Every once in a while, you run across something that just gives you the chills.
“A report presented to the World Health Organization (WHO) in 1948 states: “It is not enough to quote that about 3,000,000 deaths are caused yearly by malaria in the world, or that every year about 300,000,000 cases of malaria occur …… that malaria is prevalent in tropical and subtropical areas where food production and agricultural resources are potentially very high, and that, by affecting the mass of rural workers, it decreases their vitality and reduces their working capacity and thus hampers the exploitation of the natural resources of the country. At a time when the world is poor, it seems that control of malaria should be the first aim to achieve in order to increase agricultural output” (WHO, 1948).
Snow RW, Amratia P, Kabaria CW, Noor AM, Marsh K: The changing limits and incidence of malaria in Africa: 1939-2009. Adv Parasitol 2012, 78:169-262.
Today, April 7th. is World Health Day, an annual event sponsored by the World Health Organization to help bring attention to pressing public health issues.
This years event focuses on vector borne diseases like dengue fever and Chagas disease, which are transmitted through a third party host such as Aedes mosquitoes or triatomines (kissing bugs).
Both of these diseases are becoming increasingly relevant as the world urbanizes. Dengue and malaria form a complementary nexus of diseases. Malaria is largely associated with rural areas, and rarely found in cities, where dengue fever is almost exclusively found in urban areas. Generally speaking, dengue is a disease of development, where malaria is a disease of the lack of development.
While known to be distributed widely through Latin America and Southeast Asia, dengue has yet to make it on Africa’s radar yet, simply (in my opinion) because not enough people are looking hard enough. Africa, as the most rapidly urbanizing area of the world will eventually face a double burden of dengue and malaria and health facilities aren’t yet prepared to deal with it.
It’s a reasonable question to which no one really has an answer. I work in a field site located on Lake Victoria, the office of which is based out of the International Centre for Insect Physiology and Ecology (ICIPE) station on Mbita Point.
We do malaria field surveys and have a large health and demographic surveillance system that has monitored births, deaths, migration and health events of nearly 50,000 people over the past six years.
The goals of the project are to monitor changes in demographics, outbreaks and changes in the dynamics of the transmission of infectious diseases and gauge the effectiveness of interventions.
While I view those as scientifically important, I don’t think that people on the ground experience any immediate benefit from scientific research activities. In fact, I’m pretty sure that, unless they’re getting a free bednet, it’s mostly an annoyance. Of course, we appreciate their cooperation and they are free to tell us to bugger off at anytime.
We are seeing rapid declines in malaria incidence, infant mortality and fertility in the communities we study. This is, of course, cause for celebration. Less kids are dying and people are having fewer of them.
In fact, the shift in the age distribution was so dramatic from 2011 to 2012, that we thought it an aberration of the data: the mean age of 12,000 people rose nearly two years from the beginning of 2011 to the latter part of 2012. Old people died off, and fewer babies were there to replace them, resulting in an upward shift in the age distribution. Cause for celebration in an area where women normally have anywhere from 5 to 10 children, who often end up malnourished, poorly housed and uneducated.
But we have to ask ourselves, how much of this is representative of trends in communities similar to the ones we study and how much is directly influenced by the presence of the research station itself?
A recent article in Malaria Journal documents the positive impacts that a research facility had on the local community:
To make the community a real partner in the centre’s activities, a tacit agreement was made that priority would be given to local people, in a competitive manner, for all non-professional jobs (construction workers, drivers, cleaners, field workers, data clerks, and others). Of the 254 people employed at the CRUN, about one-third come from Nanoro. This has strengthened the sense of ownership of the centre’s activities by the community. Through the modest creation of new jobs, CRUN makes a substantial contribution to reducing poverty in the community. In addition, staff members residing in Nanoro contribute to the micro-economy there.
