December 27, 2002. 10 in the morning. Donholm Primary School. Embakasi Constituency. I am in line to cast my vote in the most important election in the country’s history up to that time. It is also my second election having voted for the first time in the 1997 election for the dynamic Charity Ngilu and her Social Democratic Party (SDP), who lost to Moi. Now in 2002, as I stood quietly in line and thought about the election I was to take part in, I was quietly confident since my favourite politician had banded with many others to form a coalition against Daniel Arap Moi’s preferred candidate, Uhuru Kenyatta. As the line got closer to the school gate, I noticed that there were posters on the floor with the message Uhuru Ni Moi. These posters had images of both the outgoing president and the presidential candidate and the jogoo that represented the political party that had been baba na mama to me for all my life. The message was simple enough. Voting for the new party leader was the same as voting for the outgoing leader.
The Moi leadership was real to me. As a child born in the 1970s and growing up in the 1980s, I would observe the leadership of this man from Sacho keenly. As a child, I was the biggest fan of Baba wa Taifa, Mkulima Number One, Everything Number One. The image of the tall, lanky man getting into the dirt to help build gabions with fellow Kenyans on VOK (now KBC) was seared in my memory. Favourably. I was one of the many children singing praise songs of the dear leader as a member of the Nairobi Primary Schools Mass Choir at the Nyayo National Stadium on national holidays.
I grew up seeing the President taking part in events every day on the television, but my life was also touched by him and the projects of his administration. My personal favourite was the free milk that would come to school every Tuesday that we knew as Nyayo Milk. The orange packs with diagonal white stripes held delicious milk. And it was free. Then there were other projects that made me proud to be a child of the land of Kenya. The All Africa Games in 1987 which brought the continent to Kenya and Michael Jackson’s brother Jermaine to perform at the opening ceremony. The Nyayo Pioneer – my country had built its own car. While the car, driven by the president at Nyayo Stadium, didn’t run for long, we could brag that we had our own car as a country like Japan had Toyotas, France had Citroen, the UK had Land Rover and the USA had Ford. In my young eyes, my country was perfect.
Goldenberg would introduce the country to the concept of “billions”.
The first time that I realised that things weren’t as rosy as they seemed in my mind was in February, 1990. I had just started my form one classes at Upper Hill School and I was headed to get public transport in town when I found drama on the streets as riot police chased citizens around town. The cause of the riots was the slain body of the then missing Foreign Minister, Robert Ouko, had been found and people were unhappy. The well-spoken, polished minister had been my favourite in the cabinet of my still beloved Nyayo. As the weeks and months went on, my carefully constructed view of the leader of the country started unravelling as more people spoke out in protest against his administration. The scales were falling from my eyes.
Not long after, we would hear of a term -Goldenberg- which put to shame all previous scandals that had been creeping into the Kenyan consciousness. Goldenberg would introduce the country to the concept of “billions”. Before then we would speak of things in hundreds, thousands, millions and hundreds of millions. This madness saw our currency devalued by one third overnight leading to hyperinflation that was never seen before nor since. The economy would almost grind to a halt and would only really recover after the dear leader had left office in 2002.
The human cost of the presidency was also steep. Kenyans would die mysteriously in Molo, Burnt Forest and other areas to subvert the elections of the 1992. With a little over 30 percent win, Daniel Arap Moi was announced President by Zacchaeus Chesoni, who was then rewarded with the Chief Justice position. Other Kenyans died in Likoni and Rift Valley in 1997, leading to the incumbent remaining in office as Samuel Kivuitu announced his “second term.” When people weren’t dying because of elections, many who had been critical of the dear leader would die in mysterious circumstances. By car accident. Shot. Others would appear broken after being tortured by state operatives. Those who weren’t dying were fleeing the country like rats off a sinking ship.
By 2002, when I was casting my vote, the country was so broken that everyone had to gang up and vote off the administration from the Survivor Island that Kenya had become. I joined my country and voted for the opposition. The tribe had spoken. We expected freedom like never before. We would have three years of plenty democracy, two years of bananas and oranges and five years of what appeared to be an uncomfortable unity government under Mwai Kibaki.
