The Link Between Healthcare and Peace in Africa

Dr. Roseanne Njiru: (00:00)
Let me say what community health workers recognize and the national strategy for community health, for their contribution in enhancing access to healthcare, especially in high burden, low income communities. So, they are sort of have become a very important part of the provision of primary health care, particularly in marginalized communities and they support health work generally. So, sort of, they are the periphery of the um, healthcare system. But they do very important work in terms of educating particularly low income communities in matters of health, making home visitations and linking people to uh, hospitals and other healthcare systems.

Mark Goldberg: (00:47)
So basically these are individuals from the community, often, often marginalized community who are really like the first point of contact for the health system and that community.

Dr. Roseanne Njiru: (01:00)
Yes, I should actually have said that they, they are people who are born in, bred in communities where they work, sometimes appointed by the communities and they are therefore the foster link with the healthcare system because they live every day in the communities where they live. And not necessarily in marginalized communities, but particularly in marginalized communities that way or provision of other services is poor and therefore these poor health and sometimes issues of violence and they are prone to I guess very many other problems.

Mark Goldberg: (01:33)
And we could say this, this idea, this concept of community health workers sometimes are called health extension workers in other contexts is something that has become increasingly prevalent in low-income settings. And in developing countries for the last 10, 15 years, it’s become like a key strategy to connect poorer or more marginalized or oftentimes actually more rural communities to a healthcare system. Having someone from that community with some training being that first point of contact.

Dr. Roseanne Njiru: (02:04)
Yes, you’re very right. In fact, they are recognized under the World Health Organizations as a declaration of 1978 that recognizes primary health, healthcare is key element for improving community health and therefore recognize the important role that community health workers might play in improving health.

Mark Goldberg: (02:25)
So what I find so interesting about your research is I have seen health workers in action. I’ve visited training centers in, in places in Africa where mostly the one I went to was mostly young women from the communities, were given some basic medical training, basic health training and communications training. And there’s lots of evidence to suggest that these community health workers have led to improvements in health outcomes and some of these marginalized communities. But was so fascinating to me about your research, is that you have identified a link between the reduction of violence and building of peace to these community health workers. How did you get the idea to study that link?

Dr. Roseanne Njiru: (03:12)
Oh, so first I do a lot of health research. I think my dissertation, my PhD doctoral dissertation focuses on the gender in HIV and I’ve done other research around health and I also work on issues of peace and peace building. And so, I thought about reading around peace work and peace building work and reading about the infrastructures of peacebuilding, which are supposed to be multilevel multisectoral if we are to have enhanced peacebuilding. And I thought that healthcare systems were excluded from the peace structures globally and nationally here in Kenya. So I thought about examining the link between health and peace because I had an idea that if community health workers are people who live in the communities who are born in the communities, therefore they understand better the issues that affect the communities issues or violence and conflict in the communities issues are structural violence that also cause health because I mean health problems because you also must understand that there cannot be development in communities without health.

Dr. Roseanne Njiru: (04:20)
So when there is violence, health is affected and development is affected. So, I thought about linking health and peace and looking at the role of the health workers and healthcare systems in general. In fact, my research is broader than just the role of community health. It focuses more on healthcare systems where community health workers are part of, to think about the connection between all the role that healthcare systems might contribute to peace building and therefore to argue that they do need to be included in the peace infrastructure globally and nationally. Because I think for lots of times Mark, I think much attention on the peace building has focused on political processes such as reconciliation, democratization, security, issues of governance, issues of economic development. We have included some sectors like religion, but we have forgotten that there is a critical link between health work and peace because there’s also people who work in communities to enhance the health of communities to provide services and therefore they contribute to peace building and development.

Mark Goldberg: (05:25)
And so how did you go about studying and figuring out the role that these health workers play in peace-building and conflict resolution?

