Turkana District - the largest district of Kenya - is the home of 270,000 Turkana, and of small numbers of other groups. These 270,000 Turkana are the descendants of the 30,000 Turkana who were there 100 years ago.

               This population probably reached its Malthusian ceiling* some centuries ago, and that until (say) 1960, the number of Turkana fluctuated under the influence of war, disease and famine, at about 30,000. During this time the Turkana evolved a strategy of coping in a harsh and unpredictably varying environment. This strategy appears to be designed to ensure the survival of the maximum number of the population; its characteristics have been described by N Dyson-Hudson [1].

               Elements of this strategy are the careful control of the composition of the herds - the numbers of animals herded, the ratio of small and large animals, their sex ratio, and so on - and a social organization based on four levels of association, the tribe, the large territorial group, the grazing group, and the family. The third of these (the grazing group or adakar) is a short-lived association which constantly dissolves and reforms according to needs.

                Since 1960 this traditional system has been disturbed by several external factors. Development agencies and governments have tried to make the system more productive. Humanitarian groups have attempted to mitigate recurrent famine by distributing relief food and establishing camps. Medicine has  reduced the death rate.

                The natural factors controlling population size have been prevented from operating, and as a result the Turkana population now greatly exceeds the carrying capacity of Turkana district. The Turkana may now be divided into:

                              1. successful pastoralists

                   2. failed pastoralists, now living in settled camps, and dependent upon outside agencies to stay alive.

                The ratio of these two groups is such that a third to a half  of the 270,000 Turkana   can no longer support themselves.

 
                There is obviously is no quick or easy solution. If there is a way out it is bound to be slow and difficult. As there already is a considerable excess of human beings, family limitation, even supposing its acceptability, has arrived much too late. Is it conceivable that significant numbers of Turkana will accept that a useful and productive life can be lived without offspring?

                What are the alternatives? Over the last 10 years or so about 7% of one part of the Turkana population has migrated out of Turkana - to the cities and to the rest of Kenya [1]. If there is no more room for pastoralists in the pastoral areas then the only alternative to dependency appears to be to join the modern world -- to migrate to the towns and seek employment -- and for this education is essential. It too is no adequate solution, since there is already considerable graduate unemployment in Kenya.

                Any programme intended, therefore, to improve the circumstances of the dependent Turkana, in however slight a fashion, would need to incorporate vigorous family planning -- perhaps the 1-child norm, as in China -- and embark upon an ambitious education programme.

                1. Are there problems that concern the Turkana which outsiders are unaware of?

               2. Is the external analysis (given above) understood and accepted by the Turkana themselves?

                 3. Is the situation clearly understood, or is there a need for further investigation?

                 4. Is there an automatic right to a certain level of medical services regardless of population questions?

                  5. What is meant by social development, and what part does it play in a medical programme?

                   6. How should we deal with the presence of a dozen or so health NGOs in Turkana, all with differing approaches?

                    7. Can anything be done in a modest piecemeal fashion, and if so what?

                    8. Does an organization such as AMREF have a role in the Turkana predicament?

                    9. How are these questions affected by the fact that AMREF has been present in the Turkana district for 13 years?

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                    1. It is likely that there are quite a lot of problems which concern the Turkana,  of which outsiders are only dimly aware, or not aware at all. The nature and extent of these  problems could be studied.  The conventional questionnaire might be appropriate, or the questions might be raised in a continuous dialogue, such as might be carried out by 'community patrols'.

                    2. Most  Turkana are probably not aware  that they have reached a Malthusian ceiling. The ideas being intrinsically straightforward, such an analysis could plausibly be put to them, and it is likely that they would be accepted. This, therefore, can and should be done. The Turkana, like any other group, should understand their problems, and should devise the solutions, whatever they may be, themselves.

                   3. The overall position is reasonably clear. Where the details are concerned there is room for a great deal of doubt and argument. Any intervention should include the requirement that further investigations should be carried out, discussed, analysed and published.

                   4. Medical ethics accepts that there is a right to a certain level of medical care. The actual level depends partly upon absolutes, partly upon the level of economic development, and partly upon other considerations (such as what may actually be available).

                    5.  Socialdevelopment may be defined in many ways. One set of definitions is:
                            (i)  actions to reduce hazards
                           (ii) stabilization of environmental resources
                           (iii) increased control of the situation by the members of the community

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                The hazards that the community faces are of several kinds. Some may be amenable to management, some may raise medical questions, and some may be beyond the scope of any project to address. For example, problems relating to drought, although crucial to the welfare of Turkana pastoralists, are beyond the scope of present-day interventions. Perhaps, in the not-too-distant future, climatic forecasting will allow some management of drought areas based on accurate predictions of what the weather will be like in the next few months.
 
                 Medical hazards that might be mitigated include such diseases as malaria, hydatid disease, tuberculosis, trachoma, and   trauma. However, we should remember,  that if a population is maintained at a certain level by resource constraints (i.e. it has reached its Malthusian ceiling), the removal of some hazards will merely make way for others.

              'Community-based health care'  includes the idea  that the community should be empowered to ask   questions, suggest  answers and take the responsibility for implementing them.  Should they be encouraged to see that they have exceeded the carrying capacity of the Turkana ecosystem, and suggest solutions, even to this?

                This presents a further question? What part does social development play in a medical programme?

                       A medical programme may have profound implications for social development, some of which  may well be negative. For example, well-meaning interventions in the eastern African famines of the 1970s and 1980s, in which starving pastoralists were given food and kept alive, has created a large dependent population. This was not the intention of the distributors of relief food, but it was an inevitable consequence of their actions. If the United Nations is successful in creating a Rapid Reaction Force, to be used to stop genocide in Burundi, then one (unwanted) consequence will be the creation of a large dependent population in Burundi.

                        Until the size of populations is no longer determined by war, disease and famine -- it is no longer so determined in the western world, for example -- interventions which deal with one problem, will merely substitute another constraint for the one which has been removed. This is the basic argument put forward  elsewhere in this website  (also) where it is suggested suggested that interventions to reduce child mortality are pointless until the population issue is resolved.

                            6. Co-ordination amongst different NGO health providers should be formalized and taken more seriously. NGOs are inherently territorial. Such territoriality is inherent in the nature of such organizations. It can, however, be channelled and used constructively. One objective of any health programme in Turkana should be to consult with and co-ordinate with, other health NGOs.

                            7. The piecemeal approach is probably the only way to tackle the problem. A small scale beginning, in a particular area, incorporating the elements suggested here, offers the possibility trying something new without making a large financial investment. If several piecemeal approaches were  tried simultaneously we might  find a useful approach faster than if we try them serially.

                            8. AMREF ought to be as good as any other health development NGO. It is an indigenous African organization with extensive links abroad.

                MHK.  I think that AMREF has got a wonderful opportunity to lead Africa lifting the Hardinian taboo,  and 'disentrapping'  Turkana.   Why not make a start, go and consult with the community's leaders, and report back to this website soonest?