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The Epidemiologic Transition in Kenya: Are Pastoralist Communities Benefitting?

demographic_transition_detailedIn epidemiology, we have a concept called the “epidemiologic transition,” which illustrates the shift in the the causes of illness and death as humans change from pre-agricultural to agrarian to affluent societies (Omron, 1971).

Traditionally, humans die from infectious causes, limiting their lifespan to a few decades at most. Through agriculture, they are able to increase their nutritional profiles, reducing infant mortality and allowing rapid population increases. As societies introduce efficiencies in transport and trade and move to technological solutions to former pathogen threats, infectious diseases become controlled and chronic conditions become more prevalent. Economic challenges restrict family size so that births and deaths reach equilibrium and population ceases to increase.

While it’s a great model for understanding the shifts in the health profile of worldwide or continental populations, it is fairly unsatisfying when examining within country or within community health and useless when looking at individuals.

The Health Transition and the Maasai

I’ve been thinking about a Maasai community in Laikipia, Kenya that I was working with this summer. We were looking at Q fever, a bacterial disease which can infect all mammals, but is particularly common in domesticated herd animals. The pathogen is transmissible to humans and can cause fevers, malaise, cardiac problems and miscarriages in pregnant women. It is an occupational hazard to those who work with animals, and potentially a threat to pastoralist communities, who depend on livestock for money and sustenance.

Now, it’s hard to know what was really happening before humans moved to agriculture for sustenance. Paleolithic peoples weren’t known for leaving written records or for data collection. We can, however, look at hunter gatherers in Sub-Saharan Africa or South America to give us at least some idea of what human health was like before we started growing crops in fixed locations.

More relevant to the Maasai, we can look at nomadic-pastoralists, who rely on domesticated animals but move from place to place, and sedentarized pastoralists, who also rely on livestock, but reside in mostly fixed locations. Sedentarization can occur due to land constraints which might include scarcity of water or the introduction of political or property boundaries.

DSC_0685Research has indicated that sedentarized pastoralists are more unhealthy than still nomadic livestock herders. Women and children in sedentary communities have been shown to have poorer nutritional profiles than nomads (Nathan, Fratkin et al. 1996, Fratkin 2001). Incidence of diarrheal and respiratory disease is lower in nomadic children than in children in sedentarized communities. Sedentarism and interaction with commercial livestock markets has been associated with declines in social cohesion, which has been associated with declining health profiles of pastoralist communities in Uganda (Pearson 2010). Sedentarization isn’t all bad, however. Nomadic communities have been found to be at greater risk for zoonotic diseases (like Q and Brucellosis), have lower rates of vaccination, poorer vitamin profiles and high rates of infant mortality(Montavon, Jean‐Richard et al. 2013).

The Direction of the Health Transition in Pastoralist Communities

In actuality, it is difficult to quantify “health,” though if we take infant mortality and life expectancy as an indicator of the quality of life of communities, we might find that sedentarized pastoralists do worse than nomadic pastoralists. This contradicts the “epidemiologic transition,” which posits that any shift towards fixed agrarian societies is beneficial to human health.

Modern societies, characterized by technological efficiencies, diversified economies and sophisticated transportation networks are significantly better for human health than nomadic hunter-gatherer contexts and pastoralist communities which exist at the mercy of weather and environmental pressures. Though it is definitely tempting to romanticize the days when humans quietly roamed the grasslands of Africa, eating whatever was available to them, it is hard to deny that humans were better off in a distant past. This would confirm the model of the epidemologic transition.

However, I believe, that though the trajectory toward development may be beneficial in the long term, the disruptions which occur along the transition have deleterious effects on humans health. I found this in Laikipia. Within a Maasai community, there were two distinct groups of people. One held on to traditional herding techniques and relied heavily on traditional medications to treat animals health problems. They mostly refused to send their children to formal school, had large numbers of children, and seemed ambivalent toward household economic diversification. The other was characterized by smaller families, eagerly sent their children to receive formal education, were open to modern herd management techniques and often took jobs or started business to diversify their household economic activities.

