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Reflections on Medical Ethics in the Era of COVID-19

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The intense centralisation of health services has killed the doctor-patient relationship while hospitals have now become centres for gathering detailed patient information that is exploited by pharmaceutical companies.

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Reflections on Medical Ethics in the Era of COVID-19
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According to William Ruddick, the wide field usually referred to as “medical ethics” comprises a range of disciplines, including medical ethics (primarily, medical doctor-centred), and healthcare ethics (including nurses and other healthcare providers), clinical ethics (focused on hospital case decisions with the aid of diverse committees and consultants), and bioethics (including general issues of reproduction, fair distribution of organs and other scarce life-saving resources, and protection of the biosphere). All discussions of medical ethics proceed from the assumption that all things being equal, all patients have moral status. As Matjaž Zwitter observes in a chapter on “Moral Status”, “There should be no doubt that all of us with a capability of deciding about ourselves have moral status.” Zwitter further points out that only beings with moral status can be meaningfully said to have rights.

However, in our time, the misconception is widespread that science, of which medicine is a part, is all about “objective” observation of facts without any consideration of values (standards by which we judge some things to be good or bad, right or wrong, beautiful or ugly, and so on). Nevertheless, we human beings cannot live without values, because it is they that make life truly human by enabling us to choose our goals and the appropriate means of attaining them. Thus, in the introduction to his Medical Ethics: A Very Short Introduction, psychiatrist Tony Hope writes, “As my clinical experience grew so I became increasingly aware that ethical values lie at the heart of medicine. Much emphasis during my training was put on the importance of using scientific evidence in clinical decision-making. Little thought was given to justifying, or even noticing, the ethical assumptions that lay behind the decisions. So I moved increasingly towards medical ethics, wanting medical practice, and patients, to benefit from ethical reasoning.” In what follows, I examine the viability of the doctor-patient relationship, undergirded by medical ethics, in the era of COVID-19.

Principles of medical ethics in the era of COVID-19

One of the best-known texts associated with medical ethics is the Hippocratic Oath authored in ancient Greece about 2400 years ago. It required a person being admitted to the position of a medical doctor to swear by a number of healing gods to uphold certain ethical standards. The oath established several principles of medical ethics that are still considered crucial to the conduct of a medical doctor today. At the heart of medical ethics are questions regarding what is morally acceptable or morally unacceptable for a doctor to do in the course of caring for the sick. Three of the key issues in medical ethics are commitment on the part of the doctor to do only good to the patient, to respect the patient’s right to accept or decline a medical procedure, and to conduct medical research in line with sound ethical principles.

Doing only good to the patient

According to William Ruddick, the Hippocratic injunction “Strive to help, but above all, do no harm” is the ruling moral maxim in the doctor-patient relationship. In current discussion, this maxim has been codified in oft-cited principles of beneficence (action to promote the good/welfare) and non-maleficence (refraining from doing evil). For the doctor to achieve these noble goals, he or she must utilize their medical knowledge in a free atmosphere in which their only concern is their patient’s well-being, without having to worry about demands from an elaborate medical care bureaucracy. Yet in the era of COVID-19, the doctor has been turned into a functionary of just such a bureaucracy, receiving instructions from local and global health authorities, and being stopped from using certain medications, even if he/she and his/her patient would have liked to use them.

Respecting informed consent

The principle of informed consent stipulates that the patient has a right to accept or decline a medical procedure after being duly furnished with information about what it entails and the possible positive and negative impacts arising from it. As I indicated in COVID-19 Vaccine Mandates in the Light of Public Health Ethics, the medical ethical principle of informed consent is based on the conviction that each and every human being is endowed with intrinsic infinite worth (dignity) and human agency (the capacity of the person to act out of his/her own uniquely human viewpoint). Underlying the two considerations is the assumption that the human person is a ‘know-er’, since it is impossible to adequately enjoy human dignity and human agency without knowledge. All this implies the idea of human rights—certain entitlements due to every person by virtue of his/her humanity.

Human dignity, human agency and human rights presume the autonomy of the individual. In his On Liberty, John Stuart Mill asserted the autonomy of the individual as follows:

“The only part of the conduct of any one, for which he is amenable to society, is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign.”

In a chapter on “Autonomy and Its Limitations”, Matjaž Zwitter highlights at least five characteristics of individual autonomy. Understood as the right to self-determination, autonomy includes the right to information and protection of privacy. In an ideal situation, a patient with full autonomy participates in all essential medical decisions, and consents to every invasive procedure. Nevertheless, even patients with full capacity have the right to transfer their autonomy to others such as family members, friends, or to their physicians. In cases where patients are unable to decide for themselves and therefore with limited autonomy, surrogate decision-making is justified. Nevertheless, a doctor is not morally obliged to respect a directive by a surrogate decision-maker if this directive is clearly against the patient’s interests. Some persons make advance directives, to be followed in case of their future incapacity to participate in decisions regarding their treatment. While such written or oral directives are helpful, their validity may be re-considered in situations that the person could not have foreseen at the time of making the advance directive.

In the era of COVID-19, the doctor has been turned into a functionary of just such a bureaucracy, receiving instructions from local and global health authorities.

Thus, in “COVID-19 Vaccine Mandates in the Light of Public Health Ethics”, I pointed out that in the light of the notions of human dignity, human agency and human rights manifesting in medical care as informed consent, any measures imposed on the patient in the name of containing COVID-19 is paternalism, that is, the treating of adults as though they were children. This is equally true in medical care where the doctor-patient relationship is in operation, as in public health policy where health authorities institute measures for the welfare of populations.

Research ethics in medicine

Progress in the medical field rides on research, but therein also lies the danger of the violation of the moral principles that ought to govern the doctor-patient relationship. Consequently, as Adebayo A. Ogungbure notes, the aim of medical research ethics is to ensure that research projects involving human subjects are carried out without causing harm to the subjects involved.