Another election was in the offing. This was again the most important election in my lifetime. It’s funny how every election is the most important election in our lifetime.
August 8, 2017. 4pm. Highway Secondary School. Starehe Constituency. Another election was in the offing. This was again the most important election in my lifetime. It’s funny how every election is the most important election in our lifetime. As I walked towards the secondary school gate, I would see some other discarded election posters as I had at previous plebiscites. Most were from activist Boniface Mwangi, who was running for area MP. While we were chatting, the security guard at the voting station gate left me to let in a truck filled with army personnel. At the sight of that many soldiers in the sleepy South B suburb, my blood went cold as I walked in to make my mark on the ballot in this latest “most important election.”
It was a half hour affair as I walked into the polling station, got my voting papers and made my decision in the booth. Choosing not to waste my vote, there were only two possibly candidates for me for the Presidential ballot: incumbent Uhuru Kenyatta and opposition leader Raila Odinga. Between the two, mine was a simple choice. It was either to stick with the incumbent who had a record over the last few years or go with a new man who was as yet untested where executive powers were concerned.
The incumbent, Uhuru Kenyatta, had come to power facing charges at the International Criminal Court for crimes against humanity for his actions during previous elections. The same applied to his running mate, William Ruto. It looked bleak for him but against the odds, he won the election, took over the State House and started pretty well. He promised free laptops for all Standard One pupils in government schools. Businesses even tendered for this project. In the end, this signature project went nowhere because of irregularities in the tendering process.
He promised a new era of leadership but what we got instead was mega corruption exposes. Arap Moi’s modus operandi had been crushing the economy with scandals like Goldenberg and bankrupting every government agency and parastatal. This new guy’s specialty was nothing short of magic. Billion dollar loans called Eurobonds disappeared mysteriously and those connected with some of his cabinet members carted off money in sacks. Then there were family members at the centre of many of the administration’s scandals that were faithfully exposed by the opposition. The worst part was that the amounts involved were gargantuan compared to his political godfather who had been running the country down for close to quarter of a century. On grand corruption, the student had outdone the master.
On grand corruption, the student had outdone the master.
The human cost of his administration hadn’t been the best either. Many people who had been witnesses to the cases at the International Criminal Court had disappeared. People who had views that differed from the country’s leadership with names like Abubakar Shariff, an imam known as Makaburi, and Sheikh Aboud Rogo, were gunned down in broad daylight. In just under 5 years, the student had learnt to use violence with the same vim as the teacher.
It was, as mentioned before, as simple a decision as I had made in 2002 when I ticked the presidential ballot and left to follow the proceedings from my house.
Friday, September 1. 11:00am. The Supreme Court was ruling on an election petition by Raila Odinga claiming that the election, which had seen Uhuru Kenyatta declared the President-Elect, had been a farce. The whole country was on tenterhooks as we waited to hear the ruling. It had been a tense few days since the final hearing of the Presidential petition in Kenya. A couple of weeks since we went to the polls with nearly thirty people killed by the state’s security machinery in that time. Chief Justice David Maraga read his ruling: the election was nullified and the country would be going to another Presidential election.
A few hours later, we would see the President, red-eyed and furious, accepting the justice of the court but undermining the court with his statements. As this voter saw him trembling from anger and possibly other substances, he remembered that poster he saw on December 27, 2002. It was right after all.
Uhuru ni Moi. Only worse.
By James Murua
Obviously They Are Fine With Mugabe
My identity straddles African borders.
I was born in Zambia to a Zimbabwean mother and a South Africa father.
Of the three countries, I carry South African citizenship.