Financial losses from livestock death by occupation. "None" means no economic activities outside of herding.  "Mpala" refers to those working as security guards at a local research station. "Other" comprises a number of activities.

Financial losses from livestock death by occupation. “None” means no economic activities outside of herding. “Mpala” refers to those working as security guards at a local research station. “Other” comprises a number of activities.

I found that those resistant to sedentarization and economic integration with the Kenyan market economy did significantly worse than those who embraced change. I collected data on herds, asking households how many animals they possessed, what kinds, how many were born in the past year and how many died. What I found was that households which engaged with the Kenyan market economy through formal employment as security guards or herders on large commercial ranches had larger and more diverse herds since they did not have to sell animals to obtain cash for health services or school fees. They sprayed their animals for ticks more often and they overwhelmingly reported fewer animals deaths as a proportion of their total herd, indicating that herds were healthier overall.

If we were to take animal health as a proxy of human health (as herding households are in maximal contact with livestock at all times), then we might see that the epidemiologic transition among the Maasai might not be linearly increase consistently, but might rather be J-shaped. Health might decline on the shift from purely nomadic to sedentarized, by might improve again as households adapt to new conditions. Thus, the pattern of the epidemiologic transition, while holding overall, might experience a series of dips along the way, presumably representing disruptions and adaptation to new conditions. It will be interesting to formally test this hypothesis.

Abdel, R. O. (2001). “The epidemiological transition: A theory of the epidemiology of population change.” World Health Organization. Bulletin of the World Health Organization 79(2): 161.
Fratkin, E. (2001). “East African Pastoralism in Transition: Maasai, Boran, and Rendille Cases.” African Studies Review 44(3): 1.
Fratkin, E. M. and E. A. Roth (2005). As Pastoralists Settle. Boston, MA, Springer US
Kluwer Academic Publishers-Plenum Publishers.
Montavon, A., V. Jean‐Richard, M. Bechir, D. M. Daugla, M. Abdoulaye, R. N. Bongo Naré, C. Diguimbaye‐Djaibé, I. O. Alfarouk, E. Schelling, K. Wyss, M. Tanner and J. Zinsstag (2013). “Health of mobile pastoralists in the Sahel – assessment of 15 years of research and development.” Tropical Medicine & International Health 18(9): 1044.
Nathan, M. A., E. M. Fratkin and E. A. Roth (1996). “Sedentism and child health among Rendille pastoralists of northern Kenya.” Social science & medicine (1982) 43(4): 503.
Omran, A. R. (1977). “A century of epidemiologic transition in the United States.” Preventive Medicine 6(1): 30.
Pearson, A. L. (2010). Health and vulnerability: Economic development in Ugandan pastoralist communities, ProQuest, UMI Dissertations Publishing.

The Ninth Millennium Development Goal: Business Development?

7_MDG_IconsLast night I was reading up Japan’s road to industrialization. Specifically, I was learning how it went from a backwards set of earthquake prone islands in 1868 to one of the most powerful economies on the planet.

In 1900, the average Japanese person could expect to live to be about 44 years old, which is almost the same as a Malawian, both in 1900 and in 2013. However, a Japanese person in 2013 can expect to live to be more than 80 years old.

How did it do this? Ignoring the complexities and numerous details, Japan developed because it recognized early on that it had to develop its business sector. Development can’t occur without livelihoods and livelihoods come from cash producing jobs.

For example, following the Meiji restoration, Japan developed a system of land taxation, took the funds and invested them into buying second hand sewing machines from Europe. Rather than aiming for labor saving technologies, Japan aimed for labor intensive, individual sewing machines so that it could leverage as many people as possible. What it lacked in economic resources, it made up for in hands. Japan in the 1920’s then became a major exporter of textiles to Europe.

Japan didn’t stop there. Out of its land taxation system, it also made sure that capital was available for merchants wishing to diversify their businesses and encouraged farmers to convert their crops into products. A soy farmer can process his output into tofu and soy sauce. Similarly, a rice farmer can manufacture sake and sell it.