One of the most outrageous violations of medical research ethics was the “Tuskegee Study of Untreated Syphilis in the Negro Male”  of which Ogungbure writes:

“The Tuskegee Study of Untreated Syphilis in the African American Male was the longest experiment on human beings in the history of medicine and public health. Conducted under the auspices of the US Public Health Service (USPHS), the study was originally projected to last six months but ended up spanning forty years, from 1932 to 1972. The men used as subjects in the study were never told that they had the sexually transmitted disease. The term “bad blood” was coined to falsely depict their medical condition. The men were told that they were ill and promised free care. Offered therapy “on a golden platter”, they became willing subjects. The USPHS did not tell the men that they were participants in an experiment; . . .

Though the study was organised and managed from Washington, the participants dealt with a black nurse named Eunice Rivers, who helped with transportation to the clinic, free meals, even burials. The project did not stop until Peter Buxtun, a former PHS venereal disease investigator, shared the truth about the study’s unethical methods with an Associated Press reporter.”

As Ogungbure further explains, the health authorities went to great lengths to ensure that the men in the “Tuskegee Study” were denied treatment, even after penicillin had become the standard cure for syphilis in the mid-1940s. He points out that the ignominious study only came to an end when the Associated Press published a well-researched article about it by whistle-blowing reporter Jean Heller. As a result, writes Ogungbure, congressional hearings about the Study took place in 1973, and the following year the United States Congress passed legislation creating the National Commission for the Protection of Human Subjects of Biomedical and Behavioural Research. Apologising for the Tuskegee Syphilis Study on 16 May 1997, President Bill Clinton described it as “deeply, profoundly, and morally wrong”.

Yet in the early years during which African Americans in Alabama were being ravaged by the Tuskegee Syphilis Study, Adolf Hitler’s regime in Germany was busy conducting grossly unethical research on segments of the population that he considered to be inferior to his mythical Aryan race in the name of eugenics (a set of beliefs and practices that aim to improve the genetic quality of a human population by excluding people and groups judged to be inferior or promoting those judged to be superior). Ogunbure explains that one of the consequences of the atrocities committed by Nazi Germany was the drafting of the Nuremberg Code by an international panel of experts on medical research, human rights and ethics, which served as the initial model for those few public and private research and professional organisations that voluntarily chose to adopt guidelines or rules for research involving human subjects.

Progress in the medical field rides on research, but therein also lies the danger of the violation of the moral principles that ought to govern the doctor-patient relationship.

The following are the ten basic principles of the Nuremberg Code: Seek the voluntary consent of the human subject; conduct only an experiment that is necessary, and whose results will promote the good of society; an experiment on humans ought to only follow experiments on animals; an experiment ought to avoid all unnecessary physical and mental suffering and injury; no experiments likely to cause death or disabling injury should be undertaken; the humanitarian importance of the problem to be solved by the experiment ought to exceed the degree of risk involved; the experimental subject should be protected against even remote possibilities of injury, disability or death; an experiment ought to be conducted only by scientifically qualified persons; the human subjects should be at liberty to opt out of an experiment at any stage; the scientist in charge must be prepared to terminate an experiment at any stage if he/she has any reason to believe that its continuation is likely to result in injury, disability or death.

Several other documents on medical research ethics have been issued since the Nuremberg Code, including the World Medical Association’s Declaration of Helsinki of 1964 which has been revised several times since, and Canada’s Belmont Report of 1979.

Centralisation killing the doctor-patient relationship 

One of the dominant trends in our day is the centralisation of services. Those of us who are older recall a time when the branch bank manager had considerable freedom to make decisions. Then, due to digitisation, came the motto “Every Branch is Your Branch”, because every branch was now directly link to the head office. What we were not told was that the branch manager would henceforth be a mere functionary who had to wait for decisions on every minor detail from the head office. We have witnessed similar developments in the university system, with the Commission for University Education (CUE) now having massive control over the operations of universities in Kenya, so that although there are over forty public universities in the country, CUE requires all of them to operate along the same lines, leaving very little room for lecturers to exercise the time-honoured academic freedom.

Similarly, as hospitals have grown in physical size as well as in the number of personnel, so have their centralizing bureaucratic procedures (“red tape”). Doctors have to comply with elaborate protocols put in place by hospital management to avoid or reduce the number of court cases filed against the hospitals. Similarly, the elaborate chains of command pile pressure on doctors to comply with the policies of the hospitals even when those policies are contrary to patients’ interests. For example, one leading hospital chain in Kenya requires doctors to “request” three different tests on every patient suspected of having malaria, significantly raising the patients’ bills. If the results show that patients do have malaria, doctors in the hospital chain are again duty-bound to administer only a specific set of drugs. In short, doctors have very little say in that whole process.

Furthermore, hospitals have now become centres for gathering detailed information about patients for purposes other than the patients’ welfare. Many of my Kenyan readers have probably noticed that they can only purchase drugs or have tests done in private hospitals after giving their phone numbers to the personnel at the front desk. This enables the hospitals to access a patient’s personal records for the purpose of building a detailed history of all the drugs and tests that he/she has procured from that hospital over the years. This is precisely the kind of information which large pharmaceutical companies are eager to buy from the hospitals for a handsome price. In the era of the Fourth Industrial Revolution, the pharmaceuticals use artificial intelligence to analyse the massive information (“big data”) to get a  very clear picture of trends in the health of individuals and populations, thereby enabling them to design business plans that bring them massive profits.

As hospitals have grown in physical size as well as in the number of personnel, so have their centralizing bureaucratic procedures.

