Documenting the health consequences of endemic warfare in three pastoralist communities of northern Kenya: A conceptual framework

Social Science & Medicine 70 (2010) 45–52

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Documenting the health consequences of endemic warfare in three pastoralist communities of northern Kenya: A conceptual frameworkq Ivy L. Pike a, *, Bilinda Straight b, Matthias Oesterle c, Charles Hilton d, Adamson Lanyasunya a, b a

University of Arizona, Anthropology, 1009 E South Campus Drive, Tucson, AZ 85721, United States Western Michigan University, Anthropology, 1001 Moore Hall, Kalamazoo, MI 49008, United States c ¨ ln, Germany University of Koln, Ethnology, Albertus-Magnus-Platz, D-50923 Ko d Grinnell College, 1118 Park Street, Grinnell, IA 50112-1670, United States b

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 31 October 2009

Violent conflict represents the third most important source of mortality around the world, yet violencerelated mortality remains profoundly undercounted (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). As a step toward documenting the consequences of even the ‘‘smallest wars’’ we offer a conceptual framework for a recently initiated project that comparatively examines the direct and indirect consequences of intercommunity violence among Pokot, Samburu, and Turkana herding communities of Northern Kenya. While a substantial body of work has accumulated on the social responses to this violence very little is known about the differential impacts on community health. Based on our cumulative ethnographic experience in the area, we offer a conceptual framework that merges a contextsensitive ethnographic approach with a comparative epidemiological one centered on documenting the lived experience of violence and inequality. In this paper, we provide evidence for the importance of a contextualized approach detailing how social environments that include chronic episodes of violence produce variations in health. We do so by presenting the results of previous work to highlight what is known and follow this by identifying what remains to be understood about how violence, inequality, and health interact in these communities. While much is known about the importance of access to livestock herds for health, nutrition, and child growth in this difficult physical environment, far less is known about how the social responses to violence interact with access to herds to create new patterns of nutrition and health. With respect to pastoralists, additional areas that remain only nominally understood include age-specific mortality patterns, reproductive health, and psychosocial/mental health, topics that we view as central to the current study. In sum, we suggest that health offers one of the most useful tools for examining the costs of violence by creating opportunities for advocacy. Ó 2009 Elsevier Ltd. All rights reserved.

Keywords: Endemic warfare Social production of health Embodiment Ethnicity Nomadic pastoralism Violence

Introduction The relationship between inequality and health differences is well established (Dressler, Oths, & Gravelee, 2005; Macinko, Leiyu, Starfield, & Wulu, 2003; Nguyen & Peschard, 2003; Sapolsky, 2004). There is a developing body of literature demonstrating the broad

q This research is funded by the National Science Foundation (Cultural Anthropology Program and The Office of Science and Technology) Collaborative Award 0822915/0822951. Research clearance has been granted by the Office of the President, Government of the Republic of Kenya (permit #13/001/38C657). We gratefully acknowledge our wonderful team of Research Assistants working in each of the three ethnic communities. We also gratefully acknowledge the assistance of our great team of students: Jen Farman, Michelle Gamber, Abigail Nappier. * Corresponding author. Tel.: þ1 520 626 2099. E-mail address: [email protected] (I.L. Pike). 0277-9536/$ – see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.socscimed.2009.10.007

health consequences of the low-intensity warfare that has become pandemic since the mid-twentieth century (Gray et al., 2003; Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002; McGinn, 2000; Nguyen & Peschard, 2003; Pike, 2004; Pike & Williams, 2006). These scholars highlight the need for more research on violence, inequality, and health, particularly research that makes careful temporal and spatial distinctions, including those between communities that are or are not directly affected by violence, and between types of war-affected communitiesdthose settled in refugee camps versus internally displaced for example. Here, we define interethnic violence at its most simplifieddviolent encounters between individuals selfidentifying as belonging to enemy communities. Analysis located at the boundaries between communities and between the conceptually complex space of individual person and community is precisely the purview of anthropology, and a substantial number of scholars working in East Africa have already contributed to cultural