On social occasions I have often been at loggerheads with my compatriots who self-identify as pan-African. There are, you see, African politicians they will not brook criticism of. And one of them is one Robert Gabriel Mugabe: truth-speaker to the West, the man who had enough gumption to take land back from the whites and whose truth-telling videos, in this age of social media, they shared every year after the United Nations General Assembly. Any attempts at telling these, my fellow ‘woke’ South Africans how rhetoric did not match action and how the man, his family and his political party had often treated Zimbabwe and its citizens with contempt was always met with disbelief and what my friend and writer Petina Gappah calls Zimsplaining from my fellow South Africans. Why, they would ask, was I taking aspirin for someone else’s headache? Obviously Zimbabweans are fine with Mugabe. If they weren’t, surely they would object, toyi-toyi and overthrow him? This was the criticism that brooked no comeback as it was something that I wondered secretly sometimes. I had grown up in a Zimbabwe that protested: not just university students full of pent-up early adult hormones but notably, the teachers’ strike of 1990. What had happened to that fire? And then last year I decided to have my 40th birthday party in my mother’s country en route to South Africa by road from the country I now call home, Kenya.
In Zimbabwe in the days after my birthday, I found out that the two currencies which had created some sort of stability, the US dollar and the South African rand, were now going to be scrapped. In their place would be bond notes which, on being brought in, would be valued one to one with the US dollar. The Minister of Finance, Patrick Chinamasa and John Mangudya, Governor of the Reserve Bank of Zimbabwe had decided that the bond notes would be back in circulation in October 2016.
Already, while I was there, people had started hoarding their dollars and some shops were refusing to accept South African rands.
It was in this context that on the evening of August 2, 2016 I got a poster via WhatsApp from a friend reading:
‘Do you want to destroy your business that you have worked for all these years? SAY NO TO BOND NOTES. Join hands and march against Bond Notes.
Date: 03 August 2016
From: Cnr Julius Nyerere/Jason Moyo
To: Ministry of Finance
#pullingtogether #notobondnote #Tajamuka/Sesjikile‘
I had already dealt with a cash crisis in the week that I had been there. My cash crisis meant I could not go and see a lot of aunts and uncles as one cannot use a Visa or Mastercard on public transport. But my inability to visit relatives seemed minor when I heard some heartbreaking stories from people who live in Zimbabwe. I was, after all, just a guest in Zimbabwe and had other places to go. What of those who stayed there on a regular basis?
I thought of the unemployed university graduates working as vendors because of unavailability of jobs. I was thinking of a conversation with my friend Tapiwa who told me he interviewed five graduates, one of whom had twenty years teaching experience and another who had a degree in Architecture – married with children – to tutor his nine-year old twins for $200 a month. What would happen to the prospective tutor in a city where a reasonably neat two bedroom flat in the low density areas cost $500 a month? What would happen to the cab driver I met who had a car and wanted to survive with his four children but could only charge three dollars because no-one was willing to pay more than that for a five kilometer trip, essentially making his cab rides cheaper than Uber in Nairobi, Lagos or Johannesburg without cheaper foodstuffs? I was thinking too of my cousin Abisai telling me that because of a lack of cash, if business people needed a thousand dollars to do transactions, they had to do a transfer to illegal cash traders by the bus station for $1,200 so that they could get the $1,000 they wanted. And this was when the dollar was still circulating in the Zimbabwean economy but people were hogging it because of fear of the threatened bond notes.
This was a protest I would sign up toyi-toyi for.
With the Zimbabwean courts having ruled against the police and the government in their quest to ban people from marching against the return of the painful notes into the economy, taking part in the protest was the right thing to do. Half of my family is, after all, Zimbabwean and the bond notes would impact them.
I had no idea who was organizing the event but whoever they were, I agreed with the reason for their demonstration and I wanted to do more than verbally support it.
On August 3rd 2016 as my fellow South Africans went to the ballot box to vote in the municipal elections. I was north of the border at a march against bond notes.
I arrived at the march just before it began. After a prayer and the singing of the old Zimbabwean anthem Ishe Komborera Africa whose lyrics and tune were taken from the late South African Enoch Sontonga, the organisers informed us of the route we would be taking. I asked one of the fellow marchers why we were not singing the current Zimbabwean national anthem and the wit responded, “it would be like listening to a speech by Grace after reading one by Sallie Mugabe.”