The death of the doctor-patient relationship on the back of intense centralisation has already taken a huge toll on the quality of health in hospitals in Kenya. According to the “Kenya Patient Safety Survey” conducted by the Ministry of Health in 2013, a patient’s safety could not be guaranteed in a majority of medical facilities in the country: only 13 hospitals out of 493 public and private health facilities in 29 counties surveyed achieved a score greater than one on an ascending scale of 0-3. The report stated, “Overall safety compliance was relatively poor, with less than one per cent of public facilities and only about two per cent of private facilities achieving a score greater than one in all five areas of risks assessed.” For instance, less than 10 per cent achieved a score greater than one in providing safe clinical care to patients. Of the 13 that scored more than one, 11 were private facilities, while only two were public. Furthermore, less than six per cent of public hospitals achieved a score greater than one in having a competent workforce. According to the report, this state of affairs had in some instances resulted in death.

Besides, in mid-2015, twenty-eight children in Busia County became partially paralysed due to medical malpractice. According to The Standard, the children had partial paralysis arising from injections given in the six months between December 2014 and June 2015, although those with severe paralysis reported initial complaints after treatment in 2013. The Standard quoted then Cabinet Secretary James Macharia as stating, “Our initial investigations point towards medical malpractice from inappropriate injection techniques as the primary cause of partial paralysis in all the 28 children.”

This is precisely the kind of inforamation which large pharmaceutical companies are eager to buy from the hospitals for a handsome price.

Yet in the era of COVID-19, the heavy centralisation of hospital operations that is stifling the traditional doctor-patient relationship has moved to an unprecedented high level. COVID-19 testing and treatment are heavily centralised and meticulously directed from the highest health authorities in each country. In many countries, doctors are strictly forbidden to use COVID-19 vaccines and therapies that have not yet been approved by the World Health Organisation (WHO) and adopted by their own top health authorities. Besides, countries are required to share their data on COVID-19 infections, hospitalisations, vaccinations and deaths with the WHO. Many health authorities at country level run online COVID-19 databases through which citizens can request for vaccination, download their vaccination certificates, and show proof of vaccination. Various governments also have arrangements among themselves to verify the authenticity of international travellers’ vaccination certificates/passports.

Furthermore, David Ngira and John Harrington inform us that generally, WHO recommendations are used as a form of quality control by domestic regulators who view them as a guarantee of safety and effectiveness. Ngira and Harrington also point out that many African states have relied wholly on the WHO Global Advisory Committee on Vaccine Safety given their weak national drug regulators and the limited capacity of the Africa Centre for Disease Control (CDC). The Africa CDC itself deems vaccines safe for use by member states on the basis of WHO recommendations. This means that the doctor no longer has the latitude to give his/her patient guidance strictly on the basis of his/her medical training and experience, but rather on the basis of protocols formulated by local and global health authorities.

Thus in the face of intense centralisation of medical care in the era of COVID-19, time-honoured principles of medical ethics such as the single-minded promotion of the good of the patient, confidentiality, respect for the patient’s right to informed consent, and the imperative for moral integrity in medical research, all of which held the doctor personally responsible for what he/she did in the course of his/her work, are inconceivable in a situation in which a doctor only acts on “orders from above”. The loser in this undesirable paradigm shift is the patient, and the winner the wealthy who have turned medical care into a business. I recently heard a senior Israeli medical professor state that when politics is mixed with science, all that remains is politics. To which I add that when medical care is mixed with business, all that remains is business.

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By

Dr. Reginald M.J. Oduor is Senior Lecturer in Philosophy at the University of Nairobi. He is the first person with total visual disability to be appointed to a substantive teaching position in a public university in Kenya. He was the founding Editor-in-Chief of the New Series of Thought and Practice: A Journal of the Philosophical Association of Kenya from 2009 to 2015. With Drs. Oriare Nyarwath and Francis E.A. Owakah, he edited OderaOruka in the Twenty-First Century. He is also Co-founder and current Chair of the Society of Professionals with Visual Disabilities (SOPVID). Email: rmjoduor@gmail.com. Blog: http://kenyancrossroads.blogspot.co.ke

Politics

Of Election 2022, the EAC And Completing the Circle

With William Ruto’s ascension to the presidency, we now have a string of governments in the East African region that hold no genuine or valuable ideological position. The job is to manage the expanding exploitation of the region’s resources on behalf of foreign capital.

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Of Election 2022, the EAC And Completing the Circle
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The basic idea behind hustling is not to change the world, but rather to game its rules so as to change one’s status within it, going from low to high. This ultimately means accepting the world as it fundamentally is.

Kenya’s new president William Ruto has demonstrated this most ably, even using it to ramp up his campaign persona during the recently concluded elections. Having started out as a ruling party hatchet man in the 1990s Moi era, he rose to become a key player in the ethno-politics of the Kenyan Rift Valley. It was the interest taken by the International Criminal Court in the 2007 post-election violence that created a marriage of convenience between himself and what was until then his nemesis: Uhuru Kenyatta, scion of an earlier hustler-founded, but now grand, family, the epitome of what Ruto had been pitched against his whole political career—the entrenched interests of a new and landed elite.

This became an opportunity to operate fully on the national stage. This last election became in part the story of his successful determination to stay there, despite the best efforts, or so it would appear, to dispose of him once the threat of ICC convictions had receded.

A problem here is that what Kenya has always desperately needed is fundamental change. Candidate Raila Odinga’s biggest handicap was his having lived a life of being half-and-half; on the one hand, he presented himself as the anti-establishment player, determined to smash this system of historical exploitation and undeserved wealth. In that respect, he was the last of the dwindling band of 1980s would-be revolutionaries that led a meandering and error-plagued voyage in search of the kind of change needed in a former European settler economy and Western anchor-state.

On the other hand, he was also a scion of an established political dynasty. In this way, he more than once made himself part of inter-factional elite schemes and plots—of which taking the endorsement of outgoing President Kenyatta against his own Deputy President candidate Ruto was arguably the latest gambit—which only served to dilute whatever claims he may have still been making to be the progressive candidate.

