December 16, 2008

V. Treatment Access during the 2008 Post-Election Violence

Between late December 2007 and February 2008, Kenya experienced serious political and ethnic violence. The violence was triggered by election fraud and controversy over the results of the presidential elections that took place on December 27, 2007. In response to opposition protests, police used excessive force against demonstrators and killed and wounded hundreds of citizens. Opposition supporters committed serious acts of violence against members of the Kikuyu ethnic group-the country's largest ethnic group-suspected of voting for President Kibaki's Party of National Unity (PNU); and Kikuyu militias carried out violent attacks against Luo, Kalenjin, and other communities viewed as opposition supporters.[208] Over 1,000 people were killed. At least 300,000 people were displaced, possibly many more; an estimated 100,000 children were displaced.[209]

Impact of Post-Election Violence on the Health Sector and on ART

The violence had a direct impact on those in need of health care. Many health workers fled their workplaces or were unable to return, due to threats against them and members of their ethnic group.[210] At the same time, the post-election violence greatly increased the need for medical care, due to injuries and sexual violence.[211]

At this writing, health facilities continue to be plagued by the absence of health workers who fled.[212] In addition, it has been reported that ethnic tensions have increased in some health facilities.For example, patients have complained that health workers give preference to patients from their own ethnic group, and have avoided seeking treatment from health workers who are not of their own ethnic group.[213] A Kikuyu woman caring for her five-year-old HIV-positive granddaughter described her experience in the Rift Valley:

The staff are Nandi or Kalenjin… The time it takes, sometimes we wait for hours, while the Kalenjin show up and get seen right away. This is because they [the Kalenjin] are running the clinics. For example, yesterday I was at the clinic and had to wait there for six hours before I got treated. Others that came in long after I did got their treatment before me. It is not fair.[214]

At the start of the violence, many patients on antiretroviral treatment-whether displaced or not-stopped their treatment. In early January 2008 the Academic Model for the Prevention and Treatment of HIV (AMPATH) reported that only 5 percent of its patients in the Rift Valley had come to refill their prescriptions for antiretroviral drugs.[215] Patients in the poorer areas of Nairobi also stopped taking their drugs.[216] MSF-Belgium found that the default rate of their patients in Mbagathi and Kibera doubled in January.[217] In some parts of the country, supply chains were interrupted, and antiretroviral drugs were unavailable. This was the case in Bondo district, where several children died when their ART was interrupted. A mother told Human Rights Watch researchers about the death of her son, Andrew, who died in March 2008:

During the post-election violence, there were no drugs. The roads were blocked. Nevertheless I took [Andrew] to Bondo [district hospital] but he passed away. I went twice to Bondo during the violence but there were no drugs. The third time I went there, he was given the treatment. That was in late February. But he died after a week. He had herpes, and his body was swollen all over…. During the crisis I also met two other women in Bondo hospital whose children passed away because they could not get ARV. They came from elsewhere in Bondo district.[218]

At present, there are no figures available on the total number of AIDS deaths due to the post-election violence.

The Emergency Response Treatment in IDP and Transit Camps

According to government figures, an estimated 21,000 people living with HIV were displaced; the real figure might be considerably higher.[219] The initial situation in the camps was dire, as many people living with HIV had stopped taking their drugs or were otherwise in need of health care. According to a UNICEF worker,

Health generally was a problem in the camps at first because people were afraid to access services outside of the camps. But once the camps got established, the health services were there.[220]

Lack of health care during the crisis affected those on ART, and also pregnant women in need of PMTCT. Some patients on ART stopped taking it due to lack of food, and babies were breastfed because there was no formula available.[221] An HIV-positive mother, who already has an older child living with HIV, told us about the lack of PMTCT programs:

My youngest girl [Helen] is now six-and-a-half months old, she was born on February 4 of this year, and at that time, I was living in the [Burnt Forest IDP] camp. At that time there was no one really working at the hospital here, so I gave birth inside a tent in the camp.[222]

A teacher leading a support network for HIV-positive teachers in Eldoret described her efforts to get ART into the camps and remembered the situation of people living with HIV:

We lost about 10 persons during that time because of lack of care. Those left had to fend for themselves…. Some refused to take their drugs because the food rations were not enough.[223]

