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New Publication: ITNs on Vanuatu

Today, in Malaria Journal, a new publication appeared with my name on it (though I am not the main author). This will be a record of one of the most challenging experiences of my life.

In 2012, my friend Akira and I went hiking in the mountains outside Osaka. It was a pretty easy hike, but on the way down Akira twisted his ankle and sort of lumbered down the rest of the trail. After a few days, the pain got worse and he had to cancel an upcoming research trip to Vanuatu. He asked me to go in his place and offered to pay my expenses. I was due to go on a couple of other research trips that summer so I couldn’t commit, but the only other gringo on the trip begged me and at the last minute I decided to go.

Long story short, it was a crazy set of interpersonal dynamics, we suffered bacterial infections, got stuck on an island for ten days because a plane needed to be repaired, one of us didn’t eat or drink water for ten days, much fish was eaten (but the people who ate), much kava was drank and stories were told. Our diet alternated between delicious seafood and fresh fruits to ramen noodles over rice.

It was a surreal experience. I lost ~16 pounds, down from 175 to 159, came back with numerous skin infections and was a general physical wreck for months, more so than usual. It was challenging, but an experience I am unlikely to forget. I hope to go back one day.

The paper can be found here.

Pictures from Vanuatu (back when I took pictures) are here.

“Background
Insecticide-treated nets (ITNs) are an integral piece of any malaria elimination strategy, but compliance remains a challenge and determinants of use vary by location and context. The Health Belief Model (HBM) is a tool to explore perceptions and beliefs about malaria and ITN use. Insights from the model can be used to increase coverage to control malaria transmission in island contexts.

Methods
A mixed methods study consisting of a questionnaire and interviews was carried out in July 2012 on two islands of Vanuatu: Ambae Island where malaria transmission continues to occur at low levels, and Aneityum Island, where an elimination programme initiated in 1991 has halted transmission for several years.

Results
For most HBM constructs, no significant difference was found in the findings between the two islands: the fear of malaria (99%), severity of malaria (55%), malaria-prevention benefits of ITN use (79%) and willingness to use ITNs (93%). ITN use the previous night on Aneityum (73%) was higher than that on Ambae (68%) though not statistically significant. Results from interviews and group discussions showed that participants on Ambae tended to believe that risk was low due to the perceived absence of malaria, while participants on Aneityum believed that they were still at risk despite the long absence of malaria. On both islands, seasonal variation in perceived risk, thermal discomfort, costs of replacing nets, a lack of money, a lack of nets, nets in poor condition and the inconvenience of hanging had negative influences, while free mass distribution with awareness campaigns and the malaria-prevention benefits had positive influences on ITN use.

Conclusions
The results on Ambae highlight the challenges of motivating communities to engage in elimination efforts when transmission continues to occur, while the results from Aneityum suggest the possibility of continued compliance to malaria elimination efforts given the threat of resurgence. Where a high degree of community engagement is possible, malaria elimination programmes may prove successful.”

In the Kenya airport again….. and talking of Marsabit, Camels and cell phones

DSC_270222JKIA has to be one of the worst airports I can think of, and my five hour delay has drawn out the awfulness of this place. No wonder someone burned it down!

While I sit here in Nairobi Java House (which now has a branch in Kisumu…. Kisumu Java House?) eating my standard “Chicken and sun dried tomato sandwich with ABSOLUTELY NO MAYONNAISE” I’m thinking about an exchange I just has with a guy in the line for check-in.

The guy was a tall, obviously northern Kenyan who turned out to be from Marsabit, one of the most remote and lawless areas of Kenya. He works at an American university on HIV things in Kenya. We started talking camels and public health and I just couldn’t help but ask.

“How did you….” I was almost ashamed to try and finish the sentence which I kind of interjected since my interest overrode wherever the conversation was going.

“I was sent to boarding school when I was six.” I didn’t even have to finish it. He knew exactly what I was asking.

To be from a place like Marsabit and working for a major American University is no small feat. First, I have never met anyone from Marsabit and the few times I’ve met people from remote places like Pokot and Turkana, I’ve been tempted to just shake that persons hand and congratulate them. Coming up through University in a place where most kids don’t go to school at all deserves a special prize.

“One cell phone is the only piece of technology you’ll see for miles. It’s an oral culture. Communication is absolutely essential and cell phones are the most prized possession a herder will have outside of his camels.”

His brother has 60 camels. I asked if we might go up there and take some blood. I could stand a trip up to Marsabit, even if armed guards have to accompany.

Nagasaki U./Gembe East Football Match 2014 (in Kenya)

DSC_0060I’ve been tasked with resurrecting and project that has been languishing in the world of neglect for years. As I was brainstorming some ideas to revitalize and reconnect with communities we work in, I invited the chief of one of them out for choma, to discuss some options. Somewhere in the conversation, the idea of sponsoring a football match came up.

Gembe East is a community of approximately 14,000 people just east of Mbita Point in Homa Bay County, Kenya. It is quite poor and filled with numerous challenges, but it’s a mostly pleasant place to be and the Chief of the area has been incredibly supportive of all of the Nagasaki and JICA activities.

