at both national and county levels.

One other place that Kenya has had some tensions is in negotiating the differences in roles between clinical officers, nurse practitioners and doctors. The facts on the ground remain that we still have a dire shortage of primary care interventionists, and our hybrid approach that allows varied cadres to see patients covers a much larger population base than a purist model would. That being said, we could still do with a more iterative, responsive understanding of who is trained to do what, so that patients are very clear about the clinical boundaries of each cadre.

A final point to note (and this list is by no means exhaustive) is that there is a general change in public attitudes to healthcare, the result of the diffuse access to information that has been occasioned by the Internet. There is more education about topics that were previously covered over by a lot of stigma and ignorance: one example is mental health. Because of this, the public has been empowered to ask more questions and demand timely, satisfactory answers from individual care givers, institutions and the sector at large. A part of it is definitely a more entrenched awareness of their rights as citizens as broken down in the Constitution, which is very explicit about the right to health and even specifically, access to emergency care. Citizens are also able to take to social media streets and host online conversations and debates, which have become offline calls for accountability that have been successful in stopping malpractice and neglect. The media are also taking the need for accessible, comprehensive information more seriously, and there has been a significant rise in health-centred human interest stories, and more expert journalists who are able to unpack complex health issues in ways that Kenyans are happy to learn from, engage with, analyse and debate.

There is a lot of room to stick it out and hope for the better—just because so much has been so bad for so long does not invalidate the good things that have been happening under the radar. All said and done, though, we must wait and see if true universal healthcare is possible within the context of what Kenyan healthcare has been and has the potential to be.

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Dr. Njoki Ngumi is a writer, maker and feminist thinker who has held positions in private and public healthcare sectors in Kenya. She is a member of the Nest Collective and coordinates learning and development for HEVA Fund.

Politics

Asylum Pact: Rwanda Must Do Some Political Housecleaning

Rwandans are welcoming, but the government’s priority must be to solve the internal political problems which produce refugees.

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Asylum Pact: Rwanda Must Do Some Political Housecleaning
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The governments of the United Kingdom and Rwanda have signed an agreement to move asylum seekers from the UK to Rwanda for processing. This partnership has been heavily criticized and has been referred to as unethical and inhumane. It has also been opposed by the United Nations Refugee Agency on the grounds that it is contrary to the spirit of the Refugee Convention.

Here in Rwanda, we heard the news of the partnership on the day it was signed. The subject has never been debated in the Rwandan parliament and neither had it been canvassed in the local media prior to the announcement.

According to the government’s official press release, the partnership reflects Rwanda’s commitment to protect vulnerable people around the world. It is argued that by relocating migrants to Rwanda, their dignity and rights will be respected and they will be provided with a range of opportunities, including for personal development and employment, in a country that has consistently been ranked among the safest in the world.

A considerable number of Rwandans have been refugees and therefore understand the struggle that comes with being an asylum seeker and what it means to receive help from host countries to rebuild lives. Therefore, most Rwandans are sensitive to the plight of those forced to leave their home countries and would be more than willing to make them feel welcome. However, the decision to relocate the migrants to Rwanda raises a number of questions.

The government argues that relocating migrants to Rwanda will address the inequalities in opportunity that push economic migrants to leave their homes. It is not clear how this will work considering that Rwanda is already the most unequal country in the East African region. And while it is indeed seen as among the safest countries in the world, it was however ranked among the bottom five globally in the recently released 2022 World Happiness Index. How would migrants, who may have suffered psychological trauma fare in such an environment, and in a country that is still rebuilding itself?

A considerable number of Rwandans have been refugees and therefore understand the struggle that comes with being an asylum seeker and what it means to receive help from host countries to rebuild lives.

What opportunities can Rwanda provide to the migrants? Between 2018—the year the index was first published—and 2020, Rwanda’s ranking on the Human Capital Index (HCI) has been consistently low. Published by the World Bank, HCI measures which countries are best at mobilising the economic and professional potential of their citizens. Rwanda’s score is lower than the average for sub-Saharan Africa and it is partly due to this that the government had found it difficult to attract private investment that would create significant levels of employment prior to the COVID-19 pandemic. Unemployment, particularly among the youth, has since worsened.

Despite the accolades Rwanda has received internationally for its development record, Rwanda’s economy has never been driven by a dynamic private or trade sector; it has been driven by aid. The country’s debt reached 73 per cent of GDP in 2021 while its economy has not developed the key areas needed to achieve and secure genuine social and economic transformation for its entire population. In addition to human capital development, these include social capital development, especially mutual trust among citizens considering the country’s unfortunate historical past, establishing good relations with neighbouring states, respect for human rights, and guaranteeing the accountability of public officials.