Another crucial benefit for Nanoro and CRUN stemming from their productive engagement was electrification for the area. This was made possible by the mayor of Nanoro leading the negotiations for extending the national electrical grid to the CRUN, and with it, to the village of Nanoro. Electrification spurred a lot of economic activity and social amenities that enhance the wellbeing of the community, such as: (1) improved water supply through use electricity instead of generator; (2) ability to use electrical devices, such as fans during the hot season (when temperatures can reach 45-47°C), lighting so students can study at night, the use of refrigeration to safely store food and the extension of business hours past sunset.
Health care services have been improved through CRUN’s new microbiology laboratory. Before this laboratory was established, local patients had to travel about 100 km to the capital city, Ouagadougou, for the service.
This agrees with my experience on Lake Victoria. The presence of the research facility (built originally in the 1960′s) and the subsequent scale up of research activities has been transformative for the area. As more and more people have moved to the area, a bridge to Rusinga Island has been built, two new ferry routes have been installed, the existing ferries have been upgraded, power has been extended to the area and finally, after years of waiting, a paved road has been built from Kisumu to Mbita Point.
..which brings back me to my initial question. It is clear that the building of research facilities can be a major spur for economic development and economic activity in a previously desolate and marginalized area. In case of Mbita Point, it is possible that these gains can be sustained even following an eventual cessation of research activities and strangled funding. In this sense, field research projects are doing at least some of the world good.
However, the gains which these communities are experience really have little to do with the research projects themselves and more to do with the influx of employment and infrastructure that come with research stations and research projects. This is non-controversial and I’m sure that the locals appreciate it.
But the quality and goals of research need to be assessed. Are the results we are seeing truly representative of communities which may be similar to the Mbita Point of the past? Are we unnecessarily influencing the outcomes of the research and then perhaps inappropriately generalizing them to contexts which little resemble our target communities? From a scientific perspective, this is troubling.
Of greater concern, however, are we claiming that gains against malaria are being made, when in fact, morbidity and mortality in communities we haven’t looked at is increasing? This could result in a dangerous shift away from scaled up ITN distributions or even a total reduction in international funding. If this happens, kids will die.
The essence of epidemiologic field trials is the RCT (randomized control trial). A random set of people get some sort of treatment (like a new drug), another random set of people don’t and we compare the results. It’s pretty simple stuff.
The trouble with RCTs is that they don’t necessarily work well when people from the two groups are able to influence each other’s outcomes. As a simple example, a trial of a vaccine which prevents people from getting infected with some pathogen might have impacts on people who don’t get the vaccine, since the number of opportunities for transmission are reduced. This is a welcome outcome (and may even be the point of the study), but it doesn’t help us to understand exactly how effective the vaccine is in the individuals who actually receive the vaccine.
Many RCTs make the (flawed) assumption that individuals are independent entities, following a long tradition of statistical analysis. This is a reasonable assumption to make in some cases, but entirely wrong in others (i.e. most public health outcomes).
Development economists have recently adopted the RCT as a means of evaluating the effectiveness of programs intended to relieve poverty or improve human well-being. On the surface, there’s nothing wrong with adopted public health methods to deal with economic problems, as most public health problems have their roots in economics. Jeff Sachs, or course, would argue that many economic problems have their roots in public health problems.
The major problem with RCTs is that while we do our best to control for all of the possible other factors that might impact outcomes given a particular treatment, without a trove of detailed data and prior knowledge of context and contingencies, we really have no idea at all whether and how some public health intervention works. Epidemiology tends to fall back on the “reasonable suspicion” argument, backing up claims of effectiveness with potentially reasonable assumptions of causal pathways. This is clearly quite easy when doing drug trials, where animals models and a century-plus of medical research has given us a reasonably clear pictures of the pathophysiological pathways that might lie between drug and outcome.
But with issues of human behavior and economics (which is essentially a science which seeks to uncover mysteries of human behavior), the causal pathways are much more difficult to assess and the factors which lie between intervention and outcome are for more difficult to measure. For example, assessing the outcome of an education program on reproductive behavior is really, really difficult without monitoring all of the possible things that happened between the time that a woman attended an NGO sponsored event at a clinic and the time when she chose to use or not use a condom. In fact, we can’t even really verify that she used the condom, since we weren’t around to observe it.