Despite coming from a political dynasty of his own, birthed by his father’s own long record as a contemporary, comrade and finally victim of Jomo Kenyatta, Raila has always positioned himself as an outsider seeking to enter the system in order to break it. Then candidate Ruto’s message was the same in reverse: an actual outsider who was going, not to smash the system, but to hustle his way to its topmost levels. With his ascension, or more relevantly, with the defeat of Odinga, one can say the last of the hopes and memories of a kind of change that could favour the ordinary Kenyan are dead; this victory finally cements Kenya as a place impervious to radical political change, in which a dominant oligarchic system will remain in control, no matter who wins or loses a particular election.

“There is now in place a regime of right-wing thuggery that will run this plantation for the next twenty years.” one veteran Kenyan Kenya observer, glumly wrote to me.

However, the real point here is that this can be said of the whole region. And with this development in Kenya, a circle has been closed and the country has become fully like the rest of East Africa.

The failings of the Kenyan progressive/revolutionary movements of the 1970s and 1980s (of which Raila Odinga was a very visible part), left a situation whereby change was not going to come from outside the system, leading eventually to this “hustler” culture. First by the wider civil society that joined in the post-Moi governments in pursuit of change, and then the more directly cynical exploits that have culminated in the Ruto presidency.

“There is now in place a regime of right-wing thuggery that will run this plantation for the next twenty years.”

The few but significant reforms that actually enabled the Ruto victory to be declared were ironically the only real change that the civil society movement managed to bring to the very rigid political system. So, the irony is that these came to serve Ruto in a way they never served Odinga, despite his years of struggle that helped put them in place.

Apart from the social migration of that section of anti-colonial figures who made peace with the system and agreed to form the post-colonial regimes in partnership with those Africans that had worked for the repressive colonial state to begin with, most Kenyans remained poor, landless and exploited.

In this, Jaramogi Oginga Odinga, veteran anti-colonial agitator, co-founder of the Kenya People’s Union and of course father to fifth-time losing candidate Raila, represented the first political tradition, while Jomo Kenyatta, father to the outgoing president Uhuru, famously represented the second.

This began the great dichotomy in the mainstream of Kenyan politics: between those who felt that Independence could and should mean more for the ordinary Kenyan, and those who felt that the struggle had done enough and, increasingly, it was for every citizen to make the best they could out of the new circumstances. In short, hustlers.

There were always more options. But in the politics of pragmatism, the most accessible position, least burdened of principles, usually wins.

Hence, Museveni over Nabudere in the Ugandan struggle against Obote; Garang against the void that killed him in the quest to shape a post-Arab-Apartheid Sudan; Desire Kabila over the impenetrable musings of dia Wamba during the race to remove Mobutu, and so forth.

There is always the one “who is” versus the idea of the “who might have been”. In Kenya, this has been Raila Odinga against just about every Kenyan President from Daniel arap Moi, onward. Until now.

William Ruto’s coming to power is the ultimate triumph over idealism, an ultimate mass endorsement of the idea of pragmatism over idealism in Kenyan politics. In that sense, Kenya now fully folds into the regional template of practical fixers and hustlers willing to work within the strictures historically imposed on their people, as opposed to embarking on a quest for genuine change.

This tells us one thing, that the largest and best organized-for-extraction economy in the region is now firmly in the grip of a very determined set of interchangeable oligarchs. Their mission in life will be to do what oligarchs do: get richer.

We can now look forward to the consolidation of a region-wide elite consensus regarding the purpose of power: which, put simply, is to get rich, and then richer.

I have written it before: the wealth of Congo has enriched many a Ugandan elite group. My prediction is that our region’s politics will increasingly take on the look of a region-wide joint elite conspiracy against the ordinary peoples of the countries therein. The entire East African region, and its resources, seems up for grabs. And the vast riches of the DRC will be at the epicentre.

William Ruto’s coming to power is the ultimate triumph over idealism, an ultimate mass endorsement of the idea of pragmatism over idealism in Kenyan politics.

President Ruto’s decision to immediately implement a commitment to the long-mooted idea of an East Africa “peacekeeping” force helps to confirm this suspicion. Kenya deployed a contingent of its Special Forces just days after President Ruto’s inauguration. This idea has always been curious; apart from the United Nations force (in its second form), Uganda’s military, and occasional forays from Rwanda (and “friends”), this adds a new layer of military presence in the country: not quite African Union, and not fully EAC either, as there is no joint command. But the goal is clear: a colonial-type pacification of the natives, so as to enable elite-managed foreign extraction.

To that end, apart from Rwanda’s occasional presence, the Congolese government made up of its own notoriously ambitious elites seems to present no real objection to other interventions, but the opinion of the general population is becoming increasingly different.

An ideal situation for the hungry wolves in Kampala would be for a consensus to emerge from among the regimes of the region as to how the region’s resources can be best looted in a sustainable way, under its overall leadership as the regime that has the best, deepest and longest established links with the Western corporations that are in need of them.

President Ruto publicly acclaimed President Museveni as the “father of the region”, which is certainly a step up from the usual “father of the nation” sobriquet pressed upon perennial African incumbents.

Long-time watchers of the Museveni regime will find this description of President Museveni as apt as it is worrying. On the one hand, it helps consolidate the long-held view that Uganda effectively works as the West’s anchor state for the region.

We may finally be reaching a point of harmony among the rulers, which will be good news for their cronies and those who want to loot the region, but disastrous for the ordinary people.

Such looting involves indentured labour, displacement, environmental destruction, as well as the attendant state-backed violence to ensure that this happens. Put bluntly, a regional “peacekeeping” force would simply be a modern version of Belgian King Leopold’s Force Publique and other colonial forces rolled into one, and designed to bring a concentration of arms to bear on any localised native rebellion protesting this state of affairs.

Progress is no longer the business of government. Democracy is no longer the concern, what we have is mere electoral-ism. Within the expanded East African Community region, we now have a string of governments that hold no genuine or valuable ideological position on the long-standing, long-held, often diverted and suppressed quest for a national conversation about these things. That has finally come to an end.