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anthropological understandings of the causes and consequences of intercommunity conflict in this region (e.g. Abbink, 1994, 1999, 2001; Bollig, 1992, 2006; Bollig & Oesterle, 2007; Broch-Due, 2005; Fleisher, 2000; Gray, 1999; Hutchinson, 1996, 2001; McCabe, 2004; Mirzeler & Young, 2000; Oesterle, 2007; Oesterle & Bollig, 2003; Straight, 2007b, 2009; Turton, 1997). Nevertheless, while these studies have richly contributed to our understanding of the causes and broadly conceived consequences of low-intensity violence, as with research aimed specifically at health and violence, more comparative work is needed, in more precise terms, on the social costs of violence (Bollig & Oesterle, 2007). Here, we present the conceptual framework and preliminary results of our recently initiated project on the socioeconomic and health consequences of violence in northern Kenya. Conceptually, we argue that bodily, emotional, psychological, and social experiences are inseparable from one another in ways that challenge methodological approaches that choose an either-or focus on populations or individual personhood. We address this challenge methodologically by fully integrating standardized quantitative methods that allow us to compare across communities with longitudinal ethnographic data informed by participant-observation, sensitive cross-cultural encounters, and open-ended interviews. Further, we employ the concept of embodiment as a heuristic tool to transcend the limitations of a mind-body dichotomy; emotions and physiology are expressed as a simultaneous experience and as a means to examine the linkages between individual and social experience. Study design and description We have chosen a path to understanding distress and trauma that balances a narrative/ethnographic approach allowing communities and individuals to tell their stories in their own words (Coker, 2004; Zarowsky, 2004) with standardized questionnaires that facilitate our comparisons within the Pokot, Samburu, and Turkana communities and with other communities experiencing low intensity warfare and marginalization. Here we do not distinguish between emotion and bodily experience, as such dichotomies are quite rare in the context of Sub-Saharan Africa (Patel, 1998), and while there is a rich tradition of drawing on illness narratives to understand embodied violence (e.g. Adams, 1998; Coker, 2004; Henry, 2006; Quesada, 1998; Tapias, 2006; Zarowsky, 2004) less attention has been paid to the importance of physiology as an interwoven part of memory (especially trauma) and emotion (see Damasio, 1999; Davis, Quas, & Levine, 2008; Scaer, 2007). For example, hunger associated with loss of animals becomes an important nutritional concern that we can measure but also serves as a powerful idiom of distress in these pastoral communities (Pike & Williams, 2006, also see Hadley & Patil, 2006). This balanced approach creates greater opportunities to record pastoralists’ experiences for the widest possible audiences (Beals, Mason, Mitchell, Spicer, & AIP Research Team, 2003; Kaaya et al., 2002). In this vein, we follow Desjarlais and Kleinman (1997) and assume that anthropology can and must examine the impact of larger forces, including the emotional impact. We believe this approach responds to the pleas of many scholars (e.g. Farmer, 2003; Flyvberg, 2001; Oliver-Smith, 1996) to design studies to reach the widest possible audiences. The longitudinal study design includes six communities, two sites each for Pokot, Samburu, and Turkana. We selected one site that is directly affected by violence and one less affected site for each of the three groups, allowing for paired comparisons of the impacts of violence. The three ethnic groups comprise a relatively small proportion of the Kenyan population, with approximately 220,000 Pokot, 150,000 Samburu, and the Turkana population at about 340,000. The highly affected Pokot site is remote and rarely attacked by neighboring ethnic groups but herdsmen from this area must take

