Peace through Health: Strategies for Change
10/06/08 22:23
The following is the text of a presentation given
to the "Peace Through Health" Programme at McMaster
University in April 2008
The Kenya Working Group is based out of the International Center for Disability and Rehabilitation at the University of Toronto. It is a collaboration between McMaster University, the University of Toronto and partners in Kenya whose focus is the care of people living with disabilities which include in the Kenyan context, severe poverty, HIV and childhood vulnerability.
Kenya established its independence from British Colonial rule in 1960 and had been relatively peaceful since that time. I find it strange to be talking about Peace through Health because all of the work that we have been doing since 2003 occurred under a seemingly peaceful environment. It never occurred to me that the work we do would be influenced by a change in political environment and that perhaps we have been peripherally peace building within a community unknowingly. With the presidential elections this past December however, political instability unleashed violence and clashes throughout Kenya that took everyone by surprise. The political crisis highlighted the fragility of peace in the area and we are relieved that the immediate crisis has settled down and we are hopefully able to evaluate the change, our response and perhaps begin to develop strategies for future direction.
To understand our programme, I need to describe our function before December and perhaps we can look at our initiatives in response to the immediate crisis and now with the fall out. Our key partner in Kenya is the Disability Service Programme a community based rehabilitation project in Nyanza Province. Because the programme is grassroots, all of the drive to provide care comes from people living in the community as stake-holders in their health care and funding comes from donations made by friends of the community. This is important because self-reliance can be both empowering as well as challenging and often frustrating when the community is resource poor. For this reason, the KWG offers support to the community as a partner, sharing responsibilities and working collaboratively with what the community envisions are the goals for the programme. Our number one strategy for promoting peace through health is this equitable partnership with community members as stakeholders in their health care and building on the sense of ownership.
Kenya has a population comparable to Canada however demographics are substantially different due to the fact that an estimated 43% are under the age of 15. Given that there are so many children, it is no surprise that the majority of clients we see are children. Our primary interest in health provision is to minimize morbidity and mortality as a result of living with disabilities.
Disabilities according to the World Health Organization account for 10% of a population and the area in which we work, is populated by 1.4 million people. That means that 140,000 people are estimated to be living with some form of disability and at the moment there are three therapists providing community based care in the region. Other health care workers are available within government and private hospital settings in which people are expected to travel to the facility and pay a fee for service but for people living with disabilities this access is often completely out of reach.
Unemployment in the area we work is close to 80% so competition for employment is competitive and able bodied people are at an advantage when positions become available. This means that many people do not go to the hospital for lack of funding (Kenya does not have a universal health care system) and people rely on free community clinics for their health care access.
One key way in which the KWG promotes peace through health is through engagement with the community in the rural areas. We actively seek out community members who would benefit from health care services by going directly to the marginalized in the rural areas and our project sets up community clinics.
The greatest need for health information is in the rural areas where 80% of the population live yet most of the services and information is disseminated within urban settings.
Through provision of service at this community level, it is conceivable that this measure may have mollified the dissent felt by rural community members towards those living in urban communities. Lessening the gap that exists between elite members of society who can afford private health care and those who cannot afford it. This disparity between the wealthy and the poor was one of the triggers of violence when disgruntled individuals claim inequality of service for elite members.
Measurably, in a single clinic day a therapist in our programme may see 100 people. Although we can quantify the number of people seen, the impact of this strategy in terms of peace is elusive.
Kenya is regionally based. People identify with particular tribal groupings and tend to live in pockets or regions throughout the country that have heavy representation from their tribal group. Where one tribal region meets with another tribal home area there are occasional violent clashes over land disputes, property or any number of grievances. The KWG works with all groups, setting aside tribal allegiances avoiding preferential treatment. In this regard, a key strategy to promotion of peace is to avoid preferential treatment to opposing tribal groups.
Because the needs are vast, volunteers work with the clinicians in the area to triage medical needs and identify other services that may be needed. (ie. shunting, surgical requirements, medication management for seizures, vocational training). A knowledge of both scope of practice and what other disciplines are capable of doing is essential.
Therapists perform a great advocacy service to assist people in accessing schools, medical procedures and vocational training. They also think a lot about designing equipment out of locally available materials which improves their engagement within the community. The clinic has a technician who makes all of the equipment including wheelchairs, crutches, calipers, splints and anything else we come up with.
