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Kawempe Babies and Uganda’s Health Care Crisis

7 min read.

A shocking photo of newborn babies stacked on hospital beds has highlighted the pathetic state of public health facilities in Uganda. MARY SERUMAGA reports on the crisis.

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Kawempe Babies and Uganda’s Health Care Crisis
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As a whole, public medical facilities in Uganda have been in the gutter for quite some time. In Kampala, the government attempted to shield us from this fact when it ambushed and took over the two new hospitals built under Jennifer Musisi’s tenure as Executive Director of Kampala City Council Authority. The city already had a number of health centres inherited from Kampala District; it was some of these that were to be transformed to branches of the National Referral Hospital.

Kiruddu and Kawempe hospitals are big, flashy and captivating at first sight but reality sets in once you enter them. They have essentially become the hospitals for the have-nots while the newly renovated Mulago has more or less been transformed into a private hospital catering to a different market.

The process was gradual, not based on consultation, and the changes were communicated in public announcements. Chiefly, that maternity care at Mulago Hospital, once free of charge, is now a chargeable service. Considerably higher rates were listed alongside the new charges in order to make them more palatable.

“Services will be classified as standard, VIP and VVIP; clinical services offered to all patients at all levels irrespective of pay. (Dr R. Aceng, Minister of Health). Charges at the Mulago Specialised Women and Neonatal Hospital begin at Shs.50,000 or US$ 13.57 for consultation, a sum equivalent to one-third of the minimum monthly wage and way above the actual average daily earnings of between US$1 and US$2. The upper limit for specialised treatment is Shs. million or US$ 814, which is twenty months’ pay at minimum wage. Accommodation alone costs Shs.80,000 per day. A Caesarian section goes for Shs.2 million ($542), with an extra Shs.200,000 for tubal ligation.

For neonates requiring surgery, charges are between Shs.1.5 and Shs.3.5 million. To clear a newborn baby’s airways costs Shs.300,000 (two months’ minimum wages) daily and to keep the baby on a ventilator (once the airways are cleared) costs Shs.1 million or US$271 per day. We shall return to the care of neonates later.

This arrangement was aimed at reducing maternal mortality, which is 336 maternal deaths per 100,000 live births compared to the global rate of 216 per 100,000 live births. The new Women’s Hospital built on the campus was meant to decongest Mulago National Specialised (formerly Referral) Hospital and enable women with complicated reproductive health problems to be treated and to reduce referrals abroad (Ministry of Health). However, since the launch of the privatised Mulago Hospital, the government has continued to fly public officials abroad for treatment, notably the Speaker of Parliament who was treated in Kenya for exhaustion.

Where the introduction of charges at Mulago has been successful is in decongesting it by driving women to the understaffed, under-equipped and overcrowded “national referral hospitals” at Kawempe and Kiruddu where between 80 and 100 babies are delivered daily.

This arrangement was aimed at reducing maternal mortality, which is 336 maternal deaths per 100,000 live births compared to the global rate of 216 per 100,000 live births.

Who are these displaced women? In 2003 the Health Sector Strategy review showed only about 20 per cent of women use government maternity facilities. These women are predominantly the poor without options, meaning that those displaced from Mulago are not the ones who would otherwise have opted for private domestic healthcare or care abroad. They are not in the market for in vitro fertilization and the other specialised treatments now offered at Mulago but primary health seekers. Their issues cannot be transferred out of existence. The rest of the birthing population who use hospital maternity services – say 80% if the statistic still holds – will continue to use private services and may or may not use Mulago or go abroad. A large number of women (25%) of those giving birth are simply not attended to by qualified birth attendants (2016, World Bank databank).

