Table of contents thesis:
Acknowledgements pp. 3-4
Introduction thesis pp. 5-7
Chapter 1: Theoretical frameworks for study pp. 8-17
1.1 Introduction
1.2 Gap in the literature
1.3 Development anthropology/Anthropology of development 1.4 Ethnomedicine
1.5 The social justice model
1.6 Traditional versus modern healthcare
Chapter 2: Methodology pp. 18-26
2.1 Introduction
2.2 The Dutch dental Care Foundation 2.3 Methodology
2.4 Encountered obstacles & reflection 2.5 Ethical considerations
Chapter 3: Research setting pp. 27-36
3.1 Introduction
3.2 Geographical, demographic and socio-economic setting in Kwale 3.3 Dentistry in Kwale
Chapter 4: Ethnographic data pp. 37-61
4.1 Introduction 4.2 Dental hygiene:
4.2A Dental hygiene practices 4.2B Dental problems
4.2C Dental healthcare seeking 4.3 Diet
4.4 Traditional beliefs and practices regarding the teeth 4.5 Religion
4.6 Aesthetics of teeth
Chapter 5: Discussion pp. 62-67
5.1 Introduction 5.2 Discussion
Conclusion with recommendations to DDC pp. 68-70
Annexes pp. 71-82
A. List of abbreviations B. List of operationalization C. Bibliography
Acknowledgements:
This thesis could not have been written without the support, the dedication, the patience of and the enthusiasm of certain people. I therefore want to thank the following people.
Dear mum and dad thank you so much for always being there for me throughout my anthropology studies. Without your support I would not have made it. You are the best parents in the world.
I want to thank my supervisor Janneke Verheijen too. I am immensely grateful for your useful feedback throughout the writing process of my thesis. I admire you as an
anthropologist and as a person. I was honoured to have such an intelligent, precise and patient mentor during the last half year. Your insights into the discipline learned me a lot.
Furthermore I want to thank Stuart Blume, who agreed to be my second reader. I chose you because you are an inspiring anthropologist and teacher. You were enthusiastic about my research idea of combining oral health with anthropology from the start and that encouraged me to continue with this study. Thank you for your time and useful suggestions in the beginning of the year.
Of course I am very grateful to DDC, who allowed me to do research about their dental project in Kwale, Kenya. Without your socially engaged organisation this study would not have been possible. You do wonderful things in Kenya. I have seen with my own eyes that your project has a large impact on the lives of children. I want mention some people in particular.
First of all Annelies Kraaijenhagen, thank you for believing in my research from the start and sending me encouraging e-mails throughout the writing process. You are a socially concerned dentist with an interest in academics; a true inspiration.
Secondly I want to thank Annelies Donk-Brian for allowing me to travel with you to Kenya to do the preparations for the project, before the rest of the group started. It gave me a good idea of what happens behind the scene and how much organisation and planning is involved on your side.
Thirdly I want to thank Marjon Santema for giving me the freedom to do my own research when you and the others were working immensely hard in the clinic. However, at night you made me feel I was part of the group. You are a socially concerned dentist too. Furthermore you are the model on the cover of my thesis, which is a beautiful and moving picture.
Finally I want to thank all the other volunteers of DDC for making my time in Kenya memorable. You are all people with your hearts in the right place.
Furthermore special thank goes out to the COHOs Godwin Kipyegon Winston and Simon Kamau. You are the link between DDC and the community and you have provided me with useful insights into the local culture. You are bright men, just what Kenya needs. After DDC had gone I could still e-mail you to ask questions and you always responded very quickly.
Ingeborg Slikker, who was also a volunteer for DDC, made the beautiful picture on the cover. Thank you so much for letting me use it. Furthermore you made a very nice photo book to remember my research period. Keep on photographing, you are truly talented.
My long-time friend Jip Canneman designed the layout and the typography of the cover. It turned out exquisite, which I knew up front because you are the best designer of The Netherlands. Thank you so much for your time and creative vision.
Furthermore I am grateful to my friend Machteld Thoomes-Dooijeweerd, who offered to read my thesis while on a well-deserved holiday. You are a skilful dental hygienist. Thank you so much for offering your expertise to see if my writings were also understandable from a dental point of view.
I also want to thank English teacher and friend of the family Marie-Louise Grooten for spending a weekend with me correcting my writings. It was a challenge for me to write this thesis in English. With your time, help and expertise it turned out well.
And last buy not least I want to thank all the wonderful schoolchildren and teachers of Kwale that shared personal information with me during this research. The children made me feel welcome and special by singing and dancing for me in the classes. The teachers were enthusiastic and helped me any way they could.
Introduction:
On 25 February 2014 an 11-year-old boy came to the mobile clinic of Dutch Dental Care Foundation (DDC), which was set up in a classroom of a primary school on the road from Ukunda to Mombasa in the Kwale district in Kenya. He smiled at me and his teeth, or what was left of it, were completely rotten. All his (newly erupted) permanent teeth were decayed. The dentist volunteering for DDC determined he had to undergo a complete extraction of his teeth. The dentist, however, decided not to do this extraction, because then the boy would have needed dentures otherwise he could not eat or speak properly anymore because his jaw would shrink within substantial time. First of all dentures are unusual for an 11-year-old child, secondly there was no dental technician on the team and moreover there was just no time to start this special procedure. As he was not in pain, the dentist sent him home without any treatment.
In Kenya there are few dentists, especially in the rural areas such as the Kwale district in the Coastal South. Dental health is found to be poor in Kwale, with a large number of children experiencing toothache and subsequently not going to school (Eijkman and
Kraaijenhagen 2011: 2). The example mentioned above shows how severe the situation can be. In 2008 two Dutch dentists therefore felt something should be done and they founded the Dutch Dental Care Foundation (DDC), a small private development initiative.
DDC goes to the Kwale district in Kenya twice a year three successive groups of about 20 volunteers consisting of a dental surgeon, dentists, dental assistants en dental hygienists. Each year DDC holds dental outreach camps on four to six primary schools, a school for the deaf and a school for physically handicapped children. DDC’s goal is to improve oral health of the schoolchildren in Kwale.
I am both a medical anthropology student and a dental hygienist. Five years ago I volunteered for DDC. It was this experience of working in Kenya that made me decide to study medical anthropology. By returning to Kenya with DDC again this year, the circle is now complete.
What is meant by oral health? Oral health concerns the health of the mouth, more precisely the teeth and gums. ‘Good oral health’ stands for a healthy mouth, which is free of gum diseases and tooth decay. From a biomedical perspective a healthy mouth is obtained through sufficient oral hygiene, by brushing and flossing which reduces bacteria to prevent tooth decay and gum disease.
DDC assumes that socio-economic determinants, such as low income, prevent parents from buying toothbrushes and toothpaste for their children and from visiting the dental clinic.
According to Eijkman and Kraaijenhagen the price of a toothbrush and toothpaste seems too high for the parents and equals a day’s income (2011:1-2). They have furthermore found evidence that the cost of a dental filling is equivalent to a weekly income (ibid.: 2). The accessibility to dental care in Kwale seems therefore poor.