Rwanda aspires to become an upper middle-income country by 2035 and a high-income country by 2050. In 2000, the country launched a development plan that aimed to transform it into a middle-income country by 2020 on the back on a knowledge economy. That development plan, which has received financial support from various development partners including the UK which contributed over £1 billion, did not deliver the anticipated outcomes. Today the country remains stuck in the category of low-income states. Its structural constraints as a small land-locked country with few natural resources are often cited as an obstacle to development. However, this is exacerbated by current governance in Rwanda, which limits the political space, lacks separation of powers, impedes freedom of expression and represses government critics, making it even harder for Rwanda to reach the desired developmental goals.

Rwanda’s structural constraints as a small land-locked country with no natural resources are often viewed as an obstacle to achieving the anticipated development.

As a result of the foregoing, Rwanda has been producing its own share of refugees, who have sought political and economic asylum in other countries. The UK alone took in 250 Rwandese last year. There are others around the world, the majority of whom have found refuge in different countries in Africa, including countries neighbouring Rwanda. The presence of these refugees has been a source of tension in the region with Kigali accusing neighbouring states of supporting those who want to overthrow the government by force. Some Rwandans have indeed taken up armed struggle, a situation that, if not resolved, threatens long-term security in Rwanda and the Great Lakes region. In fact, the UK government’s advice on travel to Rwanda has consistently warned of the unstable security situation near the border with the Democratic Republic of Congo (DRC) and Burundi.

While Rwanda’s intention to help address the global imbalance of opportunity that fuels illegal immigration is laudable, I would recommend that charity start at home. As host of the 26th Commonwealth Heads of Government Meeting scheduled for June 2022, and Commonwealth Chair-in-Office for the next two years, the government should seize the opportunity to implement the core values and principles of the Commonwealth, particularly the promotion of democracy, the rule of law, freedom of expression, political and civil rights, and a vibrant civil society. This would enable Rwanda to address its internal social, economic and political challenges, creating a conducive environment for long-term economic development, and durable peace that will not only stop Rwanda from producing refugees but will also render the country ready and capable of economically and socially integrating refugees from less fortunate countries in the future.

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Politics

Beyond Borders: Why We Need a Truly Internationalist Climate Justice Movement

The elite’s ‘solution’ to the climate crisis is to turn the displaced into exploitable migrant labour. We need a truly internationalist alternative.

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Beyond Borders: Why We Need a Truly Internationalist Climate Justice Movement
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“We are not drowning, we are fighting” has become the rallying call for the Pacific Climate Warriors. From UN climate meetings to blockades of Australian coal ports, these young Indigenous defenders from twenty Pacific Island states are raising the alarm of global warming for low-lying atoll nations. Rejecting the narrative of victimisation – “you don’t need my pain or tears to know that we’re in a crisis,” as Samoan Brianna Fruean puts it – they are challenging the fossil fuel industry and colonial giants such as Australia, responsible for the world’s highest per-capita carbon emissions.

Around the world, climate disasters displace around 25.3 million people annually – one person every one to two seconds. In 2016, new displacements caused by climate disasters outnumbered new displacements as a result of persecution by a ratio of three to one. By 2050, an estimated 143 million people will be displaced in just three regions: Africa, South Asia, and Latin America. Some projections for global climate displacement are as high as one billion people.

Mapping who is most vulnerable to displacement reveals the fault lines between rich and poor, between the global North and South, and between whiteness and its Black, Indigenous and racialised others.

Globalised asymmetries of power create migration but constrict mobility. Displaced people – the least responsible for global warming – face militarised borders. While climate change is itself ignored by the political elite, climate migration is presented as a border security issue and the latest excuse for wealthy states to fortify their borders. In 2019, the Australian Defence Forces announced military patrols around Australia’s waters to intercept climate refugees.

The burgeoning terrain of “climate security” prioritises militarised borders, dovetailing perfectly into eco-apartheid. “Borders are the environment’s greatest ally; it is through them that we will save the planet,” declares the party of French far-Right politician Marine Le Pen. A US Pentagon-commissioned report on the security implications of climate change encapsulates the hostility to climate refugees: “Borders will be strengthened around the country to hold back unwanted starving immigrants from the Caribbean islands (an especially severe problem), Mexico, and South America.” The US has now launched Operation Vigilant Sentry off the Florida coast and created Homeland Security Task Force Southeast to enforce marine interdiction and deportation in the aftermath of disasters in the Caribbean.