Kampala City Council Authority did not design Kiruddu and Kawempe Hospitals to take the spillover from Mulago, which explains the current crisis at Kawempe. Truth be told the situation has been dire for a while now. By the time the photograph of neonates stacked on beds and plastic chairs in nappies and nothing else except cannulas and nasal tubes caused a public outcry, medics who have been complaining about this for ages had grown weary and moved on. Following the outcry, the babies were transferred to Mulago Hospital and offered free services. Even then, there were complaints about the unaffordability of the meals, which remained chargeable.

The Ministry’s initial reaction was to deny the crisis and then raid Komamboga Health Centre III for cots, which did nothing to reassure the public and reportedly caused Komamboga staff to down their tools. When they finally bought cots it begged the question: if the money was available why were cots not bought in the first place?

It is hard to blame hospital management; since the hospitals opened, the directors and staff have strenuously reported their grievances to the Ministry of Health and other relevant authorities to no avail. That one photo has in many ways been a blessing in disguise; it has held a steady spotlight for longer than is usual on the state of health services.

The Ministry’s initial reaction was to deny the crisis and then raid Komamboga Health Centre III for cots, which did nothing to reassure the public and reportedly caused Komamboga staff to down their tools.

The Labour Suite at Kawempe is unbelievably busy, having essentially inherited all the clientele that used to go to Mulago; most health centres (such as Komamboga and Kisenyi) refer their patients there. It is not uncommon for Caesarian section kits to run out, with expectant mothers still in the queue. Consequently, we are always overwhelmed by the huge numbers in the nursery/Special Care Unit/Neonatal Units.

The inevitable result is that try as we might, even with triaging [prioritising the most serious cases], the general delays in patients’ seeking healthcare and the modes of transport of expectant mothers to hospital mean many babies are born with birth asphyxia. Birth asphyxia is basically poor oxygenation of the foetus occurring mostly during the period of delivery (parturition). Depending on its extent, the outcomes can range from Hypoxic Ischaemic Encephalopathy (HIE) Grade II which may leave the child with some deficits and conditions like epilepsy. In the worst cases, referred to as HIE Grade 3, if the neonate survives, the baby will develop cerebral palsy (CP). CP involves loss of muscle control which can affect mobility, speech, swallowing, bladder control etc. and is often accompanied by epilepsy. In our setting, in which support services are fewer than elsewhere, its impact on parents, whole families, not to mention the economy is devastating. While CP can be caused by diseases such as meningitis, cerebral malaria, encephalitis and even traumatic brain injury, in Uganda birth asphyxia is the main cause. One of the busiest children’s clinics at Mulago is the neurology clinic that sees children with CP.

It is hard to blame hospital management; since the hospitals opened, the directors and staff have strenuously reported their grievances to the Ministry of Health and other relevant authorities to no avail.

Many babies are born prematurely due to dangerous diseases like preeclampsia. These and other neonates at Kawempe Hospital require delicate care: daily antibiotics, two-hourly feeds, and the cannulas through which they are medicated (seen in the photo) may need to be changed. Emergency cases need nasogastric tubes, which help breathing, along with respirator bags and resuscitation.

Impact on staff

All this often falls on the shoulders of just three nurses. Understaffing at Kawempe is exacerbated by the return of some midwives to the Women’s Hospital at Mulago. In fact there is a national shortage of midwives

On International Midwives Day 2019, the plight of the midwife in the current environment was revealed. A midwife at Bwizibwera Health Centre IV, which delivers an average of 150 babies a month, described their predicament. They face constant shortages of gloves and mama kits. Sometimes there is no fuel for the ambulance. All these are shortages to which the staff frequently contribute out of their own pockets and ask those mothers who can to pay, often leading to accusations of corruption.

We need to be helped, I have worked for 15 years and what I have witnessed in health facilities is not good for us. They are always blaming midwives for charging money which in those cases it is unavoidable.” – T. Atukunda (New Vision)

The adverse effect on staffing levels is that many medics, specialists in particular, spend more time in private practice and research.