One of the problems at the start of the post-election violence was the absence of any civil emergency plan.[224] Once the crisis happened, though, the government and many agencies took action to address the situation, and did succeed in getting patients back on treatment. The emergency response was coordinated through a national-level humanitarian services committee, and through health clusters at each camp.[225] While the Kenyan Red Cross was the lead agency providing food and organizing camp management, the Ministry of Health and international agencies led the organization of health care.[226] The Kenya Red Cross set up some HIV support groups in camps.[227] Local NGOs and churches also mobilized.[228] The actors involved set up permanent clinics in larger IDP camps and organized mobile clinics in smaller camps. The government and agencies also used the radio, newspapers, posters, and other publicity tools to encourage patients to seek treatment at their nearest health facility. Médecins Sans Frontières (MSF) launched a hotline for people who had defaulted on their treatment and did not know what to do.[229]

In the Rift Valley, AMPATH played a crucial role; it has about 30,000 patients enrolled in its antiretroviral treatment program, 3,000 of them children. At ASK Showground IDP camp in Eldoret, the Ministry of Health established a dispensary; AMPATH also set up an HIV/AIDS clinic in the camp. AMPATH also ran a mobile clinic operating in camps and other locations of the Rift Valley, the region where it is based, and carried out tent-to-tent testing in some camps.[230]

According to AMPATH, many patients who fled without their medication were able to get back on treatment within a few weeks at most.[231] But despite the rapid scale-up of HIV/AIDS-related services in the camps, patients continue to suffer from several HIV-related problems. Food in the camps is sometimes insufficient and not of the kind needed by patients on ART.[232] Another problem is the lack of blankets, warm clothing, and mattresses to protect the displaced against the cold and wet climate in some parts of the Rift Valley. As a result of these living conditions, many displaced suffer from frequent illnesses.[233] People with immune systems compromised by HIV are even more vulnerable to these secondary infections. The mother of a two-year-old HIV-positive girl, Dora, told us about Eldoret ASK Showgrounds IDP camp:

Things are not working here in the showgrounds. There is no money for me to buy fruits and other balanced diet items for [Dora], so I am not getting a balanced diet for her. It is cold at night in our tent, so the risk is there for her or me to get sick.[234]

Another problem in the camps is the lack of privacy. As a result of congestion, people's movements can be easily monitored, and some have been afraid to be tested, seek treatment, or take their drugs.[235]

Operation Rudi Nyumbani and the healthcare situation in transit camps

On May 5, 2008, the Kenyan government launched "Operation Rudi Nyumbani" (Return Home), a program to return internally displaced people to their home areas. In contravention of international standards for the protection of IDPs, many displaced were forced to return.[236] Those IDPs who returned home often found that their houses had been burnt or were occupied, and many of them are currently squatting or living in some kind of provisional arrangement.[237] Ethnic tensions have also sometimes persisted and make reintegration of displaced people difficult.[238]

As many were afraid to go home or had nowhere to go as their homes and belongings had been destroyed, so-called transit camps started to spread across the Rift Valley. These were smaller camps that people moved to after they were told to leave the IDP camps. By September 2008, only 12,000 people remained in 26 camps in Rift Valley province, but another 100,000 displaced people were living in 160 transit sites near their home areas.[239]

While the larger IDP camps had on-site medical care, smaller IDP camps and transit sites usually lack such services and require patients to go to ordinary district- and sub-district-level health facilities.[240] As many displaced persons do not know the area, and sites are not always strategically located, this sometimes means long travel distances to the nearest health facility. Sometimes international agencies pay transport costs for patients, but this does not reach all people affected. A Red Cross representative found,

The challenge for people in the transit camps is that some are now far from the clinics and dispensaries, especially where such services were provided for them in the IDP camps themselves before. So in some cases we have found that people have stopped taking their medications again. We have contacted AMPATH to do transit site visits to see how people are doing in the camps.[241]

In June 2008 the government and several agencies observed that "currently a formal strategy on the provision of assistance to transit camps is not in place."[242] The government reported that "there are no funds for the establishment and delivery of basic services in transit camps."[243] This situation in transit camps was still of concern when the Kenyan government announced the closure of all IDP camps by September 30, 2008.[244]

A particular problem is the situation of children whose parents returned to their home areas without them, as they felt it was not safe for the children to return. These children are highly vulnerable and often not able to get any medical care.[245]

[208] Human Rights Watch, Ballots to Bullets: Organized Political Violence and Kenya's Crisis of Governance, March 2008, vol. 20, no. 1 (A), http://hrw.org/reports/2008/kenya0308/.