But we assume, and assume to the point of falling back to faith that our efforts did what we intended them to do.
Lant Pritchett, a Harvard economist that I’m a great fan of for his work on economic measurement in developing countries, penned an interesting article on the website of the Center for Global Development seemingly questioning the merit of the RCT as an rigorous and necessary evaluation tool for poverty alleviation development programs.
First of all, the argument that RCTs had, until recently, been used sparingly, if at all, and yet are important in achieving good outcomes sits in kind of embarrassing counterpoint with the obvious fact that lots of countries have really good outcomes. That is whether one uses the Human Development Index or the OECD Better Life Index or any social indicator—from poverty to education to health to life satisfaction—there is a similar set of countries near the top. (In the HDI the top five are Norway, Australia, USA, Netherlands, and Germany. In the OECD Better Life Index they are Australia, Sweden, Canada, Norway, and Switzerland.) No one has ever made the arguments that these countries are developed and prosperous because they used rigorous evidence—much less RCTs—in formulating policy and programs. While one might have faith that RCTs can help along the path to development, RCTs didn’t help for those that are there now.
It is very true that development in the United States occurred without the help of RCTs. In fact, malaria elimination in the United States occurred without any of the complex set of interventions that we’re so desperately selling to malaria-endemic countries. It’s even true that, despite more than a decade of research on ITNs, that we aren’t really sure whether the declines in malaria that we’ve seen all over Sub-Saharan Africa are due to ITNs or just simply due to processes associated with urbanization and development (as in the US). Actually, a lot of research is telling us that the declines in malaria might be false and that we are simply suffering from a paucity of accurate measurement in malaria endemic countries.
And this is where Pritchett comes in. He’s right. Research in developing countries is inherently challenging to the point where the conclusions we draw from research are somewhat contentious at best, and the result of blind faith at worst.
But coarse and incomplete data and loose assumptions shouldn’t discourage public health (or even economic) professionals from doing research in developing countries. While I have issues with the condescending, neo-classical nature of RCTs in economics (another discussion, but can a peasant lady’s behavior in Western Kenya be reduced to that of Homo economicus? ), the truth is that policy makers don’t care about data. They care that people are making the case for action in an impassioned and convincing way. While academics should strive to be as rigorous as possible, the sell won’t happen based on our complex data collection strategies and statistical methodologies. They (and the public) are convinced through impassioned calls for action.
I’m reading an article on African firms and why they don’t seem to grow.
There is an urgent need for job creation in Africa yet something seems to be stunting firm growth. This column shows that African firms are about 20% smaller than their counterparts in other locations. It suggests small firms put the brake on growth as the burden of dealing with government and labour costs may increase with size, or perhaps as they start facing trust issues between managers and workers.
Wow. This pretty much sums it up. African business can’t grow because of onerous regulation, corruption and a general problem of too many people wanting too much of the pie.
I wondered for a while why ladies selling bags of rice, for example, might choose to sell the same rice right next to one another for the exact same price to the exact same market. All of them would make much more money and market prices would be much lower and more competitive if a few of them would band together and form multi-lady shops. I thought it might be because the ladies don’t trust one another to enter such a relationship, but I’m thinking that raising the profile of an enterprise might invite all kinds of new and expensive problems. It still might be true that the ladies don’t trust one another, however.
The overall price level in Africa could also be a factor in determining the size of firms (Gelb et al. 2013). Relative to low-income comparators like Bangladesh, Vietnam and also India, African countries are considerably more costly. In absolute terms, and excluding South Africa as a middle-income country, the average purchasing power parity for a sample of African countries is about 20% higher than the average for the four poorest comparators (Bangladesh, Indonesia, Philippines and Vietnam). Africa’s higher costs may result in a lower level of competitiveness and consequently, in a distribution of firms that is different (smaller) than distributions in other countries. African firms may also face a steeper labour cost curve; as firms become larger and more productive, their labour costs increase more in other regions of the world.