I am looking at the UN’s Millennium Development Goals:

Eradicating extreme poverty and hunger
Achieving universal primary education
Promoting gender equality and empowering women
Reducing child mortality rates
Improving maternal health
Combating HIV/AIDS, malaria, and other diseases
Ensuring environmental sustainability
Developing a global partnership for development

Out of eight goals, not a single one focuses on private sector development and entrepreneurship, which is arguably, if the cases of Japan and Korea are to be applicable to the African context, the key to consistent economic growth.

Where is the ninth goal? Where is the goal which calls for increased access to capital for small and mid level entrepreneurs? Where is the goal that calls for an elimination of onerous export taxes and corruption which kills the ability for businesses to competitively sell their products to the rest of the world? Why is there no call for proper systems of taxation which allow domestic investment?

The goal of sustainable business development is fundamental to the success of at least each of the other eight goals. I suspect that suspicion and cynicism toward the private sector is the culprit. No doubt, this ambivalence toward business killed the Affordable Medicines Facility – malaria, a supply side subsidy intended to increase access to anti-malarial medications in small private drug shops.

Even in public health, which is supposedly focused on holistic solutions to public health problems, the issue of private sector development and the relationship of economics to human health hardly appears.

People in my field seem to be happy to stick with models of pharmaceutical solutions to health problems, delivered through publicly funded health systems. What they fail to address is how to support those public clinics and hospitals though other means than donations from first world countries.

The evidence that Africans will flourish when given appropriate amounts of capital under reasonable terms (not microfinance as it currently exists) is out there. A strategy to give money to the poor, without strings or promise to repay, conditional on a reasonable business plan found that African households will invest in tools or technology to provide them income in the long term. They find that households which enlarge their business through an influx of capital keep their kids in school longer than households which do not.

I did a small survey of business on Lake Victoria, Kenya and found that businesses’ second most common stumbling block (the first was security) was a lack of access to capital. They need money to expand. Microfinance schemes, with their very high interest rates, are not a viable option to most, though loans at more favorable terms to the right people might make a huge difference.

True development will require a dramatic shift in focus for the development world. We will have to face the reality that business is good for human health, that the negatives of entering the cash economy are small compared with the negatives of trying to fruitlessly maintain a pre-colonial lifestyle in a post-colonial world and that Africans themselves are willing to step up to the plate.

Blog of the Week: Africa is a Country

AfricaisaCountryI just ran across this great must follow blog, “Africa is a Country.”

It’s a collective of many people who write and think about Africa who seek to shatter common notions of what Africa “is” (or “isn’t”). The writing is great and the subject matter fantastic. Posts cover present and past film, books, music, photography and politics form all over the continent.

It’s the blog that “isn’t about famine, Bono, or Barack Obama.”

“Africa is a Country” sports some great articles on such subjects as:

People who go to Africa to snatch up vinyl
Cape Town hip hop
New developments in Nigerian cinema
The beginning of Africa’s first Libertarian political party
One man’s irrepressible hatred for Bono
New music in Mozambique
Mozambiquan photographer Felipe Branquinho
A crazy article on surreal Germans who get wild in Africa

and a great and truly frightening article on how a batshit church in Kansas exports hate and homophobia to Uganda.

In their words:

Of course we don’t literally believe Africa is a Country (unlike say rapper Rick Ross). The title of the blog is ironic and is a reaction to old and tired images of “Africa”. We deliberately challenge and destabilize received wisdom about the African continent and its people in Western media — that definition includes “old (nationally oriented) media,” new social media as well as “global news media”.

Media here means more than journalism; it is also art, music, film, books, graphic design, etcetera. We don’t spend all our time criticizing though. We also celebrate and feature work that we think complicate the old, ahistoric and objectional images. We want to introduce our readers to work by Africans and non-Africans about the continent and its diaspora that have worked against the old and tired images of Africa.

The blog is that, and more. As one of the core members of the collective, Neelika Jayawardane, explains in the “About” section on our Facebook page, Africa is a Country is also about constructing a state of mind. One where the “nation” operates outside the borders of modern nation states in Africa and its continental and conceptual boundaries. So, yes, the blog announces that Africa is indeed a “country,” an imagined community whose “citizens” must reinvent the narrative and visual economy of Africa.