The job is to manage the expanding exploitation of the mineral, labour, wildlife, fertility and energy resources on behalf of incoming foreign capital. As long as one can assure them of their security, and also help fend others off, then life is fine.

Democracy is no longer the concern, what we have is mere electoral-ism.

We may therefore finally be at a point where we have a region that thinks as one, where there are finally shared goals and talk of greater regional integration for markets, labour mobility and infrastructure. Unfortunately, these goals do not mean the same thing in their mouths, as they do in the mouths of the older traditional voices of pan-Africanism.

Instead, whatever the long-term plans of corporate America and the wider West in the region, these may now move ahead more smoothly. We can make a fairly informed guess as to what the key elements of those plans will be: “conservation”; agribusiness; energy, all with a knock-on effect on planning for massive urbanization, which means corporate finance for real estate. This may create just enough career jobs to settle the small but historically influential and noisy middle class into complacency. Certainly, the domestic Kenyan banking sector has been very nimble in getting into the DRC financial market already.

The Great Lakes Region/Nile Valley should now be best understood as a single space. It is a vast network of nearly all the major fresh water bodies on the continent. We should observe the privatisation and commercialisation of water in Kenya as the nascent stage to capture the regions water resources. With the expansion of the EAC to include the DRC, the imperialist dream of a single economic space from the Indian Ocean to the Atlantic as sought by the lumpen-explorer Henry Morton Stanley, is finally realised.

In his career-long quest to always be of the greatest use to Western imperialism (and thereby guarantee his incumbency), one can be sure that President Museveni has long been positioning himself as the conductor of this grand orchestra.

While we may now have unity at last, it would not be a unity in the interest of ordinary Africans.

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Politics

The Myth That Is Plastic Waste Recycling in Kenya

The quantities of recycled plastic in Kenya remain insignificant, but the long-term ecological cost of disposing plastic waste in the environment will be immeasurable.

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The Myth That Is Plastic Waste Recycling in Kenya
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One aspect of modern Kenyan urban living that takes getting used to are the regular, well-timed garbage collection days. Miss your day and you will have to keep the trash a week longer awaiting the next collection date when the beaten-up lorries full of garbage labour through city estates in mid-morning collecting the waste produced by city dwellers.

Should you find yourself in the central business district at around midnight, you may run into these rickety trucks collecting food waste from city restaurants, discarded cartons from offices, and empty drink cans from the city’s clubs that they ferry to the few landfills scattered around the city.

The barely roadworthy trucks are part of the more than 205 lorries working at the city’s many collection points in a hectic bid to keep Nairobi County hygienic. So profitable is the waste collection business that private contractors and cartels have infiltrated the trade.

In Nairobi alone, the county’s garbage collection service is complemented by nearly 150 private sector waste operators who also serve this city of over 4 million residents. Private investments have done a lot but not nearly enough to address the garbage crisis that plagues Kenya’s towns and cities.

Kenya’s urban households produce the bulk of the country’s solid waste, including a major share of the estimated 24 million plastic bags that are used and discarded every month. A significant portion of the plastic waste ends up in dumpsites alongside scrap metal, paper materials, glassware, and medical and toxic waste. Plastic waste constitutes a significant portion of this trash, and poses the biggest challenge to solid waste management in Kenya.

According to the International Union for Conservation of Nature (IUCN), 73 per cent of all plastic waste generated in Kenya goes uncollected. The National Environment Management Authority (NEMA) reports that between 2 and 8 per cent of the plastic waste is recycled while the rest is disposed of at dumpsites such as Dandora and Ruai in Nairobi, Kachok in Kisumu, and Kibarani at the coast. In Mombasa alone, some 3.7 kilogrammes of per capita plastic waste end up in the ocean, contributing to the 1,300 billion pieces of plastic that find their way into the Indian Ocean every year. Experts estimate that there will be more plastic than fish species in all the oceans globally by 2025.

Kenya banned plastic carrier bags in 2017, at the same time that the United Nations Environment Programme was launching the Clean Seas campaign to reduce marine litter. From June 2020, visitors entering game reserves, forests, beaches, protected areas and conservancies are no longer allowed to carry plastic water bottles, cups, cutlery, plates, drinking straws, and packaging within the protected areas.

On the production end, there are industry-led plastics initiatives such as the Kenya Plastic Action Plan and the creation of the Kenya Extended Producer Responsibility Organization (KEPRO), whose mandate is to ensure that plastics are mapped, ferried, sorted, and where possible, put back into circulation. Given the low garbage collection rates, and the even lower sorting rates, recycling has been misleadingly touted as the key to managing plastic waste.

For context, the cumulative global plastic waste produced since 1950 is estimated at 8.3 billion tonnes — half of which was produced in the last 13 years alone — at an average of 300 million tonnes annually.

In Kenya recycling doesn’t work    

Recycling has its limitations. Despite being cited as a major solution to the problem of plastic waste, a solution that has been taken up by 34 of the 54 African states,  numerous reports have proven that it costs more to recycle than to dispose of the waste. That of course begs the question: costlier for whom?

While disposing plastic is cheaper than recycling, the long-term ecological cost to Kenyans living close to landfills and downstream is provably much higher. Kenyan plastic manufacturers are in the business for profit and, for the most part, recycling does not offer them value for money.

According to Kenya’s PET plastic industry’s joint self-regulation effort, once plastic waste enters the recycling conveyer, it is assembled and packed into bales that are sold as industrial goods and sent to the dozens of recycling plants around the country to be sorted by quality, industrial variety, texture and colour. The waste is then shredded, sanitized, melted down, and moulded into smaller, smoother plastic pellets.

These pellets, known as nurdles, are bought and once again melted down and fashioned into other plastic products, ready for re-use by industries. This form of recycling is the optimal pathway for plastic waste, but it rarely is feasible. Recycling plastic waste is a lengthy and costly process that is avoided by many plastic producers.

