I looked at the Sustainable Development Goals for fun last week, became blinded by their Biblical length and decided that I’d revisit them when my sight returned. I still can’t really see, but managed to get through them anyway.
The SDGs are a replacement for the now-expired Millennium Development Goals (MDGs), a set of benchmarks that serve as a guide for the development trajectories of developing countries. The MDGs were widely criticized for lacking proper justification and for not providing proper means to measure the items suggested.
The items range from standard development goals such as “elimination of poverty” to far more complicated items such as number 12:
Rationalize inefficient fossil-fuel subsidies that encourage wasteful consumption by removing market distortions, in accordance with national circumstances, including by restructuring taxation and phasing out those harmful subsidies, where they exist, to reflect their environmental impacts, taking fully into account the specific needs and conditions of developing countries and minimizing the possible adverse impacts on their development in a manner that protects the poor and the affected communities.
Good god. It’s like the SDGs went out of their way to create titles for every development proposal for the next ten years so people wouldn’t have to. Unfortunately, this particular proposal will be incomprehensible to the common person. It is ironic that item 17.14 is “Enhance policy coherence for sustainable development.”
Living in Africa, it’s pretty easy to get cynical about international development projects. One of the effects of the SDGs, however, will be to stifle craetivity by being too specific. It is a reality that a lot of NGO work is redundant or ineffective, but the MDGs were at least broad enough to allow locals to come up with ideas to address them on their own that took local conditions into account. I’m not sure the the SDGs will allow that level of freedom.
I’m going to end this short post with Kurt Schwitters. It seems appropriate.
Why malaria? Over-researched, over-funded, diminishing returns? Rambling on the need for student mentorship.
Last week I gave an informal lecture on survey sampling to a small group of graduate students from a number of countries. With only one exception, all of the students were working on various aspects of malaria, primarily in basic sciences. The lone non-malaria student was from Vietnam and is interested in Dengue fever.
I praised her for working on Dengue. Dengue presents a serious threat to human health in all countries where the vectors exist, but the burden of disease will be particularly felt in rapidly urbanizing areas of developing countries.
Developing countries are ill equipped to deal with Dengue, and the antiquated nature of their health care systems, leftover by the colonialists, means that diagnostics are mostly non-existent and drugs wholly unavailable. Any fever in most of Sub-Saharan Africa is diagnosed simply as malaria, drugs administered and the patient left on their own.
We have extensive experience, however, with malaria. While there are numerous challenges to reducing malaria incidence, preventing recrudescence and postponing drug resistance, the basic fact is that the best way to eliminate or control malaria is to simply make people less poor. Even countries with holoendemic transmission, wealthier people get malaria less often than poor people, and poor people who live in wealthier areas get sick less than wealthier people in poor areas. This is known (in Game of Thrones parlance).
So, as we discussed the topic during lecture, I softly tried to encourage the students to look at other areas where they might be able to better apply their skills. They were mostly unresponsive, which is fine. Someone has to tell them, it might as well be me.
One of the students, however, indicated that “malaria is where the money is.” I couldn’t disagree. The reason that we put so much money and effort into diseases like malaria and HIV is simply because they yield marketable products. Medications for diseases like tungiasis (jiggers) are so simple as to not be profitable, customers too poor to buy them, and governments and donors too distracted by big diseases like malaria, HIV and TB to be concerned with dumping money to provide them for free.
And this is where the problem lies. We have a self propagating system of companies, researchers and donors, which simply float money between one another with little regard for the needs of the poorest of the poor. Breaking the cycle is difficult, but it starts with academics who need to push students to do work with neglected, overlooked or under-researched diseases. Even small grants can support small, but meaningful projects.
We have reached a point where malaria funding for malaria research is yielding ever diminishing returns. Money needs to be put into programs to deliver the tools we have and make ITNs, ACTs and IRS available to the people who need them, who often have trouble getting them. Moreover, we need economic development to make people less poor in developing coutnries so that fewer of their babies die. Human resources in developed countries need to start focusing on emerging (or already emerged but ignored) threats lke antibiotic resistance, Dengue fever, emerging zoonotics and others. That starts with us as mentors.