Africa is just about one of the most expensive places to do just about anything, simply because you have to do and provide so much on your own. Our research activities come at incredible expense despite the fact that labor is far, far cheaper. If you need power, you have to figure a way to deliver it yourself. If you need skills, you have to pay to train up people to perform the duties you need. If you need supplies, you have to order them from overseas since very little of what you need is manufactured on the continent.
Next, I’m looking at the graphic below and seeing that Africa only spends about .8% of all worldwide R&D dollars, despite housing a sixth of the world’s population and even including South and North Africa.
A new study which just appeared in Malaria Journal, however, calls this optimism into question.
This review presents two central arguments: (i) that empirical studies measuring change are biased towards low transmission settings and not necessarily representative of high-endemic Africa where declines will be hardest-won; and (ii) that current modelled estimates of broad scale intervention impact are inadequate and now need to be augmented by detailed measurements of change across the diversity of African transmission settings.
So, our ability to accurately determine whether transmission intensity has declined is hampered by the fact that most studies of the disease occur in areas of low transmission. This would make sense. It is much easier for us to evaluate the malaria situation in Kenyan context than in the Democratic Republic of Congo due to availability of surveillance infrastructure, official mechanisms which allow research projects to move forward, and security issues.
The obvious problem with this, is the relationship of governance, economy an instability to malaria itself. People in the poorest countries are at the highest risk for malaria and people in the poorest parts of the poorest countries are at the highest risk of all. The trouble is, despite being the populations we are most concerned about, they are the hardest to reach, and the hardest to help.
Worse yet, the estimates of malaria prevalence found in a number of studies were considerably lower than estimates for the entire African continent.
The combined study area represented by measurements of change was 3.6 million km2 (Figure 1), approximately 16% of the area of Africa at any risk of malaria . The level of endemicity within these studied areas (mean PfPR2-10 = 16%) was systematically lower than across the continent as a whole (mean PfPR2-10 = 31%) (Figure 2). While 40% of endemic Africa experienced ‘high-endemic’ transmission in 2010 (PfPR2-10 in excess of 40%) , only 9% of the studied areas were from these high transmission settings.
This is a huge issue and one that shouldn’t be limited to malaria. While it is helpful to hear good news of malaria declines in formerly afflicted areas, we need to be careful about overstating the impact of interventions. Funding for malaria projects such as the distribution of insecticide treated bed nets was incredibly high throughout the 00′s but it is unlikely that trend will continue. Offering an positive picture can show that our efforts are valuable, but might also lead policy makers and donors to suggest that money be put toward other goals. If Sri Lanka is any indication, where malaria was nearly eliminated at one time but experienced a rapid and devastating resurgence, even a brief relaxation of malaria control efforts could erase current gains completely.
It’s an old paper, but I just came across The Colonial Origins of Comparative Development: An Empirical Investigation
by Daron Acemoglu, Simon Johnson and James A. Robinson, originally published in the The American Economic Review back in 2001.
They take rough data of settler deaths back in the seventeenth and eighteenth centuries and plot them against the GDP of several countries from 1995. I’ve included the plot on the right. What they found was that a higher number of European settler deaths was associated with a long term decline in economic output.
Settling in the seventeenth and eighteenth centuries was a dangerous business, particularly in Sub-Saharan Africa and less so in what is now the United States, New Zealand and Australia. Malaria and yellow fever were responsible for killing up to 100% of groups brave enough to attempt the journey.
Acemoglu, et al.’s argument is as follows:
1. There were different types of colonization policies which created different sets of institutions. At one extreme, European powers set up “extractive states,” exemplified by the Belgian colonization of the Congo. These institutions did not introduce much protection for private property, nor did they provide checks and balances against government expropriation. In fact, the main purpose of the extractive state was to transfer as much of the resources of the colony to the colonizer. At the other extreme, many Europeans migrated and settled in a number of colonies, creating what the historian Alfred Crosby (1986) calls “Neo-Europes.” The settlers tried to replicated European institutions, with strong emphasis on private property and checks against government power. Primary examples of this include Australia, New Zealand, Canada, and the United States.