To put it in context, less than 45 per cent of Nairobi’s overall waste is recycled, most of it undergoing what is referred to as down-cycling, open recycling, or cascaded recycling.

Cascaded recycling refers to the process of using recycled plastic waste to make an item of a lower quality than the original product. These items typically have reduced recycling potential, which destines them for the landfill after use. Models of cascaded recycling in Kenya’s informal settlements therefore turn the triangular recycling loop into a one-way direction to an incinerator or landfill.

Recycling plastic waste is a lengthy and costly process that is avoided by many plastic producers.

Global research led by plastics expert Dr Roland Geyer claims that only 9 per cent of all the plastic waste ever produced has been recycled. Kenya’s cascaded recycling rates are harder to quantify but an authoritative plastics report states that only 14 per cent of global plastic packaging waste was collected for recycling in 2013. Only 8 per cent of that amount was down-cycled, of which 4 per cent atrophied during the process while only 2 per cent was recycled into a product of equal or higher value.

Even locally, recycling plastic is a costly process and sorting it, many experts assert, is unfeasible, which means that there is no way out when dealing with plastic waste other than banning the production and use of plastics.

Kenya and the global dumping of plastic waste 

The non-feasibility of recycling plastic waste has been an open secret among plastics industry insiders since as far back as the 1970s. As early as 1973, senior executives of plastics multinationals had already ruled out plastic waste recycling on a large scale. Instead, these multinationals paid for misleading big-budget advertisements extolling the virtues of plastic products, and lying about the ease with which plastics could be recycled for other uses, while also placing the responsibility of recycling or disposing plastic waste on the end-user. However, the mounds of plastic waste that are now an eyesore in many urban areas belie the claim that recycling is the solution.

Old industry memos and library archives show that as far back as the mid-1980s Kenyan scholars like Kamau Hezron Mwangi had begun to call for a serious look into the efficacy of recycling  while, in the mid-1990s, researcher Dr J.N. Muthotho and his team demanded for greater research across specific plastic products supply chains. The growing concerns linked to plastic products, their quality, disposability and the economics of the industry paint an image of an industry that has always been well aware of the problems caused by plastic waste but has lacked the motivation to address the issue. In an increasingly consumerist society, plastic has continued to be affordable, readily available, cheap, convenient, and yet very difficult to dispose of.

Ending Kenya’s relationship with plastic

A radical behavioural shift by producers, packaging firms and end-users is required in order to rid the Kenyan environment of plastic pollution. The ban on plastic carrier bags has had an estimated 80 per cent efficacy rate. Industry insiders including manufacturers and distributors now say that the ban should be extended to disposable tableware, plastic straws, plates and cutlery.

The mounds of plastic waste that are now an eyesore in many urban areas belie the claim that recycling is the solution.

This, the stakeholders say, will reduce the amount of single-use plastic in landfills, reduce waste, minimize animal deaths, improve human safety, and save our water systems. However, a concerted effort is needed to ban single-use plastic bottles, plastic straws, and plastic packaging and replace them with organic, biodegradable plastic (BDP) alternatives.

Most BDP products in the Kenyan market are made of thermoplastic starch that uses a polyester similar in material strength to plastic. Currently there is only one manufacturer in the country. However, researchers are coming closer to finding organic alternatives to plastics.

Reimagining a post-plastic country

In Kenya, the stakeholders have to begin to reimagine new models of ridding the country of plastic waste in the everyday life and habits of Kenyan citizens. Nairobi and its environs alone is estimated to produce between 2,400 and 3,000 tonnes of general waste every single day, an estimated 20 per cent of which is plastic waste.

“People don’t want to stop using plastic. It is cheap and easy to use so I understand why people like [it]”, says Kinuthia, an unlicensed collector in Uthiru.

A consumer culture that creates an ever-increasing demand and use of plastic products ought to be overhauled, reimagined, and refashioned.

Even within economic circles, the focus on GDP as a measure of economic progress while ignoring the social, ecological and cultural impacts is increasingly frowned upon. As far back as the late 1980s, the World Bank President Barber Conable recognised that the ecological cost of economic production has to be accounted for. “Current calculations ignore the degradation of the natural-resource base and view the sales of nonrenewable resources entirely as income . . . A better way must be found.” he wrote.

Kenya’s plastic producers and importers have to begin to consider how to shift the society away from plastic products and integrate the alternatives in the marketplace. Kenyans have the opportunity to have a national conversation around local plastic producers and importers, if we are to work effectively towards phasing out all plastic products sold in the market.

With imports valued at an estimated US$883 million, Kenya’s plastics sector has a critical duty to phase out plastic products so as to, at the very least, ensure that the end-user does not have to choose between affordability, disposability, and sustainability of the packaging when making a purchasing decision.

The plastic waste crisis calls for Kenyans to design products with their life cycle and their end in mind at the outset. Therefore, designing products with their utility and disposal in mind is critical. For example, utilizing snap-together parts in appliances minimizes the use of screws, making the end product easier to disassemble, recover, and recycle at the end. This evolution in design proactively shapes the journey of a product in order to ensure that as much material as possible is recycled back into the production conveyer.

Even within economic circles, the focus on GDP as a measure of economic progress while ignoring the social, ecological and cultural impacts is increasingly frowned upon.

On 24 March 2021, Kenya’s Centre for Environment Justice and Development (CEJD) held a consultative forum with 24 grassroots Civil Society Organisations in the waste management sector with support from Break Free From Plastic. The members used the existing legislative framework that bans single-use plastic carrier bags in the country to launch the CSOs for Zero Plastics in Kenya network that integrates the input of stakeholders in the affected sectors. Still, this push by CSOs towards a wider ban seems to have created a policy tension between the National Environment Management Authority (NEMA) and multi-nationals that rely on plastic products for packaging.