[209] "Kenyan post-election violence displaces over 100,000 children," UN News Center, January 17, 2008, http://www.un.org/apps/news/story.asp?NewsID=25328&Cr=kenya&Cr1=unicef (accessed September 22, 2008). According to the Kenyan Red Cross, 300,000 persons lived in IDP camps. However, others who fled their homes lived outside the camps, that is, with relatives in their home areas. Wilfred Ndolo, director of migration and resettlement in the Ministry of State for Special Programs, estimates that the total number of IDPs might have been around 650,000. Human Rights Watch interview with Wilfred Ndolo, Nairobi, August 12, 2008. According to UNHCR, an estimated 11,000 persons fled into neighbouring Uganda and another 1,000 to Tanzania; their situation is not dealt with in this report.

[210] AMREF, "Post election violence leads to humanitarian emergency in Kenya," January 7, 2008, http://uk.amref.org/news/postelection-violence-leads-to-humanitarian-emergency-in-kenya/ (accessed September 23, 2008); HERAF, "The Right to Health: The aftermath of the post election violence," January 10, 2008, http://physiciansforhumanrights.org/library/documents/statements/heraf-post-election-statement.pdf (accessed September 22, 2008).

[211] "Post elections violence report: More than 400 sexually abused," The Gender & Governance Program in Kenya, http://www.gendergovernancekenya.org/featured/78 (accessed September 23, 2008).

[212] Human Rights Watch interview with Kenny Rogers, UN OCHA, Eldoret, August 19, 2008.

[213] "Kenya: Drug resistance risk as displaced ARV patients skip ARV doses," PlusNews, January 17, 2008,  http://www.plusnews.org/Report.aspx?ReportId=76288 (accessed October 19, 2008); Human Rights Watch interview with HIV-positive woman, former resident of Burnt Forest camp, Uasin Gishu district, Rift Valley province, August 21, 2008.

[214]Human Rights Watch interview with mother of Liliane, age five, Turbo, Uasin Gushu district, Rift Valley province, August 20, 2008.

[215] "Kenya: Drug resistance risk as displaced ARV patients skip ARV doses," PlusNews.

[216] "HIV treatment in times of civil strife: Serious threats to antiretroviral drug access in the Kibera slum following the Kenyan elections," AIDS, vol. 22, no. 13, 2008, pp. 1693-1694; Human Rights Watch interviews with HIV-positive mothers and guardians of HIV-positive children in Mathare slum, Nairobi, August 13, 2008.

[217] Human Rights Watch interview with representatives of MSF-Belgium, Nairobi, August 13, 2008.

[218] Human Rights Watch interview with mother of Andrew, who died age six in March 2008, Nyangoma, Bondo district, Nyanza province, August 18, 2008. The children were two girls, ages six and seven.

[219]United Civil Society Coalition for AIDS, TB and Malaria (UCCATM), "HIV&AIDS: Impact of Post-election violence," PowerPoint presentation at NACC conference, February 4, 2008, unpublished document, on file with Human Rights Watch.

[220] Human Rights Watch interview with UNICEF staff member, Eldoret. August 19, 2008.

[221] Human Rights Watch interview with representative of Kenyan Red Cross, Nairobi, August 14, 2008; see also statement from Margaret Wambete at the 17th International AIDS conference in Mexico, quoted in "Conflicts Make Women More Vulnerable to HIV conference told," Womensphere, http://womensphere.wordpress.com/2008/08/11/conflicts-make-women-more-vulnerable-to-hiv-conference-told/ (accessed September 23, 2008). Civil society organizations expressed serious concern about the situation at the time. See, for example, HERAF, "The Right to Health"; "Post election crisis threatens gains made in fighting HIV and AIDS," UCCATM press release, January 29, 2008.

[222] Human Rights Watch interview with mother of Helen, age six months, Burnt Forest, Uasin Gishu district, Rift Valley province, August 21, 2008. At the time of the interview she was awaiting the test results for Helen.

[223] Human Rights Watch interview with Margaret Wambete, Teachers Living Positively, Eldoret, August 21, 2008.

[224] Human Rights Watch interview with representatives of HERAF, Nairobi, August 12, 2008; Human Rights Watch interview with representatives of MSF-Belgium, Nairobi, August 13, 2008; "Post election crisis threatens gains made," UCCATM press release.

[225] Human Rights Watch interview with Wilfred Ndolo, Nairobi, August 12, 2008.

[226] Among the international agencies involved were AMPATH, Médecins Sans Frontières, International Medical Corps, and Medical Emergency Relief International (MERLIN).

[227] Human Rights Watch interview with representative of Kenyan Red Cross, Eldoret, August 19, 2008.

[228] Human Rights Watch interview with Margaret Wambete, August 21, 2008.