I rotated through that place last year and it was horrible. I can’t say I enjoyed it because most of what we were doing was a charade. The morale of those that remain is low.” – (Doctor whose name has been withheld)

The Medical School has also been adversely impacted. While training used to take place at Mulago (close to the student accommodation), Obs/Gyn students must now make the trip to Kawempe and Internal Medicine students must travel to Kiruddu at a substantial cost.

Had there been adequate consultation and planning, Mulago would not have been fully shut down for renovation, certainly not for five years. Or at least a whole new private structure like the Women’s Hospital would have been built alongside it. Government has secured the US$350 million to build such a structure – Lubowa Hospital – while the renovations at Mulago only require US$9 million to complete. It is claimed that the Lubowa Hospital budget could have enabled the renovation and equipment of all Uganda’s regional hospitals as well as Mulago. As it is, US$35,874,800 has already gone missing from the Lubowa funds and is the subject of an inquiry.

Health insurance

In theory the Health Insurance Bill tabled in August 2019 will address most of these issues by making the cost of treatment affordable to government. A first attempt with a pilot scheme under the District Health Project ended without success in 2003, principally because of issues internal to the project i.e. an unrealistic timetable that led to the abandonment of the pilot and unsuccessful roll-out of untried interventions. There was also a lack of a monitoring and evaluation component. In the event, none of the health insurance schemes turned out to be appropriate.

As a final nail in the coffin, the government failed to top up the US$45 million loan with the US$17.5 million co-financing required. The co-financing shortfall is exactly half the amount that has now vanished from the Lubowa Hospital construction account. If anything indicates the lack of political will to deliver services, it is the failure of the District Health Services Scheme brought about by the failure of government to finance it.

There has been criticism of the public response to the crisis. True it should have come earlier, for example when the health insurance scheme failed to materialise fifteen years ago, or more recently in mid-2017 when the Auditor General reported, “Health facilities were experiencing persistent stock-outs of the 11 sampled Tracer drugs. […] Noticeably, Mama [safe delivery] Kits were out of stock for 320 days.” The very few medics who have commented on social media confessed boredom at the (short-term) public outrage coming decades into the problem.

Given the graphic view of the impact of haphazard and under-funded health services afforded by the Kawempe Hospital babies, the new Health Insurance Bill should be scrutinised very carefully by medics and laypeople alike working together to ensure that the interventions proposed have been rigorously pilot-tested and that the design faults that existed in the unsuccessful District Health Project proposals have been adequately addressed in the current ones.

This article is based on conversations with a Ugandan doctor about his experience as a clinician in public health in Kampala. Mary Serumaga takes responsibility for the statistical and archival material incorporated and any errors.

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Mary Serumaga is a Ugandan essayist, graduated in Law from King's College, London, and attained an Msc in Intelligent Management Systems from the Southbank. Her work in civil service reform in East Africa lead to an interest in the nature of public service in Africa and the political influences under which it is delivered.

Politics

Kenya Chooses Its Next Chief Justice

The search for Kenya’s next Chief Justice that commenced Monday will seek to replace Justice David Maraga, who retired early this year, has captured the attention of the nation.

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Since Monday, the 12th of April 2021, interviews to replace retired Chief Justice David Maraga for the post of the most important jurist in Kenya and the president of the Supreme Court have been underway.

The Judiciary is one of the three State organs established under Chapter 10, Article 159 of the Constitution of Kenya. It establishes the Judiciary as an independent custodian of justice in Kenya. Its primary role is to exercise judicial authority given to it, by the people of Kenya.

The institution is mandated to deliver justice in line with the Constitution and other laws. It is expected to resolve disputes in a just manner with a view to protecting the rights and liberties of all, thereby facilitating the attainment of the ideal rule of law.

The man or woman who will take up this mantle will lead the Judiciary at a time when its independence and leadership will be paramount for the nation. He or she will be selected by the Judicial Service Commission in a competitive process.

KWAMCHETSI MAKOKHA profiles the ten candidates shortlisted by the JSC.