In 2018, NEMA tried to extend the ban on plastic carrier bags to single-use plastic containers such as bottles made of PET. However, the companies involved in the production of PET products instead proposed a self-regulated, industry-led solution under PETCO.

Despite NEMA’s pledge in 2018 to make PETCO membership mandatory for all plastic industry players, its membership remains voluntary. This lapse has slowed the acceptance of membership by stakeholders and by industry players and minimized compliance. Kenya currently has eight PET converters, but only one of them is a PETCO member. Moreover, an estimated 900 bottling plants use PET containers but only eight (1 per cent) are members of PETCO.

The future of a post-plastic Kenya requires consolidation of existing industry efforts, ramping up scientific research on alternatives, a shift in consumer behaviour and robust incremental policies in enforcing the bans and restrictions. Only then can Kenya secure its ecology, manage the diverse interests of the stakeholders involved and still manage its ecological health with posterity in mind.

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Microplastics: the Destruction of Marine Life and the Blue Economy

Even as Kenya’s land-based resources continue to shrink because of a rapidly growing population, microplastic pollution of Kenya’s Indian Ocean is putting in jeopardy the country’s maritime resources.

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Microplastics: the Destruction of Marine Life and the Blue Economy
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Five scientists, Joyce Kerubo, John M. Onyari and Agnes Muthumbi from the University of Nairobi, Deborah Robertson-Andersson from the University of Kwa Zulu Natal, and Edward Ndirui Kimani from the Kenya Marine and Fisheries Research Institute (KMFRI), undertook a research study last year that returned a harsh verdict of a high presence of microplastics (MPs) in Kenya’s Indian Ocean.

MPs are plastic pellets, fragments, and fibres that enter the environment and are less than 5mm in dimension. The primary sources of MPs are vehicle tyres, synthetic textiles, paints, personal care products, and plastic products that have disintegrated into tiny particles because of environmental turbulence.

The study by the five scientists, Microplastic Polymers in Surface Waters and Sediments in the Creeks along the Kenya Coast, Western Indian Ocean (WIO), identified four polymer types in Kenya’s Indian Ocean. High-density polythene is the most abundant at 38.3 per cent, followed by polypropylene (34.6 per cent), low-density polythene (27.1 per cent), and medium density polythene (17.1 per cent). The research findings were published in the European Journal of Sustainable Development Research on 18 October 2021.

The concentration of MPs in the surface waters along the Kenyan coastline was higher compared to other parts of the world, the study warned. The findings of the study also confirmed those of previous studies on the presence of MPs in Kenya’s Indian Ocean.

The scientists also cautioned that the documented information on the specific polymeric composition of these particles in seawater and in the sediments along the Kenyan coast was insufficient. The findings, the study offered, demonstrated the extent of exposure to MPs in Kenya’s ocean ecosystems, therefore justifying policy intervention in the management and disposal of plastic waste, and the protection of the ocean’s rich biodiversity for sustainable development.

It drew testing samples from three creeks: Tudor and Port Reitz in Mombasa County and Mida in Kilifi County. Tudor Creek covers an area of approximately 20 square kilometres and is fed by two seasonal rivers—Kombeni and Tsalu—that originate around Mariakani, about 32 kilometres northwest of Mombasa. The two seasonal rivers collect runoff containing plastic and other waste from the mainland and discharge it into the creek.

Surrounding Tudor creek are several densely populated informal settlements that include Mishomoroni and Mikindani that may add MPs to the ocean. According to the study findings, the majority of the MPs were fibrous materials from textiles and ropes, probably from wastewater from washing clothes and from fishing activities.

Other key facilities that could contribute to the pollution include shipping activities at the Port of Mombasa, meat processing at Kenya Meat Commission (KMC), Coast General Hospital, Container Freight Stations (CFSs) and Kipevu Power Station. Before it was rehabilitated, Mombasa County Government dumped a lot of waste at Kibarani, near the two creeks and just next to the ocean.

Tudor Creek recorded the highest pollution, also as a result of rain runoff from Kongowea market and Muoroto slums, and Mikindani sewage effluent. Moreover, according to the study, which could, however, not determine the proportions, many industries on Mombasa Island release their effluent into the sea, increasing MPs in sediments.

Mida Creek was used as a control in the study as it does not have river inflows. In addition, the creek is in a marine reserve that forms part of the Watamu Marine National Park and Reserve. However, MPs from different polymers were found in sediment and surface water samples from all the sites—including Mida Creek which is within Watamu National Marine Reserve—which the researchers had thought to be safe from pollution by industrial effluent, sewage disposal, and fishing activities.

Many industries on Mombasa Island release their effluent into the sea, increasing MPs in sediments.

The study attributed the pollution at Mida Creek to high tourism activities, boat and dhow fishing activities, densely populated villages such as Dabaso, Ngala, and Kirepwe and the mangrove vegetation cover of tall trees that binds soil particles thus favouring the accumulation of MPs.

According to a United Nations Environment Programme (UNEP) report released in March 2019, plastic—which makes up a sizable proportion of marine pollution—can now be found in all the world’s oceans, but concentrations are thought to be highest in coastal areas and reef environments where the vast majority of this litter originates from land-based sources.

In Kenya, daily plastic consumption is estimated at 0.3 Kilograms per person. In 2018, Kenya imported between 45,000 and 57,000 metric tonnes of plastic.

Earlier in 2020, KMFRI had carried out its own study—Microplastics Pollution in Coastal Nearshore Surface Waters in Vanga, Mombasa, Malindi and Lamu, Kenya—that painted an even gloomier picture of MP pollution.

The four sampling locations represented the South coast, Mombasa and the North coast of Kenya’s coastal nearshore waters, and looked into considering fishing, recreation, and industrial activities, as well as the municipal effluent that finds its way into these target areas.

The objective of the study was to assess the abundance MPs and their composition in Kenya’s coastal near-shore waters during the two rainy seasons at the Kenyan coast: the north-east monsoon which runs between November and March, and the south-east monsoon which runs from April to October.