The KWG aims to bridge the gap in health care for people living with disabilities in Kenya by providing rehabilitation services to under-serviced areas. We do this through coordinating Canadian volunteers to provide direct service provision to help supplement the services that are already in the community and by providing sponsorship for individual health needs (on a case by case basis) such as those who require equipment (which the programme makes) and necessary surgery as the needs are identified.
Another key strategy to promote peace within the community based programme is to provide treatment accessibility equally to all within the community and allowing people from different tribes to learn along side one another.
After some time when people who require more intensive therapy have been identified, the programme hosts a training week. Clients and their caregivers identified throughout the region (including members of differing tribes) are invited to come from all over the area and stay at the clinic for a week. It is at these training weeks that people with similar disabilities are brought together in an in-patient environment while therapists work one on one with children and their caregivers educating and providing intensive treatments for the clients. It allows people to share their experiences and find common ground with their challenges rather than their tribal differences. Not only are people learning how to manage their disabilities, but they work cooperatively living in a communal arrangement for the week and assisting in the workload of daily living at the clinic.
Additionally, people with disabilities living in close approximation have been asked to form groups/networks of people living with disability to support each other. This has been the chief strategy for communicating with people and relaying community needs to the programme.
Up until December, all quantifiable measurement of programme initiatives has been difficult based on the variability of the rehabilitation work being done and none of it has been focused on peace because of the unexpected nature of the conflict that gripped the community. In December, disputed presidential elections divided the country along tribal lines. Overnight, peaceful communities were transformed into rioting grounds while militia groups roamed the streets and government forces clashed with mobs of angry protesters. Buildings and shops were looted, homes and churches burned down, 1500 people were killed and an estimated 600,000 people were displaced. Road blocks were erected along all the major highways and people who were not in their home areas were the target of violence.
The upheaval had changed the face of operational life. While we in Canada are used to hearing stories of political turmoil and violence coming out of Africa, this is not the norm for Kenya. It forced the KWG to rethink and react in whatever means we could because the challenges that our community faced became amplified under the stress.
As reported by the Christian Blind Mission in Australia, for people with disabilities the impact of conflict and emergency situations is greater due to: an inability to escape quickly, (e.g. a person in a wheelchair); dependence on aids and carers; difficulty adjusting to interim environments, (e.g. a person who is blind may not be able to locate things in a refugee camp). (CBMI Australia)
Similarly, our clients were severely affected as most of the people we serve are among the poorest of the poor and with the recent fighting a shortage of food hampered all of our rehabilitation efforts. For safety reasons, all foreigners left the programme area. The programme co-ordinator told us that one of the most frightening experiences during the chaos was watching as helicopters descended throughout the area and groups of white people climbed aboard and left. He asked if the world leaves, who will be watching what they do?
At the height of the violence, people sought refuge at the coordinator's home and some came to the clinic. Our volunteer programme had to cancel sending students for safety reasons however our support for the project did not diminish. We contacted Red Cross who was in the area however they were overwhelmed with the demands of providing support and relief for the displaced people in the makeshift camps that had begun to form. This is not surprising.
Kett et al in 2005 reported that in the acute-conflict stage, the needs of disabled persons are in general completely ignored in evacuation and refugee situations. Conflict situations increase the vulnerability of existing disabled persons and their families. At the same time, conflict situations make more people disabled both directly (with injury through mines, bombs etc) and indirectly (breakdown of health and other infrastructures). (Kett et al 2005)
It appeared as though the strategy we have been using to provide support with our community based groups became essential in maintaining a health based infrastructure with the change in needs. The CBR groups that had already been formed before the violence realized that it needed to band together to support each other in the absence of external support.
The KWG entered a relief mode so that service provision shifted and where we normally would provide funding support for surgeries, equipment, training weeks and rehabilitation support, our first priority was to provide food kits for 50 families who are our clients and will need food before disability management is their priority. The food kit provision project was implemented to decrease the vulnerability of the population with which we work and was distributed to families identified by the CBR groups themselves.