The cost of shipping things to Africa

road (2 of 1)-2I was in Durban, South Africa a couple of weeks ago. It turns out that Durban is the busiest port in all of Africa. There are 57 berths and more than 4000 ships load and unload cargo in Durban every single year. The port is open 24 hours a day, seven days a week. Though the largest port in Africa, it is only about half the size of the port of Los Angeles and not even a tenth as big as the largest port in the world, Shanghai.

The Durban port, however, is expensive. It is more expensive to park a ship at Durban than in any American port. Boats must sit in port an average of four days to clear and unload at a cost of nearly $200,000 per day. Owned by a single private company under few restrictions, Transnet is free to charge what it likes and offer service of any quality it likes. In Africa, there are few competitors.

Kenya’s port in Mombasa is even worse. On average, ships must wait nearly nine days in port. The Mombasa port is run by the state owned Kenya Port Authority.

After totaling up costs from extended time at port, onerous duties and fees on imported goods, numerous police “checkpoints” and “inspections,” a single container imported at Mombasa and shipped to Kampala, Uganda can cost nearly $4,000.

Exporting goods is no cheaper. While it takes only 10 days and costs only $1,000 to export a 20 foot container in OECD countries, it takes nearly 40 days and costs nearly $3,000 in the East African Community. If Kenya, for example, really wants to get serious about positioning itself as an export economy, it will have to tackle this major, major problem. Goods sitting in port waiting for “documents” lose value through export fees, storage and lost market opportunities.

Nearly 20% of goods shipped into Mombasa are retail goods. The costs of onerous shipping conditions are, or course, passed on to the consumer. Kenyan and Ugandan consumers pay more in shipping of imported goods as a percentage of the total price of an item than do Americans. Africa has the highest transport costs in the world.

Again, I don’t know why I went down this road, but I’m often thinking of reasons for Africa’s hobbled development. I began to consider the simple costs of goods. Transportation costs amount to more than 30% of the operating expenses of an African business. Minimizing these costs would mean that businesses could potentially reduce prices and increase sales volume. Others share my view:

The Mombasa-Nairobi segment takes on average 29.8 hours, most of this time spent at various regulatory delays, such as waiting at the two weight stations (+ 6 hours), delays to several police checkpoints (+2 hours; there can be 8 to 10 such checks for the 430 km journey) and other driver delays such as rest and personal errands (+ 11 hours). Under normal circumstances the latter would be unnecessary for such a short distance, but the various regulatory delays force the driver to rest a night during transit. A similar distance in North America would be serviced in less than 6 hours. Therefore, such a system hinders economic development because supply chains tend to be unreliable while consumers and manufacturers pay higher prices for goods and inputs. In such a setting, various public authorities are using freight transportation to generate income in a rent seeking (predatory) fashion.

It is not clear that Kenya is using money from ports or “checkpoints” to upgrade current services. I am fairly certain that the money is going into public sector employees’ pockets.

It’s easy to blame “corporate exploitation” for just about everything that’s wrong with Africa. However, there are basic structural problems which complicate doing business there. Just as it costs money to get things in to African countries from port, it costs money to get things out. Until Kenya, for example, upgrades their port facilities and relieves restrictions on trade, the cost of doing business in Africa will remain high. Contracts negotiated by international entities will continue to be unfavorable.

In short, the problem with Kenyan business is only partially with international business. The Kenyan government parasitically profits of the current inefficiencies. Until that problem is mitigated, the poor will continue to pay a premium for just about everything.


Microcredit: Hardly a Panacea for Entrenched Poverty

Hair dresser in Mbita, Kenya

Hair dresser in Mbita, Kenya

My friend, Rensselaer Polytechnic Institute PhD Student Ben Brucato, posted an interesting article this morning on the links between feminism and neoliberalism. Within the article, there was an interesting portion on microcredit:

“A telling example is “microcredit”, the programme of small bank loans to poor women in the global south. Cast as an empowering, bottom-up alternative to the top-down, bureaucratic red tape of state projects, microcredit is touted as the feminist antidote for women’s poverty and subjection. What has been missed, however, is a disturbing coincidence: microcredit has burgeoned just as states have abandoned macro-structural efforts to fight poverty, efforts that small-scale lending cannot possibly replace.”

