A fighting chance: translating routine vaccination for Kakuma’s multilingual refugee population
Sometimes to build demand for vaccines, just speaking the right language can be enough, especially in one of the world’s largest refugee camps.
- 10 March 2023
- 6 min read
- by Allan Kiprotich Cheruiyot , Maya Prabhu
“I came from Ethiopia in 2016, because of insecurity. I fled my home, and went to Dadaab refugee camp,” says Chukulisa Molu Adi, a young mother of two. “In 2017, I was relocated from Dadaab to Kalobeyei. I stayed there for five years. Here I am now: at Kakuma.”
From the air, Kakuma is acres and acres of corrugated sheet-metal rooves, gridded inorganically on the flat dry ground of Kenya’s northwestern Turkana County. More than 220,000 refugees, most of them fleeing conflict and crisis in South Sudan, Somalia, the Democratic Republic of Congo, Burundi and Ethiopia, are housed here and in nearby Kalobeyei. That number is always growing: freshly-displaced people arrive, babies are born.
“I just hear about vaccination nowadays. Before, in our village, there is no something like vaccination. Now I do believe vaccination is very important, because it prevents many diseases – like measles, rotavirus and polio especially. I think it’s an important thing that was introduced to me.”
– Chukulisa Molu Adi
“The camp is different from home. The harsh weather, no family here – you live alone, without relatives,” says Adi. Still, she says, “sometimes you find it an advantage because there’s no insecurity – no fight here.”
But some threats transgress international borders more fluidly than conflict does. In the camp’s mobile, clustered population, infectious disease is a pressing concern. And worse, according to Dr Sila Monthe, Health Manager for the International Rescue Committee’s Kakuma programme, many new arrivals to Kakuma have never heard of vaccination.
“You have people from diverse nationalities coming to the camp,” she explains. “In their countries of origin they basically do not have functioning healthcare systems. And without a functioning healthcare system, it’s usually quite difficult to deliver vaccines to children.” Literacy levels, and especially “health literacy” levels, tend to be very low, she says.
As recently as 2014, Kenya’s Demographic Health Survey (DHS) showed that only 62.5% of children in Turkana – a statistic including the county’s refugee population – qualified as reached with all basic vaccines at 12 to 23 months of age. Kenya-wide, the same statistic stood at 79%.
“We need our children to be healthy. If our community is healthy, even our economy will be developed.”
– Tegegn Fufa Dheresa, a CHP from Ethiopia resident in Block 101
Efforts by the government and its NGO partners to extend Turkana’s lagging coverage rate hit a roadblock in 2020, when COVID-19 landed, overwhelming Kakuma’s health system. Dr Monthe recalls the period as “one of the hardest moments in my career”. In 2022, the DHS recorded 60.1% of Turkana 12- to 23-month-olds as vaccinated with “all basic antigens”.
“The repercussions from the COVID-19 pandemic are actually still being felt, because during that period, there was a decrease in parents going to facilities to follow up on immunisation of their children,” explains Dr Monthe. A larger pool of unvaccinated children meant a larger risk of epidemics.
That risk bit quickly: in December 2022, IRC reported 37 laboratory-confirmed cases of measles, a wildfire-contagious, deadly, disabling virus, called the “canary in the coalmine” of vaccine-preventable diseases by epidemiologists for its capacity to act as an early signal of dangerous breaches in a population’s immunity ramparts.
Adi’s two children are safe – both of them, she tells us in late January, are up-to-date on their shots, based on Kenya’s routine immunisation schedule. But when she arrived in the country, vaccination was a foreign concept. “I just hear about vaccination nowadays. Before, in our village, there is no something like vaccination.”
She adds, “Now I do believe vaccination is very important, because it prevents many diseases – like measles, rotavirus and polio especially. I think it’s an important thing that was introduced to me.”
She speaks in crisp, comfortable English, but many of her fellow refugees land up here siloed in their languages of origin. Language fragments the camp, and that can make spreading the word about the importance of vaccination especially challenging.
The IRC’s answer to that challenge has been the recruitment of what Dr Monthe describes as a “vast and efficient network of community health workers” who are drawn from the communities they serve.
“I myself am South Sudanese and I can speak the language – my language – and I can also speak Kiswahili to those who can speak Kiswahili, and I can speak English to those who know English,” says Buoy Chol Deng, who began working as a community health promoter (CHP) in 2016. Seven years later, he’s a veteran in the role – part interpreter, part roving educator, and an important component part of the camp’s public health safety net.
More women give birth in hospitals than they used to, Deng observes. More children are vaccinated than they were. Missed-out “defaulter” kids are now “minimum”, he says, and concentrated among camp newcomers – an implicit testament to the effectiveness of the CHP-outreach system.
The CHP system is finally one of connection-building in a population characterised by broken bonds, of people torn from their native relational systems.
Deng, in a bright yellow IRC tabard, greets his neighbours with an easy grin and a fist-bump as he strolls the dusty lanes of his Kakuma block. He thinks that vaccination gaps don’t originate in cultural difference – by Deng’s analysis the problem is straightforwardly informational. “The importance of using mother tongue is for them to understand,” he says. But it’s also clear that familiarity and trust course the same pathways.
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The wind is up, and the meter or so above the ground is blurred with stirring reddish dust. On the approach to the health centre, Deng passes a yellow sign that reads, “The COVID-19 vaccine is safe. Get yourself vaccinated.” Misinformation about the COVID-19 vaccine has been an issue here, Dr Monthe says, and alarmingly, those rumours have metastasised in some parts of the camp, attaching to other vaccines in the routine schedule.
Not everywhere, though. We ask Tegegn Fufa Dheresa, a CHP from Ethiopia resident in Block 101, whether he’s encountered a new volley of vaccine misinformation among “defaulters”.
“In my community? About the children? No, no rumours,” he says.
“We need our children to be healthy. If our community is healthy, even our economy will be developed,” he explains.
Misunderstandings may persist – some mothers, for instance, don’t understand why a child vaccinated at nine months against the measles should be vaccinated again. The concept of a booster dose is not necessarily intuitive. There are logistical hurdles too – who will look after the other kids when you take the baby to the clinic? But broadly, Dheresa appears confident that clear, comprehensible communication is sufficient remedy.
Mohammad Osman, a supervisor community health worker from Somalia, concedes that sometimes it takes time to bring a defaulter on board. “Some people, maybe they refuse because – maybe – they are new. So it takes time. To make them accept, it takes time. You need to go back several times.”
He’s willing to take that time. “Our mission is to identify our community challenges, and our community issues, and then address those challenges and complaints appropriately,” he says.
“Those who are here for many, many years, they know the importance of immunisation,” he adds. “We tell them: immunisation can save lives and prevent disease. Mostly they accept, and they know now.”
Word spreads laterally between camp residents, too. “I encourage other mothers to take their child to the clinics to get vaccinated,” says Adi. “If an outbreak of disease comes, they’ll be able to fight back.”
A fighting chance is, after all, what she’s here for. “I have to have a bright future for myself and my kids,” she says. “Just something that will change my life forever. I hope that something comes,” she laughs, “fast!”
