Climate change and primary health care in Chakama, Kilifi County, Kenya

Chakama is an area of 46 small villages in Kilifi County, Kenya. Climate change has led to more frequent and longer periods of drought in this semi-arid region as well as locust invasions. This has led to a lack of water, with many rivers drying up and poor water quality as a result of pollution of the remaining river water. The lack of water and locust invasion have led to a failure of the crops and loss of livestock. Many pastoralists and farmers have lost their livelihood. Wild animals from local nature reserves have also come into conflict with the community over water scarcity. Many families have migrated in search of water and income. The health effects are seen in the rising number of people suffering from malnutrition and gastroenteritis as well as in terms of mental health problems. Primary health care services are not always available, and the quality of such services is poor. Facilities and healthcare workers also struggle to be resilient in the face of the same environmental challenges. Local nongovernment organisations are attempting to assist through health and social services, community engagement and multisectoral action.


Climate change, locust invasion, pollution, health
In sub-Saharan Africa, the frequency of droughts has increased in the last few decades, and they have become more prolonged. 1 One of the key contributing factors is climate change, leading to reduced rainfall in the region. This in turn has reduced the quantity and quality of water for people. Polluted and contaminated water results in outbreaks of gastroenteritis in populations already weakened by food insecurity. This part of Kenya did not have any rainfall for over 18 months and also suffered an invasion of locusts, which destroyed the crops in early 2020. 2 The coronavirus disease 2019 (COVID-19) pandemic also restricted movement and led to rising fuel and food prices, which further exacerbated the suffering of the people and limited their ability to access services. Rivers which were once over one's head are now trickling at ankle level. Irrigation upstream has further reduced the water volume. The water quality in this river system has deteriorated due to stagnation and contamination with industrial and human pollutants. Rains finally came for about three weeks in December 2021. The next few months again saw no rain, and heat intensity increased. Several older persons in different villages have testified to M.S. that the weather has changed in recent years. 'I have never experienced such heat and dry spate since my birth', said Karisa, a 70-year-old man who M.S. met during a community meeting in Hawewanje village. Another man, who walked several hours to the village where M.S. was stationed in to request food, had this to say: 'Yes, this place is hot and dry, but the intensity this time is definitely different. We have never experienced this kind of drought and heat before. Our suffering this time is much worse.' Chakama is an area of 46 small villages in Kilifi County, Kenya. Climate change has led to more frequent and longer periods of drought in this semi-arid region as well as locust invasions. This has led to a lack of water, with many rivers drying up and poor water quality as a result of pollution of the remaining river water. The lack of water and locust invasion have led to a failure of the crops and loss of livestock. Many pastoralists and farmers have lost their livelihood. Wild animals from local nature reserves have also come into conflict with the community over water scarcity. Many families have migrated in search of water and income. The health effects are seen in the rising number of people suffering from malnutrition and gastroenteritis as well as in terms of mental health problems. Primary health care services are not always available, and the quality of such services is poor. Facilities and healthcare workers also struggle to be resilient in the face of the same environmental challenges. Local nongovernment organisations are attempting to assist through health and social services, community engagement and multisectoral action. Another feature of this story is the impact of the locust invasion at the end of 2019 and beginning of 2020, which devastated crops. This is linked to climate change. 3 In May 2018, an unusually powerful cyclone hit the Arabian Peninsula, and the heavy rainfall enabled desert locusts to hatch, develop and breed. A further cyclone in October 2018 kept these locusts alive, and they spread to Yemen. From Yemen, the winds of another cyclone in 2019 carried the locusts across the sea to East Africa. Climate change increases the severity and frequency of cyclones through warming of the oceans. 4

Human-wildlife conflicts
Compounding these effects are human-wildlife conflicts. Wild animals from the Tsavo National Park have left the park because of the drought and moved into inhabited areas where they destroy crops and come into conflict with humans. 5 Elephants are often seen where they had not been seen in decades, and they destroy crops grown by hardworking farmers. Hippos congregating in the remaining water are more aggressive, and there have been several attacks and some deaths reported recently. Such conflicts have led to increase in food insecurity, as the farmers cannot work on their land due to the marauding wild animals. The increase in trauma highlights the need for improved emergency transportation and management of trauma at health facilities, which need better training for health workers and medical equipment to deal with such emergencies.