Dr. Roseanne Njiru: (05:35)
The ways in which I went about my research, so I thought I would focus because I live in Nairobi and I do understand issues in Nairobi. I think we have gone through phases of violence. If you think about the post election violence in Kenya in 2007, 2008, again in 2017 and we had a community…

Mark Goldberg: (05:57)
You’re referring to elections that fall or pardon me, you’re referring to violence that followed elections in those years, the worst of which was in 2007 when over a thousand people were killed. And that violence largely fell along sectarian and ethnic lines.

Dr. Roseanne Njiru: (06:12)
Exactly. And we do have some places that the government has marked as hotspots areas that experience like very high levels of violence during those electro cycles. And so many of these are the informal settlements or what we would call the slum. These are low income areas, marginalized areas that are poorly serviced where I don’t know if people are employed or they are in very low income and in jobs. And those areas are sometimes very politically charged.

Dr. Roseanne Njiru: (06:50)
And you have many different groups that live in those areas. And so, I thought I would focus, obviously I went into a history and thinking about the ways in which those particular informal settlements came about. We have to think about the colonial histories of the creation of the informal settlements in Nairobi, the division of Nairobi into ratio zones and the ways in which those particular areas have historically or since the colonial era been marginalized and that has continued to date it’s sort of like very systematized structural violence. And so, I thought I would focus on those areas because they have experienced high levels of violence. So I thought about thinking about the primary health care system in those communities and particularly focusing on the role of community health workers who are people who received there and therefore know the issues of those communities have experienced violence themselves.

Dr. Roseanne Njiru: (07:44)
For example, when I interviewed one community health worker and she was telling me about the ways in which as a community health worker, people see her as a person who is selfless, likes to help people and therefore would not touch her people from other ethnic groups. Uh, she is Kikuyu and people from other ethnic groups would not touch her because she was helping people from all ethnic groups and helping to take them to hospital. So I thought I would focus on these informal settlements and think about the significance and the ways in which in fact the principles and the features of the healthcare system also increases the agency of peace building as community health workers are also doing the health work.

Mark Goldberg: (08:25)
So that’s interesting. So, so it’s the idea that they are a health worker that even if they are from a different ethnic group that might otherwise arise suspicion because they’re from the community and because they have this kind of like patent of legitimacy as a health worker, they’re seen as someone that people could confide in and trust. Whereas other, in other situations they might not.

Dr. Roseanne Njiru: (08:48)
In others, yes I did find a few situations where people obviously watch using some community health workers sometimes or discriminating against some certain groups of ethnic groups that did not belong to them. But uh, in the main, I think I did find that many community health workers were not thinking about their own ethnicity, I think because they have received some sort of training on community health work. And part of the training is thinking about the features of a healthcare system, which include the selflessness or issues or treason and the ability to be able to access community and to be able to be legitimate to the community. And people see them as people who are legitimate and people who are doing good in the communities. So there are a few cases where some community members might feel, or community health workers were reporting some that in some cases community residents have felt that they also discriminating.

Dr. Roseanne Njiru: (09:40)
And that can be obviously a negative in terms of the building peace because then it creates a further I guess uh, widens the gap between the communities rather than closing the cup. Yeah. But in the main, I think I found that they were practicing the things that they are dragged in community health work. And were being very altruistic and selfless. But also, I think another important thing that we have to think about is the issue of being able to access different groups of people. So, community health workers are people who can access people who are divided by gender, age ethnic group, political affiliation, class, etc. As they are providing health. Remember that these are people who walk into communities to go in to educate people on health. Uh, there are people who walk into who are called at any one time in the night to go and visit sick persons.

Dr. Roseanne Njiru: (10:36)
And for them it doesn’t matter who that sick person is. I mean, the cost of visiting sick persons in their homes. But of the things that I found and I was told, for example, several community health workers told me of the ways in which they would make home visits and while they’re making the home visits, people would start to talk about family disputes and they will have to act as arbiters in family disputes to try and reconcile their families. And sometimes also because of accessibility and also because of their legitimacy. And that they’re people who are accepted in the communities. I also did find that people found them as an important link between the community and the administration. So for example, they would tell them, you go and tell the security administration that we are experiencing these problems in our community.