Until he was forced to resign on 21st of November 2017, when talking to many Zimbabweans, it was never quite clear who they resented more: their then senior citizen President, Robert Mugabe who stubbornly held on to power way past his sell-by date or his flamboyant and vituperative wife, Grace. Further, I sometimes wonder whether the affection that is given to the late Sallie by Zimbabweans who talk of her fondly would still be there if she were still alive. I also wonder whether Mugabe would have retired gracefully if she were alive. Random musings.
But back to the protest.
The organisers informed us of the route we would be using and we proceeded to march.
I noted that the face of protests had changed drastically. Prior to 2016, most protests consisted of either members of the opposition party or employees of non-governmental organizations who sometimes were both. While many people my age felt the pinch, they were members of what I dub The Sandwich Parents. When asked to boycott bread because it had become overpriced, for instance, their response would be something akin to, “Ah manje, my children need sandwiches. If I boycott bread for a week, what will my children take to school?”
But now, knowing how this may hurt them, they were among those who were taking part in the protest. A friend in the banking industry called in sick so she could take part in the protest. I encountered some high school friends during the march, among them a former classmate who, not only had actively spoken of the abuse of power by the Mugabe administration but who got thrown in jail together with her partner and others for daring to screen the Arab Spring when they took place. For her actions, Tafadzwa and her comrades were charged with attempts to overthrow the government. They received a suspended sentence “if they do not repeat it” by a court system that was largely state-captured.
Another high school friend was at the march because her brother-in-law, a former Zimbabwean liberation war veteran, was arrested and charged for speaking out against abuse of power by the political leadership of the governing party. Saner minds in Zimbabwe’s High Court, which now seemed keen to no longer be puppets to the puppet-masters that are ZANU government, prevailed and the case was struck off the roll. I saw friends who had returned from the diaspora with their savings hoping to invest in the country. Among those in the crowd too were unemployed university graduates in their gowns and grandmothers. There was something about this particular demographic that I had not seen in previous marches in Zimbabwe. There was a certain unity of purpose across age, gender and class that seemed to highlight that people were fed up. I did not know it then but I had just witnessed the beginning of the end for the Mugabe leadership which would topple a little over a year later.
The government had attempted to ban the march. The organisers went to court and the courts allowed it. Knowing that despite the court ruling, the law will not always act lawfully towards protestors, flyers were handed to the police reading:
OPEN LETTER TO THE POLICE
We are not your enemies, but we are your brothers and sisters, fathers and mothers. All we want from life is to be able to feed our families and to be able to send our children to school so that they can get jobs and do the same for their children. We want them to work in Zimbabwe, not outside the country as it is now. We want doctors and medicines in our hospitals. When we stand up to ask our government for these basic human rights, do not beat us, rather stand with us as we want the same basic human rights. Above all, we are all Zimbabwean, let us unite in demanding these rights from our government.
It was doubtful that the police would really care. They were there to do the bidding of their masters but it was good to see an attempt by the organisers to wake them up.
In Zimbabwe, there seemed to be questions about the government’s relationship with China as heard from the popular song on the march:
Bobo, watengesa nyika kumaChina
Tisu takakuisa, tichakubvisa
A song that accused Bob, the President of having sold the country to the Chinese and reminding him that they were the ones who put him in power and had the power to remove him. It was an entertaining song but I wondered just how much power these people with their energy had, to remove Uncle Bob from power.
By the time we got to Treasury, many had joined and there were now thousands in a march that began with a few hundreds. It was then that I realized that perhaps something had changed. Zimbabweans were not only talking in private about being fed up with Mugabe, they were coming out in the street and publicly declaring it.
And so, on 18 November this year, although I was at a literary festival in Nigeria, I locked myself up in my room for a major part of the day to root for and follow the #MugabeMustGo protest through updates on social media. Zimbabweans were showing, this time in the glare of international media, that they were done with their geriatric leader.
Mugabe is now gone. I heard this announcement in an anti-climactic moment while in Nairobi making dinner.
