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Kenya Day 3: Malaria Journal

Girl with a motorcycle, Homa Bay, Kenya

Girl with a motorcycle, Homa Bay, Kenya

As part of our research in Kenya, we have hired a couple of local people to keep journals on malaria. Basically, we give them a notebook, they observe people in the community, watch for conversations about malaria or malaria related things, and write down what they hear.

Called “hearsay ethnography,” it makes ethnographers out of non-professional folks who are already embedded within the community. To date, it has been used in understanding the cultural understanding of HIV in Malawi.

We are turning local young people into anthropologists.

Through this technique, we can minimize the observer effect, i.e. the problem of influencing the data collection environment by being the odd, linguistically challenged white people of ambiguous intent. The writers have to write in English, in a manner assumed to be understood by educated folks, which presents problems of its own, but it’s a somewhat more flexible methodology.

It’s a valuable tool for medical anthropology. Through this study, we hope to begin to understand how people in this area conceptualize malaria, malaria treatment and health delivery.

I hired these guys last May, the money ran out, and I thought that the project was just a bust. To my surprise and delight, the data collectors are still writing in their journals and I was finally able to see the results.

Here’s a sample:

I attended the funeral of a child below five years old at Kamyeri. There were so many people who attended irrespective of their age or gender. The discussion about malaria broke out when the child’s father was narrating the cause of her death. He said that many people may think that his daughter had been bewitched but according to him, her death was as a result of his wife’s negligence.

He went on saying that he wasn’t at home when he received the news about her daughter’s illness. He told his wife to take the child to the hospital. However, he arrived home after two days to find out that the child had not been taken to hospital and have not received any kind of medication. He rushed her to the hospital but it was too late because the child died dew hours after the doctor had confirmed that she had serious malaria.

He went on saying if she would have diagnosed early enough, maybe she could have not died.

He added that before someone make or jump to any conclusions about the cause of any illness, he/she should go to the hospital and get tested in order to know the real cause of a disease he/she must be suffering from.

Then an old woman who was just in front of me said that she had informed the child’s mother to take to her the child so that she could treat her through “frito” and “suro.” ”Frito” means a method in which powder traditional herbs are administered to a patient through snifting, while “suro” means a method in which herbs in a powdered form is put on small cuts made using a knife. However, the woman did not turn up instead she went to a preacher to seek divine healing.

The old woman continued saying that the shivering and headache could have been treated using traditional herbs.

God is the source of human needs. Why Christianity is at odds with Buddhism

God is the source of human needs. Why Christianity is at odds with Buddhism

Kenya Day 2

Lady cooking dinner under election posters

Lady cooking dinner under election posters

This time I got to ride over from Nairobi to Lake Victoria instead of having to take the plane. In the end, it takes just as much time and is fraught with fewer hassles.

We got into an interesting discussion with our driver. Joseph is a great guy and, most salient on African roads, a great driver. He asked me if I was a Christian. I told him flat out that I didn’t believe in anything. I usually try to hold back, but maybe I was too tired to care.

He asked why, and I told him: The Abrahamic God is a despot. He let’s children die. He punishes his faithful followers with poverty and suffering and astonishingly still demands tribute. Paradoxically, the people that don’t believe in Him live relatively bountiful lives. I told him that I respect and do not think badly of people who choose to believe, but I, personally, have serious problems with religion. We can coexist peacefully.

Joseph struggled to come up with some reason why, pointing out that it is the spiritual failings of the children’s parents that cause infant death. We discussed the subject further, and it expanded into a political discussion of the nature of foreign aid and development.

“Africa is behind because our ancestors weren’t faithful. The white people came to give us the message of Christ, but it was too late. It will take us 100 years to develop.”

Of course, I jokingly replied that the white man came because he want to enslave Africans to act as farming tools and steal African gold.

This brought up some important issues. It’s a pretty sad state of affairs to assume that one’s continent is in disarray because people 300 years ago had made the mistake of practicing indigenous religions (as opposed to a foreign import). It’s worse that white people, in their exploitative glory, are seen as saviors and not the raw opportunists they were (are).

It’s even worse to think that common Africans are stuck in a state of self-loathing simply for not being born European. Western contributions to the world cannot be denied, but it’s fantasy to believe that the world couldn’t live without us. I don’t think that Joseph is particularly set in his views and was likely merely making enjoyable conversation, but the statement was revealing.

