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. Nairobi is the capital city of Kenya, and Kibera is a slum approximately 7 kilometers 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, an Oscar-winning film adaptation of John le Carre’s similarly-named book.
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 by the British in appreciation for 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 important 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 clearly demarcated 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 plastic bags, slum residents wrap the contents then hurl them out, away from their own shacks. Wherever the bags land, they become part of the “normal” environment of Kibera. When it rains, the mixture of domestic garbage, raw sewage and layers of accumulated debris in what is essentially an open drainage system can truly test the senses.
Although Kibera attracts low-income earners from all of Kenya’s ethnic groups (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" (domestic employees), watchmen, "shamba boys" (gardeners) or casual construction workers for minimum wage. Therefore, the only place where they can afford to live is the Kibera slum. Kibera also attracts a large number of female-headed households. Many, trying to escape marriages gone sour or the deaths of their spouses 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 their jobs, or due to serious illness like HIV/ AIDS, move to Kibera. There is a growing sense that the slum is becoming 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 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, the majority of the latter-day landlords do not reside in Kibera; they simply come to collect their rents, or pay agents to collect them 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 put up a large number of these structures, and I have heard that some politicians with clout easily collect huge 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. The residents pay taxes to the local authorities, buy goods and services, and are even good targets for bribes. It is, therefore, not surprising that a slum-upgrading program, 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 brought there during emergencies, especially at night when the outlying dispensaries are closed. One has only 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, the women are ashamed that their children are malnourished, 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 the mothers of malnourished children because they assumed the women were the source of the problem. Many of the mothers had previously 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 would be worse. Many of the children were severely dehydrated from constant diarrhea; 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 intervene 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 to accommodate an observation clinic for the 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 to KNH for hospitalization and further treatment.
It was hoped that, after initiating community interventions for these slum mothers, the team would use the insights it had gained in Kibera to intervene in other areas of the country where child malnutrition was endemic. In the meantime, having identified suitable premises for our needs (we had rented a permanent structure on the outskirts of the slum), we embarked on our project. We mainly spent the first week 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, those from the second group would bring their children on Tuesday, those from the third group would bring their children on Wednesday, and those from the fourth group would bring their children on Thursday. Friday was left open for administrative functions like data entry, project monitoring and the 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 are among them. It was not common, for example, to see malnourished Maasai children, unless the situation was one of famine. By contrast, children from historically-marginalized communities tended to form the majority of malnourished children. It did not take long for us to confirm that, while some of these malnourished children had been born and raised in the slum, a majority had come from upcountry in this weakened state. In fact, the 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 their main dietary staple. Maize is a poor source of important nutrients that would typically have contributed to the proper utilization of dietary proteins.
A familiar pattern soon emerged among our clients: The mothers and their children lived in the rural areas, where they endured poverty. When the children got ill, their mothers would bring them to their migrant-worker husbands in the city slum. Many migrant workers tend to forge new relationships with new women in the city. Therefore, they 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. Thus, the rural mothers would use the children's illnesses to justify their visits. 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 helped to explain why KNH continued to receive a large burden of malnourished children from Kibera slum.
Previously published on East Africa in Focus.