Mnangagwa is in the driver’s seat.
I am cautiously optimistic for my mother’s country as I reflect on the coup that was not a coup from my father’s country. I like to think that Zimbabweans have realized the power they have and will not surrender it easily now to any politician.
A Healthy Serving of Reality
I never thought I would be on the receiving end of gratitude until cancer happened. This show of kindness has kept me on the other side of Kenya’s health care system. I consider myself lucky. I am able to afford chemotherapy drugs, monthly tests and doctor’s visits and supplements.
It is common knowledge that cancer is not cheap and this is universal. At the height of my treatment, I was spending 140,000 shillings a month on treatment, the cost of my bone marrow transplant has more zeros and commas. It is thanks to family, friends, colleagues and strangers that I was and still am able to afford my treatment. Acknowledging this fills me with a sense of humility. I struggled with the kindness that was showered my way. My therapist who helped me grapple with the many twists and turns of this journey told me to be ‘open to kindness’. Pride stood in my way, but the bitter truth was that I could not have done this alone. We as a family, could not afford this alone.
Our healthcare system is us! It will be us, the people, holding one another until we have a public healthcare system that will be able to provide universal, affordable and quality healthcare services. My diagnosis gave me new eyes to accompany this new normal. I was hugely aware of the shortcomings of our public healthcare system and once you experience it, it scares you. And if you have private medical insurance, you will appreciate the cover. But these health covers are not bottomless pits. If anything, they cushion and if it’s excellent, it offers restful nights. During the two weeks of my hospitalisation, I spent over six hundred thousand shillings of my one-million-shilling in-patient cover. Thankfully, NHIF, knocked off another 100k. My outpatient cover was going to be blown in sixty seconds and I was tapping into my savings.
Alice Membao Tawa, was my nyanya, my grandmother. Sometime in 1999, she was admitted to the burns unit of the Kenyatta National Hospital (KNH). She spent many weeks there until she passed away. The burns unit is not pretty, but we made our visits to the hospital hoping nyanya would get better. That period introduced me to the harshness of our public health system.
It is functional, though not wholly efficient. Kindness doesn’t come easily for some members of staff. There is a tough-love, ji-sort, hii-ni-kazi and uta-do attitude that is harboured by some of the staff. I witnessed patients lying on mattresses on the floor, and there were patients sharing single beds. Beds were currency. There were no three-course meals like the Nairobi Hospitals, Maters or Aga Khans, the food was bland, stodgy and uninviting. It provided the most basic of nutrition. The hospital and the wards had a beaten and drab feel to them. They didn’t offer comfort or healing. I’ve been to Kenyatta many times after that, for several reasons, and there have been vast improvements, but it is far from perfect.
We work hard to able to afford private healthcare, but sadly not everyone in Kenya can access this. I don’t take this for granted. I was saddened by the many stories of patients being turned away or dying due to the lack of medical personnel during the doctor and nurses strike. I heard medics being described as selfish for downing their tools. I bet these critics made sure their health premiums were up to date nor had they slept or walked into a public health facility.
Let us not deceive ourselves, as we live in Kenya, we are not too far from experiencing the ‘other side’ of our health care. I keep on imagining what if I was to have an accident in public either in Nairobi or elsewhere? I would probably be rushed to public health hospital before my insurance provider is notified. I have thought about it constantly. What if the only place that I would have been able to afford or receive treatment for my cancer would have been from a public health facility? If I had to receive chemotherapy intravenously and not orally, I’d be making an early morning pilgrimage to KNH and camping on the hospital grounds as I wait my turn. It would be a process of waiting hours to see a doctor for minutes and hoping that on that day they would show up.
Over the last 24 months, I have met other cancer patients who have lived that experience of waiting, wondering and hoping. There was six-year-old Waithera who was scheduled for surgery on the day the doctors’ strike began. She was only able to get badly needed surgery when her father was informed about the Faraja Cancer Trust, but before this, the hospital in Nakuru had become a second home.