Migration
Migration of families has also been reported due to the extended drought. One family, comprising of Kesi, her physically challenged husband and five children, recently relocated to another village in the Chakama area to be closer to the river, as their home was in an area that had no water at all. Chakama's land has become extremely dry, hitting subsistence farmers badly. Grass is depleted, and cows and goats are dying in large numbers, devastating livelihoods, especially those of pastoralists, who totally depend on their livestock. Only those farming near the river are still able to grow some crops, yet many of these too have suffered from elephants moving out of the wildlife parks. The family, with several children, were living on open ground without a house, next to the river. There was no toilet and they were using the bush. The village had no health facility, just like the village they had come from. They wanted to fish and farm the land, to provide food for their family. The mother mentioned that many children in the village had suffered from diarrhoea and vomiting after playing in the river. They had to leave two of their older children behind to attend primary school, as the new area did not have a school. The separation was very stressful, but they wanted their children to complete school and help lift the family out of poverty.

Land use and livelihoods
One source of income that has thrived is making charcoal. Many families have intensified cutting down and burning the bush to make charcoal, which they sell on the roadside to passing cars and lorries. Most of the earnings are used to buy water and maize flour, their staple, and for many this is their only food in days. Cutting down the bush is already showing obvious changes in the environment, which is difficult to restore as there is no culture of growing trees. People are complaining that they have never felt such intense heat in many years. The reduction of bush cover is obvious and there is danger that the consequent loss of the nutrient-rich top soil may negatively impact farming activities and food security. The increasing deforestation leads to the lack of shade with increased risk to livestock of high temperatures.

Health and health services
There are some public dispensaries, run by nurses, which provide basic medicines and maternity services. The structures have a few consultation rooms, a labour, a delivery room and a pharmacy. When available, trucks fill the water tanks, as water is needed for hygiene, staff accommodation and toilets. There are no surgical or laboratory facilities at this level. Often there are shortages of medicines, and patients are given prescriptions to buy from local chemists. The latter are run by untrained individuals and may provide the wrong medicines from their scarce stock of supplies. The local people often complain of poor-quality care and even mismanagement, and they have to travel to the towns to receive further treatment. Many cannot do so because of the costs involved. These have increased recently because of the fuel crisis and the consequent rise in cost of transport.
There is a network of community health volunteers (CHV) which is activated when there is funding for specific projects, such as polio or measles vaccination campaigns. The CHVs meet at the dispensaries on a monthly basis to discuss various health-related issues. However, many lack insight into public health needs and are poorly motivated to carry out their functions. They are unpaid and have competing demands on personal economic and sociocultural activities, which affect their voluntary work in health services; 6 hence, their effect on the ground is very limited. There are unmet needs for consistent social and health services to prevent illnesses, promote health and provide quality curative services to the villages. There are gaps in the provision of quality maternal and childcare services. With multiple stressors in the community, there are obvious mental health issues and an increase in alcohol and substance abuse. However, these are not appropriately assessed or documented.
When primary health care services are stretched thin and performing poorly, it is difficult to respond to the health effects of climate change caused by the drought. The resilience of such primary health care facilities and services is low, as they face many of the same climate-related challenges such as the lack of water and high temperatures. There are increasing reports of gastroenteritis from several villages due to the use of contaminated river water, which is at a very low level with flow slowed down, leading to greater concentration of contaminants from upstream villages. The lack of toilets with the common practice of open defaecation worsens the risk of contamination of river water and diseases spread by oro-faecal route. Human-wildlife conflict, especially due to elephants, leading to the destruction of crops in farms which cannot be appropriately fenced due to prevailing extreme poverty, increases food insecurity and risk of malnutrition. Women, children and the elderly are affected most adversely. The government as well as the nongovernment sector have been trying to respond to the crisis.
The CHEPs' response to the crisis has been multifold. 7 Firstly, it has expanded its contact with leaders in each of the 46 villages to obtain news of community-wide as well as individual household-level adverse effects. Secondly, it is increasing its capacity to respond through staff training, mentorship and partnerships with similar organisations. The CHEPs keep donors alerted about changing situations and possible needs. Thirdly, village-wide meetings encourage the community to plan and implement their own initiatives to combat the situations they face. Fourthly, resilience-building initiatives have been implemented such as community-led total sanitation, rainwater harvesting, setting up borehole water, desalination plants, village clean water storage, farming training for improved food security and nutrition, various activities to increase school enrolment and quality and adult literacy, as well as community mobilisation for education.

Conclusion
Chakama in Kilifi County, Kenya, is typical of many such communities in the Horn of Africa that are trying to survive the prolonged drought and effects of climate change. The drought has had many consequences such as the lack of food, the lack of water, poor water quality, conflict with wild animals and migration, which have led to many health effects such as malnutrition, gastroenteritis, trauma and mental health problems. Primary health care services were challenged even before the effects of climate change, and there are significant unmet needs which need to be responded to. Nongovernment organisations, such as CHEPS, have been supporting primary health care through community engagement, multisectoral action and provision of support for health and social services.