Labour migration as climate mitigation

you broke the ocean in
half to be here.
only to meet nothing that wants you
– Nayyirah Waheed

Parallel to increasing border controls, temporary labour migration is increasingly touted as a climate adaptation strategy. As part of the ‘Nansen Initiative’, a multilateral, state-led project to address climate-induced displacement, the Australian government has put forward its temporary seasonal worker program as a key solution to building climate resilience in the Pacific region. The Australian statement to the Nansen Initiative Intergovernmental Global Consultation was, in fact, delivered not by the environment minister but by the Department of Immigration and Border Protection.

Beginning in April 2022, the new Pacific Australia Labour Mobility scheme will make it easier for Australian businesses to temporarily insource low-wage workers (what the scheme calls “low-skilled” and “unskilled” workers) from small Pacific island countries including Nauru, Papua New Guinea, Kiribati, Samoa, Tonga, and Tuvalu. Not coincidentally, many of these countries’ ecologies and economies have already been ravaged by Australian colonialism for over one hundred years.

It is not an anomaly that Australia is turning displaced climate refugees into a funnel of temporary labour migration. With growing ungovernable and irregular migration, including climate migration, temporary labour migration programs have become the worldwide template for “well-managed migration.” Elites present labour migration as a double win because high-income countries fill their labour shortage needs without providing job security or citizenship, while low-income countries alleviate structural impoverishment through migrants’ remittances.

Dangerous, low-wage jobs like farm, domestic, and service work that cannot be outsourced are now almost entirely insourced in this way. Insourcing and outsourcing represent two sides of the same neoliberal coin: deliberately deflated labour and political power. Not to be confused with free mobility, temporary labour migration represents an extreme neoliberal approach to the quartet of foreign, climate, immigration, and labour policy, all structured to expand networks of capital accumulation through the creation and disciplining of surplus populations.

The International Labour Organization recognises that temporary migrant workers face forced labour, low wages, poor working conditions, virtual absence of social protection, denial of freedom association and union rights, discrimination and xenophobia, as well as social exclusion. Under these state-sanctioned programs of indentureship, workers are legally tied to an employer and deportable. Temporary migrant workers are kept compliant through the threats of both termination and deportation, revealing the crucial connection between immigration status and precarious labour.

Through temporary labour migration programs, workers’ labour power is first captured by the border and this pliable labour is then exploited by the employer. Denying migrant workers permanent immigration status ensures a steady supply of cheapened labour. Borders are not intended to exclude all people, but to create conditions of ‘deportability’, which increases social and labour precarity. These workers are labelled as ‘foreign’ workers, furthering racist xenophobia against them, including by other workers. While migrant workers are temporary, temporary migration is becoming the permanent neoliberal, state-led model of migration.

Reparations include No Borders

“It’s immoral for the rich to talk about their future children and grandchildren when the children of the Global South are dying now.” – Asad Rehman

Discussions about building fairer and more sustainable political-economic systems have coalesced around a Green New Deal. Most public policy proposals for a Green New Deal in the US, Canada, UK and the EU articulate the need to simultaneously tackle economic inequality, social injustice, and the climate crisis by transforming our extractive and exploitative system towards a low-carbon, feminist, worker and community-controlled care-based society. While a Green New Deal necessarily understands the climate crisis and the crisis of capitalism as interconnected — and not a dichotomy of ‘the environment versus the economy’ — one of its main shortcomings is its bordered scope. As Harpreet Kaur Paul and Dalia Gebrial write: “the Green New Deal has largely been trapped in national imaginations.”

Any Green New Deal that is not internationalist runs the risk of perpetuating climate apartheid and imperialist domination in our warming world. Rich countries must redress the global and asymmetrical dimensions of climate debtunfair trade and financial agreements, military subjugation, vaccine apartheidlabour exploitation, and border securitisation.

It is impossible to think about borders outside the modern nation-state and its entanglements with empire, capitalism, race, caste, gender, sexuality, and ability. Borders are not even fixed lines demarcating territory. Bordering regimes are increasingly layered with drone surveillance, interception of migrant boats, and security controls far beyond states’ territorial limits. From Australia offshoring migrant detention around Oceania to Fortress Europe outsourcing surveillance and interdiction to the Sahel and Middle East, shifting cartographies demarcate our colonial present.

Perhaps most offensively, when colonial countries panic about ‘border crises’ they position themselves as victims. But the genocide, displacement, and movement of millions of people were unequally structured by colonialism for three centuries, with European settlers in the Americas and Oceania, the transatlantic slave trade from Africa, and imported indentured labourers from Asia. Empire, enslavement, and indentureship are the bedrock of global apartheid today, determining who can live where and under what conditions. Borders are structured to uphold this apartheid.