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IMF and SAPs 2.0: The Four Horsemen of the Apocalypse are Riding into Town

Stabilisation, liberalisation, deregulation, and privatisation: what do these four pillars of structural adjustment augur for Kenya’s beleaguered public health sector?

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IMF and SAPs 2.0: The Four Horsemen of the Apocalypse are Riding into Town
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The International Monetary Fund’s announcement on the 2nd of April 2020 that it had approved a US$ 2.3 billion loan for Kenya prompted David Ndii to spell it out to young #KOT (Kenyans on Twitter) that “the loan Kenya has taken is called a structural adjustment loan (SAPs). It comes with austerity (tax raises, spending cuts, downsizing) to keep Kenya creditworthy so that we can continue borrowing and servicing debt”, adding that the “IMF is not here for fun. Ask older people.” With this last quip, Ndii was referring to the economic hardship visited on Kenyans under the structural adjustment programmes of the 80s and 90s.

Well, I’m old enough to remember; except that I was not in the country. I had left home, left the country, leaving behind parents who were still working, still putting my siblings through school. Parents with permanent and pensionable jobs, who were still paying the mortgage on their modest “maisonette” in a middle class Nairobi neighbourhood.

In those pre-Internet, pre-WhatsApp days, much use was made of the post office and I have kept the piles of aerogramme letters that used to bring me news of home. In those letters my parents said nothing of the deteriorating economic situation, unwilling to burden me with worries about which I could do nothing, keeping body and soul together being just about all I could manage in that foreign land where I had gone to further my education.

My brother Tony’s letters should have warned me that all was not well back home but he wrote so hilariously about the status conferred on those men who could afford second-hand underwear from America, complete with stars and stripes, that the sub-text went right over my head. I came back home for the first time after five years — having left college and found a first job — to find parents that had visibly aged beyond their years and a home that was palpably less well-off financially than when I had left. I’m a Kicomi girl and something in me rebelled against second-hand clothes, second-hand things. It seemed that in my absence Kenya had regressed to the time before independence, the years of hope and optimism wiped away by the neoliberal designs of the Bretton Woods twins. I remember wanting to flee; I wanted to go back to not knowing, to finding my family exactly as I had left it — seemingly thriving, happy, hopeful.

Now, after eight years of irresponsible government borrowing, it appears that I am to experience the effects of a Structural Adjustment Programme first-hand, and I wonder how things could possibly be worse than they already are.

When speaking to Nancy* a couple of weeks back about the COVID-19 situation at the Nyahururu County Referral Hospital in Laikipia County, she brought up the issue of pregnant women having to share beds in the maternity ward yet — quite apart from the fact that this arrangement is unacceptable whichever way you look at it — patients admitted to the ward are not routinely tested for COVID-19.

Nancy told me that candidates for emergency caesarean sections or surgery for ectopic and intra-abdominal pregnancies must wait their turn at the door to the operating theatre. Construction of a new maternity wing, complete with its own operating theatre, has ground to a halt because, rumour has it, the contractor has not been paid. The 120-bed facility should have been completed in mid-2020 to ease congestion at the Nyahururu hospital whose catchment area for referrals includes large swathes of both Nyandarua and Laikipia counties because of its geographical location.

According to Nancy, vital medicine used to prevent excessive bleeding in newly delivered mothers has not been available at her hospital since January; patients have to buy the medication themselves. This issue was also raised on Twitter by Dr Mercy Korir who, referring to the Nanyuki Teaching and Referral Hospital — the only other major hospital in Laikipia County — said that lack of emergency medication in the maternity ward was putting the lives of mothers at risk. Judging by the responses to that tweet, this dire situation is not peculiar to the Nanyuki hospital; how much worse is it going to get under the imminent SAP?

Kenya was among the first countries to sign on for a SAP in 1980 when commodity prices went through the floor and the 1973 oil crisis hit, bringing to a painful halt a post-independence decade of sustained growth and prosperity. The country was to remain under one form of structural adjustment or another from then on until 1996.