A respect for the community based partnership offered some protection from the violence to the health care infrastructure that was formed in the programme area when the community stood to protect the clinic against looters who broke down the doors and began to take apart the clinic. Members of the community saw this and banded together to stop them from so doing because the work the clinic does is seen as valuable by rival groups in the conflict. The respect that is afforded to the importance of health care served to protect this community asset.
Additionally, the visibility of the programme vehicle having entered into rural areas to meet with our clients paid off when the vehicle was allowed to pass through barricades set up along the highways. People on both sides of the conflict recognized the vehicle as providing relief and support to the most marginalized from community and allowed it to pass barricades where other vehicles had been confiscated and the occupants beaten. The vehicle was used to deliver goods to the community hospital, at other times it provided ambulance services and sometimes carried the deceased.
The strategies of the KWG to promote peace are difficult to measure quantifiably. The only means that we have to measure are through the actions and the number of people who protect their right to health care. Despite the danger in traveling on the roads during the violence, people with disabilities still made the effort to come to the clinic.
The day after the announcement of a Power Sharing Agreement by political leaders on February 28, 2008, our clinic opened its doors to 120 new clients who witnessed the continued work in the community. Peace returned to the community but the realization of its frailty is still present. It is still early to say if the newly formed government will lead to lasting peace and many people are skeptical. We are in the process of thinking of strategies towards healing.
Attempts to rebuild community are underway in the Disability Service Programme but these are still in response to the immediate needs. Helping to counsel both displaced people to return to the area as well as their neighbours who may have been the source of fear. The CBR workers have begun to experience the need for diplomacy, mediation, and conflict resolution in bringing groups together around food scarcity and the need to continue to support each other to assure their security in the days following the assault on their resources.
It has been only a week since the new government has been sworn in (April 17, 2008) but we are continuing to make plans for a return to the programme area.
We are sending a team of rehabilitation professionals beginning in August. Post-conflict environment is a completely new area of interest to us. We are interested to see what disabilities have arose as a direct result of the conflict. There may be opportunity to examine strategies to assist with the healing that may be required after trust among community members has been damaged. We have begun to think about effectiveness in the community looking at goal attainment scoring for individuals.
Why do we need to be involved? Peace ultimately returned to Kenya with pressure placed by the international community
The Kenya Working Group is based out of the International Center for Disability and Rehabilitation at the University of Toronto. It is a collaboration between McMaster University, the University of Toronto and partners in Kenya whose focus is the care of people living with disabilities which include in the Kenyan context, severe poverty, HIV and childhood vulnerability.
Kenya established its independence from British Colonial rule in 1960 and had been relatively peaceful since that time. I find it strange to be talking about Peace through Health because all of the work that we have been doing since 2003 occurred under a seemingly peaceful environment. It never occurred to me that the work we do would be influenced by a change in political environment and that perhaps we have been peripherally peace building within a community unknowingly. With the presidential elections this past December however, political instability unleashed violence and clashes throughout Kenya that took everyone by surprise. The political crisis highlighted the fragility of peace in the area and we are relieved that the immediate crisis has settled down and we are hopefully able to evaluate the change, our response and perhaps begin to develop strategies for future direction.
To understand our programme, I need to describe our function before December and perhaps we can look at our initiatives in response to the immediate crisis and now with the fall out. Our key partner in Kenya is the Disability Service Programme a community based rehabilitation project in Nyanza Province. Because the programme is grassroots, all of the drive to provide care comes from people living in the community as stake-holders in their health care and funding comes from donations made by friends of the community. This is important because self-reliance can be both empowering as well as challenging and often frustrating when the community is resource poor. For this reason, the KWG offers support to the community as a partner, sharing responsibilities and working collaboratively with what the community envisions are the goals for the programme. Our number one strategy for promoting peace through health is this equitable partnership with community members as stakeholders in their health care and building on the sense of ownership.
Kenya has a population comparable to Canada however demographics are substantially different due to the fact that an estimated 43% are under the age of 15. Given that there are so many children, it is no surprise that the majority of clients we see are children. Our primary interest in health provision is to minimize morbidity and mortality as a result of living with disabilities.
Disabilities according to the World Health Organization account for 10% of a population and the area in which we work, is populated by 1.4 million people. That means that 140,000 people are estimated to be living with some form of disability and at the moment there are three therapists providing community based care in the region. Other health care workers are available within government and private hospital settings in which people are expected to travel to the facility and pay a fee for service but for people living with disabilities this access is often completely out of reach.