So DDC expects that offering free dental care, biomedical oral hygiene education and handing out toothbrushes and toothpaste will improve children’s oral health. However, I wondered whether cultural factors might influence children’s oral health too. This led me to the following research question: ‘What are the cultural and socio-economic factors that influence the oral health of the children in the Kwale district targeted by DDC?’
A theoretical paradigm that inspired me to conduct this research is the liberation theology of the renowned anthropologist and medical doctor Paul Farmer. Article 25 of the Declaration of Human Rights states: ‘Everyone has the right to a standard of living adequate for the health and the well-being of himself and his family, including…medical care and necessary social services….’ (Farmer 2002: 655). Farmer sees health as a fundamental human right (Farmer 2003: 152). Therefore, in my opinion, access to high quality dental care is a human right too. By their project DDC tries to improve the well-being of a vulnerable group of children and their parents and I admire that initiative. Farmer rightfully warns academics for ‘Ivory-tower engagement with health and human rights….’ (2002: 658). He argues it is vital to be careful not to become ‘seminar-room warriors’ that only discuss and analyze human-rights abuses, but never take any action (ibid.: 658). He pleads for ‘operational research’, which means research linked to health care services (ibid.: 663). This is exactly what I have done, viz. a combination of research and providing free preventive dental care to the Kenyan community.
An answer my research question is important for the dental profession, because through my anthropological insights DDC will get a better understanding of the Kwale culture. Taking in consideration cultural factors can lead to a more effective approach. In my opinion DDC does not yet have enough understanding regarding the local beliefs and
practices regarding the teeth that shape the oral health of children from Kwale. In this
research I looked at how teeth are valued in Kwale. I investigated both the cultural aspects as well as the socio-economic factors shaping oral health of the children targeted by this
programme. I am interested in conveying these insights to DDC so they can improve their preventive dental health programme, by adjusting it to the local ideas and circumstances.
My research question is relevant to medical anthropology too, because little research has been done on cultural approach to oral health. Since oral health is an important part of
general health and there is a gap in the literature on this topic, my research may be a good start in this particular niche. I my ‘operational research’ found place in the Kwale County, in and around Ukunda and Kwale town, in February and March 2014. Unique about this
research is the access I had to the field through participating in this project. Moreover being a dental hygienist gives me original point of view on this matter. Together with an
anthropological point of view this could lead to interesting insights.
The table of contents of my thesis is as follows. The first chapter will be about the theoretical frameworks that were used as a foundation for this study. As a result of my findings I came across a much new literature, which I incorporated in chapter two, three and four. Chapter two contains an explanation of the project of DDC. Furthermore I will go more deeply into the methodology, it contains a personal reflection and the ethical considerations. Chapter tree describes the research setting and in particular the socio-economic, geographical and demographic situation and dentistry in Kwale. In chapter four I will present the empirical data I collected about the dental hygiene practices, dental problems and dental healthcare seeking, the diet, the traditional ideas and practices regarding the teeth, the influence of religion on oral health and the ideas about aesthetics regarding the teeth in Kwale. Chapter five deals with the discussion of my research results versus the literature. I will end with a conclusion with recommendations for DDC. The annexes consist of a list of abbreviations, a list of operationalization and the bibliography.
Chapter 1: Theoretical frameworks for research 1.1 Introduction:
In this chapter I will present the theoretical frameworks that were used as the foundation of this research. First I will discuss the gap in the literature regarding oral health in medical anthropology and sociology. Afterwards I will elaborate upon development
anthropology/anthropology of development, which was used as a reflective tool during my study. Then I will discuss ethnomedicine and which questions for operationalization that I derived from that theory. Furthermore I will discuss the theory of liberation theology and the questions for operationalization that were based on this theoretical paradigm. Finally I will discuss the theory about traditional versus modern healthcare seeking, which is at the core of my research.
1.2 Gap in the literature:
Because oral health has a large impact on general health1 the WHO rightfully argues that oral health care should be integrated into primary health care (Petersen 2008: 115). In global health there is a lot to gain from improving oral health. The WHO has made an action plan for the promotion of oral health and integrated disease prevention based on common risk factors approaches (ibid.: 115) It is essential that oral health measures should not be isolated
activities, but should be integrated into global health programs (ibid.: 115).
However, oral health is a neglected topic in global health policies, according to the renowned oral surgeon Benzian (2011: 124). Oral health is not high on the global political priority agenda because of a complex set of issues deeply rooted in the global oral health sector: the stakeholders’ conflicting interests, the lack of coherence in the overall strategy, the lack of agreement by the stakeholders and the portrayal of the problem of oral health and its possible solutions (ibid.: 124). Benzian organized the first conference on oral health in Africa in 2004 for ministers of health and finance. According to Benzian: ‘The conference ended with the ground-breaking Nairobi Declaration confirming for the first time that good oral health is part of the basic human rights’ (2014: 202).
It seems that oral health is neglected in medical anthropology too. There is little anthropological theory about how culture can shape oral health. However, how people treat
1 Research has shown that there is a negative synergy between Periodontitis (a chronic gum-disease caused by poor oral health) and chronic diseases such as diabetes, cardiovascular diseases, oral cancer and other diseases such as premature birth in women. Oral disease has the same risk factors as some other chronic diseases (related to life-style): dietary habits, use of tobacco, excessive consumption of alcohol and the standard of hygiene (Petersen 2008: 115).
their mouth is highly cultural. Body modifications and mutilations such as dental
modifications, perforation of the lower lip and piercing of the tongue are often performed as rituals or used for folk medicine. In different parts of Africa dental modifications have taken the form of removal of one or more incisors (for example during initiation rites of the Masai in Eastern Africa) or sharpening or chipping of the teeth. ‘Perforation of the lower lip…for insertion of a decorative plug…was once widespread amongst Africans’(in ethnic groups such as the Mursi and Sara and beyond). 2 Such modifications often mark the social position of an individual.3
Medical sociologist Catherine Exley has written a literature review about the (lack of a) sociology in oral health and healthcare. She quotes social scientist Ross, who argued in 1965: ‘when one focuses on dentistry, it is quite obvious that there is little contact with the social sciences, few, if any, studies in the field of sociological dentistry are reported’ (Exley 2009: 1093). Ross furthermore stated:
‘For many reasons, I would suggest that the dental profession should look to the social sciences for help. The social sciences will not solve all – or perhaps very many – of the problems dentists confront. But they will help in many specific situations, and, in any case, familiarity with the social sciences will bring an understanding of society and individual behavior that cannot be acquired otherwise’ (1965: 1111 in Exley 2009: 1093).
It seems as if not much has changed over the past 40 years. Graham argues in 2006: ‘sociology has shown relatively little interest in exploring the mouth, or engaging in dentistry itself: a sociology of the mouth remains absent’ (2006: 53 in Exley 2009: 1093). The mouth and the teeth are however important in physical appearance and social interactions. Exley argues ‘the position of the mouth in the centre of the face makes it - in many cultures – highly visible, and as such is important to the outward appearance, to which others respond and react to us’ (Exley 2009: 1094).