Damaris Parsitau, who has written about the impact of Structural Adjustment Programmes on women’s health in Kenya, already reported in her 2008 study that, “at Nakuru District Hospital in Kenya, for example, expectant mothers are required to buy gloves, surgical blades, disinfectants and syringes in preparation for childbirth”. It would appear that not much has changed since then.

The constitution of the World Health Organisation states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition” and that “governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures.”

The WHO should have added gender as a discrimination criteria. Parsitau notes that “compared to men, women in Kenya have less access to medical care, are more likely to be malnourished, poor, and illiterate, and even work longer and harder. The situation exacerbates women’s reproductive role, which increases their vulnerability to morbidity and mortality.”

With economic decline in the 80s, and the implementation of structural adjustment measures that resulted in cutbacks in funding and the introduction of cost sharing in a sector where from independence the government had borne the cost of providing free healthcare, the effects were inevitably felt most by the poor, the majority of who — in Kenya as in the rest of the world — are women.

A more recent review of studies carried out on the effect of SAPs on child and maternal health published in 2017 finds that “in their current form, structural adjustment programmes are incongruous with achieving SDGs [Sustainable Development Goals] 3.1 and 3.2, which stipulate reductions in neonatal, under-5, and maternal mortality rates. It is telling that even the IMF’s Independent Evaluation Office, in assessing the performance of structural adjustment loans, noted that ‘outcomes such as maternal and infant mortality rates have generally not improved.’”

The review also says that “adjustment programmes commonly promote decentralisation of health systems [which] may produce a more fractious and unequal implementation of services — including those for child and maternal health — nationally. Furthermore, lack of co-ordination in decentralised systems can hinder efforts to combat major disease outbreaks”. Well, we are in the throes of a devastating global pandemic which has brought this observation into sharp relief. According to the Ministry of Health, as of the 6th of April, 325,592 people had been vaccinated against COVID-19. Of those, 33 per cent were in Nairobi County, which accounts for just 9.2 per cent of the country’s total population of 47,564,296 people.

The Constitution of Kenya 2010 provides the legal framework for a rights-based approach to health and is the basis for the rollout of Universal Health Coverage (UHC) that was announced by President Uhuru Kenyatta on 12 December 2018 — with the customary fanfare — as part of the “Big Four Agenda” to be fulfilled before his departure in 2022.

However, a KEMRI-Wellcome Trust policy brief states that UHC is still some distance to achieving 100 per cent population coverage and recommends that “the Kenyan government should increase public financing of the health sector. Specifically, the level of public funding for healthcare in Kenya should double, if the threshold (5% of GDP) … is to be reached” and that “Kenya should reorient its health financing strategy away from a focus on contributory, voluntary health insurance, and instead recognize that increased tax funding is critical.”

These recommendations, it would seem to me, run counter to the conditionalities habitually imposed by the IMF and it is therefore not clear how the government will deliver UHC nation-wide by next year if this latest SAP is accompanied by budgetary cutbacks in the healthcare sector.

With the coronavirus graft scandal and the disappearance of medical supplies donated by Jack Ma still fresh on their minds, Kenyans are not inclined to believe that the IMF billions will indeed go to “support[ing] the next phase of the authorities’ COVID-19 response and their plan to reduce debt vulnerabilities while safeguarding resources to protect vulnerable groups”, as the IMF has claimed.

#KOT have — with outrage, with humour, vociferously — rejected this latest loan, tweeting the IMF in their hundreds and inundating the organisation’s Facebook page with demands that the IMF rescind its decision. An online petition had garnered more than 200,000 signatures within days of the IMF’s announcement. Whether the IMF will review its decision is moot. The prevailing economic climate is such that we are damned if we do take the loan, and damned if we don’t.

