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Dr. Nelly’s journal: Kibera

Published February 9, 2010

This series was inspired by Dr. Nelly’s experience working in Kibera slum as a consultant pediatrician with a research interest in malnutrition. The characters and events are fictional. Dr. Nelly’s work can be viewed at www.nutritionafrica.com. All Rights reserved.

Kibera slum: A resource for rich landlords and home to the urban poor

In 1992, I got an opportunity to work in the Kibera slum, Nairobi, as a consultant to a donor-funded project whose main aim was to assess the extent of under-five malnutrition in slum children. Kibera is a slum approximately 7 kilometres from the city center. It has been described as the largest slum in Africa, with population estimates ranging from half a million to one million people. Not many cities in the world have such a large slum situated within walking distance of the city center. Maybe this is one reason Kibera attracts so much attention from researchers, NGOs, religious groups and tourists. Kibera also attracts many film crews, including the makers of The Constant Gardner, a film adaptation of John le Carre’s book by the same name which won an Oscar nomination.

The site where Kibera stands today was dense forest at the beginning of the last century. In fact Kibera is a corruption of the Kinubi word “Kibra”, which means “jungle or forest.” After the First World War, the British allowed Wanubi army recruits from the King’s African Rifles to settle at the site. Because they had originally been brought from the Sudan, they had been rendered “detribalised natives” after the war. They were awarded plots on which to build their homes but, by the 1940s, many had become landlords to the poor urban migrants who came to Nairobi in search of jobs. The Wanubi had perfected skills in distilling gin (chang’aa). It has been said that the skill was also passed to them as appreciation of their war exploits. Some believe that the ready availability of chang’aa in Kibera (although criminalised) was what initially attracted tenants in large numbers to the slum. This is because Kibera was by no means the only slum in Nairobi.

After Kenya’s independence in 1963, Kibera acquired many more landlords from other tribes, the Kikuyu being the majority. Since Kibera remained essentially government land, only temporary structures were allowed. Housing in Kibera therefore consists mainly of one or two-room shacks crowded together, with no clear demarcation for roads. Basic infrastructure is absent as are government services. Kibera therefore lacks roads, running water, a sewage system, street lights etc. Its famed features include “flying toilets,” which essentially mean that after defecating into a paper-bag, slum residents wrap the contents then hurl them out, away from the shack. Wherever the bag lands, it becomes part of the “normal” environment of Kibera. When it rains, the mixture of domestic garbage, raw sewage and layers of accumulated debris in what has become an open drainage system can truly test the senses.

Although Kibera attracts low-income earners from all of Kenya’s ethnicities (and even from neighboring countries), a significant majority tend to come from Western Kenya. In a bid to escape rural poverty, many get employment as house boys, watchmen, shamba boys or casual construction workers for minimum wage. The only place they can therefore afford to live in is the Kibera slum. Kibera also attracts a large number of female-headed households. Many, trying to escape marriages gone sour or the death of a spouse land in Kibera. Then there are the city’s own economic migrants who, having landed on hard times, e.g. due to the loss of a job, or due to a serious illness like HIV/AIDS, move to Kibera. There is a growing sense that the slum is becoming a home to more Nairobians as the gap between the haves and have-nots continues to widen. Some researchers estimate that up to one third of Nairobi residents live in the slum.

The area occupied by Kibera is estimated to be 1% of the area occupied by Nairobi city. Yet it is estimated (by yet others) that the slum carries 20-25% of Nairobi’s population. Kibera is therefore highly populated, with up to 2,000 people per hectare. Because of poor hygiene and crowding, poverty-related communicable diseases are rampant in the slum. It has been estimated that 1/5 of Kenya’s AIDS burden is borne by 15% of the Kibera population. Kibera is divided into 12 contiguous villages, each headed by a village elder. They are administered by government-seconded chiefs who keep law and order. They also decide who can get plots to build rental shacks. Oral rather than written contracts prevail. Usually, rich people bribe the chiefs and are allocated land on which they are allowed to build shacks for rent.