2 Parwani, N., 2014, body modifications and mutilations—Encyclopedia Britannica,
http://www.britannica.com/EBchecked/topic/71151/body-modifications-and-mutilations (04-02-14) 3 Parwani, N., 2014, body modifications and mutilations—Encyclopedia Britannica,
http://www.britannica.com/EBchecked/topic/71151/body-modifications-and-mutilations (04-02-14)
She states that there are inequalities in oral health and healthcare. Research suggests inequalities in oral health are present throughout the life course, but that poor pre-school children have the most decayed primary teeth (Hinds and Gregory 1995 in Exley 2009: 1095). In adulthood, the highest percentage of edentate people is found in adults of low
socio-economic groups (Kelly et al. 2000 in Exley 2009: 1095). Furthermore there seem to be regional inequalities. Locker et al. found poorer oral health experiences in rural areas compared to urban areas in Ontario (1991 in Exley 2009: 1095). Thomson et al. argue that various studies in dental scientific literature also provide evidence that groups with a lower socio-economic status have poorer oral health than groups with a higher socio-economic status (2004: 346). In 1976 therefore Cohen and Jago already called for the development of ‘sociodental indicators’ in oral health. They argued one should look beyond clinical factors and consider individual, socioeconomic, cultural and lifestyle influences an oral health (1976 in Exley 2009: 1099). Although some interesting articles have been written about the field of sociology and oral health, Exley argues there is still a gap in the literature.
In the past teeth have been studied by anthropologists as a part of physical
anthropology, because they possess qualities valuable for anthropological archaeology study (such as durability, genetically determined traits and give information about health,
behaviour, ecology and diet). The term “dental anthropology” first appeared in 1900 (Scott & Turner 1998: 99, 119). Nowadays this field has fallen into oblivion.
Likewise in the science of dentistry, ‘social dentistry’ is not officially recognized as a specialization and does not have the same research tradition as social medicine. Some say that ‘social dentistry’ must be considered as a broad field and should be called ‘dental public health’ (Den Dekker 2004: 23). Dental public health must look at concepts of oral health, socio-economic determinants of oral health, market forces in dental health care, inequality in oral health and quality of dental care, according to Den Dekker (ibid.: 23).
‘An anthropology of the mouth and oral health’ remains absent too. This means oral health and the rituals teeth are a relevant field of study for me as an anthropology student with a background in dental hygiene. There are some other useful theories that I used as a
framework for this research, which I will discuss now.
1.3 Development anthropology/anthropology of development:
There is a large amount of anthropological literature about development aid. According to Gow the anthropological study of development has blossomed over the 20th century and it is a reflection of anthropologists’ increasing involvement in development projects, whether as
researchers, consultants, or practitioners (1996: 165). There are two different currents in this type of anthropological study: ‘the anthropology of development’ and ‘development
anthropology’ (1996: 165).
Escobar argues that development anthropology favours active involvement with development institutions on behalf of the poor, hoping to transform development from within (1997: 498). This is, in other words, an applied practice. Gow argues that much of the
literature consists of studies about specific types of development activities written by anthropologists who were actively engaged in the projects and could provide it with recognition in the academia (1996: 165).
However, there are shortcomings: Firstly Nielsen (1990) argues that development anthropology tends to have ‘a simple-minded faith in the neutrality of language, particularly in its written form’ (Gow 1996: 165). Secondly development anthropology often ignores ‘the relationship between language and power’ (ibid.:165) Nielsen argues ‘it has accepted at face value the “scientific” basis of development discourse and development research’(Gow 1996: 165).
On the contrary, in the anthropology of development development itself is the object of study. According Escobar it is ‘a radical critique of the development establishment’ (1997: 498). It gives ‘reflective awareness of the relational context of thought and action’ of
international development, according to Eyben (2006 in Mosse 2013: 240). Western
specialists have expertise based on scientific, evidence- and experienced-based knowledge. Gow argues: In development discourse this is always opposed by local knowledge: ‘a body of ideas and practices which can be adapted to changing circumstances’, thus a more practical form of knowledge (1996: 170). Hobart discusses the problematic relationship between “expert” knowledge and local knowledge.
‘As systematic knowledge increases, so does the possibility of ignorance. This is a condition which people attribute to others, one laden with moral judgement, since ignorance implies some conscious effort to remain in the dark, unenlightened’, according to Hobart (1993 in Gow 1996: 170).
Gow states that the development anthropologist can be a mediator between “expert” knowledge and local knowledge, but often prefers ‘….“development from the outside” over “development from within”’ (Gow 1996: 166). Because “development from within” may raise awkward questions about the need and justification for a development project’ (ibid.: 166).
Ferguson rightfully argues there is an ambiguity between anthropology and development. He states that development is anthropology’s ‘evil twin’, they are alike and intertwined but at the same time have an uneasy relationship. According to Ferguson: ‘….the field that fetishizes the local, the autonomous, the traditional, locked in a strange, agonistic dance with the field that, through the magic of development, would destroy locality, autonomy, and tradition in the name of becoming modern’ (2005: 150).
Since this research was conducted under the wings of a dental development organisation, this framework was useful as a reflexive tool. It provides a critical view on development projects on oral health and the assumptions that underlie. Campbell argues that ‘Biomedicine…has a very narrow scope in which to view the phenomenon of illness or epidemic. Everything is expected to have an explanation grounded in biology or ‘science’’ (2011: 4). This also goes for Western dentistry. The DDC-team, which I was a part of, has expertise based on scientific knowledge. Anthropology of development critically investigates these dilemmas of power and knowledge (Eyben 2006 in Mosse 2013: 240). Because
anthropology may utilize a more holistic approach than dentistry to identify all factors that contribute to oral health problems, this research is valuable. Moreover, anthropology concentrates on ‘the root’ of where things come from (Porter in Campbell 2011: 3). 1.4 Ethnomedicine:
An anthropological study of cultural and socio-economic factors that shape oral health would be helped by an ethnomedical approach. ‘The Etnomedical perspective focuses on health beliefs and practices, cultural values and social roles ….’, according to McElroy (in Levinson and Ember 2002 [1996]: 4). ‘All societies have medical systems that provide a theory of disease etiology, methods for the diagnosis of illness, and prescription and practice of curative therapies’, according to Barfield (1997: 316). In contemporary societies where more medical systems co-exist we talk of medical pluralism. McElroy argues:
‘A key concept in ethnomedicine is the “explanatory model” introduced by Arthur Kleinman (1980). Explanatory models (EMs) are notions about the causes of illness, diagnostic criteria, and treatment options. In a clinical encounter, the EMs held by practitioners, patients and family often differ. The ensuing communication and negotiation of decisions for managing illness lead to the cultural “construction” of illness. To the extent that disparity among EMs continues because of cultural, ethnic, or class differences, communication remains problematic’ (ibid.: 5).