I have long been skeptical of microcredit (or its sibling, microfinance, I will use the terms interchangeably). Microcredit claims to offer a seemingly simple solution to the problem of female disenfranchisement. It allows poor women access to seed funds with which they can start tiny, income generating businesses. In the past, women has entered microcredit schemes and started cel phone rental business, small shops, textile based businesses and handicraft manufacture. Borrowers are able to then return the money from profits generated from the business. Borrowers return the money with interest.

The problem with microcredit is what’s normally touted as its strength. Microcredit aims to raise the economic profile of women, by empowering them to start small self-proprietorships selling phone time, manufacturing small handicrafts or textile products, or tiny corner stores (dukas).

Anyone who has ever visited Africa knows that once a business idea shows promise, multitudes of people will show up doing the exact same thing. Lines of women selling the exact same tomatoes for the exact same price in the exact same place to the exact same market are not uncommon.

Hypercompetition, though, causes prices to drop and margins to plummet so that no one makes any money. Profits are so low, that the recipients of microcredit wind up doing nothing more than paying back the loan prinicipal and interest so that the only entity that makes money is the lender.

Worse yet, medium sized businesses which might introduce efficiencies and provide reasonable wages and benefits are bumped out of the market, opportunities for employment and diversification of products are missed and the entire economy stagnates. Microcredit’s bottom up strategy directly encourages this phenomenon.

The emphasis on economically empowering individuals, of course, comes straight out of neo-classical economics. “The invisible hand” will turn the tide of developing economies through the hard work of a collection of individuals. The cynic could even evoke a Randian ideal: the lady with the best fruit stand will win.

And this is where I have the greatest problems. Keywords like “empowerment of women” are fine. We should, of course, encourage women to be independent both socially and economically. However, there is nowhere in the world where development has occurred simply by lending women a few dollars at exorbitant interest rates.

Microcredit doesn’t live in a bubble. In fact, it’s part of a number of strategies which are largely doomed to fail, and will do nothing but allow a significant percentage of Africa’s poor to stay right where they are. Strategies aimed at small scale agriculture risk throwing the entire sector backward by impeding the development of medium scale farms which consolidate costs and risks (some writers have even referred to the “primitivisation” of the African agricultural sector).

By far, the worse effect of microlending (and the greater neo-classical, bottom up strategy) is that it lets African governments off the hook. Rather than encouraging governments to standardize and enforce taxation, develop standards of business and production, and create systems which offer medium scale businesses access to credit, microcredit does the opposite.

It idealistically assumes that the “invisible hand” of the individual will correct for any structural problems which may already exist (which should sound like something from the American Republican Party). Microcredit undermines the ability and agency of governments to improve the economic profile of their states.

China, the US Government Shutdown and the “End of the Pax-Americana”

I was perplexed when a recent essay from the Chinese Communist Party’s propaganda mouthpiece XinHua News came running through my social meida feeds. The article in question, “Commentary: U.S. fiscal failure warrants a de-Americanized world,” which spouts a litany of transgressions that the United States has committed throughout the world, calls for an end to the “Pax Americana” and even suggests a new, international currency.

The essay is, of course, quite odd in that it conspicuously ignores China’s dangerous territorial disputes with Japan and overt threats to the sovereignty of Taiwan and the brutal occupation of Tibet. It’s glaring in its zeal to criticize America as a dangerous hegemon, but ignores China’s stated quest to become a broker of all things East Asian. It also fails to offer who would back this new, mythical international currency (can one *really* imagine the world seriously using the Chinese Yuan as a foreign reserve currency?).

The entire article sounds like a wishful hegemon-to-be poking at an existing hegemon, and bizarrely offers itself as a benign counter-factual aligned with the poor and downtrodden of the world.

Such alarming days when the destinies of others are in the hands of a hypocritical nation have to be terminated, and a new world order should be put in place, according to which all nations, big or small, poor or rich, can have their key interests respected and protected on an equal footing.

