Archive by Author | Pete Larson

On the way back from Kwale

Spent the week in Kwale, a sleepy town on near the Mombasa coast. The security situation prevents me from spending a whole lot of time there. I find this to be incredibly saddening but its unavoidable. Some people brave it out and stick with it, but I just can’t justify the awful risks.

The Japanese folks are mostly oblivious to it all, or maybe just indifferent. I’m convinced that they have no real concept of threat, given the relative safety of Japan itself. It’s a horribly dangerous situation but fortunately they stay locked inside. Japanese people love to sit at desks, even when they don’t really have to. Japan has yet to appropriate the concept of the mobile office. (Sorry, generalizations abound….)

I’ve caught some infection, but it’s hard to say exactly what it is. At first, it looked a lot like malaria, but then everything looks like malaria. Now, I’m just in a general state of not feeling well. It’s not responding to antibiotics, which makes me suspect that it’s not bacterial in nature. I started a round of ACTs just in case. They leave me a bit loopy, but I’m improving somewhat. A malaria test turned out faintly negative, but it’s possible the antibiotics are skewing the result or that the guy doing the test spilled to much assay onto the test. So, I’m not sure. I have a somewhat better appreciation for why the tests are treated with suspicion by the locals.

In any case, I feel like total hell, but thankfully have a normal appetite and digestion. I deeply crave red meat though, which leads me to suspect that the dizziness is anemia and thus, the cause could be malaria. This might be wishful thinking though. I could simply be exhausted.

Kenyatta is universally hated on the Coast, which explains a lot of the violence here. Though people apt to disregard domestic politics when talking of terrorism here, it’s hard to rule it out given the vast resentment toward the Jubilee party here on the coast. In fact, the lack of attention to security by the Kenyatta administration is likely fueling even more resentment, which might be fueling even more violence or at least, helping improve recruiting numbers for Al Shabab. As crazy as I think Luo politics are, Raila Odinga would have made a far better president.

People here are convinced that Kenyatta is a weed-head. “He is smoking the mari-ju-a-na.”

I spent the last two days convalescing in a hotel located within the Shimba Hills Nature Reserve. As much as I wanted to tough out the guest house in Kwale (which really isn’t so bad at all), I really needed a decent few hours of rest in a somewhat pleasant environment. It was worth it. A real hot shower and a set of clean sheets is worth the extra cash every now and again. The only wildlife to be seen were bush babies and squirrels, who seem to have worked out a deal where one begs for food in the day, and the other at night.

Malaria transmission here is low and it shows. Malaria endemic areas are characterized by low levels of education, part of which may be attributable to the inhibited cognitive development of children due to repeated malaria infections. Even if educational opportunities are available, kids in malaria endemic areas appear to have worse outcomes. It’s somewhat staggering at times, after having worked in Western. Part of it also could be the influence of Islam.

I’m now flying back to Nairobi where I’ll crawl into my bed. If I’m lucky, I’ll not come out for a few days.

(Mostly) Vindicated: Euclidean measures of distance are just as good as high priced, fancy measures

DistancePlotsITNIn my seminal paper, “Distance to health services influences insecticide-treated net possession and use among six to 59 month-old children in Malawi,” I indicated that Euclidean (straight line) measures of distance were just as good as more complicated, network based measures.

I didn’t include the graph showing how correlated the two were, but I wish I had and I can’t find it here my computer.

Every time I’ve done presentations of research of the association of distances to various things and health outcomes, someone inevitably asks why I didn’t use a more complex measure of actual travel paths. The idea is that no one walks in a straight line anywhere, but rather follows a road network, or even utilizes a number of transportation options which might be lost in a simple measure.

I always respond that a straight line distance is as good as any other when investigating relationships on a coarse scale. Inevitably, audiences are never convinced.

A new paper came out today, “Methods to measure potential spatial access to delivery care in low- and middle-income countries: a case study in rural Ghana” which compared the Euclidean measure with a number of more complex measurements.

The conclusion confirmed what I already knew, that the Euclidean measure is just as good in most cases, and the pain and cost of producing sexy and complicated ways of calculating distance just isn’t worth it.

It’s a pretty decent paper, but I wish they had put some graphs in to illustrate their points. It would be good to see exactly where the measures disagree.