Kleinman divides the health care system into three social arenas: the popular arena, the professional arena and the folk arena. The popular arena consists of the family, the social network and the community. The professional arena consists of scientific (Western) biomedicine, but also professionalized traditional medicine (such as Chinese/Aryuvedic medicine). The folk arena are non-professional traditional (sacred) healing specialists (such as medicine men) (1978: 86-87). These three arenas all have different EMs, which can lead to conflicts and non-compliance, even though all see the importance of health (ibid.: 88).
It is difficult for people from different social arenas to enter into another way of thinking. There is a hierarchy of knowledge and professional values associated with biomedicine. This leads to hostility from biomedical practitioners towards alternative modalities, according to Nissen and Manderson (2013: 4).
However, lately more medical practitioners incorporate alternative approaches in their biomedical repertoire. There has been a move away from biomedical dominance towards a more integrated and holistic medicine (Karchmer 2010; Lang and Jansen, this issue in Nissen and Manderson 2013: 2). In 1978 the WHO already emphasized the importance of integrating traditional medicine into national health systems and particularly in primary care back in 1978. The WHO also called attention to the need to preserve local knowledge and resources by protecting indigenous intellectual property and the sustainable production of medicinal plants (WHO 1978 in Nissen and Manderson 2013: 3).
Nissen and Manderson argue that despite anthropological research into medical pluralism and its critique of biomedicalization, scientists have paid too little attention to the diverse practices of non-biomedical therapies in different settings (ibid.: 3).
There are exceptions. Kemoli et al. argue that although considered a primitive means of maintaining oral hygiene by the biomedical and dental science, in development countries the use of chewing sticks (Miswaki) is still a common practice and a means of controlling dental plaque (2001: 183). ‘The chewing sticks have been widely used in the Indian subcontinent, the Middle East, and Africa since ancient times’, according to Prashant et al. (2007: 148). The traditional chewing stick can be a good alternative to the toothbrush as it is easily available in rural areas, suitable for cleaning the teeth, costs nothing and possesses various medicinal properties (ibid.: 148).
Some studies have found proof of the positive antimicrobial effects of some of these chewing sticks on plaque reduction, dental caries and periodontal disease (Kemoli et al. 2001:
183). Inhibitory actions of some chewing sticks on the growth of certain oral bacteria have been observed. Furthermore chewing sticks may lead to improvement of the dental health by means of stimulation of the salivary glands and the gingival tissues (ibid.: 187).
The Neem stick is the most frequently used chewing stick in Kenya. Botelho et al. have demonstrated that mouthrinse based on leaves of the Neem-tree is equally effective in reducing periodontal diseases as a 0,12% chlorhexidine mouthrinse (a well-known anti-plaque agent) (2008: 344). The results showed a significant reduction of gingival plaque and bleeding indexes with both mouth rinses. Additionally the count of the cariogenic bacteria (causing cavities) in the saliva was reduced immensely (ibid.: 344). ‘Therefore, A.indica (Neem) can be regarded as a valuable plant source for the rationalization of its use in traditional medicine and for modern drug development as well’, according Van der Nat et al. (1991 in Botelho et al. 2008: 345). According to Prashant et al. Neem contains anti-cariogenic components such as fluoride, as well as analgesic components such as alkaloids and abrasive components such as silica (2007: 150).
The above-mentioned studies show that the professional EM is not by definition better, but biomedical/dental ‘truths’ just happen to be scientifically established more often than traditional ‘truths’. These insights are vital for this study of oral health in Kenya because the goal is to bring the different EMs from the popular arena and the professional arena closer together through a better mutual understanding.
For this research I derived several important questions from this perspective, for example: ‘What are the cultural beliefs and practices the children participating in this project (popular arena) have concerning their oral health? How is oral health conceived in relation to other aspects of (a healthy) life? How are teeth valued in the Kwale culture? Is there any social or cultural meaning given to teeth, the mouth, the tongue or breath? How do the ideas about personal hygiene and brushing behaviour from the community (popular arena)
influence these children? How do the children, targeted by DDC, care for their teeth? How are oral health problems like dental caries, Gingivitis or Periodontitis experienced by the
children? Does the local EM and construction of gum disease or dental problems differ from DDCs EM? How are dental problems treated when there are no dentists (professional arena) around?
1.5 The social justice model:
This applied research could also be helped by the liberation theology of Farmer. This theoretical framework is a human rights theory and challenges health providers to make ‘a
preferential option for the poor’, giving them a choice (2003: 139-140). Medicine has the ethical obligation to devote itself to poor populations struggling against illnesses, according to Farmer (ibid.: 139-140). He calls for applied research by use of liberation theology. The methodology of liberation theology has three phases: observe, judge and act (ibid.: 140). ‘Liberation theology uses the primary tools of social analysis to reveal the mechanisms by which social and economic structures cause social misery’, according to Farmer (ibid.: 143).
A large number of problems in the world result from the oppression of some human beings by others. Farmer calls this ‘structural violence’ (ibid.: 142). The problem is that authorities seldom blame structural causes for the prevalence of diseases, they instead point to biological causes or cultural and psychological barriers resulting in non-compliance (ibid. 147).
Farmer argues that the solution is ‘pragmatic solidarity’. This means solidarity
accompanied by goods and services that can diminish hardships (ibid.: 146). He calls this the social justice model. ‘Pragmatic solidarity’ cannot solve ‘structural violence’. It does however cry out to researchers and medical personnel to actively participate in creating a better world.
According to Campbell ‘Anthropologists have gone from being the handmaidens of colonial power to advocates for the afflicted and suffering’ (2011: 4). Liberation theology is relevant for this study because it inspired me to do this ‘operational research’. It can possibly reveal the mechanisms by which social and economic structures cause oral health diseases in children from Kwale.
Questions following from this theory (focusing on social inequality) are: What socio-economic determinants influence oral health in children from the Kwale district? For example, how does the income of the household influence these children’s oral health? To what extent do these socio-economic factors explain oral health, as opposed to cultural
factors? Unfortunately these questions do not help to solve structural violence, but by offering ‘pragmatic solidarity’, we work towards a better world.
1.6 Traditional versus modern healthcare:
Finally I will present the available literature about the factors contributing to the choice for traditional versus modern healthcare.
Livingston states that public health in Africa has its roots in the development sector and its focus has therefore long been on infectious diseases, malnutrition and childbirth instead of chronic diseases (2012: 34, 40). Oral health was also not prioritized. Even though, as Petersen and Yamamoto put it ‘Destructive periodontal diseases are among the most
common afflictions of mankind’ (2008: 341), the majority of health systems in developing countries continue to be designed to manage acute infectious diseases.
Hoy argued that the burden on the Kenyan healthcare was changing from infectious diseases towards chronic diseases because of improved living conditions and an increase in smoking (1992: 791). He stated that Kenya’s healthcare problems were aggravated by illiteracy, widespread communities, poor sanitation in some areas and tribal customs and traditions (ibid.: 789). Hoy stated that the solution towards a better healthcare system is health education and in order for healthcare education to be effective, the nurse or doctor must fully comprehend the culture and traditional medical practices of individual ethnic groups (ibid.: 791).