Apart from the Wanubi landlords therefore, a majority of the latter-day landlords do not reside in Kibera; they simply come to collect their rents, or pay agents to collect the rents on their behalf. The shacks are therefore a very good investment because they are cheap to put up, rents are largely unregulated, and no maintenance is expected. Many well-connected landlords easily put up several of these structures, and I have heard that some politicians with clout easily collect large sums of money in monthly rents. Kibera is therefore a valuable resource to the well-connected landlords. It is also a resource for the government because it houses cheap laborers, without any input from the government. They pay taxes to the local authority, buy goods and services and they are even good targets for bribes. It is therefore not surprising that a slum upgrading programme initiated by the government and donors has been challenged in a court of law. The case is yet to be determined.

Kibera is very close (about 3 kilometers) to Kenyatta National Hospital (KNH), the nation’s referral hospital. Because of its proximity, many children from the slum are often brought there during emergencies, especially at night when the outlying dispensaries are closed. One only has to work in the emergency ward for a few months to realize that mothers with malnourished children tend to bring their children at night. The reasons are twofold: first, they are often ashamed to be seen with a malnourished child during the day, and second, if they came during the day, they would be referred back to the nearest dispensary by the duty nurse.

In my experience, the nurses tended to be very harsh with mothers of malnourished children because they assumed the mothers were the source of the problem. Many had been admitted with their children for the same problem, but even after health education on the ward, they always came back. In many cases, the children’s malnutrition was worse. Many of the children were severely dehydrated from constant diarrhoea; others simply refused to eat, or kept vomiting when force-fed. The large number of affected children and the recurrence of the problem convinced the hospital administration to secure funding for a community study in order to identify the factors that had contributed to the problem, and to intercede accordingly at the community level. I was seconded to the project as the Consultant Pediatrician. That is how the medical team and I found ourselves surveying the slum to identify suitable premises for our project one chilly morning. We needed an office space large enough for an observation clinic for mothers and their children, including consultation facilities for those who were ill and needed attention. The intention was to lighten the burden of care at KNH by intervening at the community level. Only very ill children would be referred for hospitalization and further treatment.

It was hoped that after initiating community interventions for these slum mothers, the team would shift their focus to other areas countrywide identified as being endemic in child malnutrition using the insights gained in Kibera. In the meantime, having identified suitable premises for our needs (we had to rent a permanent structure on the outskirts of the slum), we embarked on our project. We spent the first week mainly familiarizing ourselves with the slum residents and passed around fliers announcing the launch of the project. The village headmen were very helpful, taking us around and generally assisting with logistics. The health outlets that dot the slum were also mobilized to refer any under-fives to our clinic. By the end of the first week, we had determined that we needed to lump the villages into 4 groups in order to cope with the caseload. Mothers from the first group would bring their children on Monday, group two on Tuesday, group 3 on Wednesday and the 4th group would attend on Thursday. Friday was left open for administrative functions like data entry, project monitoring and harmonization of activities.

A Kenyan doctor working with malnourished children in any part of the country soon learns to recognize the common features of this communal problem: poverty and ethnicity featured prominently. It was not common for example to see malnourished Maasai children, unless in a famine situation. On the contrary, children from historically marginalized communities tended to form the majority. It did not take long for us to confirm that, while some of the children were born and raised in the slum, a majority came from upcountry, already in this weakened state. In fact, a majority came from Nyanza and Western provinces, with a smaller number coming from Ukambani, especially Kitui district. These were all politically-marginalized areas dating from independence. Diets in such areas were typically monotonous and deficient in essential nutrients. Most of the people in the most affected areas subsisted on maize as the main dietary staple. Maize is a poor source of important nutrients, and their deficiency contributed to proper utilization of dietary proteins.

A familiar pattern soon emerged among our clients: the mothers (and their children) endured rural poverty, and when the children got ill they would bring them to their migrant-worker husbands in the city slum, using the children as an excuse for their visit. Many migrant workers tend to forge new relationships in the city and therefore usually demand that their wives remain in the village until they are invited to visit. Alternatively, they insist that their wives inform them of such visits in advance. After the children received treatment, they would go back to the same environment that had created the initial problem. In a few months, the children would get worse again, thus creating a vicious circle. This then helped explain why KNH continued to receive a large burden of malnourished children from Kibera slum.

Dr. Nelly’s Journal continues next week.

Reach Dr. Nelly M’mboga at dr_nelly@hotmail.com

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