Background
Access to skilled attendance at childbirth is crucial to reduce maternal and newborn mortality. Several different measures of geographic access are used concurrently in public health research, with the assumption that sophisticated methods are generally better. Most of the evidence for this assumption comes from methodological comparisons in high-income countries. We compare different measures of travel impedance in a case study in Ghana’s Brong Ahafo region to determine if straight-line distance can be an adequate proxy for access to delivery care in certain low- and middle-income country (LMIC) settings.

Methods
We created a geospatial database, mapping population location in both compounds and village centroids, service locations for all health facilities offering delivery care, land-cover and a detailed road network. Six different measures were used to calculate travel impedance to health facilities (straight-line distance, network distance, network travel time and raster travel time, the latter two both mechanized and non-mechanized). The measures were compared using Spearman rank correlation coefficients, absolute differences, and the percentage of the same facilities identified as closest. We used logistic regression with robust standard errors to model the association of the different measures with health facility use for delivery in 9,306 births.

Results
Non-mechanized measures were highly correlated with each other, and identified the same facilities as closest for approximately 80% of villages. Measures calculated from compounds identified the same closest facility as measures from village centroids for over 85% of births. For 90% of births, the aggregation error from using village centroids instead of compound locations was less than 35 minutes and less than 1.12 km. All non-mechanized measures showed an inverse association with facility use of similar magnitude, an approximately 67% reduction in odds of facility delivery per standard deviation increase in each measure (OR = 0.33).

Conclusion
Different data models and population locations produced comparable results in our case study, thus demonstrating that straight-line distance can be reasonably used as a proxy for potential spatial access in certain LMIC settings. The cost of obtaining individually geocoded population location and sophisticated measures of travel impedance should be weighed against the gain in accuracy.

Sick animals in Gembe East

OLYMPUS DIGITAL CAMERAI went on a hunt for some sick animals… and finally found some! We were visiting some families in Gembe East, and area close to Mbita Point in Homa Bay County and found a man who had more than 50 goats and nearly 20 cows. In Maasai-land, that’s a tiny herd, but in Luo-land, its gigantic.

He had a sickly goat which had just aborted, vaginal discharge, was feverish, emaciated and had a hard coat. A friend suggested it might be Brucella, but without a test, we’ll never really know. Either way, I suggested that it might not be a terrible idea to make choma out of it (as he said he was going to do) and get it away from the pregnant lady in the house. He reported that there had been a couple of other abortions in his herd.

The cows in Luo-land don’t look very good. It’s possible that the scant rains recently are having an impact on the vegetation. Pink-eye is everywhere right now.

So much is made about potentially zoonotic diseases in giant pastoralist herds, but the issue goes mostly ignored around Lake Victoria. Though animal possession per household is low, there are more households living in more densely populated conditions, meaning that there are potentially more animals per square kilometer in Nyanza than in Northern Kenya.

A combination of high human and animal density, poverty and a shared water source could create perfect conditions for a zoonotic disease outbreak.

Yesterday, someone gave me a live chicken

I am the owner of this chicken.

I am the owner of this chicken.

Later next month we’re planning to have a soccer match in Gembe East, a village of approximately 15,000 people located just east of Mbita Point in Homa Bay County. We’ve been doing research work there for the past decade or so but I don’t think that my employer has really taken the time to try to integrate with the community in any capacity other than research and health interventions.

We were having choma with the chief of the area a few weeks ago, and we came up with the idea of having a regional soccer match. Yesterday was the first meeting of the planning committee. (Turns out that putting on a soccer match is like setting up a punk show, except that people will probably turn out.)

We discussed the particulars of the football match, and then ate a great chicken dinner from the chief’s mother. We also met the chief’s father, an 87 year old ex-school teacher who had his last child 12 years ago and learned of that gentleman’s mother who died two months ago at the incredible age of 105. In an area where the average life expectancy hovers just around 40, these are some tough people indeed.

After eating, we went and checked out the soccer pitch, which has an amazing view of Lake Victoria and some nearby mountains. It’s going to be a great day.

The roads out there are terrible. I was getting sea sick on the way back, when the guys in the car suggested that we go an visit on of our staff members. I reluctantly said ok since I was just hoping to get out to the main road as quickly as possible. (Plus the Iran/Argentina game was about to start.)