Structural adjustment supposedly “encourages countries to become economically self-sufficient by creating an environment that is friendly to innovation, investment and growth”, but the recidivist nature of the programmes suggests that either the Kenyan government is a recalcitrant pupil or SAPs simply don’t work. I would say it is both.

But the Kenyan government has not just been a recalcitrant pupil; it has also been a consistently profligate one. While SAPs do indeed provide for “safeguarding resources to protect vulnerable groups”, political choices are made that sacrifice the welfare of the ordinary Kenyan at the altar of grandiose infrastructure projects, based on the fiction peddled by international financial institutions that infrastructure-led growth can generate enough income to service debt. And when resources are not being wasted on “legacy” projects, they are embezzled on a scale that literally boggles the mind. We can no longer speak of runaway corruption; a new lexicon is required to describe this phenomenon which pervades every facet of our lives and which has rendered the years of sacrifice our parents endured meaningless and put us in debt bondage for many more generations to come. David Ndii long warned us that this moment was coming. It is here.

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East Africa: A ‘Hotbed of Terror’

African states are involved in the War on Terror more than we think. They’re surrounded by an eco-system of the war industry.

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In late January, reports circulated on social media about a suspected US drone strike in southern Somalia, in the Al-Shabaab controlled Ma’moodow town in Bakool province. Debate quickly ensued on Twitter about whether the newly installed Biden administration was responsible for this strike, which was reported to have occurred at 10 p.m. local time on January 29th, 2021.

Southern Somalia has been the target of an unprecedented escalation of US drone strikes in the last several years, with approximately 900 to 1,000 people killed between 2016 and 2019. According to the nonprofit group Airwars, which monitors and assesses civilian harm from airpower-dominated international military actions, “it was under the Obama administration that a significant US drone and airstrike campaign began,” coupled with the deployment of Special Operations forces inside the country.

Soon after Donald Trump took office in 2017, he signed a directive designating parts of Somalia “areas of active hostilities.” While the US never formally declared war in Somalia, Trump effectively instituted war-zone targeting rules by expanding the discretionary authority of the military to conduct airstrikes and raids. Thus the debate over the January 29 strike largely hinged on the question of whether President Joe Biden was upholding Trump’s “flexible” approach to drone warfare―one that sanctioned more airstrikes in Somalia in the first seven months of 2020 than were carried out during the administrations of George W. Bush and Barack Obama, combined.

In the days following the January 29 strike, the US Military’s Africa Command (AFRICOM) denied responsibility, claiming that the last US military action in Somalia occurred on January 19, the last full day of the Trump presidency. Responding to an inquiry from Airwars, AFRICOM’s public affairs team announced:

We are aware of the reporting. US Africa Command was not involved in the Jan. 29 action referenced below. US Africa Command last strike was conducted on Jan. 19. Our policy of acknowledging all airstrikes by either press release or response to query has not changed.

In early March, The New York Times reported that the Biden administration had in fact imposed temporary limits on the Trump-era directives, thereby constraining drone strikes outside of “conventional battlefield zones.” In practice, this means that the US military and the CIA now require White House permission to pursue terror suspects in places like Somalia and Yemen where the US is not “officially” at war. This does not necessarily reflect a permanent change in policy, but rather a stopgap measure while the Biden administration develops “its own policy and procedures for counterterrorism kill-or-capture operations outside war zones.”

If we take AFRICOM at its word about January 29th, this provokes the question of who was behind that particular strike. Following AFRICOM’s denial of responsibility, analysts at Airwars concluded that the strike was likely carried out by forces from the African Union peacekeeping mission in Somali (AMISOM) or by Ethiopian troops, as it occurred soon after Al-Shabaab fighters had ambushed a contingent of Ethiopian troops in the area. If indeed the military of an African state is responsible for the bombing, what does this mean for our analysis of the security assemblages that sustain the US’s war-making apparatus in Africa?