According to economist Azusa Sato there is a relationship between income and care seeking. Based on a study in Ghana, she argues that a rising income has a positive effect on the choice of modern care as a first provider and as income rises the utilisation of traditional care as a first choice decreases. Poorer individuals are more likely to use traditional care on account of cheaper fees and the possibility of paying in instalments (2012: 1451, 1456-1457). Furthermore the level of education, the age of the individual, the illness severity, the
travelling distance to the health care facility and whether someone has a health care insurance also seems to influence whether traditional care or modern health care is chosen (ibid.: 1453-1455). As the educational level rises individuals are more likely to choose for modern care (ibid.: 1453).
However, Assan et al. argue that the choice for either modern or traditional healthcare depends on more factors that just income. In their research amongst ethnic groups in southeast Sulawesi the availability of a health payment scheme, personal preferences for and
professionalism of biomedical staff, a younger age and a higher social status of the village were reasons to choose for modern healthcare. On the other hand poverty, the costs of modern care, the distance (long travel times and high transportation costs involved in travelling to the medical facility), the lack of biomedical staff, long waiting times in medical facilities, high user fees, lack of trust in healthcare workers, an elder age, a lower social status of the village and strong cultural beliefs were associated with choosing for traditional healthcare (2009: 98-103).
Assan et al. state ‘Haddad et al. (1998) argued that the decision on where to seek healthcare depends upon many factors including the availability of a provider within the community, the reputation of the provider, perceived quality of the service, cost of treatment and the arrangements for payment’ (ibid.: 101).
Mwabu argued that the type of illness influences the shape of distribution of Kenyan patients’ visits across a given set of health care providers. According to Mwabu other factors that influence this distribution are: ‘A. Personal and socio-economic characteristics of patients such as age, education, household’s income, severity of disease, sex, religion and experience in treatment. B. Attributes of health providers, e.g. quality of treatment, accessibility, money and time prices that patients pay to receive treatment, and personal relationships of providers with patients’ (1986: 317).
Traditional practitioners have more important roles in some locations than biomedical healthcare workers: they are readily available, cheaper and culturally more accepted (Joseph and Philips 1984 in Assan et al. 2009: 103). According to Assan et al. in their research in Sulawesi, most respondents did not have any social relationship with the medical teams in their communities, these were seen as outsiders. However, with the traditional practitioners they had a stronger bonds, because the healer was their neighbour and friend (2009: 102). Which healthcare system is used seems therefore to depend on social construction, socio-economic status and culture (ibid.: 105) and trust seems to be an important aspect in the choice for a healthcare provider.
Mishra et al. therefore talk about the crucial role of community health workers in immunisation practices in Malawi (and India). These community health workers connect the formal health system with the communities, they can act as mediators (2013: 151, 161). The village level health workers have social bonds in the communities and these lead to trust in the biomedical services offered by them and reciprocal relationships (ibid.: 167-168). DDC therefore works together with Kenyan COHOs (community oral health officers). They understand the local culture and traditional practices.
All in all the above-presented theoretical frameworks were the foundation of this research. A combination of my previous knowledge of Kwale and this literature led me to the following research question: ‘What are the cultural and socio-economic factors that influence the oral health of the children in the Kwale district targeted by DDC?’ Unfortunately there is little attention for and knowledge of non-clinical factors that may impact upon oral health. I hope this thesis contributes to filling the gap in the medical anthropological literature on this topic.
Chapter 2: Methodology 2.1 Introduction:
In this chapter I will elaborate upon the type of anthropological research I conducted. First of all this research took place under the wings of DDC, so I will explain the development project of DDC in Kwale. Furthermore I will describe the particular methodologies that were used to collect my empirical data. Finally I will reflect upon the obstacles that I encountered during this research and the ways I have tried to deal with them.
2.2 The Dutch Dental Care Foundation:
This study was conducted for DDC, which is a Community based Organisation (CBO). DDC is a Dutch foundation that was set up to perform curative and preventive dentistry by simple means to schoolchildren, their parents and the community.4
DDC organises four to six dental outreach programs a year. During these dental camps a classroom of a primary school is changed into a ‘mobile dental clinic’. In this ‘mobile clinic’ the Dutch dentists, the assistants, the dental hygienists, the Kenyan COHOs and the other volunteers (for the administration, sterilization etc.) offer their expertise and provide free (preventive) dental care for a week. Meanwhile the dental hygienists and COHOs go around the classes with an educational program for the schoolchildren and the teachers about oral health and oral hygiene.
DDC has also founded and renovated several clinics in Kwale. Their ultimate goal is ‘dental help by Kenyans for Kenyans’.5 DDC has one clinic in Ukunda and recently opened a clinic in Lunga Lunga (near the Tanzanian border) where Kenyan COHOs work. Furthermore DDC sponsored the renovation of the dental department of the Msambweni District Hospital, where a Kenyan dentist works for the government.
After six years of existence it is a lot busier in the dental clinic in Ukunda than in the beginning. The clinic is sponsored by DDC (with money from fundraising) and prices are intentionally kept low, to make it more accessible for the general public.
In comparison the price for a consultation in a private clinic in Mombasa is 1000 KSH (Kenyan Shilling), an extraction costs 1500 KSH, a scaling 4500 KSH and a filling costs 3500 KSH. In the public hospital in Msambweni a consultation costs 50 KSH, an extraction costs 250 KSH, a scaling 800 KSH and a filling 800-1000 KSH. In the DDC clinic the price for a
4 Unkown, 2014, Dutch Dental Care – Home, http://www.dutchdentalcare.nl/ (08-05-2014)
5 Unkown, 2014, Dutch Dental Care – Verslagen, http://www.dutchdentalcare.nl/Verslagen.htm (08-05-2014)
consultation is a 100 KSH, an extraction costs 200 KSH, a scaling costs 500 KSH and a filling costs 500 KSH.
During my research I visited both the dental clinic in the private Palm Beach Hospital in Kwale as well as the dental ward of the public Jomo Kenyatta National Hospital in Nairobi [69]. Both were in an abominable state. Although the dental personnel seemed
knowledgeable, concerned and enthusiastic and, as far as I could see, the hygienic procedures were followed, the chairs, the instruments, and other equipment were out-dated and corroded. There were old, stained curtains in between the units. Therefore it looked unhygienic. Patients often have to wait for hours. The head of the dental department in the hospital in Nairobi told me that they get little money from the government [43]. The DDC clinic in Ukunda appears much more attractive in my opinion. The furniture is new and white and hygienic protocols drawn up by the DDC-team are followed. The waiting time is limited.
Because of the shortage of dental personnel, the dentist in Palm Beach Hospital only works there two days a week. The rest of the time he works in other clinics elsewhere in the district. The managing director of the hospital told me that, when the dentist is absent, he sends the patients to the DDC clinic in Ukunda (informal conversation, 14-03-2014 [44]). All in all DDC has increased the number and the quality of dental facilities in the area. Before there were few dental clinics and they were in very poor shape, just as the clinics in Palm Beach Hospital and the dental ward of Jomo Kenyatta National Hospital. Through their dental camps DDC has improved the accessibility to dental care for the population of Kwale.