We met a couple of times, had a few discussions as to what should happen and who should do what, set up a budget for the event and proceeded to pull everything together. It was a lot like putting on a rock show, but with considerably more politics.

Gembe East is divided into four sub-locations, each of which has a soccer team. It was decided that the four teams would play and the winner would receive a new set of uniforms, some money and a trophy.

In addition, we’d have a match between Nagasaki U. and some older folks from Gembe East, a band and a few speeches from “opinion leaders.”

For the two days before the match, we strapped a sound system to the top of a Land Cruiser and drove around the area making announcements. I love seeing trucks like this do political speeches. It was great to be in the car driving around in the bush on awful roads announcing a soccer match (over Luo music) to people tending their farms.

The day of the match came yesterday, things fell unsurprisingly behind schedule, there were a few planning problems and some usual chaos, but in the end everything kind of fell into place.

The first of rounds went smoothly, though one of the teams was late. At first, the spectators were just a few old ladies, but soon the place filled up. We probably had about 2,000 people over the course of the day.

The old man team from Gembe East turned out to be guys closer to their late 20′s (though there was one guy who must have been 60). I haven’t ever played soccer in my life. Unfortunately for the team, the ball came into my vicinity a couple of times.

A real highlight was the Omena Jazz Band, a four piece outfit who have been together since 1970 and whose members were all born before 1950.

I did some speeches on the meaning and nature of our research and presented some simple results to the community. It’s incredibly satisfying to present research results to the people who are actually being surveyed. We can’t do this research without these people. They have a right to know.

Overall, it turned out to be a great day. It was great to meet so many people from the area and have the chance to interact with them. There were some challenges, but there always are when putting on big events. I hope we can do it again in the future.

After all of the negative stuff that’s happened recently, this was a welcome change.

An injured field worker and unfair labor practices in research projects

Good day and bad day. Good news is that our field manager Paul invited all of us over for dinner at his home tonight. Katie (Masters student) is leaving on Sunday and he wanted to give her a good send off. His wife made us an excellent meal that I’m going to be sleeping off for the next week.

Earlier in the day, though, I was walking up to the office when I saw a couple of our staff outside looking troubled. I asked them what was up and they told me that Lucy, a survey worker who has done projects for me multiple times over the past few years, had just been assaulted by a local drunk while out working for me. He accused her of stealing his cell phone, she said that she didn’t know him at all and he punched her in the head.

People around grabbed him and were about to kill him when a police officer showed up and broke it all up. Apparently, the guy was bleeding profusely and was in terrible shape.

Lucy now suffers from a ruptured ear drum.

It’s doubly painful since she had stopped me early in the day to tell me that she needs to get a loan to help pay for her four kids’ school fees, which total $2800.00 per year. I can’t figure out where she gets the money. She only pulls a little more than half that working for me but the financial lives of people around here are far more complicated that one would normally assume. She’s a single mom.

Lucy works without a contract, only doing temporary work for whoever will hire her, and receives no benefits. Since she, and all of the other people who work around here, have no access to health insurance, I paid her medical bills since they would have taken nearly two weeks pay away from her. She was injured in a work capacity. There is no reason she should have to bear the financial impact of an event which would have not otherwise occurred.

Troubling, of course, is that this isn’t an uncommon occurrence. Lucy was lucky in that I know her quite well and happened to be around. Other people aren’t so fortunate.

Research projects have to start taking seriously the fact that they have human beings working for them. Labor practices by many research projects border on the deplorable, assuming that workers are disposable, uncomplaining and easily replaced. While the argument can be made that we are providing employment opportunities where none existed before, many of us seem uninterested in doing any sort of community development, or creating sustainable work opportunities for experienced and capable field workers.

If we don’t take care of our field workers, our projects can’t exist. Worse yet, it is unacceptable to stick to a double standard of providing generous benefits to nationals, while refusing similar benefits to the people on the ground who work day and night to collect our data for us.

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.

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?

Back to Mbita, Kenya

DSC_0562I’m kind of thrown off by what a relief it is to be out here again after being in Nairobi. I really like Nairobi and all it has to offer, but the stress of crowded roads, crime, terrorism, politics, bad air and the constant hemorrhaging of money wears at the soul in ways that aren’t all that obvious until you get away from it.

Just arriving in Kisumu alone allows you to breath a sigh of relief. The traffic moves slower, people don’t push you around and anything you buy is half or even a quarter what it costs in Nairobi. There’s probably not as much to do, but it’s a good getaway.

Plus, Luo-land, despite it’s odd politics, is just a great place to be. I ran into one of the security guards at the place I usually stay on Lake Vic on the ferry. It was great to talk to him outside of work.

I took this picture off the boat as I was breathing in non-polluted air for a while. The moment was kind of sad, though, when I started thinking about how fresh all this was back when I first started coming here. Now, it’s kind of a routine experience, a bit less exciting, maybe, but perhaps special nonetheless.

Now it’s time for bed, until the church bells start going off at 6 a.m.

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