Thanks to the work of scholars, activists, and investigative journalists, we have a growing understanding of what AFRICOM operations look like in practice. Maps of logistics hubs, forward operating sites, cooperative security locations, and contingency locations―from Mali and Niger to Kenya and Djibouti―capture the infrastructures that facilitate militarism and war on a global scale. Yet what the events of January 29th suggest is that AFRICOM is situated within, and often reliant upon, less scrutinized war-making infrastructures that, like those of the United States, claim to operate in the name of security.

A careful examination of the geographies of the US’s so-called war on terror in East Africa points not to one unified structure in the form of AFRICOM, but to multiple, interconnected geopolitical projects. Inspired by the abolitionist thought of Ruth Wilson Gilmore, who cautions activists against focusing exclusively on any one site of violent exception like the prison, I am interested in the relational geographies that sustain the imperial war-making infrastructure in Africa today. Just as the modern prison is “a central but by no means singularly defining institution of carceral geography,” AFRICOM is a fundamental but by no means singularly defining instrument of war-making in Africa today.

Since the US military’s embarrassing exit from Somalia in 1993, the US has shifted from a boots-on-the ground approach to imperial warfare, instead relying on African militaries, private contractors, clandestine ground operations, and drone strikes. To singularly focus on AFRICOM’s drone warfare is therefore to miss the wider matrix of militarized violence that is at work. As Madiha Tahir reminds us, attack drones are only the most visible element of what she refers to as “distributed empire”—differentially distributed opaque networks of technologies and actors that augment the reach of the war on terror to govern more bodies and spaces. This dispersal of power requires careful consideration of the racialized labor that sustains war-making in Somalia, and of the geographical implications of this labor. The vast array of actors involved in the war against Al-Shabaab has generated political and economic entanglements that extend well beyond the territory of Somalia itself.

Ethiopia was the first African military to intervene in Somalia in December 2006, sending thousands of troops across the border, but it did not do so alone. Ethiopia’s effort was backed by US aerial reconnaissance and satellite surveillance, signaling the entanglement of at least two geopolitical projects. While the US was focused on threats from actors with alleged ties to Al-Qaeda, Ethiopia had its own concerns about irredentism and the potential for its then-rival Eritrea to fund Somali militants that would infiltrate and destabilize Ethiopia. As Ethiopian troops drove Somali militant leaders into exile, more violent factions emerged in their place. In short, the 2006 invasion planted the seeds for the growth of what is now known as Al-Shabaab.

The United Nations soon authorized an African Union peacekeeping operation (AMISOM) to “stabilize” Somalia. What began as a small deployment of 1,650 peacekeepers in 2007 gradually transformed into a number that exceeded 22,000 by 2014. The African Union has emerged as a key subcontractor of migrant military labor in Somalia: troops from Burundi, Djibouti, Ethiopia, Kenya, and Uganda deployed to fight Al-Shabaab are paid significantly higher salaries than they receive back home, and their governments obtain generous military aid packages from the US, UK, and increasingly the European Union in the name of “security.”

But because these are African troops rather than American ones, we hear little of lives lost, or of salaries not paid. The rhetoric of “peacekeeping” makes AMISOM seem something other than what it is in practice—a state-sanctioned, transnational apparatus of violent labor that exploits group-differentiated vulnerability to premature death. (This is also how Gilmore defines racism.)

Meanwhile, Somali analyst Abukar Arman uses the term “predatory capitalism” to describe the hidden economic deals that accompany the so-called stabilization effort, such as “capacity-building” programs for the Somali security apparatus that serve as a cover for oil and gas companies to obtain exploration and drilling rights. Kenya is an important example of a “partner” state that has now become imbricated in this economy of war. Following the Kenya Defense Forces (KDF) invasion of Somalia in October 2011, the African Union’s readiness to incorporate Kenyan troops into AMISOM was a strategic victory for Kenya, as it provided a veneer of legitimacy for maintaining what has amounted to a decade-long military occupation of southern Somalia.