animals to insecure areas where they are subject to attack, leaving women and children behind with very few animals. It should be noted that Samburu, Turkana, and Pokot corroborate one another in citing Pokot as the strongest contemporary aggressors. The site is adjacent to Turkana grazing areas with good access to water but limited access to health care services and basic food supplies. The less affected Pokot site is secure with raids having occurred long ago. However, access to water is restricted to one small dam that is used to water livestock and for human consumption. The highly affected Samburu site has experienced direct raiding by Pokot and has also become a refuge for Samburu fleeing from nearby areas affected by more intense fighting. By official police reports, the area has suffered three major raids in March and April 2009 alone, accounting for major livestock losses and three fatalities. Moreover, in September 2009 a major attack by Pokot on Samburu in an adjacent community resulted in approximately thirty fatalities, spreading perceptions of insecurity widely. The less affected Samburu site is relatively insulated from border areas, with the most recent violence having occurred in the 1960s. The Turkana highly affected site sits at a junction adjacent to important Samburu grazing areas, with Pokot herders in the surrounding areas. Since October 2008, smaller-scale theft of livestock occurs at least twice a month, with one major raid resulting in major livestock losses and the death of two young Turkana men and five men experiencing major injuries. This highly affected site also serves as an important location for internally displaced Turkana who have fled other insecure areas. In addition to widespread violent attacks, livestock losses, fatalities, and injuries, over seventeen schools have closed due to insecurity along the border areas affecting both the Turkana and Samburu communities from which our highly affected samples are drawn. The less affected Turkana site, suffers from tit-for-tat theft of livestock but no major raids have occurred recently. However, more Turkana are moving toward this site as they are displaced from less secure areas. Additionally, this site lies along a road prone to armed attacks by rogue thieves who target vehicles. As such it is less affected but far less secure than is true for the other ethnic communities. Beginning in November 2008, we recruited thirty households at each of these six sites by randomly drawing names out of a bowl at community meetings. We completed the second of four rounds of data collection for each of these communities. The first round of data collection serves as a means to pilot the survey instruments. The survey portion of the project includes a household census, wealth assessments including changes in livestock holdings due to raids, and nutritional/anthropometric and health assessments for all members of the household. In addition, we are administering the Self-Report Questionnaire (SRQ-20) (WHO, 1994) to each person in the household over the age of 15 years. The SRQ is a useful tool for assessing psychosocial health experiences and it can be used effectively by trained lay personnel (Harpham et al., 2003). This instrument has been validated in rural Kenya. In general, pastoral zones report low rates of literacy. Our sample is no exception, with nominal levels of literacy (using completion of primary school as a proxy) for men and exceedingly low levels for women (see Table 1). The highest literacy rates are for the Turkana less affected site (16.4% of men, 10.3% of women) which includes families who have resided in this area for a very long time and have access to schools. Access to even basic health care is a challenge in pastoralist zones (Omar, 1992; Sheik-Mohamed and Velema, 1999). Table 2 contains information on the approximate distances from each of the study sites to basic and more comprehensive health care facilities. The Pokot sites are fairly remote and served by mobile clinics sponsored by a faith-based non-governmental organization. A few of the sites have government sponsored clinics/dispensaries that offer child immunizations, maternal health screening and a few basic medical supplies. Larger, provisional or district hospitals are

I.L. Pike et al. / Social Science & Medicine 70 (2010) 45–52 Table 1 Percentage of participants who have completed primary school. Pokot

Samburu Less affected site

N ¼ 356

N ¼ 260

N ¼ 132

N ¼ 179

N ¼ 322

N ¼ 329

4.7% 1.4%

7.6% 2%

5.2% 2.3%

2.4% 0%

16.4% 10.3%

Men 5.2% Women 0%

Highly affected site

Turkana

Highly affected site

Less affected site

Highly affected site

Less affected site

generally quite far for nomadic families and typically require using public transport, if available. The illness experiences reported across the sites reflect similar challenges of seasonal malaria, access to clean water, hygiene, and the persistent issue of respiratory infections in children. Based on qualitative interviews, while treatment practices vary by illness, pastoralist households generally prefer to start illness treatments with local herbs, with some illnesses treated first at clinics (e.g. injuries, malaria). Local constructs of disease etiology guide treatment and medicinal practices in each of these pastoralist communities. The ethnographic portion of this research includes qualitative interviews with adult members of the households to document concerns, distress, and strategies for contending with the violence. We are compiling a detailed account of any population displacement, and the timing and intensity of violent encounters that occur in the region. Ethical considerations We employ multiple strategies to minimize any distress associated with collecting data on the lived experiences of intercommunity violence. First, our Kenyan research assistants were recruited from these six communities and received extensive training in research ethics and methods. Second, the ethnographic interviews that elicit direct discussions of violence and loss are conducted by the senior team in the local language. Third, considerable evidence indicates that the very act of being asked to tell one’s story, while sometimes difficult, can offer some catharsis (Summerfield & Toser, 1991; Zarowsky, 2004). Illness narratives can offer a ‘‘cultural document’’ that allows painful, subjective experiences to be understood and mediated so that grief can slowly be transformed (Becker, Beyene, & Ken, 2000; Henry, 2006; Scheper-Hughes & Bourgois, 2004). Indeed, this has been our experience in these three ethnic communities, humbling words of thanks after telling stories of great loss and fear. We acknowledge that the telling of a story may not always offer sufficient support for grief and loss; although this has not been necessary to date we plan to facilitate pastoral care with local clergy if necessary. As Njege (2002) laments, this strategy is the only option available to the majority of Kenyans, since only 53

Table 2 Approximate distances to health care facilities for research sites. Pokot

Served by mobile clinics Government clinic / dispensary Government hospital

Samburu

Turkana

Highly Less Highly Less Highly affected affected affected affected affected site site site site site