It is now almost cliche to talk of the evils of aid and the creation of the problems of dependence. If foreign governments are so motivated, they can simply stop sending money. There are other ways of helping Africa’s economies to grow (ending US/European farm subsidies is one). An issue of identity, however, is a much more difficult problem to solve. If one of the African economies joins the top ranks of the world, as I think one will in the next 50 years (it might be even Kenya), we may, perhaps, see significant change.

WHO Stating the Absolute Obvious

From the WHO’s “Malaria Elimination: A Field Manual for Low and Moderate Endemic Countries“:

“Malaria transmission is particularly difficult to interrupt in areas with efficient mosquito vectors, a long or year-round transmission season, poor state of overall development, marginalized populations and weak health systems with inadequate coverage of health services, as well as in areas with civil unrest, illegal cross-border movement, or areas that border high-burden neighboring countries and experience intense cross-border population movement. Each of these factors will reduce the feasibility of malaria elimination”

Shouldn’t this be completely obvious? They are describing every place where malaria is, outside a few exceptional cases at this point. The WHO is stating clearly that malaria elimination in Sub-Saharan Africa is absolutely impossible.

What the Business School Taught Me and What Business Can Teach Science

Video store in Tanzania

Video store in Tanzania

Recently, I’ve taking a course in the UM Ross School of Business. In general, I’m a guy that likes to escape his comfort zone. I like to talk to people I don’t agree with, and go to places that I’m not expected to go. It keeps things interesting.

The course I took is probably pretty atypical for a business course, though. Ted London, one of my coworkers at the William Davidson Institute, teaches a class entitled “Business Strategies for the Base of the Pyramid.” Basically, it argues that profitable business ventures which target the poorest of the poor are possible and can have positive impacts in terms of poverty alleviation and improvements in public health. He advocates a strategy that partners developed country expertise and capital, with local entrepreneurship and knowledge.

What I’ve learned:

1) Business is about problem solving. I used to think that business was about profit maximization. In essence, though, it is about identifying problems and creating new ways to solve them for mutual benefit. Certainly, part of this includes profit making but often profits mean sustainability. Certainly, if short term gains are your only goal (stock markets, for example), someone will lose. Long term success, however, depends on creating relationships for mutual benefit. Look at the successes of a company like Toyota.

Science, however, is about discovery. We ask questions and seek answers. The limitation here, is that nobody wants to be wrong and thus the identification of problems is of low priority.

2) People in business are easy to talk to. Businesses are primarily about relationships and cooperation. Opportunities are produced by making contacts and listening to what people have to say. People with poor social skills will do badly in business. People like me.

In science, you can have the social skills of a doorknob and it might not make a bit of difference. You can be hardheaded and happily work away in your bubble oblivious to the outside world. This is fine, in an increasingly diversified and interdisciplinary world, a bit of communication and ability to navigate connections between people is becoming ever more important.

Scientists have to learn to talk to people outside science, or we will fail. Not the issue of climate change. The wishy washy (though necessary) language of science doesn’t translate well to policy makers, giving climate deniers plenty of fodder to work with. The world might end, partly because scientists have poor communication skills.

We could learn a lot from business schools. I noted that they write few papers and do multitudes of presentations, which are often graded on form as well as content.

3) Business is not, by definition, evil. Last night, I went to a Holiday Party for the Emerging Markets Club of the Ross School of Business at UM. Half the people there had served in the Peace Corps, hardly what one would expect of MBA students. They are determined to create careers which benefit the world. Certainly, there are evil business people out there, but there are also evil NGOs and evil scientists (known a few). Business is about what you bring to the table and how your goals align with those around you. If you gather conscientious and dedicated folks together, good things can happen. If you can make it profitable, someone will fund you.

In science, we talk about grants in the hundreds of thousands and several millions of dollars. This funds discovery, but does little to benefit impoverished communities directly. In business, they are talking about tens of millions and sometimes hundreds of millions of dollars in capital. Given the right people and the right project, this money can multiply itself and can directly transform the lives of the poorest of the poor in a sustainable fashion. Often, I really wonder what we’re doing. While the information we generate can inform the development of new ways to fight malaria, for example, it often seems like we work in a bubble.

In short, it’s been a great experience. I’m happy to have been able to have the chance to work and learn at the UM B School.