We arrived to his house and it was already dark. The staff guy is there standing outside holding a radio. His wife looks like she’s just come from church.

Everyone suddenly jumps out of the car and proceeds to run around greeting one another. I talk to the staff guy for a moment. He’s exceedingly friendly but looks somewhat impatient. I figure out that the radio means that he’s waiting for the game to begin.

Silas (another staff member) asks me if I like watermelon. I say yes, and the wife comes up behind me and puts a live chicken in my hands. “This one will be very sweet” comes out in a really confident, educated brand of English that’s somewhat uncharacteristic of the area.

I’m not sure what to do. I’ve never held a live chicken before. I say thank you and carry it over to the car and put it in the back with the watermelons. We quickly say thank you, get in the car and drive on.

On the way back, I have to keep making sure that the chicken doesn’t get crushed by a rolling melon. After we get home, we put the chicken in a box and set it in the food pantry with some corn and rice.

We’ve resolved to have the house lady transform the chicken into dinner tomorrow, which gets me off the hook, because I have no idea how to do such things.

Mfangano (and missionaries in Kenya)

White lady comes to save African children from themselves by having her photo taken with them.

White lady comes to save African children from themselves by having her photo taken with them.

I went and checked out Mfangano, an island close to here that’s home to about 25,000 people (or 16,000 depending on who you ask). It is famous for some 2,000 year old rock paintings done by the Twa people, a group of hunter gatherers whose range historically extends all the way over to Western Africa.

Unfortunately, the Twa are long gone from the island, which is now occupied by Suba and Luo people, though the Suba are quickly being assimilated into the Luo through marriage.

It’s an odd place. They’ve got a small tourism industry, are currently installing new power lines and have recently gotten true ferry service from the mainland, but the roads are still terrible.

We ran into a group of missionaries on the way back. I always feel somewhat violated after talking with missionaries in Africa. What are they doing here? This looked like some polygamous group of Mormons but it turned out they were from Alberta and Kansas.

One of them asked us what we were “lonesome for.” I didn’t know how to respond so we asked them what they were lonesome for, to which they said “Wal Mart.”

While I hate to judge, it was telling that they all introduced themselves to us, but not Victor, an employee of the Kenyan Medical Research Institute who was standing right next to us. I’m convinced that they don’t see the locals as people.

What developmental role do missionaries play? They make no demands on politicians to solve pressing problems of political dysfunction, infrastructural weakness, employment, a lack of access to capital, crippling bureaucracy, corruption, graft, nepotism and terrorism. None of these problems can be solved through missionary activities which emphasize odd moral codes more fitting to white, rural Kansas than complicated and chaotic Kenya.

Development as unfreedom….

Was reading Chris Blattman’s list of books that development people should read but don’t and found this in the Amazon description of “The Anti-Politics Machine: Development, Depoliticization, and Bureaucratic Power in Lesotho.”

Development, it is generally assumed, is good and necessary, and in its name the West has intervened, implementing all manner of projects in the impoverished regions of the world. When these projects fail, as they do with astonishing regularity, they nonetheless produce a host of regular and unacknowledged effects, including the expansion of bureaucratic state power and the translation of the political realities of poverty and powerlessness into “technical” problems awaiting solution by “development” agencies and experts.

Note that I do not harbor any ill will toward development or even, as a general rule, “technical solutions.” Having been involved with bed net distributions and having watched the outcomes of reproductive health interventions, for example, I can say that there are many positive outcomes of development projects. In my area, fewer kids are dying and women are becoming pregnant a whole lot less, decreasing the risk of maternal mortality.

Disclaimers aside, there is no doubt that development projects often fail for a number of reasons, the first of which is that leaders have no interest in seeing that they succeed. While leaders are indifferent to the outcomes, they happily take on the power that comes with them, embracing bureaucratic reforms, which are mostly just expansions of power at all levels of government.

This wouldn’t necessarily be a bad thing, except that African countries never embraced many of the protections of individual rights which restrict the powers of the state. Independence movements in much of Africa was predicated on an eventual return of power to the majority. Not many (none?) of these movements sought to protect the rights of the minority, much less the individual. Thus, there is little restriction on the types of rules which may be created and since many of these development projects influence policy, development projects unwittingly feed into the autocracy machine.