Ignoring for the moment how uninterested China is in the having the world respect the key interests of Taiwan and Japan, are we really under the illusion that China cares whether the interests of Sub Saharan African countries are respected or not? Can we really take China’s call for democracy and regional understanding seriously when it fails to do either domestically?

The record of China in developing countries and its commitment to doing anything besides resource extraction, however, is decidedly mixed. Soccer stadiums and lavish dinners for African bureaucrats don’t feed people (except the fat African bureaucrats, of course).

Given its suspicious record, China is a poor spokesperson for the developing world.

Further, the article is laughable in the context of China’s own fiscal and political problems. China’s economy is export driven and follows the same model that Japan and South Korea did by encouraging household savings to fuel investment in public services through interest, while discouraging consumption. Though South Korea and Japan both moved on to consumption economies, it is unclear (at least to me) whether the Chinese Communist Party has the courage to take the political and social risks associated with such a move.

As another blogger pointed out, our disastrous Government shutdown and the public reaction to it are actually indicators that the US system works, and this fact hasn’t been lost on Chinese microbloggers. “Where are the riots?” Political violence, rioting and heavy handed responses are commonplace in China.

In the States, though the shutdown was devastating for public employees and an embarrassing waste of money and time, the effects of the political impasse were largely unfelt by the American populace (outside of some rising blood pressures). Though a repeat performance is infuriating (and inexcusable), it’s interesting to me that the long term effects are few. In fact, I would argue that, despite all of our ideological and social problems, the political system itself may have been strengthened, though it’s too early to tell.

If nothing else, we’ll see a few less Tea Party Republicans in Congress in November of 2014.

The purpose of this post is not to relieve the US of criticism. It deserves plenty. But critics need to be aware that China is not without major problems. Rage on the us all you want, but using China as a benchmark for the future of the United States is wholly unproductive.

“Band Aid”

Starving, crying kids!

Starving, crying kids!

I don’t know why but I recently thought of “Band Aid,” Bob Geldof’s feelgood project that aimed to provide food for those afflicted by the 1981-1983 famine in Ethiopia. While attempting to do what one can to help other is a laudable goal, “Band Aid” is pure comedy when viewed through a 2013 lens.

The sleeve itself is worthy of copious ridicule. It is a collage designed by Peter Blake, who is famous for having done the sleeve to the Beatles’ “Sgt. Peppers Lonely Hearts Club Band.” Note the fly covered pastoralist kids at the bottom.

I’m fairly sure that period is where most of the worst images of Africa come from, images that we are unfortunately stuck with.

Whenever I go there, I’m still struck by the disconnect between how the continent is presented by NGO’s and aid groups, and how the place really is. From fundraising ads, you wouldn’t even know that nearly 40% of Africans live in cities and that Africa has 43 cities with more than one million people. While we certainly need to worry about the plight of rural communities and displaced people, a greater challenge will be how to provide sanitation to the hundred of millions of people who live in cities designed for mere fractions of their current populations.

I’m wondering if Geldof and Bono actually visited Africa before embarking on branding Africa. Though it’s pointless to blame a bunch of hair sprayed 80’s musicians for the plight of Africa, I don’t think that they did the continent any PR favors.

It’s interesting to note that not a single African appears in the video, outside of two people of African decent who may or may not be entirely British. In fact, the voices of the supposed recipients of aid play no role whatsoever it the projects implementation as represented by this video. To me, “Band Aid” is a perplexing confluence of the supposed responsibility the West has toward the “uncivilized” world and crass American commercialism. I suspect, however, that emphasis is placed on the latter, and that the plight of “starving children” is merely a vehicle with which to sell and brand goods.

Though the vast majority of the participants of “Band Aid” faded into relative obscurity (Bananarama?), Bono himself and to a lesser extent Sting, continued this model of commercialized philanthropy. Bono created Product (RED), a business model which branded certain upscale products and offered a percentage of the sales to the Global Fund. While the proponents of Product (RED) and similar initiatives claim that they are meaningful simply by creating “awareness” for the issues they target, the near total absence of the recipients of this goodwill prevent one from taking the projects seriously.


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