To close, here’s are a couple of videos about Bottom of the Pyramid ventures. The first is about a program that CEMEX, a large Mexican cement manufacturer, has to profitably sell housing to poor communities and the second is a video from the late C.K. Prahalad, a former Professor in the UM B School who pioneered the thinking behind these ventures.

Kenya Submits Film to Oscars

half-life1Kenya has made its first entry for Best Foreign Language Film in the 85th Academy Awards. “Nairobi Half Life,” directed by David ‘Tosh’ Gitonga, is the story of the criminal underworld of Nairobi.

Nairobi is famous for suffering from a deep seated problem of petty and organized crime. Carjackings, pickpockets and cel-phone grabs are common. Gitonga set out to make a film about these criminals, who often come from the villages, seeking opportunities in the city.

The addition of a Kenyan film to the Oscar rolls is momentous. To date, few countries have ever submitted. Most of the submissions come either from northern Africa or South Africa, though there have been submissions from Cameroon and Senegal.

Nigeria’s film industry is massive, but the low quality and disposable nature of production doesn’t produce Oscar material. Kenya has struggled to carve out a cinematic space for itself. Notable is the Kenyan International Film Festival, which has been bringing films to Kenya and showcasing Kenyan made films since 2006.

From the trailer, “Nairobi Half Life” looks great. I can’t wait to see the whole thing. Josephy Warimu, the star, has already won the award for best actor at the 33rd Durban International Film Festival.

Uganda Drops Death Penalty for Homosexuals

uganda-5The Times reported this morning that the Ungandan lawmaker who originally introduced the now famous bill recommending the death penalty for homosexuals, has drop that particular portion. Instead, he favors imprisonment for homosexuals and people who advocate of behalf of them.

There’s no doubt that Sub-Saharan African countries have become a battleground for the debates of the United States, much as the DRC and Angola were de facto theaters of war for the US and the Soviet Union. However, as complicit as we are, the elephant in the room is that Uganda should spend more of its time figuring out how to lift its numerous poor out of poverty and how to protect the health of its children.

Worse yet, the sill hypocrisy is evident. Anti-Gay proponents claim that homosexuality in Africa will undermine African family values. As near as I can tell, poverty, HIV and massive gender inequality have done more than their fair share of damage to African family values. Like the US, conservative voices are remarkably silent on these issues.

Politicians love to pick on the defenseless, particularly when they are in small numbers and especially when they can’t vote. David Bahati, the bigot (and member of the fundamentalist US Christian group The Family) who introduced the bill, no doubt receives political concessions and maybe even financial contributions from abroad.

Even if the bill does pass, enforcement will be laughable. Police in any Sub-Saharan country are noticeably absent, particularly in the rural areas. The trouble is that, where police are not present, mob violence is. In Kenya, a petty thief at a rural market can expect to be horribly beaten and publicly burned to death without trial. The Ugandan Parliament merely fans the flames of this type of sickening violence by codifying hatred into law.

British Man Faces Prison For Staging Theater Play on Homosexuality

While public acceptance of homosexuality and gay rights is rapidly improving in the United States, the debate rages in Sub-Saharan Africa.

Uganda is now famous for the introduction of a bill which sought to criminalize homosexuality. Some offenders would be punished with death. Though the Amendment never got passed, American Evangelistic Christians were implicated in inspiring the bill, presumably feeling that the damage they do domestically isn’t enough.

Now, David Cecil, a UK born theater producer living in Kampala faces a two year prison sentence for the awful crime of putting on a play dealing with homosexual themes.

From Xindex:

On 13 September, he was arrested in Kampala and held in detention for three days. Eventually released on bail, he now faces two years in jail or deportation on a charge of “disobeying lawful orders” after refusing to let the authorities suspend and review his play the River and the Mountain.

The play, which tells the story of a successful gay businessman who is murdered by his employees when he comes out, was always likely to cause controversy in Uganda.

Issues of homosexuality in Sub-Saharan Africa are as fascinating as they are repulsive. From the story of Tiwonge Chimbalanga and Steven Monjeza, the two men who attempted to marry in Malawi and were sentenced to 14 years in prison (they were later freed) to the horrible death of David Kato, a Ugandan gay rights activist who was publicly outed and bludgeoned to death in his home, the debate over gay rights in Africa as as contentious as it is dangerous.