2.3 Methodology:
The first week of my research period I participated as a dental hygienist at a dental camp of DDC, together with the other volunteers. Meanwhile and the weeks afterwards I did
anthropological research on oral health in children from Kwale.
This research was conducted in and around Kwale town in Matuga and in and around Ukunda in Msambweni in February and March 2014. My main research question was ‘What are the cultural and socio-economic factors that influence the oral health of the children in the Kwale district targeted by DDC?’ In order to come up with an answer to this question I used a qualitative research design, furthermore my research was inductive because I have gathered a large number of new data.
My methodology included (participant) observation of the whole DDC project, at night I wrote down my field notes. I would say it was more observation than participation.
Although I participated as a dental hygienist at the camp I was also an outsider. I did not really live among the children for a longer period. I had a hierarchical position because of my profession. There was no possibility to really ‘go native’, because they saw me as a member of the DDC-team.
15 question rounds were held in the classes (often up to 60 pupils, mixed boys and girls [7-21]) as part of the oral hygiene education. I started the lessons with a 15-minutes question time regarding the children’s oral healthcare practices and perceptions. Afterwards I held four FDGs consisting of 2-5 participants (3 with boys, 13-17 yrs, and 1 with girls, 12-14 yrs [22-25]). My questions for operationalization in the question rounds and the FDGs were:
- ‘What are the cultural beliefs and practices the children participating in this programme have concerning their oral health?’
- ‘How is oral health conceived in relationship with other aspects of (a healthy) life?’ - ‘How are teeth valued in the Kwale culture?’
- ‘Is there any social or cultural meaning given to teeth, the mouth, the tongue or breath?’
- What is the function of the mouth?
- ‘How are dental problems treated when there is no dentist around?’
- ‘How do the children, targeted by DDC, take care for their teeth and why?’ The answers have given me insights in the beliefs and practices of children from Kwale concerning their oral health and what they do in case of a toothache. The biggest challenge was the language, sometimes they did not understand my English or my questioning. I tried to solve this by rephrasing the question in simpler words. For example: Is there any social or cultural meaning given to teeth, the mouth, the tongue or breath?’ became: ‘Do you give any special meaning to the teeth, the mouth, the tongue or the breath?’ And: ‘How is oral health conceived in relationship with other aspects of (a healthy) life?’ became: ‘Do you see the relationship between your mouth and your body?’ The impact of this hindrance on my data may have been that I sometimes did not get to the bottom of things.
Furthermore I conducted 10 semi-structured interviews with schoolchildren of various schools (1-15 yrs, mixed boys and girls [26-36]), as well as 2 interviews with the COHOs, named Winston and Simon (both 27 yrs [1-2]), and 4 interviews with the teachers (29-40 yrs [3-6]). I selected the children for the interviews on the basis of the answers they gave in the FGDs and in class. One girl named Christine (15 yrs [26]) was particularly bright
and has given me a large number of useable data. Later on I decided to visit her house to thank her and bring her and her family some presents. This provided me with another chance to ask questions.
The interviews were semi-structured and held in English. Oral consent was asked of the respondents beforehand. They were all recorded, stored on the computer and transcribed later. Each respondent was free to refuse their collaboration to this research, but instead they all proved to be very cooperative.
My questions for operationalization in the interviews were: - ‘How are teeth valued in the Kwale culture?’
- ‘Is there any social or cultural meaning given to teeth, the mouth, the tongue or breath?’
- ‘How do the ideas about personal hygiene and brushing behaviour of the community influence these children?’
- ‘How do the children, targeted by DDC, take care of their teeth and why?’ - ‘How are oral heath problems like dental caries, Gingivitis and Periodontitis
experienced by the children?’
- ‘Does the local EM (Explanatory model) and construction of gum disease or dental problems differ from DDCs Explanatory model?’
- ‘How are dental problems treated when there is no dentist around?’
- ‘What socio-economic determinants influence oral health in schoolchildren from Kwale district?’
- ‘What would effective preventative health care, adjusted to the local circumstances, look like?’
- ‘How does the income of the parents influence these children’s oral health?’
Again some of these questions were rephrased in simpler words. The answers have given me insights to the value and social or cultural meaning attached to teeth, the mouth, the tongue and breath. Furthermore the answers have given me insights into the socio-economic status of the children.
I asked the older children to fill in a ‘nutritional anamnesis’, this is a form used in dentistry on which people fill in their dietary habits for two days in a row. 19 nutritional anamnesis were filled in and returned [45-63], giving me insights into the diets of the respondents.
I asked about 50 of the youngest children to draw their mouth and their favourite foods, I wrote down the answers and made some pictures of their drawings [68]. The plan was to analyse this according to simple creative therapy methods, but this proved to be more difficult than I thought beforehand. So I did not used these methods after all, because in creative therapy methods you are supposed to sit down with children and ask them questions about their drawing. The dental hygiene lessons were just too hectic to have a personal conversation with some children. I had to supervise the rest of the class (60 pupils) too.
Furthermore I visited two houses of schoolchildren in Kwale town [64-65] and I visited a boy’s boarding school next to the school [66]. I also visited the workplace (a sewing atelier) of a schoolboy’s mother [67]. These house visits and personal contacts gave me insights in the living conditions and socio-economic status of various households of children attending the schools.
In addition I visited 2 NGOs in Kwale: KEMRI Kwale and Plan Kenya. KEMRI (the Kenyan Medical research Institute) Kwale provided me with information about their research into the quality of the water in the area and their deworming-programmes in primary schools [37]. The staff of Plan Kenya [38] provided me with information about their programmes. They run a health programme, a child protection programme, a governance programme, a sustainable livelihoods programme and an education programme in the area of Kwale town. All programmes are interrelated. These visits were relevant to my research because they gave me insights into the geographical setting, the living conditions, the healthcare and sanitary circumstances in Kwale.
Also I had some informal conversations with random people, such as a male night guard (26 yrs [39]) and a Luhya women (28 yrs [40]), and a Masai man (25 yrs [42]) who shared information about their oral hygiene with me. These conversations gave me insights in beliefs and practices regarding oral health care. A Belgian lady who runs a school in Ukunda (40 yrs [41]) gave me insight into the diets of her schoolchildren.
Finally I visited the public Jomo Kenyatta National Hospital in Nairobi (connected to the University of Nairobi) and the private Palm Beach Hospital in Ukunda. In the hospital in Nairobi a staff member gave a tour of the dental department and the head of the dental department provided me with data about several themes related to this research and she confirmed some information I had heard before [43]. In the hospital in Ukunda I spoke to the managing director and he showed me around in the dental clinic in the hospital [44].
When I came back from the field I used the ‘cutting and sorting’ method for coding and analysis. According to Ryan and Bernard:
‘Looking for themes in written material begins with pawing through texts and marking them up with different colored pens…After the initial pawing and marking of text, cutting and sorting involves indentifying quotes and expressions that seem somehow important and then arranging the quotes/expressions into piles of things that go together’ (2003: 88, 94).