[229] Human Rights Watch interview with representatives of MSF-Belgium, Nairobi, August 13, 2008. Perhaps not surprisingly, the secretary-general of the International Federation of Red Cross and Red Crescent Societies has praised his organization's response to the crisis as a success. International Federation of Red Cross and Red Crescent Societies, World Disasters Report. Focus on HIV and AIDS, http://www.ifrc.org/Docs/pubs/disasters/wdr2008/WDR2008-full.pdf (accessed October 8, 2008), pp.8-9, 134-135.

[230] Human Rights Watch interviews with AMPATH clinical officer, Turbo, Uasin Gishu district, August 20; and IDP camp manager, Kenyan Red Cross, Eldoret ASK Showground IDP camp, August 19, 2008; "Turmoil disrupts AIDS care in Kenya," Bulletin of the WHO, vol. 86, no. 3, March 2008, http://www.who.int/bulletin/volumes/86/3/08-030308.pdf  (accessed September 22, 2008), pp. 168-169.

[231] Human Rights Watch interview with Winstone Nyandiko, associate program manager, AMPATH, Eldoret, August 19, 2008. This was confirmed by the mother of an HIV-positive girl in Eldoret ASK Showgrounds IDP camp who managed to get the girl back on treatment after about one week of interruption, thanks to AMPATH intervention in the camp. Human Rights Watch interview with mother of Judith, age 12, Eldoret ASK Showgrounds IDP camp, August 19, 2008.

[232] Human Rights Watch group interview with members of HIV support group in Eldoret ASK Showgrounds IDP camp, August 19, 2008; "Kenya: Camp conditions harsh for HIV-positive displaced people," PlusNews, April 29, 2008, http://www.plusnews.org/Report.aspx?ReportId=77973 (accessed September 23, 2008).

[233] Human Rights Watch group interview with members of HIV support group in Eldoret ASK Showgrounds IDP camp, August 19, 2008; Human Rights Watch interview with representative of Kenyan Red Cross, Eldoret, August 19, 2008.

[234] Human Rights Watch interview with mother of Dora, age two, Eldoret ASK Showgrounds IDP camp, August 19, 2008.

[235] Human Rights Watch group interview with members of HIV support group in Eldoret ASK Showgrounds IDP camp, August 19, 2008; "Kenya: Camp conditions harsh for HIV-positive displaced people," PlusNews.

[236] "Kenya: Stop Forcing Displaced People to Return Home," Human Rights Watch news release, May 22, 2008, http://hrw.org/english/docs/2008/05/22/kenya18922.htm.

[237] Human Rights Watch interviews with former camp residents in Turbo, Uasin Gishu district, Rift Valley province, August 20, 2008; and in Burnt Forest, Uasin Gishu district, August 21, 2008.

[238] Human Rights Watch interview with Kenny Rogers, August 19, 2008.

[239] USAID, "Kenya – Complex Emergency," September 17, 2008, http://www.reliefweb.int/rw/RWFiles2008.nsf/FilesByRWDocUnidFilename/YSAR-7JKMPZ-full_report.pdf/$File/full_report.pdf (accessed October 8, 2008).

[240] Margaret Aguirre, "A New Emergency in Kenya," June 24, 2008, http://www.imc-la.com/content/article/detail/1826/ (accessed October 8, 2008); Central Emergency Response Fund, "CERF allocates $1.5 million to support displaced persons in Kenya," http://ochaonline.un.org/CERFaroundtheWorld/Kenya2008/tabid/3519/language/en-US/Default.aspx (accessed October 8, 2008).

[241] Human Rights Watch interview with representative of Kenyan Red Cross, Eldoret, August 19, 2008.

[242] "Cluster Meeting Nairobi," June 24, 2008, http://www.humanitarianreform.org/humanitarianreform/Portals/1/cluster%20approach%20page/Kenya/Intercluster%20meeting%20minutes_24_June08.pdf (accessed October 8, 2008).

[243] Ibid.

[244] "Kenya: IDPs struggle to rebuild their lives," IRIN, September 30, 2008, http://www.irinnews.org/report.aspx?ReportId=80665 (accessed October 8, 2008).

[245] Human Rights Watch interview with IDP camp manager, Kenyan Red Cross,  Eldoret ASK Showground IDP camp, August 19, 2008; "Kenya: Separated children eking a living in Rift Valley town," IRIN, September 10, 2008, http://www.reliefweb.int/rw/rwb.nsf/db900sid/ASAZ-7JCHDS?OpenDocument&rc=1&cc=ken (accessed November 11, 2008).