Nearly all SSA countries have some law criminalizing homosexuality. Many of these laws are left over from the old colonial governments. The Brits have moved on, but have left their an awful, awful legacy. Now, ironically, the debate centers around what some people see as a heavy handed attempt by western countries to impose a dangerous morality.

Of course, I am always shocked to hear people rage about the damage homosexuality causes in SSA, while the HIV epidemic, fueled by heterosexual sex devastates the continent. Politicians, of course, have little to lose by alienating a small and defenseless population. Screaming about condom use, concurrent sexual relationships and prostitution might cost votes.

Sometimes, when Good Ideas Die, Kids Die (from Malaria)

The Affordable Medicines Facility – Malaria (AMFm), an innovative subsidy program designed to increase access to life saving malaria medications in poor countries, died last week.

I would argue that malaria is the most important health issue in the world. This ancient disease kills the young, debilitates the living, and universally strikes the weakest of the weak and the poorest of the poor. Malaria’s complex biology doesn’t lend itself to the easy creation of vaccines, and its deep relationship with poverty makes it nearly impossible to eradicate. The only way to successfully eradicate malaria will be to eradicate poverty itself, not an easy task.

We have been able to create drugs which successfully treat malaria, but the parasite quickly finds and exploits weaknesses in the drugs. After time, the drugs become utterly useless. Right now, our last hope is medical cocktail based on artemisinin, a ancient plant grown in China, Artemisinin Combination Therapies (ACTs). The drugs are effective, and the cocktail based nature of the drug means that the parasite has difficulty developing a resistance to it.

Despite ACTs being effective, most people in parts of the world where malaria is most common have no access to it. ACTs are expensive, delivery difficult and developing country health systems poor and ineffective. In the public sector, stockouts are common making them an unreliable source. Distance from facilities is also a barrier. In Sub-Saharan Africa, for example, most people (often the poorest) live too far away from a facility to justify the trip.

This is where the AMFm comes in. The AMFm takes money from the Global Fund to Fight TB, Malaria and HIV and pays it directly to manufacturers for ACTs. Private wholesalers in participating countries are then able to procure ACTs at low prices. Wholesalers then pass this discount on to small private drug retailers, who are able to sell ACTs at a price equivalent to less effective (and cheap) anti-malarial medications. As private drug retailers exist just about everywhere, cheap ACTs become widely available to the poorest and most remote of populations at a price they can afford. The private sector, with profit as a motivator will maintain consistent stocks and older, ineffective medications are crowded out of the market.

At least, this was the hope. A meeting of the Global Fund last week effectively killed the AMFm.

The program was first proposed in 2002, has been piloted in 8 countries (7 in Africa and 1 in South East Asia), and has been under review for the past few years. Full disclosure, I was a part of a review of the AMFm as part of a a group affiliated with the UM Business School.

We found that under the AMFm, availability of ACTs increased, stocks were more consistent and prices fell. Our results agreed with other evaluations. Granted, problems in equity of access still existed, but, given the challenges of drug delivery in Sub-Saharan African countries, the AMFm was a rounding success, and potentially a more effective method of increasing access to meds than strategies which exclusively rely on the public sector.

The AMFm, despite all the indications that the program was going to bring (and has brought) life saving meds to populations that would normally go without, faced intense criticism. The critics most notably came from within the United States. The Presidents Malaria Initiative (PMI), a program started under George W. Bush to fight malaria was the most vocal. Some critics worried about diversion to non-AMFm countries. The same critic, with almost no data, (right wingers) even claimed that the AMFm supported organized crime.

PMI claims that the AMFm haphazardly doled out ACTs to people who did not need them, wasting resources and potentially inducing parasite resistance to the drug, rendering it ineffective. They claim that the AMFm undermined the public sector’s ability to provide services. They claim that ACTs under the AMFm disproportionately went to areas which had low levels of malaria transmission, such as the nearly malaria-free island of Zanzibar. The problem isn’t that these claims are false. They are all based on an independent evaluation of the AMFm sponsored by the Global Fund. The problem is in how the results were spun.

The reality, that PMI (and others) seem to ignore, is that nothing is perfect in Sub-Saharan African countries. In a world where the extent of poverty and human suffering is so great, a less than perfect result might be better than anything that was there before. Even if people are being misdiagnosed, the truth is that a number of people who do have the disease and did not have access before, now have access to drugs. Even if the public sector is being crowded out, the truth is that public sector health delivery in SSA is frought with problems. In survey after survey, people state that the private sector is their first choice for medical treatment. Bolstering health delivery through the private sector is an obvious solution.