Through carefully constructed discourses of threat that build on colonial-era mappings of alterity in relation to Somalis, the Kenyan political elite have worked to divert attention away from internal troubles and from the economic interests that have shaped its involvement in Somalia. From collusion with Al-Shabaab in the illicit cross-border trade in sugar and charcoal, to pursuing a strategic foothold in offshore oil fields, Kenya is sufficiently ensnared in the business of war that, as Horace Campbell observes, “it is not in the interest of those involved in this business to have peace.”

What began as purportedly targeted interventions spawned increasingly broader projects that expanded across multiple geographies. In the early stages of AMISOM troop deployment, for example, one-third of Mogadishu’s population abandoned the city due to the violence caused by confrontations between the mission and Al-Shabaab forces, with many seeking refuge in Kenya. While the mission’s initial rules of engagement permitted the use of force only when necessary, it gradually assumed an offensive role, engaging in counterinsurgency and counterterror operations.

Rather than weaken Al-Shabaab, the UN Monitoring Group on Somalia observed that offensive military operations exacerbated insecurity. According to the UN, the dislodgment of Al-Shabaab from major urban centers “has prompted its further spread into the broader Horn of Africa region” and resulted in repeated displacements of people from their homes. Meanwhile, targeted operations against individuals with suspected ties to Al-Shabaab are unfolding not only in Somalia itself, but equally in neighboring countries like Kenya, where US-trained Kenyan police employ military tactics of tracking and targeting potential suspects, contributing to what one Kenyan rights group referred to as an “epidemic” of extrajudicial killings and disappearances.

Finally, the fact that some of AMISOM’s troop-contributing states have conducted their own aerial assaults against Al-Shabaab in Somalia demands further attention. A December 2017 United Nations report, for example, alleged that unauthorized Kenyan airstrikes had contributed to at least 40 civilian deaths in a 22-month period between 2015 and 2017. In May 2020, senior military officials in the Somali National Army accused the Kenyan military of indiscriminately bombing pastoralists in the Gedo region, where the KDF reportedly conducted over 50 airstrikes in a two week period. And in January 2021, one week prior to the January 29 strike that Airwars ascribed to Ethiopia, Uganda employed its own fleet of helicopter gunships to launch a simultaneous ground and air assault in southern Somalia, contributing to the deaths—according to the Ugandan military—of 189 people, allegedly all Al-Shabaab fighters.

While each of the governments in question are formally allies of the US, their actions are not reducible to US directives. War making in Somalia relies on contingent and fluid alliances that evolve over time, as each set of actors evaluates and reevaluates their interests. The ability of Ethiopia, Kenya, and Uganda to maintain their own war-making projects requires the active or tacit collaboration of various actors at the national level, including politicians who sanction the purchase of military hardware, political and business elite who glorify militarized masculinities and femininities, media houses that censor the brutalities of war, logistics companies that facilitate the movement of supplies, and the troops themselves, whose morale and faith in their mission must be sustained.

As the Biden administration seeks to restore the image of the United States abroad, it is possible that AFRICOM will gradually assume a backseat role in counterterror operations in Somalia. Officially, at least, US troops have been withdrawn and repositioned in Kenya and Djibouti, while African troops remain on the ground in Somalia. Relying more heavily on its partners in the region would enable the US to offset the public scrutiny and liability that comes with its own direct involvement.

But if our focus is exclusively on the US, then we succumb to its tactics of invisibility and invincibility, and we fail to reckon with the reality that the East African warscape is a terrain shaped by interconnected modes of power. The necessary struggle to abolish AFRICOM requires that we recognize its entanglement in and reliance upon other war-making assemblages, and that we distribute our activism accordingly. Recounting that resistance itself has long been framed as “terrorism,” we would do well to learn from those across the continent who, in various ways over the years, have pushed back, often at a heavy price.

This post is from a partnership between Africa Is a Country and The Elephant. We will be publishing a series of posts from their site once a week.
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