First I marked the data in my field notes with coloured markers and the quotes in my transcribed interviews. Afterwards I arranged the data and the quotes into different files (chapters) by theme on my computer. By sorting the data into chapters and then within the chapters into sections, I tried to get a grip on the many issues at play. Consequently the analysis started early in the process by making certain choices regarding my research such as which people to interview and which quotes to use.
Throughout the process of writing my thesis I constantly searched for new literature in medical, sociological, anthropological and dental science journals. Finally I conducted web-research on the internet. With these methods I managed to gather enough valid information for my thesis.
2.4 Encountered obstacles & reflection:
This applied approach had both advantages and disadvantages. The main advantage was of course the direct and easy access to the research field. Being a member of the DDC-team, I could start my research right away and I did not need a starting period for ‘deep hanging out’ with my informants. Secondly the fact that I was in Kwale with DDC five years ago gave me a head start as well. Consequently I had already some knowledge of the research setting and knew what to expect. Finally this was the perfect opportunity to combine my two disciplines (dentistry and anthropology).
It was ‘a public intervention at the boundaries of two worlds’ as anthropologist Stuart Blume very well puts it (2000: 140). It is therefore favourable to this research that I have knowledge of both disciplines.
There were also disadvantages on account of the combining the two disciplines. Through working in dental health for 10 years I am inclined to think from a Western biomedical
perspective. Such a strong biomedical inclination is in conflict with an ideally open anthropological perspective. It was especially hard when I saw that traditional ideas and practices were detrimental to someone’s (dental) health. As Pigg rightfully argues: ‘Relativist principles vanish when scientifically established truths seem so critically important to health and well-being that it would be morally wrong not to educate people about them’ (2005: 58). In such cases it was hard to stay neutral and objective, as an anthropologist should do.
However, I tried my best to avoid this conflict of interests. Blume struggled with conflicting interests too in his research in the deaf community being both a parent of a deaf child and being a researcher, but found a good solution for this problem:
‘Gradually, my sense of what Rabinow (1996) calls the “ethical mean” shifted to an acceptance of the equal validity of the two very different constructions of deafness, each rooted in the authentic experiences, commitments and cultures from which it has grown. People had to see this and learn to respect one another’s intentions’ (2000: 156).
He proposed a dialogue based on mutual respect and became a mediator between the different stakeholders (ibid.: 158, 164). I tried to follow his example. My goal is to be a mediator between both worlds, just as Blume was. The challenge in this is ‘Getting each side to recognize and accept the legitimacy of the other’, according to Downey and Dumit (1997:16 in Blume 2000: 156).
The other obstacles I encountered during this research arose from doing research among children. Such research is often controversial, but anthropologist Van der Geest argues that children are the perfect informants, because they have no inhibitions, follow their imagination and speak the truth. Van der Geest states: ‘One sometimes discovers most about practices and beliefs of adults by listening to children’. He therefore hopes for ‘a medical anthropology of children’ (1996: 340, 344).
As a matter of fact I discovered that it is not so easy. The school system in Kenya is very hierarchical and teachers still use corporal punishment (they hit kids with sticks when they are ‘out of control’ or too loud). The teacher is almighty. Consequently it is strange for the children to suddenly talk to someone of the teacher’s age in an equal way and give their candid opinion about something. Most of them were shy and talked very softly. Others were a little more communicative, such as Christine. I dealt with it by trying to let the children feel as
comfortable as possible by making some jokes. I also asked the COHOs and the teachers to either confirm or deny the things the children told me.
As mentioned before, the language barrier was an obstacle sometimes. Even though a translator was promised by DDC, I could not make use of her, because she was working in the clinic. I had to adjust some questions and repeated them if necessary. I also took the COHOs with me to the classes for the dental hygiene education and the question rounds. When the little children did not understand my questions, I asked the teachers or the COHOs to translate them into Kiswahili.
Finally it was also hard to find a quiet place to talk to the children. There was no classroom available, so we usually sat on a school bench under a tree. Curious onlookers sometimes disturbed us because they were standing around us and yelling. Also I could not sit very close to the clinic, because the noise of the generator would disturb my recording. That limited my options even more. Eventually I found a relatively quiet place in an old Makuti (a hut with a straw roof) on the border of the school premises. There were still curious
onlookers, I sent them away patiently and asked for some privacy.
All in all this applied approach had both advantages and disadvantages. The advantages such as easy access through DDC, inside knowledge of the project and having knowledge of both dentistry and anthropology hopefully favoured my research. I tried to cope with the obstacles such as a conflict of interests, research among children, the language barrier and no quiet place for interviews as well as I could, by improvising and staying reflective at all time. 2.5 Ethical considerations:
A study among children is often controversial, but Van der Geest argues that children have been a widely neglected “tribe” in anthropology and sociology. Children are often seen as an incomplete version of adults. He states this the ‘ultimate form of ethnocentrism’ (1996: 339-340).
Reis and Dedding state that research with children is ambiguous. How childhood is conceptualized is different in every culture. Age, childhood and adulthood are flexible concepts. They are even flexible and disputable in criminal law (2004: 80, 82). Christensen states that vulnerability is often seen as the ’master identity’ of a child (2000: 4 in Reis and Dedding 2004: 82). Therefore they are assumed to need protection of adults. In child-patients adults therefore dominate as to what they should think, ask and wish for. Children form a ‘muted group’, just as women a quarter of a century ago, according to Hardman (1973 in Reis
and Dedding 2004: 83). Researchers of children in medical settings do not only have to deal with medical ethical issues, but also with medical specialists and parents as gatekeepers of children (ibid.: 80, 86).
According to Reis and Dedding studies of psychologists and educationalists have shown that even very young children have agency and that they should be treated as social actors in research. (2004: 79-84) We should give children the opportunity to make their own decisions in medical treatment and research (ibid.: 88-89). At the Convention on the Rights of the Child of the United Nations it was decided that a child who is capable of forming its own views has the right to express those freely in all matters affecting the child (1990: 4).
These reflections are relevant for this research because it was conducted among children. Van der Geest argues it is important to ‘grasp the children’s point of view’, because this is in line with our anthropological ‘tradition of entering the world of “others” and giving voice to their muted views’ (1996: 343). This theoretical framework was used for ethical considerations, because in research with children, cautiousness is desired.
According to the AAA anthropologists have ethical obligations to their informants, for example: do no harm and respect their well-being (1998: 2-3). On the Convention on the Rights of the Child it was stated that what is most important, is to have the best interests of the child in mind. A child has the right to health and the right to education (1990: 2-9). The project of DDC contributes to the realization of these rights. My research aimed to further promote the health and well-being of the children by gaining insights to local context and so help to improve the services of DDC.
Secondly anthropologists must protect the safety, the dignity and privacy of their informants. Anthropologists must determine if their informants wish to keep their anonymity (AAA 1998: 2-3). I protected the anonymity of the children that participated. I am used to this confidentiality in my profession as a dental hygienist. Dentistry too has ethical codes in order to protect the privacy of patients. Because of the size of the classes and time limitations (40-60 pupils) it was simply not practical to get to know everybody’s name.