I learnt that it was faster and cheaper if you got admitted as an overnight patient at Kenyatta for chemotherapy treatment. I hope the new equipment at Kenyatta will reduce patient waiting times. I was told that it was faster for patients in the western part of the country to go to Uganda for radiotherapy treatment rather than coming to Nairobi. Yes, Uganda, whose only radiotherapy machine hit the global headlines when it broke down last year. Yet, there is a radiotherapy machine in Kisumu lying idle because there aren’t enough numbers to justify the cost of operating it. Apparently, there aren’t any oncologists in Kisumu. One must go to either Eldoret or Nairobi for treatment.
In rural medical centres, there are numerous stories of misdiagnosis because of some patients (some now deceased) were tested and treated for malaria or typhoid before the discovery of cancer or either a preventable or treatable malady. I still get angry thinking about this. Early diagnosis of breast, cervical and prostate cancer make these three cancers treatable and affordable. Being diagnosed with cancer doesn’t necessarily mean death.
Our healthcare system is us. ‘Naomba serikali’ does not cut the mustard anymore. The mode of referrals for specialists, surgeons, pharmacies, and hospitals both in Kenya and abroad is word of mouth. I created a spreadsheet of the different outlets that I could source my medicine from and the phrase, ‘naenda kutafuta dawa‘ became real. There was one time I went to three hospitals looking for a drug because it was in short supply. That was when I realised that there are many of us on this journey. A journey to find the best possible healthcare that our money can afford to buy.
I followed the doctors and nurse strike keenly, read the Collective Bargaining Agreement (CBA) and cried tears of joy when an agreement was reached. We need to put more into our public health system. I am sure we know of cases of patients being transferred to KNH from private hospitals because it was cheaper cost wise. Remember those bottomless pits? They don’t exist. We have a cadre of men and women who are passionate about their work in public health. We can only reward their duty by making sure that they work under the best possible conditions. I have seen it work in the UK, through the National Hospital Service. It is not perfect, it has its critics, but it works. I look forward to the day when we will have a system that we too can boast of. One can dream, right?
But until then, our healthcare system will continue to be us. Where we look out for one another, attend medical harambees or give towards Mchanga campaigns, share a referral or WhatsApp messages on cancer, diabetes and blood pressure cures! We cannot afford to have a health system that ‘others’ individuals or provides care that is dependent on the size of one’s purse.
For we all know that death and disease do not discriminate.
Counting People in a Broken Health System
I remember, a young woman, a freshly minted teacher named Leah- who was very fond of my father. I was a little boy then. She looked up to father as a senior teacher and a mentor to help her grow into the profession. My father and mother were fond of her and she was a common visitor to our house. In our young minds, age sets were binary: you were either nyithindo or jomadongo, children or adults. Children were the people you could play with, the people you called by their first names and complained about to your parents. Adults were a whole other matter, separated by a chasm that moved through time. They were people who even when informal in their manner, had to be treated with the formality that adulthood conferred.
Leah was confusing for my binary world. She was at a stage my elder siblings had not gotten to yet, somewhere in between a child and an adult. When she was around she cooked with us, referred to my mother as “mama”, and seemed more at ease with my teenage sisters and cousins. Yet she held adult conversations with my parents and could gently disagree with them in conversation. I probably had a little puppy crush on her. She straddled that space with some aplomb. My parents loved her. My elder brother’s eyes never left her swaying hips as she navigated the ten metres or so between our detached kitchen and the main house holding a tray of food or kettle of tea in her hands. My sisters could not wait to be her- she had all the big girl privileges: she could choose her own clothes, she wore jewellery, and she earned a salary at the end of the month!
Even after she moved to a different school further away, the warmth of her company whenever she returned to visit did not change.
One day, word arrived that Leah had died. The whole family was left reeling. My sisters cried. My brother went off to the simba- my second to last unmarried uncle’s house- lost in a daze of disbelief. Although my parents were stoic, they could not hide their pain. Nobody wanted to explain death to a little boy. Up until then death was an exciting and rare occurrence associated with screams tearing the bucolic night air from the direction of the home of an ailing elderly man. They were not people I knew. In my little sheltered, small town rural existence, I had never met anyone who later went off and died.