Dr. Roseanne Njiru: (11:24)
For example, people are stealing clothes from one another, there is physical assault, there’s a lot of sexual assault. So go and report this to us because sometimes as community residents, we have tried to go and report this to the local chief or administration police and they wouldn’t listen to us. But as a community health worker, this is a person who also will be listened to by the chief and by the police officers and by other health workers in the hospitals and other health facilities and therefore that legitimacy allows them to be that link that creates the peace and reduces tensions within communities as well as solving family disputes.

Mark Goldberg: (12:01)
Yeah, please. Yeah. I’m really interested if you could share a story from one of your, from one of your research.

Dr. Roseanne Njiru: (12:10)
Yeah, I guess I should have said I picked two informal settlements. That is Mathare and the Kibera.

Mark Goldberg: (12:16)
And these, these could you describe these two places? Kibera is very well known around the world is like a very large informal settlement. You know, people might call it a slum in Nairobi. Um, the other?

Dr. Roseanne Njiru: (12:29)
Mathare is also the same. Mathare was smaller than the Kibera, but experiences similar problems as Kibera. Yes. So I chose these two communities and in one community in Mathare I found a female community health worker who was telling me how she went into her home and was going to visit a sick person. And then she found that in that home there was a small girl, young girl that had been abused by, sexually abused by her male relative. And that the mother of the girl had not reported to this case, to the police. And so the community health worker sort of convinced the mother that she needed to go to the police and report and they went through the process of reporting the case to the police because I think the mother was fearing because it is a male relative that they live with.

Dr. Roseanne Njiru: (13:23)
So how do I import somebody that I live with and is the person that also helps that helps us in the family. So they did go and report the case of sexual abuse of these younger and at the time of the interview, in fact, I remember one day I interviewed her twice and one of the days that I was interviewing her, I had to wait for her to come from court because she acted as a witness to the court case that was going on. Um between the young girl and the male relative that had abused her and the police. And you know what? She was using her own money because the government does not give resources to community health workers to do those extra kinds of work that they’re doing. So I call it sort of invisible peace work. But she was using her own money to help the family and to also travel to the court as a witness to the sexual assault case.

Mark Goldberg: (14:14)
So that’s interesting. So that’s like a direct connection between strengthening the role of law in an informal settlement where the role of law is not strong and the role of the community health worker. Is there like a similar story or example that you came across in your field research that connects more organized violence or political violence even to the role of the, to the peace building role of a peace worker, of a community health worker?

Dr. Roseanne Njiru: (14:42)
Yes. Yes, yes. So, in Kibera, I interviewed um, another female community health worker. I must say that most of my respondents and my research participants who are female, I think there is a connection between community health work and women’s work.

Mark Goldberg: (14:59)
Can I ask, are most community health workers female or is there an equal gender distribution?

Dr. Roseanne Njiru: (15:05)
What I’m saying is that most of them are female and when I asked, I was told most of them are female. And the thing is, let me say that before I go to this specific case, is that men join community health work when they are going for training, but there’s always the expectation of some stipend or some small salary at the end of the month. But this is mostly, community health work is really something that you do voluntarily. There’s very little support from government or other non-government organizations that support community health work. There’s very little that you can expect in terms of financial assistance. So a lot of people get into community health work thinking that there might be some monetary reward and then they find that there is none and they drop out and particularly the men will do that.

