No Such Number

Out of the eight provinces in Kenya, the two most disadvantaged, using a range of about 50 indicators, are North Eastern and Coast. The two most advantaged are Central and Nairobi. When you compare HIV prevalence, the two provinces with the highest rates are Nyanza and Nairobi and the two with the lowest are North Eastern and Central.

A broad range of advantages does not necessarily mean low HIV prevalence and a broad range of disadvantages does not necessarily mean high HIV prevalence. This is why it is important to look at development as a whole, rather than obsessing about HIV; it's just one disease and for many people, it is not even the worst thing that can happen.

If you look more closely at some districts you get even clearer insights into serious instances of underdevelopment. If you compare urban populations, they appear to have a lot of advantages over rural populations. But if you look at slums, and there are many in Kenya, you get a completely different picture. An estimated 71% of urban dwellers in Kenya live in slums (probably around 2.8 million people in Nairobi alone).

Some of the social indicators (health, education, infrastructure, etc) for slum areas are even poorer than they are in rural areas. Slums are growing, especially now as many IDPs are moving to urban areas. Others are moving from rural areas to find work, so there is particular pressure on urban areas right now.

A report published last year on the burden of disease in two of Nairobi's slums, Korogocho and Viwandani, list many features of these areas that differ from Nairobi as a whole. Although the report does not have the scope to measure HIV prevalence, it suggests that it, too, is higher there than in other parts of the country. Prevalence fell slightly in Nairobi between 2003 and 2008 but this is unlikely to reflect the situation in slums.

The report measures mortality in years of life lost to premature mortality (YLL). It found that under fives had four times the mortality rate of the rest of the population (standing at 692 years per 1,000 person years). The chief causes of death are pneumonia (22.8%) and diarrhoeal diseases (19.5%). It is notable that these two causes can be addressed, in part, by introducing intermediate technologies such as solar cookers and other techniques for sterilising water.

Infant mortality was 96.0, 82.6 and 81.8 per 1,000 live births for the years 2003, 2004 and 2005 respectively (compared to 79 per 1,000 nationally in 2005 and 96 per 1,000 in 1970). Under five mortality is 139.1, 119.1 and 121.4 per 1,000 live births (compared to 120 per 1,000 nationally in 2005 and 156 per 1,000 in 1970). Malnutrition is known to be an underlying cause for more than half of childhood deaths but may be underestimated by this survey methodology. Malnutrition and anaemia account for 8.4% of YLL.

In Nairobi province 20.3% of children are stunted, 6.3% of under fives are underweight and 2.1% suffer from wasting. Poor health and nutrition in children can be related to low maternal education, poverty, lack of food security, etc. Only 69.2% of children have full childhood immunisation. This suggests weak and inaccessible health systems and poor attendance at ante-natal clinics.

It is clear that nearly forty years of development has had little impact on infant and child mortality in Kenya. In fact these figures have mainly been disimproving nationally since the 1970s in Kenya. The HIV epidemic may have had some part in this but the trend started before HIV would have had much impact.

Among those over five years of age, around 50% of mortality is caused by HIV/AIDS and TB. TB has been counted with HIV because deaths caused by either are difficult to distinguish. Mortality in the population as a whole is 205 YLL per 1,000 person years.

Other findings are equally appalling: population density in this area is estimated to be 60,000 per square kilometre. Homicide is the second most common contributor to mortality (12.1%) in those over 5 years old. Road traffic accidents are the third most common (5.8%). These figures are higher than for Sub Saharan Africa as a whole

The ratio of males to females in these areas is similar to much of Nairobi and a large part of the population consists of those from productive age groups. Between the ages of 20 and 35, males outnumber females considerably. Where there are a lot of men relative to women, this can result in high levels of commercial/transactional sex. Nairobi had a particularly high ratio of males to females in the 1980s, a time when HIV was known to have spread very rapidly.

Health systems, clearly, are poor in these slum areas. Most people die outside the formal health care system. Verbal autopsy was used for the report in question but this has its limitations. Official death certificates are not common. For Nairobi as a whole, life expectancy is 57; 54.1 for men and 59.8 for women. 40% of people are not expected to survive to over 40, the worst figure for this indicator in the country. 54% of people have poor access to a qualified doctor.

The Human Development Index, a composite index widely used and recognised by the development community, is currently the highest in the country for Nairobi province. But this hides many problems faced by a huge number of the city’s population. The fact that many of the richest people in the country have a residence in Nairobi must distort many of the figures.

Slums are sometimes politely referred to as informal urban settlements or by some similar construction. They are barely alluded to by politicians and few official statistics exist to allow proper evaluation. But they are a reality for an increasing number of Kenyans, a reality that needs to be addressed now.