2. The colonization strategy was influenced by the feasibility of settlements. In places where the disease environment was not favorable to European settlement, the cards were stacked against the creation of Neo-Europes, and the formation of the extractive state was more likely.
3. The colonial state and institutions persisted even after independence.
They argue that the disease environment determined the nature of settlements, which determine the nature of institutions which, in term, determined the economic trajectory of a country.
Interestingly, they control for all of the things that one might control for, such as distance from the equator and the percentage of inhabitants that were European, being landlocked and the ruling power, ruling out the effect of some obvious potential influences. Property rights, a solid judiciary and limits on political power in the colonies and upon independence, they argue, had a greater effect on long term GDP, and the development of those institutions was enabled or inhibited by early settler mortality.
It’s a fairly compelling argument, though not without its critics.
A few gems from the paper interested me. One, the return on investment in the British colonies during the nineteenth century was a whopping 25%, far more than one could have expected domestically. In the late 19th and early 20th centuries, this dropped so that returns on colonial and domestic investments were the same.
I found (finally!) a reference to indicate the willful choosing of high altitude and thus less malarious areas for colonial settlements. Note that in Europe and the US, the location of cities is often along river ways and sea sides, where in Africa large cities tend to be placed inland (with some exceptions). There has been no industrial revolution in Africa and little regional trade (a condition which persists to this day) so that cities along water based shipping routes are not necessary. Extraction in Africa was largely done by rail, further alleviating the need to be close to rivers.
Kenya, lacking mineral or oil resources, is an agricultural economy. Specifically, they are really good at growing tea, and, to a lesser extent, coffee. This helps explain why Kenya’s developmental trajectory has been far more successful than that of other economies. Tea production is labor intensive and often depends on small and mid-sized farms which employ lots of people. Instead of money flowing in the pockets of the corrupt, who often squirrel it away in overseas accounts, money goes directly in the pockets of growers.
Kenya is the UK’s biggest tea supplier, but Egypt buys more tea by volume from Kenya than any other country. A piece in Think Africa Press today wrote on the dual problem of falling demand for tea from Egypt due to prolonged unrest, and that of falling commodity prices worldwide.
The cause of the farmers’ problems lies far to the north of the cool, tea-covered slopes of the Aberdares, in the heat of Cairo and the continuing fallout from the Arab Spring. In 2010, the last year before the uprising in Egypt, Kenya supplied the tea-obsessed UK with around half of its tea, but Egypt was the the single largest destination for Kenyan tea exports, buying nearly a fifth of what the factories around Nyeri produce. With the overthrow of President Mohammed Morsi in July 2013 and the ongoing campaign against the Muslim Brotherhood causing continued political instability, demand has plummeted and prices have gone with them.
“It’s a supply and demand issue,” says Chai Kiarie, Field Services Manager at Gitugi Tea Factory. “We produced more tea this year, but we still made nearly $2 million less than we did last year. With these problems abroad, the demand just isn’t there.”
This isn’t an isolated problem. Coffee prices, once riding high on a boom in commodity prices have been steadily falling since the financial collapse. The commodity boom was a winning sitaution for African economies and helped drive much of the rapid growth seen throughout the 00′s. Regulation has started curbing speculative practices that drove the increases, removing a source of destructive volatility which drove up food prices in developing countries, but has also decreased badly needed foreign exchange revenues.
I visited a few farms the last time I was in Kenya. Farmers aren’t waiting around for subsidies to help pull them out of a potential mess. All of the farmers I spoke with are looking for new ways to diversify their operations and meet potentially lucrative world wide demand for competitive products. All of them wanted to think of ways to increase productivity while decreasing the cost of inputs. The pressures from falling tea demand could help push them to find ways to innovate and increase both revenues and stability.