Dr. Roseanne Njiru: (15:57)
So in terms of the question that you asked the link between political violence in community health work. Yes, I did find one community health worker who in Kibera again during the 2017 political violence. She is a she is Luo and you know, there was the division between the Luos and the Kikuyus, etc. And she said that in fact it was also the Kikuyus who were saying that do not touch, do not touch this woman because she is doing good work and she’s preaching peace and, and, and she got protected by the Kikuyus who would otherwise have been against her. And so what she did as a result of that is she went on preaching peace to the communities and telling the communities that, you know what, after the election, after the elections, the politicians will go and we shall remain here as the people who experienced the same problem. So it is important for us to forget about our ethnicities and to forget about our political differences and just come together as a group and think about or marginalization and the ways in which to deal with any demand for better justice and the provision of services.

Mark Goldberg: (17:15)
So that’s so interesting. So because she was a health worker, even though she was a Luo and even though there is a, an election that pitted Luo versus Kikuyu at the national level and that had created a level of violence that trickled down to places in the informal, like the informal settlements. Uh, she was protected by the Kikuyu in the community and she used that, her special status, as a way to kind of preach peace.

Dr. Roseanne Njiru: (17:42)
Yes. So she definitely drew on again the issues of acceptability and legitimacy of being a community health worker to be able to go on a work of preaching this.

Mark Goldberg: (17:54)
So what are some of the broader lessons that you can draw, based on your research from the connection between health workers and peacebuilding? Um, that might be broadly applicable, not just say in the places where you’ve researched, but elsewhere in Africa or really elsewhere in the world where community health workers are an important feature of the health system.

Dr. Roseanne Njiru: (18:16)
I think one of the uh, I guess broadest uh, thing that I can see from my, as a finding from my research is that there is great potential in recognizing and thinking about health as a bridge for peace, not just in Kenya, but I think everywhere. I also read research that says the same in a few other countries globally where employing the health is a bridge for peace framework has helped in sort of is an intentions within communities between refugees and, and residents or where the refugees live. And there’s that kind of evidence. And I think my research contributes to the fact that health a peace building bridge is important and it is something that you need to critically think about and perhaps needs to be part of our national strategies and global strategies for peacebuilding.

Dr. Roseanne Njiru: (19:15)
Uh, the other important lesson, Mark is the idea that the healthcare system itself, yeah. I guess perhaps to elaborate more on the health for a bridge for peace, has specific features that are important in increasing the agency of the community health workers. In terms of building this, I think I have drawn, and I have talked about issues of legitimacy, issues of the length of time that community health workers have spent in those communities, which makes them very important in terms of understanding the issues of the community and therefore can be able to inform other formal peace building structures. So, in other words, what I am saying also is that there is important, including the local and informal peace building work of community health workers in the global and national peace building infrastructures. And that’s very important.

Mark Goldberg: (20:10)
Is there anything else you think you wanted to emphasize or discuss or?

Dr. Roseanne Njiru: (20:13)
What I can also say Mark is this, I think I talked about issues of, perhaps inadequate support of community health workers because you know, they do a lot of work. So, they do, they work within their core mandate of providing health. But outside of the community, they are doing a lot of invisible peace-building work without much support. I have given the example of the woman that is, was acting as a witness in a, in a sexual assault case and using her own finances. But there are also many other community health workers who talked about the ways in which there were two families to visit a sick person and you’ll find people do not have food and there are fights within the communities and sometimes people can’t get to hospital because they don’t have the money and they have to use their own resources even though they do not have those resources to be able to do the work that they are doing. And also, to be able to go around preaching peace and doing health work at the same time. So thinking about community health workers, not people who exist at the margin of community health care and therefore do not need any form of adequate financial support, but to budget for enough financial support because they clearly are very important for both, for him and for improving the health and peace of communities.

Mark Goldberg: (21:23)
Yeah, I mean, so like one very clear outcome and conclusion of your research is that these community health workers need more support from the government or from whoever can provide it.

Dr. Roseanne Njiru: (21:34)

Mark Goldberg: (21:35)
Uh, well thank you. Thank you so much for your time.

Dr. Roseanne Njiru: (21:38)
Thank you, Mark. Thank you and it was nice talking.