Less affected site

Yes

Yes

No

No

No

No

50 km

15 km

6 km

11 km

80 km

45 km

20 km

35 km

Available in this location 60 km

Available in this location 90 km

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trained psychiatrists are available in Kenya to treat over 31.5 million people (Ndetei et al., 2007). As an additional policy goal linked to the pleas of Kenyan psychiatrists and more broadly the Lancet Global Mental Health Group (2007) we will make these data available as a summary report to support current initiatives to better fund psychiatric health workers in divisional hospitals. Finally, this project received Human Subjects Institutional Review Board approval from the University of Arizona and Western Michigan University. Small arms, small wars, identity and experience The close of the twentieth century was marked by an increase in the number of wars, and by longer lasting wars, to the point that Gantzel notes that ‘‘war is becoming a ‘normal’ feature of global development’’ (Gantzel, 1997: 126). This fact is, if anything, truer in the first decade of the twenty-first century. At twentieth-century’s end, two-thirds of the world’s wars were internal, or, domestic wars, a type of war that the international community is still struggling to develop the strategies and mechanisms to deal with effectively (Gantzel, 1997). The largest concentration of contemporary violent conflict is in Asia (38% as of 2006) and Africa (41% as of 2006) (The Ploughshares Monitor, 2007); a trend that has negatively influenced popular perceptions, alongside the fact that a preponderance of these conflicts have been in areas identified as pastoralist zones (in Africa for example, this includes the Sahelian region, Horn, and East Africa). Many of Africa’s conflict areas include pastoralist communities, with the Karamoja cluster, the Nuer and Dinka in Sudan, Somalia, and the Touareg rebellion as examples (Nori, Switzer, & Crawford, 2005). The dominant weapons in these conflicts are socalled ‘‘small arms and light weapons’’, especially automatic rifles like the notorius AK-47, all currently trafficked on a global scale (Kamenju, Mwachofi, & Wairagu, 2003; Lumpe, 2000; Mirzeler & Young, 2000; Mkutu, 2007, 2008; Oesterle, 2007). Whether describing conflict in the former Soviet Union or in decolonized Africa, the popular media have tended to foreground ethnicity, typically characterizing internal wars as ‘ethnic conflicts’. While such oversimplified explanations tend to plague media coverage of contemporary violent conflict (Oesterle, in press; Straight, 2007b, 2009), anthropological approaches to violent conflict have deepened in nuance and subtlety over the past decade and a half. While the problem of ethnicity remains in the foreground, it does so with the recognition that ethnicity is a mutable aspect of modernity and a convenient category to be drawn upon strategically in staking claims about identity, belonging, and rights to resources (Broch-Due, 2005; Turton, 1997). Any attention to ‘ethnic conflict’ must be cast within the larger context of national, regional, and global political economies (Bay, 2006; Broch-Due, 2005; Scheper-Hughes, 1996; Simpson, 2006; Whitehead, 2004), or in terms of the ‘‘conscious mobilization of cultural differences in the service of a larger national or transnational politics’’ (Appadurai, 1996: 15). In this context of ethnicity as tactical to interests both transecting and transcending the local, Nancy Scheper-Hughes’ (1996) cautious assertion that the proliferation of ‘small wars’ might be regarded as ‘invisible genocides’ is a propos: Violence has become increasingly ‘routine’ (Broch-Due, 2005), a taken-for-granted feature of a geopolitical structure for which marginalization appears as necessary to the political, economic, and social order (Straight, 2009; see also Bay, 2006). Seen in these terms, there is an urgencydwith both theoretical and policy implicationsdto investigate and describe the ways in which ‘small wars’ and the politics of marginalization mutually produce one another (Straight, 2007c; see also Straight, 2009).