Unemployment in the area we work is close to 80% so competition for employment is competitive and able bodied people are at an advantage when positions become available. This means that many people do not go to the hospital for lack of funding (Kenya does not have a universal health care system) and people rely on free community clinics for their health care access.
One key way in which the KWG promotes peace through health is through engagement with the community in the rural areas. We actively seek out community members who would benefit from health care services by going directly to the marginalized in the rural areas and our project sets up community clinics.
The greatest need for health information is in the rural areas where 80% of the population live yet most of the services and information is disseminated within urban settings.
Through provision of service at this community level, it is conceivable that this measure may have mollified the dissent felt by rural community members towards those living in urban communities. Lessening the gap that exists between elite members of society who can afford private health care and those who cannot afford it. This disparity between the wealthy and the poor was one of the triggers of violence when disgruntled individuals claim inequality of service for elite members.
Measurably, in a single clinic day a therapist in our programme may see 100 people. Although we can quantify the number of people seen, the impact of this strategy in terms of peace is elusive.
Kenya is regionally based. People identify with particular tribal groupings and tend to live in pockets or regions throughout the country that have heavy representation from their tribal group. Where one tribal region meets with another tribal home area there are occasional violent clashes over land disputes, property or any number of grievances. The KWG works with all groups, setting aside tribal allegiances avoiding preferential treatment. In this regard, a key strategy to promotion of peace is to avoid preferential treatment to opposing tribal groups.
Because the needs are vast, volunteers work with the clinicians in the area to triage medical needs and identify other services that may be needed. (ie. shunting, surgical requirements, medication management for seizures, vocational training). A knowledge of both scope of practice and what other disciplines are capable of doing is essential.
Therapists perform a great advocacy service to assist people in accessing schools, medical procedures and vocational training. They also think a lot about designing equipment out of locally available materials which improves their engagement within the community. The clinic has a technician who makes all of the equipment including wheelchairs, crutches, calipers, splints and anything else we come up with.
The KWG aims to bridge the gap in health care for people living with disabilities in Kenya by providing rehabilitation services to under-serviced areas. We do this through coordinating Canadian volunteers to provide direct service provision to help supplement the services that are already in the community and by providing sponsorship for individual health needs (on a case by case basis) such as those who require equipment (which the programme makes) and necessary surgery as the needs are identified.
Another key strategy to promote peace within the community based programme is to provide treatment accessibility equally to all within the community and allowing people from different tribes to learn along side one another.
After some time when people who require more intensive therapy have been identified, the programme hosts a training week. Clients and their caregivers identified throughout the region (including members of differing tribes) are invited to come from all over the area and stay at the clinic for a week. It is at these training weeks that people with similar disabilities are brought together in an in-patient environment while therapists work one on one with children and their caregivers educating and providing intensive treatments for the clients. It allows people to share their experiences and find common ground with their challenges rather than their tribal differences. Not only are people learning how to manage their disabilities, but they work cooperatively living in a communal arrangement for the week and assisting in the workload of daily living at the clinic.
Additionally, people with disabilities living in close approximation have been asked to form groups/networks of people living with disability to support each other. This has been the chief strategy for communicating with people and relaying community needs to the programme.
Up until December, all quantifiable measurement of programme initiatives has been difficult based on the variability of the rehabilitation work being done and none of it has been focused on peace because of the unexpected nature of the conflict that gripped the community. In December, disputed presidential elections divided the country along tribal lines. Overnight, peaceful communities were transformed into rioting grounds while militia groups roamed the streets and government forces clashed with mobs of angry protesters. Buildings and shops were looted, homes and churches burned down, 1500 people were killed and an estimated 600,000 people were displaced. Road blocks were erected along all the major highways and people who were not in their home areas were the target of violence.
The upheaval had changed the face of operational life. While we in Canada are used to hearing stories of political turmoil and violence coming out of Africa, this is not the norm for Kenya. It forced the KWG to rethink and react in whatever means we could because the challenges that our community faced became amplified under the stress.
