It’s late July, cool and dark in predawn Nairobi, Kenya, when Bhavya Joshi heads to the airport. She is starting her 500-mile journey to Kakuma refugee camp in northern Kenya. The wind through the lowered windows is slightly smoky and Whitney Houston’s “I Wanna Dance with Somebody” streams from the radio as Joshi bobs her head, humming in time while texting on two phones, confirming travel logistics.
“Are you tired?” asks the driver, and Joshi smiles. A doctoral student at UC Berkeley School of Public Health, she has flown tens of thousands of miles over the last three months—crisscrossing between the United States, Canada, India, Europe, and Africa.
The night before this trip in the summer of 2024, Joshi finished a round of antibiotics for a sickness that racked her body for a week. Tired doesn’t even begin to explain it.
But the 32-year-old couldn’t be happier to be here.
“It’s that feeling of coming back to your family,” said Joshi, who first traveled to the sprawling Kakuma camp on a research trip in February 2024. The camp encompasses roughly 50 square kilometers and hosts more than 290,000 refugees from South Sudan, Ethiopia, Somalia, the Democratic Republic of Congo, and beyond. It was established in 1992 to care for refugee youth whose parents were killed in the Second Sudanese Civil War, and is run by the Kenyan government and the UN Refugee Agency.
Joshi’s Kakuma research, supported by the UC Berkeley School of Public Health, the Bixby Center for Population, Health and Sustainability, and the UC Berkeley Center for African Studies, is among the first to analyze the self-identified health needs and access to care of these displaced South Sudanese women living through compounded crises: armed conflict, food insecurity caused in part by climate change, and the lingering effects of the COVID-19 pandemic.
Every step of Joshi’s research is taken in partnership with the refugee women of Kakuma. The women have worked alongside Joshi to develop research questions and study tools; interview other refugees; transcribe recordings; and otherwise contribute to the project. The methodology falls under the principles of community-based participatory research (CBPR), developed at UC Berkeley Public Health as a collaborative process that equitably involves community members, researchers, and other stakeholders in the research.
“As a scientific community, we have overlooked and excluded marginalized communities from our work, and that’s why there’s a dearth of data on these communities,” Joshi said. “Having come from a developing country myself [India] and having been exposed to the other side of the decolonizing global health movement, I understand the importance of sustainability of this work.”
The stakes are high: South Sudan has the worst rate of maternal mortality in the world—1,223 maternal deaths per 100,000 live births, compared to the United States’ 21 deaths per 100,000, or Germany’s five deaths per 100,000. All told, countries like South Sudan, for which the UN has issued a Humanitarian Appeal, account for 58% of global deaths in childbirth.
In these settings, sexual and reproductive health services are often deprioritized for what are perceived to be more urgent needs. Existing standards on reproductive health delivery in humanitarian settings are not always based on empirical evidence, or applicable to the specific context. Joshi’s research seeks to fill that gap.
In a landscape where a huge amount of global aid funding has either paused or sharply declined, micro-research projects like hers are even more important.
Joshi’s preliminary findings suggest challenges with women giving birth before reaching a health care center; a shortage of healthcare providers and supplies; the use of outdated equipment and limited specialized services. There is no cervical cancer screening. Family planning remains critically low, and abortion provisions are non-existent, due to social norms. Joshi also found that cases of maternal mortality are not reported.
“Compounded crises amplified these challenges, placing refugee women at heightened risks of gender-based violence, unintended pregnancies, and child marriages,” Joshi said. “Health providers also reported women resorting to transactional sex for survival.”
A lifelong passion for helping other women
Joshi was born and raised in New Delhi, India, a dense megacity thronged by more than 33 million people. She lived with her grandparents, brother, and parents, who worked as mid-level public service servants and always encouraged Joshi’s big dreams. Her large extended family lived close by, the house always filled with people.
At 14, Joshi learned about the United Nations in a textbook. “I came back home and showed that to my parents,” she said, laughing. “I said this is where I will work one day, and I have invested my entire life for that.”
A competitive dancer and star student, Joshi’s rich academic and personal life didn’t insulate her from exposure to sexual abuse. That reality shapes the way she engages with her work.
“I think my passion stems from the incidences of violence that I have experienced,” she said. “I always shudder to think that if in my privileged bubble I could undergo something like this, what is it like for millions of women and girls who belong to marginalized communities?”
Joshi received her bachelor’s in political science from Delhi University. She went on to become the first in her family to study abroad, first earning a master’s in international law and human rights at the UN’s University for Peace in Costa Rica, and now at UC Berkeley.
Joshi began studying health care in humanitarian settings long before her research in Kakuma. In recent years Joshi has studied migration health in Greece, and worked with Ukrainian women refugees seeking reproductive healthcare in Croatia. Earlier, she led research teams across rural India and Bangladesh tackling issues of reproductive health, education, disability inclusion, and women’s economic empowerment.
For Joshi, working with South Sudanese women—the population most impacted by maternal mortality and also experiencing compounded crisis—was a natural next step.
“I want to ensure we are reaching the furthest behind communities first, with the aim to leave no one behind on the grounds of age, gender, race, economic status, and nationality,” Joshi said.
She partnered with AMREC, a Kenyan consultancy firm, to initiate a relationship with the Kakuma community and start the research process. She then recruited six young women, all under 30 and living in the camp, to work as paid data collectors. Joshi trained them to conduct interviews, log data, and engage with the community on sensitive issues—in the Dinka, Dadinga, Nuer, and Arabic languages—all represented among the South Sudanese population.