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Our project draws on richly detailed ethnographic accounts that document the inexpressibility of pain and terror and how this in turn becomes a part of every day life. Valentine (1996: 139) remarks that ‘‘pain is highly localized. Its outermost limit is the boundary of the victim’s body. Its inner limit can be as small as a point in one’s foot where a nail is being pounded in’’. Das (2007) suggests violence is only partly speakable, rather it can be enacted through the mundane tasks through which people reshape the ‘‘relationships in everyday life’’ (160). Through embodiment, individuals experience violence in multiple ways. The extraordinary is made ordinary in the work of stitching daily life but the aftershocks of violence linger in major and minor bodily complaints, expressions of hunger and want, vivid dreams, and fears about the health of those one loves. Chronic violence causes disruptions in the social fabric that may come to characterize the everydaydcreating new forms of habitus that may have implications for a violence-begetting-violence cycle (see Mamdani, 2001). Habitus encapsulates memory, forgetting, and routine activities (Straight, 2005). Straight (2007a) draws on the term ‘expansive experience’ to describe the ways in which narrative and embodiment are irreducibly linked as a central way of experiencing the world. With respect to habitus, the varieties of memory and forgetting occur at both individual and collective levels (also see Adams, 1998; Green, 1995). Collectively, these can include culturally structured forms of memorialization and celebration, state-sponsored denials of certain events, or shame-induced public forgetting. Individually, traumatic events may be repressed or conversely, remembered in exaggerated detail (see Henry, 2006; Young, 1997) while events too shameful or unspeakable to narrate publicly or even privately nevertheless manifest themselves in bodily ways. Thus, habitus is a convenient shorthand for activities so routine and understandings so taken for granted that they are performed unconsciously and accepted without question, as with the bodily comportment associated with riding a bicycle, ordin our studydwith carrying an AK-47. Body memory and identity merge in the taken-for-granted practices of daily routine. When violence becomes a part of everyday life, its features are likewise incorporated into conscious and unconscious ways of being, doing, and knowing. As with experience generally, violence is expansively experienceddexperienced through a lifetime of previous experiences that always combine the ‘cognitive’ with the brute physical sensations and associated memories of smell, sound, sight, and emotion. Narration to self or others elicits traces of these embodied memories so that narration itself is enacted through the body. For example, a Pokot woman related that while in the hospital with symptoms that eventuated in pregnancy loss, her husband was killed by a Samburu warrior. In narrating her story, she described herself as broken hearted and hate-filled, emotions that pastoralists in our study identify as originating in the body. Similarly, a Samburu woman describing Pokot attacks against her family described the seemingly cognitive act of worrying this way: ‘‘You get worried completely and sometimes when you remember, your whole body trembles at night, when you remember your people who were killed. And when you wake up your whole body shakes, ‘rir’ trembling, and the heart is beating, ‘tau’, ‘tau’.’’ We argue that the particular marginalization enacted through violence is an outcome measurable in psychosocial and health terms through methods that are sensitive to embodied manifestations of direct and indirect outcomes of inter-ethnic violence. We suggest that the direct and indirect consequences of such violencedfor example, community-wide insecurity, displacement, individual trauma, and loss of access to sufficient food and other necessary resourcesdcan be linked to measurable health and psychosocial outcomes (see Fig. 1). Moreover, the particularities of these measurable outcomes lend a deeper sense of the cultural,

Direct Consequences: Increased Mortality / Fatalities Physical Injuries associated with raids Trauma/ Grief associated with death and loss

Indirect Consequences: Loss of Herds / Livestock Loss of Identity Distress Fears of Impoverishment Distress Hunger / Limited access to food Distress Decreased Nutrition decreased immune function / higher morbidity poorer reproductive health outcomes Displacement or Residing in Remote Areas for Security Shifts in Access to Local Resources Knowledge of local foods (fruits, tubers, berries, etc) Access / rights to water resources Acess to health clinics / mobile clinics Shifts in Social Networks

Fig. 1. A simplified schematic diagram unpacking the direct and indirect consequences of violence on health.

historical, and political contexts in which low-level violence becomes a permanent aspect of the social environment, with great benefits for some and large costs for many others. Because our understanding of the lived experience of violence transcends simple dichotomies between the mind and body we draw on the psychosocial model of health inequalities (Krieger, 2001; Krieger & Davey Smith, 2004) to link emotional and physical health. Advocates of this model suggest that health disparities associated with inequality can be linked to activation of psychsocial stress pathways, after statistical control of income and access to health care (Marmot & Wilkinson, 2001). Stressful life circumstances have well documented effects on psychosocial health and mental health burdens (Araya et al., 2007; Broadhead & Abas, 1998; Patel, 1998; Patel & Kleinman, 2003), with additional links to variation in general health. More than simply imagining violence as triggering stress responses or being exclusively linked to traumatic events, this project traces the importance of stress to threats to identity, one of the most potent stressors (Sapolsky, 2004), through loss of land and livestock. To be without cattle, as Blystad (1999) suggests of the Datoga of Tanzania, is ‘‘to be a person without anything.’’ and ‘‘.the suffering linked to being people without anything is the focus of daily conversation.’’ (73). These discussions of life without animals, destitution, and loss of identity emerge across the conflict zones of Northern Kenya. As stated by one Pokot herdsman ‘‘wealth (in animals) is life and poverty is like death’’. Losing one’s animals is the same as becoming extinct, with a corresponding loss of personhood and identity (Broch-Due, 1999). Indeed, all three communities cite loss of livestock as a known cause of men’s suicides. The fears associated with raids become a major concern for pastoralists, with considerable social, psychosocial, and biological consequences for individuals and households. As one Turkana woman describes after experiencing the third attack on her livestock: ‘‘.[W]hen I was taking my animals for water. bandits, believed to be Pokot, attacked us again and took all of our goats. Again, I managed to escape. But when I was running I fell into a thorn tree and hurt my arm. When I saw the blood from my hand and arm I thought I might have been shot. I cried as I was running and asked myself ‘am I dead? Are my children now alone?’ When I reached home, I became sick. from that day I have struggled with a heart that always races.’’