I’m only a middle author, but I have a new publication out. After being involved in this, I will never eat mukimo (Kenyan mashed potato dish) ever again. Ever again.
First Report of a Foodborne Providencia alcalifaciens Outbreak in Kenya.
Shah MM, Odoyo E, Larson PS, Apondi E, Kathiiko C, Miringu G, Nakashima M, Ichinose Y.
Am J Trop Med Hyg. 2015 Jun 29. pii: 15-0126.
Providencia alcalifaciens is an emerging bacterial pathogen known to cause acute gastroenteritis in children and travelers. In July 2013, P. alcalifaciens was isolated from four children appearing for diarrhea at Kiambu District Hospital (KDH) in Kenya. This study describes the outbreak investigation, which aimed to identify the source and mechanisms of infection. We identified seven primary and four secondary cases. Among primary cases were four mothers who had children and experienced mild diarrhea after eating mashed potatoes. The mothers reported feeding children after visiting the toilet and washing their hands without soap. P. alcalifaciens was detected from all secondary cases, and the isolates were found to be clonal by random amplified polymorphic DNA (RAPD) fingerprinting. Our study suggests that the outbreak was caused by P. alcalifaciens, although no fluid accumulation was observed in rabbit ileal loops. The vehicle of the outbreak was believed to be the mashed potato dish, but the source of P. alcalifaciens could not be confirmed. We found that lack of hygiene, inadequate food storage, and improper hand washing before food preparation was the likely cause of the current outbreak. This is the first report of a foodborne infection caused by P. alcalifaciens in Kenya.
© The American Society of Tropical Medicine and Hygiene.
PMID: 26123962 [PubMed – as supplied by publisher]
I traveled out to Kwale on the Kenyan Coast and celebrated Eid (the end of Ramadan) with my friend Juma and his family in Mwachinga. It was a great time for everyone (except the goat). It rained on and off, but the ladies made up some great Pilau and the men had some conversations about Islam and witch doctor Senators. Juma even gave us a detailed family history. Finally, everyone had a serious discussion on the impacts of social media on family relations.
After a grueling 12 hour bus ride from Nairobi to Mombasa, the highlight of the trip was a two hour tuk tuk ride across the ferry and all the way out to Kwale Town. I’m still not sure how it made it up all the hills.
Infectious disease transmission dynamics and the ethics of intervention based public health research
I think a lot about ethics and ethical issues. Research in Sub-Saharan Africa presents unique risks for ethical breaches. Given income and power disparities between individuals and foreign researchers and even between individuals and local political leaders the possibility of coercive research is ever present. Pressure to produce can lead to unrealistic assumptions of risks and benefits to very poor individuals. Inadequate knowledge or willful ignorance of local political issues can compromise future research activities, both by international and domestic groups.
Recently, though, an interesting situation came across my desk that included an intersection of ethics and the dynamics of infectious disease transmission.
As everyone knows, not all infectious diseases are the same. Some, like measles, impart full immunity upon exposure, whereas diseases such as malaria impart only partial immunity, requiring repeated exposures to acquire full or adequate immunity to prevent death or serious injury. Moreover, as immunity and immune reactions change over the life course, the time (age) of exposure are sometimes crucial to prevent serious disease. Polio is a great example. Exposure in infancy leads merely to diarrhea, where exposure at older ages can lead to debilitating paralysis.
I was thinking of an population based intervention study which provides some sort of malaria medication to a small population in a holo-endemic area. Given the year round nature of malaria transmission in this area, we would expect that even with a depression in symptomatic and asymptomatic cases, active transmission in the surrounding areas would lead to recrudescence within a very short time. Given the short time frame, we would assume very little interruption in the development of immunity in small children and might even see a short term reduction of childhood mortality. Assuming that this medication presented little or no risk of serious side effects, I believe that there is little reason to assume an ethical breach. A short term reduction in malaria would suggest that the benefits far outweigh the risks.