The results showed a widely varied distribution of MPs between the two seasons, with the overall highest concentrations occurring during the south-east monsoon when surface runoff from rainwater and from effluent from the major towns is high.

As confirmed in other research studies, the concentrations recorded by KMFRI, were quite high compared to other parts of the world. This provided baseline data for MPs, showing that population, anthropogenic activities and seasonal variations a play key role in influencing pollution by MPs.

Total MP concentrations in all the study areas during the north-east and the south-east monsoon seasons ranged between 83 MPs/m³ and 8266 MPs/m³ and between 126 MPs/m³ and 12,256 MPs/m³ respectively, with a mean of 3228 MPs/m³. The highest microplastic levels were found in Mombasa at 12,256 MPs/m³ during the south-east monsoon season, where runoff and effluent due to heavy rains are thought to be the primary source. The next highest levels were found in Malindi, occurring during the south-east monsoon season, because of inflows from River Sabaki.

Boat activities and tourism during the north-east monsoon season and runoff from the town during the south-east monsoon season mostly affected Lamu, while fishing activities, as well and runoff from the town, could be responsible for the abundance of MPs recorded in Vanga.

Solid waste management remains an enormous challenge in coastal towns, with Mombasa County facing the biggest challenge due to a burgeoning population. Although most of the solid waste generated in the county is organic—largely from households, hotels, restaurants and agricultural produce markets, the largest being Kongowea and Marikiti—plastic takes up a significant share.

In its County Sessional Paper No 01 of 2019, Mombasa County estimated daily waste production at 2,200 tons, 68 per cent of which is organic. Approximately 18 per cent of this waste is plastics, cardboard, paper and metals.

Other inorganic waste such as e-waste, construction waste and junk makes up an estimated 14 per cent of the waste generated. Public and private health facilities generate an estimated 2 to 3 tonnes of biomedical waste daily.

Solid waste management remains an enormous challenge in coastal towns, with Mombasa County facing the biggest challenge due to a burgeoning population.

Most of the solid waste generated is disposed in undesignated open grounds—in VOK, Kwa Karama, Kadongo, Junda, Saratoga, and Mcheleni. It is disposed in the same form as it is generated without being recycled or reused. Disposal of solid waste in the open has continuously had a negative environmental health impact through the contamination of water sources.

Moreover, with the limited investment in solid waste recycling and recovery systems, disposal methods in the county have been a contributor to public nuisance.

There are two designated dumpsites, namely Mwakirunge in Kisauni and Shonda in Likoni. However, these dumpsites are poorly managed and do not respect the prescribed environmental health standards while Mombasa County government’s budgetary allocation for solid waste management is not sufficient to meet the desired results.

MPs are harmful to human health, experts say. The ingestion of MPs by species at the base of the food web causes human food safety concerns, as little is known about their effects on the food that finally lands on our menu.

The minuscule size of MPs renders them invisible to filter-feeding fauna, leading to unintentional ingestion. In a study published in December 2020 in the Africa Journal of Marine Science, W. Awuor, Agnes Muthumbi and Deborah Robertson-Andersson confirmed the presence of MPs in marine life. The study investigated MPs in oysters and in three species of brachyuran crabs.

They did sampling in eight stations distributed between three sites—Tudor, Port Reitz and Mida Creek—in January and February 2018, during low spring tide. The sample comprised 206 crabs and 70 oysters.

The study identified MP fibres of different colours—red, yellow, black, pink, orange, purple, green, blue—as well as colourless ones. Colourless fibres were the most prevalent, comprising at least 60 per cent of the total MPs. The mean lengths of the MP fibres were between 0.1 and 4.2 mm.

The study exposes MP pollution along the Kenyan coast and its uptake by marine fauna, and thus strengthens the case for better control of plastic waste in the ocean. “Marine plastic litter pollution is already affecting over 800 marine species through ingestion, entanglement and habitat change,” said the head of UN Environment’s coral reef unit, Jerker Tamelander, in 2019.

“Waste continues to leak from land, and coral reefs are on the receiving end. They also trap a lot of fishing gear and plastic lost from aquaculture. With the effects of climate change on coral reef ecosystems already significant, the additional threat of plastics must be taken seriously.”

According to UNEP, there remains a significant lack of knowledge on the true impact of plastics on the reef environment, including the level of concentrations of MPs across coral reef eco-regions in order to understand the scale of the issue in a standardised manner.

“Marine plastic litter pollution is already affecting over 800 marine species through ingestion, entanglement and habitat change.”

Concerns about ocean pollution have been raised at a time when the country is looking at the Blue Economy as the country’s next economic growth frontier. In effect, Kenya’s land-based resources have been shrinking because of a rapidly growing population and it is therefore prudent for the government to shift the focus to the country’s ocean resources spread over an area of 245,000 km², or 42 per cent of the country’s total land mass.

Kenya has from the outset not been keen on growing the maritime sector. Even Kenya’s first independence economic blueprint, African Socialism and its Application to Planning in Kenya, published in 1965, failed to anchor the Blue Economy in the country’s economic growth agenda, despite its significant role in transporting 95 per cent of the country’s global transactions.

The Western Indian Ocean has resources worth more than KSh2.2 trillion in annual outputs, with Kenya’s share standing at about 20 per cent of this figure. The marine fishing sub-sector alone had an annual fish potential of 350,000 metric tonnes worth KSh90 billion in 2013. However, the region only yielded a paltry 9,134 metric tonnes worth KSh2.3 billion during that year.

In 2018, the then Agriculture Cabinet Secretary, Mwangi Kiunjuri, said that by failing to fully exploit the Blue Economy, Kenya was losing over Sh440 billion annually. But if the opportunities offered by the Blue Economy are to be exploited, a policy intervention in the management and disposal of plastic waste is urgently required to protect the ocean’s rich biodiversity for sustainable development.

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