Can the use of technology in surveys change the nature of responses?

In the past, surveys were done on paper, either through a designed questionnaire or by someone frantically writing down interview responses. When computers came around, people would be hired to type in responses for later analysis.

Nowadays, with the advent of cheap and portable computing, research projects are rapidly moving toward fully digital methods of data collection. Tablet computers are easy to operate, can be cheaply replaced, and now can access the internet for easy uploading of data from the field.

Surveyors like them because large teams can be spread out over a wide space, data can be completely standardized and the tedious process of data entry can be avoided.

Of interest to me, however, is whether the technology is influencing the nature of the responses given. That is, will someone provide that same set of responses in a survey using digital data collection methods as in a paper survey?

Recently, we attempted using a tablet based software for a small project on livestock possession and management on Mbita Point in Western Kenya. I intended it as a test to see if a particular software package might be a good fit for another project I`m working on (the one that`s paying the bills).

We had only limited success. The survey workers found the tablets clunky and a number of problems with the Android operating system made it more trouble than the survey was actually worth. Of interest, though, was how the technology distracted the enumerators from their principle task, which was to collect data.

Enumerators would become so wrapped up in trying to navigate the various buttons and options of the software that they couldn`t effectively concentrate on performing the survey. Often they appeared to skip questions out of frustration or would just frantically select one of the many options in the hope of moving on to the next one.

In a survey of more than 100 questions, the process started taking far more time than households were willing to give. We eventually had to abandon the software and revert to a paper based method.

Surveys went from lasting more than one hour, to taking under 30 minutes. Workers were more confident and had more time to interact with the respondents. Respondents had more of an opportunity to ask questions and consider the meaning of what they were being asked. They offered far more information than we expected and felt that they were participating in the survey as a partner and not just as a passive victim.

One of our enumerators noted that people react differently to a surveyor collecting data on the tablets than with paper. She described collecting data with technology as being “self absorbed” and alienating to the respondents. Collecting data on paper, however, was seen as a plus. “They can see me writing down what they say and feel like their words are important.”

I`m thinking that the nature of the responses themselves might be different as well. Particularly with complex questions of health and disease, often the surveyors will have to explain the question and give a respondent a chance to ask for further clarification. Technology appears to inhibit this process, perhaps compromising the chance for a truly reasoned response.

While I am absolutely not opposed to the use of technology in surveys, I think that the survey strategy has to be properly thought through and the challenges considered. At the same time, however, data collection is a team effort and requires a proper rapport between community members and surveyors who often know each other.

Is technology restricting our ability to gather good data? Could the use of technology even impact the nature of the response by pushing them in ways which really only tell us what we want to believe rather than what actually exists?

Kenya: Movin’ on up

IMG_1372Currently, I’m staying in Mbita, a small fishing community in western Nyanza province, located along Lake Victoria. Sometimes, we can see Uganda, and Tanzania is just a stone’s throw away.

I’ve been coming here for close to three years, and I’m struck at the rapidity of change here. There used to be only two ferry trips a day to Luanda Port, where you can catch a minibus to Kisumu, Nyanza’s largest city. Now, there’s not only multiple trips a day, but also two ferries, a small one and a large one.

You can also catch a ferry to neighboring Mfangano island, a small but heavily populated place which was formerly mostly isolated from the mainland.

The power still comes on and off, but blackouts are shorter and more infrequent. There are multiple places to see music now, a direct result of people having more money. Local and national acts are taking advantage of Mbita’s increased affluence.

Mirroring much of Kenya, though, construction of a few “high rise” buildings has been completed, but it’s kind of unclear as to who is going to move in. “Mbita Towers” is mostly empty.

People look better, the cars are in better shape, there are more buses going to Kisumu and Nairobi and there is a larger variety of foods and goods available at the local market. This is due in part to the semi-completion of a road connecting nearby Homa Bay to Mbita. There are still a few rough spots between, but it’s mostly passable now. Someone told me that just four years ago it took two days to get from Nairobi to here, despite there being only 400 km between them.