Leah died. She was the first person I had met, known, even loved, who died. She had died during childbirth. One moment she was full of life and carrying the promise of a brand-new life, the next moment she was dead. Cause of death. Maternal mortality. Leah had come up against maternal mortality and lost.
Maternal mortality is a sterile pair of words. It is impersonal and jarring. I did not know who the father of Leah’s child was but I felt for him. Maternal mortality is the sudden shot between the closed eyes, blissfully sucking on the lollipop of life. Maternal mortality is a rusty serrated knife piercing your back. One moment you are tingling with excitement and looking forward to holding a new life in your hands and looking at the incomparable poem of joy that is the face of a new mother. The next moment you are planning a funeral.
A woman went out, and two coffins came in. A big one and tiny little one.
I did not know these things then. But, I know them now. I became a pharmacist. Then I drifted, a journeyman into public health with a penchant for math. So I count things. I count ratios and rates, odds and people’s chances. I create pivot tables and run scripts. I find blips and upticks and trends. And to stay human I try not to think of counting Leahs and little babies who have not had the chance at a name. A simple name.
2017 has been a rough year for mothers, babies and families across the country. The year opened to a doctors’ strike that was a month old and would continue into March stretching for a 100 days. Public health facilities were on their knees. Clinical officers and nurses did what they could and sent those they could not handle to private health facilities, which sometimes is the same as being sent home to die. After a brief respite, the health system would once again go into the convulsions of massive labour unrest with the nurses’ strike. That strike would last 5 months before getting called off.
If doctors are the analytical mind of the health system, nurses are its beating heart. A formidable nurse-doctor team, with the backing of a working health system, is what makes maternal mortality quake in its shoes. For the better part of 2017, there has been no team. No team means that Caesarean sections and assisted deliveries are not happening. Blood transfusions and resuscitation are nowhere to be found. Incubators are not whirring; bleeding mothers are not stirring. Ambulances are running across the land blaring sirens of death.
One of the simplest pieces of health data that indicates the health of the health system is vaccination coverage rates. It is simple because vaccines are given at predetermined intervals and ages. When a baby is born they get BCG- the tuberculosis vaccine- and the polio vaccine. Kenyans have about 30 babies for every one thousand people every year. If there is a community of about 5000 people then we expect that a baby is born every two days or so and 12 children get birth vaccines every month. Vaccine coverage responds quickly, positively or negatively, to failures in the health system- when people cannot get to the health system for reasons such as flooding, when medicines or syringes are not available, when there is no energy supply for refrigeration and when staff are not at their posts because they are on strike.
Vaccine coverage has dropped precipitously in communities that rely primarily on the public health system. Less than 5% of Kenyans have private health insurance, so this means almost every mother who is not on Facebook. Vaccines protect children individually but also as a group in what is called herd immunity. The chances of a vaccinated child getting the infection they have been vaccinated against is lower than for an unvaccinated child and if they do get the infection it commonly runs a shorter course and is less severe and less likely to lead to death.
This means that they are less likely to spread it to other children who also, if vaccinated, are less likely to catch it. Vaccination is therefore equivalent to children locking arms and standing shoulder to shoulder against vaccine-preventable diseases. Unvaccinated children are a big hole in that wall- their own risk rises massively but they also increase the risk for vaccinated children.
More ominously still, falling vaccination coverage is an outward sign of an ailing health system. For four years of my working life, I kept verbal autopsy tables: Excel sheets where in a community the size of a small district it was my business to know who died, where, when, and why. I learnt what makes people die. In what seasons people killed one another and when people killed themselves. I got to know intimately how the health system fails babies, children, mothers, and other people and how the consequences are felt in communities are far removed from tables and graphs.
As the Kenyan health system convulses, children are dying from immunizable diseases. People are missing precious doses of chronic medications such as diabetes and HIV medicines. Women are bleeding to death in ambulances and that is one Leah, too many.
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