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Even if the violence is not experienced directly at the site of the body (e.g. wounded, tortured, mutilated, killed) we expect that both the immediate socioeconomic results of violence and the constant fear of violence will be embodied as both emotional and physical symptoms. As such, psychosocial stress pathways integrate perceptions and experiences of one’s social environment to biology in potentially powerful ways, suggesting this approach is a critical tool for understanding the embodiment of violence (Marmot & Wilkinson, 2001; Pike & Williams, 2006). Context of endemic warfare in Kenya Popular conceptions of chronic, low-intensity warfare in northern Kenya as portrayed in media and public discourses, follow the familiar global pattern of characterizing such conflict as ethnically driven and resource motivated. Although scholarly approaches to these conflicts have deepened our understandings, Pottier (2002) has used the case of Rwanda to demonstrate that when asked for concise, publicly accessible expert opinions, ‘tribal conflict’ summarizes scholarly discourses as well. This is at least partly due to the fact that ethnicity does play a significant role in conflict in East Africa; yet as a ‘‘talking point,’’ ethnicity obscures as much as it reveals, creating a black box that encompasses within the same causal field, enormously divergent violent events such as Rwanda, the 2008 post-election crisis in Kenya, and the ongoing low-intensity violence that plagues the entire northern part of Kenya that is the focus of our research. Unpacking the adjoining presumptive causal categories of ‘ethnicity’ and ‘resource competition’ is essential to the goal of dispelling popular myths but more practically, it is critical to the task at hand of identifying with rigor and precision the ways in which the human costs of chronic, low-intensity conflicts are embedded in self-perpetuating cycles of violence. As such, we incorporate into a single project, three communities in direct conflict with one another. These three communities, occupying contiguous and overlapping areas of northern Kenya, ethnically selfidentify as Samburu, Pokot, and Turkana livestock herders. Indigenous northern Kenyan herders occupy dwindling grazing lands that are best suited for livestock production but subject to periodic drought. Drought, disease, and other natural challenges exacerbate and act as convenient scapegoats for politically created land-based resource scarcity. Moreover, these herders suffer from a legacy of colonial, as well as post-colonial, discourses that portray them as backward and warlike, contributing to easy popular and elite dismissal of northern conflicts as ‘timelessly tribal’. Yet the fact that during the weeks of finalizing this submission, one Turkana community defended their Samburu neighbors against hostilities from another more distant Turkana group, thus privileging an interethnic Turkana-Samburu alliance over inter-ethnic solidarity, belies such facile ethnic explanations. In this respect, local belonging and protecting local resources in the face of chronic scarcity may take precedence over ethnic affiliation. It is also critically relevant that Kenya’s northern regions are underdeveloped at the national level, affording northern herding groups the worst schools, roads, health services, and overall infrastructure. Thus, contemporary pastoralist conflict entangles local and regional economies in a series of overlapping alliances, locale-based identities, and political goals that cross all of these divisions (Oesterle, 2007). This hybrid arena is consistent with so-called endemic warfare in other regions globally, making this particular ‘‘small war’’ of larger relevance than such remote locations might imply. The social production of health among pastoralists Here, we offer a review regarding how livestock production and social organization interact to create health differences within and