As reported by the Christian Blind Mission in Australia, for people with disabilities the impact of conflict and emergency situations is greater due to: an inability to escape quickly, (e.g. a person in a wheelchair); dependence on aids and carers; difficulty adjusting to interim environments, (e.g. a person who is blind may not be able to locate things in a refugee camp). (CBMI Australia)
Similarly, our clients were severely affected as most of the people we serve are among the poorest of the poor and with the recent fighting a shortage of food hampered all of our rehabilitation efforts. For safety reasons, all foreigners left the programme area. The programme co-ordinator told us that one of the most frightening experiences during the chaos was watching as helicopters descended throughout the area and groups of white people climbed aboard and left. He asked if the world leaves, who will be watching what they do?
At the height of the violence, people sought refuge at the coordinator's home and some came to the clinic. Our volunteer programme had to cancel sending students for safety reasons however our support for the project did not diminish. We contacted Red Cross who was in the area however they were overwhelmed with the demands of providing support and relief for the displaced people in the makeshift camps that had begun to form. This is not surprising.
Kett et al in 2005 reported that in the acute-conflict stage, the needs of disabled persons are in general completely ignored in evacuation and refugee situations. Conflict situations increase the vulnerability of existing disabled persons and their families. At the same time, conflict situations make more people disabled both directly (with injury through mines, bombs etc) and indirectly (breakdown of health and other infrastructures). (Kett et al 2005)
It appeared as though the strategy we have been using to provide support with our community based groups became essential in maintaining a health based infrastructure with the change in needs. The CBR groups that had already been formed before the violence realized that it needed to band together to support each other in the absence of external support.
The KWG entered a relief mode so that service provision shifted and where we normally would provide funding support for surgeries, equipment, training weeks and rehabilitation support, our first priority was to provide food kits for 50 families who are our clients and will need food before disability management is their priority. The food kit provision project was implemented to decrease the vulnerability of the population with which we work and was distributed to families identified by the CBR groups themselves.
A respect for the community based partnership offered some protection from the violence to the health care infrastructure that was formed in the programme area when the community stood to protect the clinic against looters who broke down the doors and began to take apart the clinic. Members of the community saw this and banded together to stop them from so doing because the work the clinic does is seen as valuable by rival groups in the conflict. The respect that is afforded to the importance of health care served to protect this community asset.
Additionally, the visibility of the programme vehicle having entered into rural areas to meet with our clients paid off when the vehicle was allowed to pass through barricades set up along the highways. People on both sides of the conflict recognized the vehicle as providing relief and support to the most marginalized from community and allowed it to pass barricades where other vehicles had been confiscated and the occupants beaten. The vehicle was used to deliver goods to the community hospital, at other times it provided ambulance services and sometimes carried the deceased.
The strategies of the KWG to promote peace are difficult to measure quantifiably. The only means that we have to measure are through the actions and the number of people who protect their right to health care. Despite the danger in traveling on the roads during the violence, people with disabilities still made the effort to come to the clinic.
The day after the announcement of a Power Sharing Agreement by political leaders on February 28, 2008, our clinic opened its doors to 120 new clients who witnessed the continued work in the community. Peace returned to the community but the realization of its frailty is still present. It is still early to say if the newly formed government will lead to lasting peace and many people are skeptical. We are in the process of thinking of strategies towards healing.
Attempts to rebuild community are underway in the Disability Service Programme but these are still in response to the immediate needs. Helping to counsel both displaced people to return to the area as well as their neighbours who may have been the source of fear. The CBR workers have begun to experience the need for diplomacy, mediation, and conflict resolution in bringing groups together around food scarcity and the need to continue to support each other to assure their security in the days following the assault on their resources.
It has been only a week since the new government has been sworn in (April 17, 2008) but we are continuing to make plans for a return to the programme area.
We are sending a team of rehabilitation professionals beginning in August. Post-conflict environment is a completely new area of interest to us. We are interested to see what disabilities have arose as a direct result of the conflict. There may be opportunity to examine strategies to assist with the healing that may be required after trust among community members has been damaged. We have begun to think about effectiveness in the community looking at goal attainment scoring for individuals.
Why do we need to be involved? Peace ultimately returned to Kenya with pressure placed by the international community
History will have to record that the greatest tragedy of this period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people.Martin Luther King, Jr.