How al Shabaab attacks have hurt health services in Garissa

For the regional community, health services are critical to them at this challenging time when they have lost all their livelihood to the prolonged drought.

Health infrastructure and rapid disease surveillance missions along the Kenyan northern frontier border with Somalia are important as they will offer border communities solutions to strange diseases.

The dream and hope of having such facilities and rapid health response to community needs have been shattered for many years by threats from al Shabaab.

Fafi subcounty in Garissa is the epicentre and flashpoint of past numerous al Shabaab attacks and the presence of sympathisers roaming the area that borders Somalia has worsened disruption of social, economic and health services in the region. It has also contributed to fear in parts of the county.

Fafi hosts Hagardere refugee settlement, which is one of the camps that forms the Dadaab refugee towers.

Due to the subcounty's proximity to Somalia, the terrorist group uses the area as an entry point to Kenya and a smuggling route for its fighters, weapons and sneaking recruited youths from Kenya into al Shabaab training bases in Somalia.

In Diiso village, Fafi, residents are counting losses in form of disruption of health and other services by al Shabaab and the closure of the only health facility.

The community members at the village meet twice a day to deliberate on the problems facing them.

They also suggest solutions that might alleviate suffering and address rising cases of strange diseases and other critical services like maternal health, primary health services, referrals made from their village to Garissa Level 5 Hospital and handling of health emergencies.

In one of their village meetings, community members talk in low tones as they look around for any outsider or any suspicious movement within the vicinity of the gathering.

The fear and community surveillance on "outsiders" is caused by threats and the systematic network al Shabaab manages or operates in the far-flung Kenyan border village with the aim of expanding its terror leverage.

The community surveillance involves a community member who checks the road that leads into and out of the village and a woman member who checks areas within the meeting space for any uninvited person or a new face.

Diiso is among areas that have witnessed al Shabaab attacks. In 2019, a health facility that served 2,000 people was hit by a rocket-propelled grenade.

The attack raised fears that the terrorist group was abducting non-local health officials, which led to the evacuation of health personnel by authorities.

"It was in December 2019 that al Shabaab fighters attacked Diiso health facility using heavy weaponry. It was the only health lifeline we had," Abdi Hanshi, an elder and a member of the community meeting space, said.

According to a nurse who was working at the Diiso health facility, the attackers surrounded the compound and started hurling grenades. Residents also heard a loud sound which they later learned was from a rocket propelled grenade.

"I was out of the health facility and heard a sound which was followed by a huge bang. As a non-local working as a nurse in the area, I knew I was a target for al Shabaab and decided to take cover in one of the houses in the village," a medic, who sought anonymity as he plans to return to the region and offer his services, said.

"Fortunately, after the attack, they moved round the village with the aim of showing their strength before fleeing."

The al Shabaab attackers also targeted telecommunications masts, which provide communication and information sharing between communities, government agencies and health service providers.

Local observers say that al Shabaab militants understand the strength and capacities of Kenyan multiagency forces in northern Kenya and hence deploy their trick of cutting communication between attacked villages and multiagency command centres in Garissa and other subcounty headquarters.

"You have to know al Shabaab is a dangerous rag-tag terrorist group and they fear engaging the Kenyan multiagency forces. They target telecommunications masts to disrupt communication and information exchanges between the attacked villagers and security command centres," Khalif Hussein, a member of Garissa human rights network, said. 

A mass exodus of non-local health officials operating in border areas and withdrawal of local medics forced some community members to seek primary health services from the neighbouring border town of Somalia.

Hussein Olow, a taxi operator and cross-border trader, has made a fortune by ferrying patients from Amuma in Kenya, to the Somalia side of the border, where Kenyan patients get health services.

The cross-border trader plies various routes like Alinjughur–Amuma and Amuma-Somalia routes, where he ferries goods and people across the border.

Ali understands the border terrain well as he was born and brought up in Amuma.