49

across communities. We draw on previous results to highlight the importance of access to herds for community health and nutrition but also to point out new areas of concern in the face of the social responses to endemic warfare that the current project aims to address. Decades of social science and rangeland ecology research indicates that livestock production offers the only viable livelihood in the marginal physical environments occupied by pastoralists throughout East Africa (Ellis & Swift, 1988; Fratkin, 1991; Homewood & Rogers, 1987; McCabe, 1990). Highly seasonal patterns of rainfall combined with frequent multi-year droughts limit agricultural production to irrigation schemes along the banks of ephemeral streams, but even these schemes fail on a regular basis. The pastoral strategy includes multiple species herds (cattle, camels, donkeys, goats, and sheep) that capture as much of the limited environmental resources as possible. Herding requirements thus vary by species and season. While each pastoral group organizes the labor required for livestock production in different ways, all households in the pastoral zones of Northern Kenya experience seasonal shifts in diet and workloads, and thus in nutritional status (Curran & Galvin, 1999; Galvin & Little, 1999; Straight, 1997 on seasonal shifts in Samburu workload). Access to milk from livestock is an important determinant of pastoralist nutrition and overall health. Noteworthy differences in higher rates of child malnutrition have been documented in settled pastoral groups with few or no animals compared to nomadic households with larger herds (Nathan, Fratkin, & Roth,1996). Despite highly variable herding strategies and social organization across pastoralist groups, as a general trend women and smaller children have greater access to milk and men have greater access to meat and blood (Nathan et al., 1996). When this pattern varies there are clear consequences. For example, among Karimojong pastoralists in Uganda, the nutritional status of men is significantly better than women’s and children’s because men move with the animals for security reasons (Gray et al., 2003; Holtzman, 2006). As a result, infant mortality and under-five mortality are higher among Karimojong when compared to neighboring Turkana herders (measured prior to the recent escalation in violence) (Gray et al., 2003). This finding held true despite better access to health facilities and mobile clinics in Karimojong communities compared to Turkana. As additional evidence of the social production of health, ‘‘gendered expressions of biology’’ (Krieger, 2005) in pastoral communities can be directly linked to gender roles and the importance of women’s ‘‘local moral worlds’’ (Inhorn, 2006) and moral authority. Women’s roles in livestock production vary across pastoral communities but in general women’s workloads are quite demanding (Curran & Galvin, 1999), with a documented decrease of six percent body fat in Turkana women occurring over the course of the dry season (Galvin & Little, 1999). The cultural value placed on children and the corresponding social status afforded to women who are good mothers translates into intense and demanding reproductive experiences for pastoral women, with an average completed family size of approximately seven children (East Pokot Medical Project, 2008; Leslie, Campbell, Campbell, Kigondu, & Kirumbi, 1999). Women experience age- and reproduction- related decreases in fat stores, also known as maternal depletion syndrome (Little, Leslie, & Campbell, 1992). While far less is known about maternal mortality one study suggests that the risk of dying in childbirth is one in thirty for Gabbra pastoralists (Mace & Sear, 1996), although maternal mortality appears to be rarer among Turkana women (Pike, 1996). Nutritional buffering of children’s diet associated with chronic food shortages has been documented in an age-related pattern of moral responsibility (Galvin, 1985; Gray, 1996; Pike, 1999); older women buffer younger mothers and all women forego food when children are hungry. Given pastoral women’s biosocial experiences,

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women serve as important barometers of community well-being (Inhorn, 2006), with strong evidence that they bare the brunt of the indirect consequences of violence (Krug et al., 2002; Plumper & Neumayer, 2006). Children generally serve as sensitive barometers of the quality of the social and physical environment. Overall patterns of growth among pastoralist children are prolonged and slow compared to international reference standards (Little, 1989; Little, Gray, & Leslie, 1993). Little (1989) suggests this pattern of growth is linked to the pastoralist diet which is high in protein and low in carbohydrates, allowing the attainment of full growth potential but at a slower pace. Few studies directly address population specific patterns of infant and child mortality, although Hill (1985) suggests that rates are generally high in pastoralist communities, with measles, diarrhea, malaria, and acute respiratory infections as the primary causes of morbidity and mortality (Shell-Duncan, Shelley, & Leslie, 1999). Yet there is mixed evidence that child morbidity and mortality are aggravated further by endemic warfare. In a cross-sectional study, Gray et al. (2003) found significantly higher reports of prolonged child morbidity among Karimojong, a pastoralist group with a long history of armed raiding, despite greater than 50% immunization coverage and close access to health facilities. In contrast, mortality rates documented by mobile clinics in East Pokot district suggest infant and child mortality rates that are considerably lower than among the Karimojong (East Pokot Medical Project, 2008). Social responses to violence in pastoral communities can also be linked to shifts in health. Displacement and corresponding changes in mobility configure access to food, health care facilities, and work loads as well (Gray et al., 2003; Pike, 2004), serving as important sources of stress for households (see Pike, 2004). The Pokot, Turkana, and Samburu are employing different security strategies that we presume have different health consequences. For example, Turkana herders have chosen security measures that keep all of the animals and family members together in very large herding units, with frequent moves (see McCabe, 2004). While all members of the household have access to livestock products, the higher mobility and an inability to purchase even small amounts of maize meal at trading centers led to a decline in overall nutrition status (Pike, 2004), but the degree to which this is true now and in the Pokot and Samburu remains undocumented. In one of our Pokot field sites, households reside in very remote locations, which function as security watchtowers, placing even heavier demands on household production, especially for women. In this field site, livestock come and go depending upon security. Samburu communities in contrast, engage in different strategies in lowland versus highland areas but strategies in both areas frequently separate men and herds from the homestead, and Samburu women express great concern over the reduced access to high quality food this represents. Such data emphasize the need for systematic comparisons of responses to endemic warfare. While each community discusses the distress and fear associated with this violence, almost no data document the psychosocial health consequences of the violence, a gap in knowledge our project aims to address. Any shift in access to livestock production in these low productivity eco-zones results in direct nutritional and health consequences. Untangling the interactions of shifts in dietary quality, access to trading centers for additional food, and proximity to mobile clinics and health facilities is an important objective for the project. Concluding discussion Linking violence with health offers tools for documenting experiences while also creating opportunities for advocacy (Broch-Due, 2005; Farmer, 2003). From the public health perspective, violence is always associated with a considerable cost to health care systems,