The freedom to stay and the freedom to move, which is to say no borders, is decolonial reparations and redistribution long due.

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The Murang’a Factor in the Upcoming Presidential Elections

The Murang’a people are really yet to decide who they are going to vote for as a president. If they have, they are keeping the secret to themselves. Are the Murang’a people prepping themselves this time to vote for one of their own? Can Jimi Wanjigi re-ignite the Murang’a/Matiba popular passion among the GEMA community and re-influence it to vote in a different direction?

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The Murang’a Factor in the Upcoming Presidential Elections
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In the last quarter of 2021, I visited Murang’a County twice: In September, we were in Kandiri in Kigumo constituency. We had gone for a church fundraiser and were hosted by the Anglican Church of Kenya’s (ACK), Kahariro parish, Murang’a South diocese. A month later, I was back, this time to Ihi-gaini deep in Kangema constituency for a burial.

The church function attracted politicians: it had to; they know how to sniff such occasions and if not officially invited, they gate-crash them. Church functions, just like funerals, are perfect platforms for politicians to exhibit their presumed piousness, generosity and their closeness to the respective clergy and the bereaved family.

Well, the other reason they were there, is because they had been invited by the Church leadership. During the electioneering period, the Church is not shy to exploit the politicians’ ambitions: they “blackmail” them for money, because they can mobilise ready audiences for the competing politicians. The politicians on the other hand, are very ready to part with cash. This quid pro quo arrangement is usually an unstated agreement between the Church leadership and the politicians.

The church, which was being fund raised for, being in Kigumo constituency, the area MP Ruth Wangari Mwaniki, promptly showed up. Likewise, the area Member of the County Assembly (MCA) and of course several aspirants for the MP and MCA seats, also showed up.

Church and secular politics often sit cheek by jowl and so, on this day, local politics was the order of the day. I couldn’t have speculated on which side of the political divide Murang’a people were, until the young man Zack Kinuthia Chief Administrative Secretary (CAS) for Sports, Culture and Heritage, took to the rostrum to speak.

A local boy and an Uhuru Kenyatta loyalist, he completely avoided mentioning his name and his “development track record” in central Kenya. Kinuthia has a habit of over-extolling President Uhuru’s virtues whenever and wherever he mounts any platform. By the time he was done speaking, I quickly deduced he was angling to unseat Wangari. I wasn’t wrong; five months later in February 2022, Kinuthia resigned his CAS position to vie for Kigumo on a Party of the National Unity (PNU) ticket.

He spoke briefly, feigned some meeting that was awaiting him elsewhere and left hurriedly, but not before giving his KSh50,000 donation. Apparently, I later learnt that he had been forewarned, ahead of time, that the people were not in a mood to listen to his panegyrics on President Uhuru, Jubilee Party, or anything associated to the two. Kinuthia couldn’t dare run on President Uhuru’s Jubilee Party. His patron-boss’s party is not wanted in Murang’a.

I spent the whole day in Kandiri, talking to people, young and old, men and women and by the time I was leaving, I was certain about one thing; The Murang’a folks didn’t want anything to do with President Uhuru. What I wasn’t sure of is, where their political sympathies lay.

I returned to Murang’a the following month, in the expansive Kangema – it is still huge – even after Mathioya was hived off from the larger Kangema constituency. Funerals provide a good barometer that captures peoples’ political sentiments and even though this burial was not attended by politicians – a few senior government officials were present though; political talk was very much on the peoples’ lips.

What I gathered from the crowd was that President Uhuru had destroyed their livelihood, remember many of the Nairobi city trading, hawking, big downtown real estate and restaurants are run and owned largely by Murang’a people. The famous Nyamakima trading area of downtown Nairobi has been run by Murang’a Kikuyus.

In 2018, their goods were confiscated and declared contrabrand by the government. Many of their businesses went under, this, despite the merchants not only, whole heartedly throwing their support to President Uhuru’s controversial re-election, but contributing handsomely to the presidential kitty. They couldn’t believe what was happening to them: “We voted for him to safeguard our businesses, instead, he destroyed them. So much for supporting him.”

We voted for him to safeguard our businesses, instead, he destroyed them. So much for supporting him

Last week, I attended a Murang’a County caucus group that was meeting somewhere in Gatundu, in Kiambu County. One of the clearest messages that I got from this group is that the GEMA vote in the August 9, 2022, presidential elections is certainly anti-Uhuru Kenyatta and not necessarily pro-William Ruto.