In the end, the AMFm was held to a standard that was impossible to reach. I can think of no program in the past decade which has been held to this level of scrutiny. The AMFm, in this regard, was doomed to fail from the start.

Malaria metrics are often elusive. Information on malaria mortality exists, but only for people who show up and die at a formal facility. Estimates of infection prevalence exist, but asymptomatic cases and the difficulty of reaching remote and very poor populations reduces confidence. We know that malaria cases are down everywhere, but determining the exact causes of this decline are difficult. it is admittedly difficult to know how many kids the AFMm saved. We do know, however, that untreated symptomatic malaria in children is dangerous and that drugs are hard to get.

The odd thing to me, is that PMI, being a American group started by a free-market Republican would disparage an effort to bolster private sector health delivery. In essence, PMI is suggesting that a top down, government centered form of health delivery is optimal, which is entirely backwards from the stated philosophy of the Republican Party. Domestically, we know the attitude to be quite different. Personally, I think this smacks of paternalism. Private sector health care in the US is lauded, but Africans can’t be trusted with the same models.

I admit, before I became involved with this project, I was also skeptical of private health care delivery in developing countries. While regulation and certification programs are key to optimizing efficiency and insuring that standards of effective delivery are met, the results of the AMFm evaluations indicate that the private sector can be very effective. Really, it took me going to these areas and visiting these shops to realize how effective it can be. I wonder if the administrators of PMI ever took the time to visit.

Improving access to medications saves lives. Now that the AMFm is dead, I worry that kids will die, simply because a few people didn’t take the time to put their feet on the ground.

Heroic Congolese Doctor Survives Assassination Attempt

It has been reported that one of my heroes, Denis Mukwege, has survived an assassination attempt today in the DRC. Dr. Mukwege runs a clinic in Kinshasa which specializes in reconstructive surgeries for vaginal trauma in women who have been raped in the ongoing conflict in the DRC.

Mukwege has performed more than 20,000 surgeries on women, but has recently moved on to speaking out against the conflict on the world stage. He often publicly points to the DRC government and the the government of Rwanda as fostering conditions that put Congolese women in danger.

Recently, he spoke before the UN and accused DRC President Joseph Kabila as being complicit. Apparently, someone was listening and sent gunmen out to murder him today. His guard was killed but Mukwege survived the attack.

I had the pleasure of meeting Dr. Mukwege about two years ago. I’m glad to see that he’s alive to fight another day for the women of the DRC.

Romney and the Return of the Global Gag Rule

Sadly, I have been pondering the possibility of a Romney win in November. It hadn’t occurred to me, but Romney looks poised to reinstate the “global gag rule.” That is, international groups receiving funds from the United States will be barred from discussing abortion with patients, or risk losing funding.

The past three Republican Presidencies have all used the global gag rule, and Romney promises to bring it back on his first day in office.

Of course, this is fine for domestic right wingers, many of whom have never been to the countries affected by the rule. Romney gets his votes and Christians can go home and sleep happily, knowing that their will, God’s will, has been successfully imposed on hapless poor people in Africa.

Deaths from abortion, often provided untrained individuals under deplorable conditions, are common in Sub Saharan Africa. There were nearly 3,000,000 abortions performed in East Africa in 2008. 36% of these were performed under unsafe conditions. It is estimated that 18% of all maternal deaths in East Africa are due to unsafe abortion practices.

The evidence for wider access to abortion services and reductions in maternal deaths in sub Saharan Africa is out there. South Africa reduced its abortion related mortality rate by 91% following full legalization and the expansion of safe and available abortion providers. Abortion still remains illegal in most sub-Saharan African countries though the extent of the laws vary by country. In some areas with strict laws, governments are known to turn a blind eye to certain NGOs providing services.

While right wingers in the US can smugly claim that their efforts are saving babies, the truth is that women faced with an unwanted pregnancy in Sub Saharan Africa will seek an abortion if they want one. Romney’s vision would leave even victims of rape in conflict ridden areas such as the DRC with no option but obtain a home abortion. Granted, women in these areas have little access to medical care at all, but this restrictive policy only serves to make a bad situation even worse.

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