He has been in the cross-border business for five years. He works closely with security agencies to ensure he complies with all necessary border checks and compliance from various Kenyan security agencies manning border routes and sections of the Amuma border frontier.

"Cross-border communities share the same language. They hail from the same community and clan and what separates them is the border between Kenya and Somalia. But other dangerous people can take advantage of the porous border and sneak into the country and cause insecurity," Ali said.

"We work and cooperate with security agencies and also report any suspicious movements or incidents along the border." 

From Amuma border point, Ali makes one trip per day and he ferries 10 passengers, with most of them crossing the border to seek health services.

"Out of 10 passengers crossing the border from Kenya into Somalia in Amuma, almost seven are patients seeking medical assistance from Somalia's side of the border," Ali said.

In the Somalia side of the border, patients are attended to by Somali health professionals who offer a range of health services like laboratory, consultation and treatment.

Amuma is among other border towns whose health facilities have shut down, partially opened but offering no services and others operating with no medical personnel.

The other affected areas in Fafi and Ijara in Garissa are Galmagala, Bula Golol, Bodai, Elkanbere, Yumbis, Haji Jimay, Deka Harja and Diiso, which offered rural health services to the community.

Other community members in the far-flung villages are using the services of traditional healers for treatment and medical advice.

Traditional healers collect medicinal plants from the expansive Boni Forest to treat various ailments.

Boni Forest straddles Lamu county and Ijara subcounty with larger sections of the forest found on Somalia's side of the border.

Gathering medicinal plants, tubers, roots and leaves from the forest comes at a huge cost as it involves seeking security, transport and clearance from forest authorities.

"Locals complain that some of our products are expensive but we traditional healers pay a lot of resources to cater to our security and transport," traditional healer Bashir Kunow said. 

"The forest cuts across Kenya and Somalia and hence the presence of al Shabaab fighters have been reported in some sections of the forest. Some products are expensive and others are sold at reasonable prices." 

Traditional healers conduct community and patient consultations based on symptoms and explanations. The healer uses indigenous knowledge in diagnosing the patient.

"I use indigenous knowledge and skills transferred to me by my late father. My traditional health services are sought after by local communities after the closure of dispensaries and other health facilities due to al Shabaab threats and attacks," Kunow said.

A regional expert from northern Kenya said the national government and the devolved unit need to come up with a strategic intergovernmental action plan to address disruption caused by violent extremism.

"Yes, there is a sound relationship between national and county governments but much more needs to be done in northern Kenya. Strategic inter-governmental action plan is needed so that national government can intervene and assist in addressing disruption of health services,” Asha Abdi of Horn Africa consultancy group said.

The group works on development and anti-violent extremism matters.

Asha said health is a devolved function, while security, which includes neutralising al Shabaab attacks, is a national government responsibility.

"Extra cooperation and coordination between national and devolved units are needed in taking health services to frontier border region and centres,” Asha said.

Garissa Health executive Ahmed Nathir acknowledged the challenges of insecurity and mass exodus of health personnel which led to the closure of health facilities in border areas and far-flung villages.

"Well, the challenges are there and the new county administration is working with national security agencies and other partners in ensuring the facilities are open and running. The county government has procured medical equipment and other items for health facilities," Nathir said.

The Garissa county administration is also encouraging local students to take medical courses and bridge the gap left by the mass exodus of non-local health personnel.

However, Northeastern regional commissioner James Kianda said the national government is working closely with the Garissa government in ensuring seamless service delivery and maintenance of law and order.

"We have deployed security forces to protect key critical facilities like health dispensaries and telecommunications masts," he said.

Kianda urged the county government to ensure health staff hired by the county show full commitment to serving in rural and remote areas of Garissa.

"Security is already there, but again some health personnel have a problem of forming attitude of fear and insecurity. Garissa government should get full commitment that the health staff are ready to serve in hard-to-reach areas," Kianda said.

"The government has set up security camps near health dispensaries in rural Garissa and no point of alarm arising from past insecurity issues."