Thirdly anthropologists must obtain informed consent in advance of the study (AAA 1998: 2-3). I asked oral consent to record the interviews beforehand.
Ideally there must also be reciprocity in the relationship between the researcher and the respondent (AAA 1998: 2-3). I had therefore collected about 2000 toothbrushes,
toothpaste, soap, notebooks, pens and schoolbags. I handed them out to the children and the teachers who helped me during this research.
Chapter 3: Research setting 3.1. Introduction:
In this chapter I will describe the research setting. First I will draw a picture of the
geographical, demographic and socio-economic situation of Kwale County. Afterwards I will describe dentistry in Kwale.
3.2 Geographical, demographic and socio-economic setting Kwale:
Kwale County is located on the southern coast of Kenya. Kwale is a rural district. It covers an area of 8.322 km2. It is the most southern county in the Coastal province. According to Kahuthu et al. ‘Kwale is bordered by the Taita Taveta district to the West, the Kilifi district to the North, Mombasa district and the Indian Ocean to the East and The United Republic of Tanzania to the South…Politically it is divided in 3 constituencies: Msambweni, Matuga and Kinango’ (2005: 3).
In 2008 Kwale district had an estimated population of about 630.000 persons (Kahuthu et al. 2005: 5). The number of people under 15 years formed about 46% in 2005, whereas the age group 15-59 formed about 49% and the elderly counted for 16% of the total population (ibid.: 5). The young population puts pressure on the available educational, health and other social facilities.
Kwale is a resource-poor setting, the poverty rate was about 75% in 2005/2006. The number of poor people was 483,090.6 In 2005 the poverty headcount ratio at $1.25 a day for the whole of Kenya was 43,4 % of the population.7 According to Adeladza Kwale district has some of the worst socio-economic and health indicators in Kenya (2009: 1572). The major causes of poverty in the Kwale district were the poor infrastructural development such as poor electricity, roads, telecommunications and water, inadequate agricultural production due to land tenure problems, undeveloped agricultural marketing (Kahuthu et al. 2005: 7-8).
In this area the education level is low. In 2009 the education level of the male rural population was: 20% never went to school, 55% went to primary school, 11% went to secondary school, 2% went to tertiary school and 0% went to university. Of the female rural population 32% never went to school, 48% went to primary school, 8% went to secondary school, 2% went to
6 Unknown, 2014, Poverty Rate by district – Open Data Kenya – Transparent Africa, https://www.opendata.go.ke/Poverty/Poverty-Rate-by-District/i5bp-z9aq (22-01-2014) 7 The World Bank, 2014, Poverty & Equity data – Kenya – The World bank,
tertiary school and 0% went to university.8 This means that a large number of the parents is illiterate.
In 2005 the district had 274 primary schools with an enrolment rate of 71,5% for boys and 58,6% for girls. There was a high dropout from primary to secondary school. Hoorweg et al. argued this is largely due to the financial status of the parents (2000: 403). According to one teacher (40 yrs [3]) children in primary school are often poorer than children in high school, because the primary education only demands a very small fee for the exams from the parents. For secondary school a much higher fee is required, consequently it is only for ‘the happy few’.
At all the schools DDC worked at, there were a lot of children with dirty, ripped school uniforms held together with safety pins. According to a teacher (33 yrs [4]) they lack the money to buy new ones. He told me: ‘There is a big difference (in socio-economic backgrounds) between the students in school. Some are better off than others. If you look at the way they are dressing, there is a gap’.
From my observation I can tell that the primary schools are overcrowded, each class consists of nearly 60 pupils. A classroom can turn into a ‘sauna’ because of the heat and the large number of pupils in the room. Therefore working and studying conditions are
uncomfortable. Sometimes the children study outside under the trees.
The major problem of low enrolment in schools, particularly for girls, is the increasing poverty level in the district. The sex ratio shows that there are more women than men. There is a large number of female headed households, respectively 29.352 households (Kahuthu et al. 2005: 5-8). Non-married heads of households (single, divorced, widowed or separated) are quite common in Kwale (Foeken and Hoorweg 1990: 17). Gender related problems such as discrimination against girls, marginalization of women in education, income and property rights and low participation of women in development are an issue (Kahuthu et al. 2005:14). According to Hoorweg et al. there is a relationship between female education and child care, therefore improvements in female education will lead to improvements in child care (ibid.: 404).
The Swahili make up 0,06% of the population and make up the largest part of the population in Kwale. Although these people do not have a common heritage, they have a linguistic link:
8 Unknown, 2014 Population, 3 years and above by Sex and Highest Level of Education reached up to District Level 2009 – Open Data Kenya – Transparant Africa,
https://www.opendata.go.ke/Education/Population-3-years-and-above-by-Sex-and-Highest-Le/x4e7-whsh (08-05-2014)
Kiswahili, which is a Bantu based language which was the means of communication between Africans, Arabs, Persians and Portuguese who colonised the African coast in the past. The word Swahili is derived from the Arabic word for coast: Sawahil. Mombasa was the centre of the East African slave trade between the 7th and the 19th century. The cultural origins of the Swahili therefore find their roots in intermarriages between the Arabs, Persians and African slaves, consequently they can be seen as a cultural ethnic group brought together by trade routes rather than an ethnic group of a distinct biological lineage. Because of the historical Arabian influence the Swahili largely practice Islam.9 However Christianity and traditional religions are also practiced in this area.
The Swahili have long dominated the larger coastal identity and politics, so the Islam was and still is the main religion. These different religions have lived in harmony together for centuries, although the coast has never been culturally homogenous (Hoorweg et al. 2000: 396-397). Recently there have been tensions due to this mixture of religions; there were various riots, murders and terrorist attacks in the area. I noticed that people did not talk positively about people from another religion, there is ‘othering’ going on. One day I was in a taxi during my research, the driver (Christian) told me [69]: ‘Muslims are a different kind of people (than Christians), they are untrustworthy’.
Kwale long stayed behind in development due to poor agricultural and economic prospects, which were magnified by cultural and climatic factors (Hoorweg et al 2000: 393). This can partly be explained by history and partly by geography.
First, as mentioned above, historically Mombasa was the centre of the East African slave trade. Arab and Swahili traders kidnapped about four million slaves from the interior and sold them to plantation owners and households in the Middle East and Arab-controlled African states.10 Early on, most contacts were with other coastal communities, even with far away cultures, but there were few ties with the African hinterlands (ibid.: 393). Later on, in colonial times, the main priority was given to the agricultural development in the White Highlands and therefore the coast stayed behind in agricultural development (Hoorweg et al. 2000: 393, Klaver and Mwadine 1998: 283). The abolition of slavery created two problems: the problem of land titles and the problem of scarcity of labour. The immigration over time caused even more unemployment and poverty (Hoorweg et al.: 395-397).
9 2012, Ham. A., Butler, S. and Starnes, D., Lonely Planet Kenya, pp. 308 [1991] 10 2012, Ham. A., Butler, S. and Starnes, D., Lonely Planet Kenya, pp. 308 [1991]