“The Murang’a people are really yet to decide, (if they have, they are keeping the secret to themselves) on who they are going to vote for as a president. And that’s why you see Uhuru is craftily courting us with all manner of promises, seductions and prophetic messages.” Two weeks ago, President Uhuru was in Murang’a attending an African Independent Pentecostal Church of Africa (AIPCA) church function in Kandara constituency.

At the church, the president yet again threatened to “tell you what’s in my heart and what I believe and why so.” These prophecy-laced threats by the President, to the GEMA nation, in which he has been threatening to show them the sign, have become the butt of crude jokes among Kikuyus.

Corollary, President Uhuru once again has plucked Polycarp Igathe away from his corporate perch as Equity Bank’s Chief Commercial Officer back to Nairobi’s tumultuous governor seat politics. The first time the bespectacled Igathe was thrown into the deep end of the Nairobi murky politics was in 2017, as Mike Sonko’s deputy governor. After six months, he threw in the towel, lamenting that Sonko couldn’t let him even breathe.

Uhuru has a tendency of (mis)using Murang’a people

“Igathe is from Wanjerere in Kigumo, Murang’a, but grew up in Ol Kalou, Nyandarua County,” one of the Mzees told me. “He’s not interested in politics; much less know how it’s played. I’ve spent time with him and confided in me as much. Uhuru has a tendency of (mis)using Murang’a people. President Uhuru wants to use Igathe to control Nairobi. The sad thing is that Igathe doesn’t have the guts to tell Uhuru the brutal fact: I’m really not interested in all these shenanigans, leave me alone. The president is hoping, once again, to hopefully placate the Murang’a people, by pretending to front Igathe. I foresee another terrible disaster ultimately befalling both Igathe and Uhuru.”

Be that as it may, what I got away with from this caucus, after an entire day’s deliberations, is that its keeping it presidential choice close to its chest. My attempts to goad some of the men and women present were fruitless.

Murang’a people like reminding everyone that it’s only they, who have yet to produce a president from the GEMA stable, despite being the wealthiest. Kiambu has produced two presidents from the same family, Nyeri one, President Mwai Kibaki, who died on April 22. The closest Murang’a came to giving the country a president was during Ken Matiba’s time in the 1990s. “But Matiba had suffered a debilitating stroke that incapacitated him,” said one of the mzees. “It was tragic, but there was nothing we could do.”

Murang’a people like reminding everyone that it’s only they, who have yet to produce a president from the GEMA stable, despite being the wealthiest

It is interesting to note that Jimi Wanjigi, the Safina party presidential flagbearer is from Murang’a County. His family hails from Wahundura, in Mathioya constituency. Him and Mwangi wa Iria, the Murang’a County governor are the other two Murang’a prominent persons who have tossed themselves into the presidential race. Wa Iria’s bid which was announced at the beginning of 2022, seems to have stagnated, while Jimi’s seems to be gathering storm.

Are the Murang’a people prepping themselves this time to vote for one of their own? Jimi’s campaign team has crafted a two-pronged strategy that it hopes will endear Kenyans to his presidency. One, a generational, paradigm shift, especially among the youth, targeting mostly post-secondary, tertiary college and university students.

“We believe this group of voters who are basically between the ages of 18–27 years and who comprise more than 65 per cent of total registered voters are the key to turning this election,” said one of his presidential campaign team members. “It matters most how you craft the political message to capture their attention.” So, branding his key message as itwika, it is meant to orchestrate a break from past electoral behaviour that is pegged on traditional ethnic voting patterns.

The other plunk of Jimi’s campaign theme is economic emancipation, quite pointedly as it talks directly to the GEMA nation, especially the Murang’a Kikuyus, who are reputed for their business acumen and entrepreneurial skills. “What Kikuyus cherish most,” said the team member “is someone who will create an enabling business environment and leave the Kikuyus to do their thing. You know, Kikuyus live off business, if you interfere with it, that’s the end of your friendship, it doesn’t matter who you are.”

Can Jimi re-ignite the Murang’a/Matiba popular passion among the GEMA community and re-influence it to vote in a different direction? As all the presidential candidates gear-up this week on who they will eventually pick as their running mates, the GEMA community once more shifts the spotlight on itself, as the most sought-after vote basket.

Both Raila Odinga and William Ruto coalitions – Azimio la Umoja-One Kenya and Kenya Kwanza Alliance – must seek to impress and woe Mt Kenya region by appointing a running mate from one of its ranks. If not, the coalitions fear losing the vote-rich area either to each other, or perhaps to a third party. Murang’a County, may as well, become the conundrum, with which the August 9, presidential race may yet to be unravelled and decided.

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