However, conducting the same study on a very large population in the same area might have very different outcomes. Delivering a malaria medication to, say, an entire county surrounded by other areas of extremely high transmission would indicate that recrudescence is also inevitable but that the time required to return to pre-intervention levels is extended. Infectious disease transmission requires a chain of hosts. The longer that chain, the longer it will take for new hosts to become newly infected.
Theoretically, this could delay infections in small children and it is theoretically possible that we might see a spike in childhood mortality, since the timing of initial malaria infection and frequency of infections are crucial to preventing the worst outcomes.
Of course, I’m not suggesting that people should just get infected to induce immunity, but I am suggesting that a study which seeks to reduce transmission through pharmaceuticals given only intermittently (as opposed to prophylactically) consider all possible implications. Insecticide treated nets (ITNs) provide protection over time and are a form of vector control. A medication given at a single time point merely clears the parasite, but does nothing to prevent bites or kill mosquitoes.
Though I could be overthinking the issue, my worry is that ethical approvals approach the issue of mass distributions of pharmaceuticals as a one size fits all issue without taking other factors such as population size and acquired immunity into account. Malaria, as a complex vector borne disease introduces complexities that, say, measles does not. Researchers, IRBs and ethics board would do well to consider this complexity.
Since I’ve arrived here in the Gambia, I’ve been searching for music. Unfortunately, I’ve come up dry every night. Last Thursday, I heard music from behind the research compound, but was too tired to pursue it and, really, you can never be sure. Sometimes things sound cool through the echoes, but you might follow the sounds only to find Kenny Rogers being played for tourists.
Last night, I heard it again, and decided to chance it. It was so loud and chaotic, it sound like it might be a live band. I leave tomorrow, so this is my only chance.
I followed the sounds out to the back of the compound and found a group of old ladies gathered on plastic chairs around a giant stack of speakers, blaring out some kind of ultra hard beats. A kid with a laptop was DJing but it looked like people were just arriving. The scene was bizarre. Old ladies and grandkids politely chilling out to heavy beats through a wall of speakers.
I decided to go back later. I was wary. It could be some religious thing. It’s Islam here, but still…
When I went back, it was total chaos. This is definitely NOT a religious event (in the Abrahamic sense) and most certainly NOT a tourist event.
More people had arrived and were standing in a circle watching young dude do impossibly athletic dances while an old man MC egged them on and called other people to join. I had heard stories of dancing in West Africa and I have to say the stories are absolutely true. The young guys were the craziest, but kids, old ladies, women in fancy dresses and old men all got in the circle and showed their moves off and every time, people would go nuts with approval.
All to an energetic soundtrack that would get the cops out in a second in the US. I had never seen anything like it.
At one point, a blindfolded guy dressed as a woman comes out hold a dead chicken in one hand and money in the other. He does his chicken dance over a money pot and starts handing out notes to whomever is brave enough to get close to him. After the money runs out, he starts doing this thing where he leans over just barely touching the ground, seemingly suspended in air. Eventually, he disappears and returns out with a giant cinder block balanced on his back and does the same thing again. I have no idea what it was about but it’s clear that there’s order to this chaos.
After people start showing their moves again, a guy tries to get me to go into the circle. I’m like “no way.” I’m not going to be that bad dancing white guy. Some kids are egging me on trying to show me moves and cheering and laughing when ever I try. I should have tried harder. Music is a wonderfully great thing.
Unfortunately, I didn’t have a camera on me, but I did get an audio recording and a couple of pictures with my cell phone. I’m am most certainly coming back to West Africa.
Not much else to post, so I’ll add a few pictures of a bird watching trip in the Gambia. Turns out the Gambia has an incredible bird diversity. Unfortunately, my camera couldn’t capture it but we play with the cards we are dealt with…