particularly in poorer countries with low health care investment and those stressed by high burdens of infectious disease. For those fortunate enough to survive violent encounters, treatment, when available, pulls scarce resources away from struggling families (Valenti, Ormhaug, Mtonga, & Loretz, 2007). For example, a recent study of gunshot wounds in Nairobi hospitals revealed an average cost of USD $6000. No data exist to document the number or expense of gunshot wounds for the northern pastoral zone of Kenya (but see Mkutu, 2007 for Karamoja, Uganda) yet a recent survey suggests 90– 95% of households own weapons (Hugenberg, Odhiambo Anjango, Mwita, & Opondo, 2007). Such statistics suggest a critical need for gunshot wound data that allows the public health and human rights sector to develop effective strategies to meet such medical challenges (Marsh, 2007; Valenti et al., 2007; WHO, 2001). This project starts from the assumption that poverty alone creates suffering but that poverty combined with limited state integration/marginalization and endemic warfare create new groups of vulnerable pastoralists. It is our sincere hope our project will offer much needed data on the emotional and economic burden of endemic warfare in the northern pastoral zones. Studies that directly link increased armed conflict and shifts in health experiences are exceedingly rare. Such research has important implications across Sub-Saharan Africa and the globe with dramatic increases in violence related displacement of populations (UNHCR, 2007). Our project aims to contribute to the understanding of violence and health by using a framework that blends history, inequality, and context to tests of the direct and indirect health consequences of violence. While we acknowledge that the ethnographic experiences this research team draws on to design this project is neither practical nor feasible in some circumstances we do consider this a fortuitous strength of the current project. As such, we offer our framework as an example of our quest for what Fineberg and Wilson (1996) call the ‘‘holy grail’’ of epidemiologylinking historical context and ethnography to biological variation (also cited in Farmer, 1999), and our efforts to understand how health is socially produced in the face of endemic warfare. Appendix. Supplementary material Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.socscimed.2009.10.007 References Abbink, J. (1994). Changing patterns of ‘‘ethnic’’ violence: peasant–pastoralist confrontation in southern Ethiopia and its implications for a theory of violence. Sociologus, 44(1), 66–78. Abbink, J. (1999). Violence, ritual, and reproduction: culture and context in Surma dueling. Ethnology, 38(3), 227–242. Abbink, J. (2001). Violence and culture: anthropological and evolutionary-psychological reflections on inter-group conflict in southern Ethiopia. In B. Schmidt, & I. Schroder (Eds.), Anthropology of violence and conflict (pp. 123–142). New York: Routledge. Adams, V. (1998). Suffering the winds of Lhasa: politicized bodies, human rights, cultural difference, and humanism in Tibet. Medical Anthropology Quarterly, 12(1), 74–102. Appadurai, A. (1996). Modernity at large: Cultural dimensions of globalization. Minneapolis: University of Minnesota Press. Araya, M., Jayanti, A., Chotai, A., Ivan, H., Komproe, A., & de Jong, J. (2007). Effect of trauma on quality of life as mediated by mental distress and moderated by coping and social support among postconflict displaced Ethiopians. Quality of Life Research, 16, 915–927. Bay, E. (2006). Introduction. In E. Bay, & D. Donham (Eds.), States of violence: Politics, youth and memory in contemporary Africa (pp. 1–15). Charlottesville: University of Virginia Press. Beals, J., Manson, S., Mitchell, C., Spicer, P., & , AIP-Research Team. (2003). Cultural specificity and comparison in psychiatric epidemiology: walking the tightrope in American Indian Research. Culture Medicine and Psychiatry, 27(3), 259–279. Becker, G., Yewoubdar, B., & Ken, P. (2000). Memory, trauma, and embodied distress: the management of disruption in a Cambodian refugee’s story. Ethos, 28(3), 320–345.

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