Photo: Maggie Andresen
“For the first day, it was hard,” said Alik Alak, a 25-year-old data collector. “We had to work extra hard to get these participants.”
Alik Alak was born in Kakuma camp. Her mother had settled there in the early 1990s. Shy and thoughtful, she described one woman she interviewed whose story stays with her.
“She can stay the whole day in the house because of lack of sanitary towels,” Alik Alak said, referring to the pittance of roughly $8–10 each refugee is allotted every month, which is rarely enough to cover the cost of menstrual products after purchasing food and other necessities.
“She’s doing a lot so that she can make sure the kids go to school, the kids get some food to eat,” Alik Alak said, softly. “She has no option.”
Alik Alak is part of the large group gathered in July at the Cairo Palace Hotel, in Kakuma, to hear Joshi’s preliminary results from her February 2024 research trip there. Five of her interviewers are present, as are participants from the four health care provider focus groups she conducted, and representatives of the health facilities she assessed for delivery of care.
Nearly all of the people present are refugees living in Kakuma and the adjacent settlement Kalobeyei, which hosts newer arrivals.
Instead of waiting to return to the community after her report was published, Joshi chose to come back earlier, to solicit feedback and seek permission for publishing the data. The decision for this study to go forward now rests not with Joshi, but with everyone else in this room.
“You know, not many of the researchers do that,” Alik Alak said. “They just come collect the data and go with it. They don’t come back and show you the overview of what you have done. We are really proud, and we are happy that Bhavya came back.”
After Joshi presents initial findings from the research, participants organize into groups and reflect on the implications of the research on the individual, family, societal, and institutional levels. They provide feedback on large sheets of paper and Post-it notes scattered across the room, sharing what resonates from the findings, and what’s missing.
“The use of [a] community-based participatory research approach is very encouraging as it allows [the] community to own the research,” one Post-it reads.
“Looking forward to future collaboration,” reads another. By the day’s end, the community buy-in is clear.
Reproductive health interventions
The night after the workshop, a rainstorm rages and lingers into the morning, turning the dirt roads that connect Kakuma camp into impassable muck. In spite of the weather, Joshi heads into a meeting with the Kenya Red Cross in their secluded Kakuma compound shared with other international NGOs.
The office is small and neat, rain dinging off the steel roof. Bhavya is greeted by Christine Simiyu, who has worked as a coordinator for reproductive health and gender-based violence in Kakuma for eight years.
Simiyu said that many women in the camp neglect their reproductive health to focus on basic needs, in particular because women there are expected to defer to their husbands on family planning—or lack thereof.
“People are always looking for survival,” she said.
Simiyu recalled one woman who—exhausted from repeated pregnancies and miscarriages—was surreptitiously getting contraceptive injections every few months at the clinic without permission from her husband.
“[The nurse] told her to come in the afternoon when [her] husband was out there working, and this husband suspected and decided to monitor his wife’s movements,” Simiyu said.
After finding his wife about to receive a contraceptive injection, the woman’s husband attempted to attack the nurse, but was removed by hospital security.
“There are a lot of issues around reproductive health mixed with gender-based violence,” Simiyu said. She also says that demystifying family planning is an important way to address that violence.
“Male involvement is very important,” Simiyu said, further acknowledging the complex relationship Kakuma’s South Sudanese population has to family planning methods.
“They tell us that for anyone who is dying in South Sudan, they have to be replaced here in the camp,” Simiyu said. “They are seeing it as a way of continuing the generation and the family by having more children so that they can cover up for the population that was lost.”
It’s an understandable position when one considers the conflict’s death toll since 2011, which has surpassed 400,000.
Joshi scribbles notes and asks follow-up questions. She wants to hear more about a series of male focus groups on family planning held recently by the Red Cross. A small preliminary project, the participants were limited to one village in the camp—where after just four group discussions, family planning uptake went from 9% to 15%.
“It’s low-hanging fruit for a reproductive health intervention” Joshi said, noting that a combined approach pairing focus group discussions with information campaigns in partnership with male leaders might lead to a large uptake in family planning.
This could be a next step in her research. Other areas of research might include school-based interventions exploring the use of digital health tools and mobile technology to address child marriage, teenage pregnancy and menstrual hygiene among adolescents, or a larger campaign against gender-based violence.
The magic of community-based work
At six am the next day, Joshi leaves Kakuma for Nairobi. The road is clouded by mist, cut only by the headlights of the rare car speeding down the highway in the other direction. In silence, Joshi watches from the front seat of the car—a brief, quiet pause in a week of almost incessant activity.
Back in Nairobi, she begins to prepare for a stakeholder meeting planned for the next day, this one with a group of representatives from the Ministry of Health, the Population Council, researchers from Kenyatta University, and more. The meeting will be well-attended, and Bhavya’s findings well-received. Her peers will offer valuable feedback, which she will integrate into her analysis. But that’s for tomorrow.
For now, she sits in the hotel restaurant, processing the last few days between updating powerpoints, responding to emails, and sipping a glass of wine.
“On day two of the February interviews, some of the women said that they really felt a burden was lifted off them by talking to us about their reproductive health,” Joshi said. One woman said that she’d been waiting to share her story for the last three years.
“We finished that interaction with her and she said, ‘There are a bunch of my friends who feel the same… just take that burden off them if you can.’”
And that’s the magic of this community-based work—when requests like that come up, the study can rise to meet them. Because it’s not about working for, or even in service of, communities—it’s about working together to create something real.
“We hope the insights from our findings could lead to improvements in refugee’s reproductive health in Kenya and guide policy makers to plan for compounded crisis management,” Joshi said.