No doubt, this isn’t due to the good graces of any particular development project at all, but rather to the increased affluence of Kenya as a whole. Kenyatta’s government would inexplicably love to credit the Chinese, and they should be credited for constructing some of the road infrastructure, but the real credit has to be given to the development of the domestic economy and Kenya’s status as the most liberal economy in the region.

Kenyans are increasingly not only connected with the world, but also to each other. Cell phones, for example, have allowed Kenyans greater mobility so that they can take advantage of money-making opportunities elsewhere, and mobile banking allows money to flow out of Nairobi, where it was traditionally concentrated.

Kenya still ranks low on “ease of doing business” indicators, and continues to be excessively bureaucratic. New rules seem to appear each day, the goals of which are often unclear and seem to be aimed only at corrupt officials on every level of government. A recent ban on tinted windows, supposedly aimed at terrorism, and an onerous highway speed limit of 80 km/h for small trucks, billed as reducing traffic fatalities, are providing a steady source of cash for hungry highway policemen. It’s worth noting that the latter rule doesn’t apply to SUV’s, the vehicle of choice for Kenya’s elite.

Fortunately, many people simply ignore the government and carry on like it doesn’t exist. This is particularly true out here. My taxi driver completely ignored the speed rules and sped on at 120 km/h. Of course, there’s not a policeman to be seen anywhere out here outside of the the local bar at 3 p.m. The relative peace out here makes them mostly unnecessary, anyway.

Management dilemmas: ask and ye might receive…. or not

I just had one of those moments. I walked into the office and the staff complained that the uninterruptible power supply was not functioning. I noticed that there were at least 30 items plugged into the UPS, which itself occupied only one outlet.

I was annoyed. “You’ve killed the UPS by plugging so much stuff into it.” This was true. After instructing the staff to only plug a certain number of essential items into the UPS, I discovered that there was only one functioning outlet in the entire room, which was the one being used.

So the cause of the problem was not an irresponsible (and dangerous) use of the outlet, but rather because there weren’t any other options available.

I had to fault the staff for not asking anyone to fix the broken outlets (which is the real reason the UPS failed) and asked them why they hadn’t brought it up. They said that they don’t bother to ask since they don’t expect anyone to do anything about it. They didn’t seem to have any problem asking for a new UPS, however.

It was a complicated feeling. On the one hand, I had to confront my own kneejerk biases (WTF IS WRONG WITH YOU?), on the other, I felt really bad that the staff feels like they can’t ask to get shit fixed, on the other, I’m confused that it’s ok to ask for new stuff rather than to fix a persistent problem.

Perhaps I’m not cut out for this?

A sick mother will make a sick baby who becomes a sick adult

As much as we’d like to believe it, babies aren’t a blank slate. Babies not only bear the social and economic legacies of the families which produce the, but also the scars of a lifetime of immunological insults.

This week, a paper, “Does in utero Exposure to Illness Matter? The 1918 Influenza Epidemic in Taiwan as a Natural Experiment,” appeared in the journal of the National Bureau of Economic Research which tracks the long term effects of the 1918-1920 worldwide influenza pandemic.

Turns out that babies which were born to mothers in that period were, on average, shorter than people born in other years, had more developmental problems, and, possibly, suffered from long term problems of chronic disease.

This paper tests whether in utero conditions affect long-run developmental outcomes using the 1918 influenza pandemic in Taiwan as a natural experiment. Combining several historical and current datasets, we find that cohorts in utero during the pandemic are shorter as children/adolescents and less educated compared to other birth cohorts. We also find that they are more likely to have serious health problems including kidney disease, circulatory and respiratory problems, and diabetes in old age. Despite possible positive selection on health outcomes due to high infant mortality rates during this period (18 percent), our paper finds a strong negative impact of in utero exposure to influenza.

It’s interesting to me, in that it’s a study of health on one of Japan’s former colonies, but also because Taiwan’s indicators in 1918 were atrocious. More than a fifth of babies didn’t live to see their fifth birthday, deaths in childbirth were common and life was short. In other words, it’s a lot like a lot of African contexts today.

The long term outcomes of common developing world diseases have mostly been ignored. There is every reason to believe that one of the reasons African countries suffer economically is that people’s developmental trajectory is set before even exiting the womb. SO we’re fighting against not only a bleak economic past, but also against a constant legacy of infectious insults.

And to moms in the developed world…. get your flu shots.

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