Noah and the cursed Africa

noah-posterI was just watching Russel Crowe’s version of the Noah story at some friends’ house. Setting all of the other absurdities of the story aside, like the impossibility of successfully saving all the animals on the earth from only a pair of each (the lions alone would decimate any chances for herbivore reproduction in days, let alone the massive problems of an extremely limited gene pool), I remembered the crux of the story.

Noah discovers grapes, learns to make wine and then proceeds to become a raging alcoholic. The movie implies that he’s drowning his sorrows over failing to kill his two female grandchildren, thus preventing God’s plan to eliminate humanity from coming to fruition.

His son Ham finds Noah drunk and sees Noah’s genitals. The 950 year old Noah then curses Ham. Noah’s three sons then move out to establish the three races of humanity, the Europeans, the Asiatics and the Africans.

Ham moves to the African continent. All Africans, then, are descended from Ham.

To racists, this would provide a great explanation for Africa’s developmental problems. Africans are suffering under an ancient curse, because a guy saw his drunk Dad’s penis.

People in the United States believe this shit. What’s scarier is that they vote.

The need to look for more than just malaria

I was just reading a comment in the new Journal of the American Society of Tropical Medicine and Hygiene “After Malaria is controlled, what next?”

Fortunately for all of our jobs, there is little to worry about. Malaria, as a complex environmental/political/economic public health problem, won’t be controlled anytime soon. As there’s no indication that many sub-Saharan countries will effectively ameliorate their political problems and also no sign that, despite the “Rising Africa” narrative, African countries will develop in such a way that economic rewards will trickle down to the poorest of the poor, malaria transmission will continue unabated. This is a horribly unfortunate outcome for the people, particularly small children, who have to live with malaria in their daily lives.

In all of the places it occurs, malaria is merely a symptom of a greater political and economic failure.

Indeed, we really know less about the causes of suffering and death in the tropics than many believe. Even vital statistics of birth and death are unrecorded in many areas of the world, much less the accurate causes of disease and death. Some diagnoses, such as malaria, dengue fever, and typhoid fever, are often ascribed to patients’ illnesses without laboratory confirmation. Under the shadow of the umbrella of these diagnoses, other diseases are lurking. I have found significant incidences of spotted fever and typhus group rickettsioses and ehrlichiosis among series of diagnostic samples of patients suspected to have malaria, typhoid, and dengue in tropical geographic locations, where these rickettsial and ehrlichial diseases were previously not even considered by physicians to exist.4–8 Control of malaria or dengue would reveal the presence and magnitude of other currently hidden diseases and stimulate studies to identify the etiologic agents.

This is the problem with our public health fascination with malaria. We are missing all of the other pathogens and conditions which case untold suffering in the poorest and most isolated communities. It can’t be the case that malaria acts in a box. In fact, it could be the case, that multiple pathogens coordinate their efforts to extract as many human biological and behavioral resources as possible to obtain maximum opportunities for reproduction and sustenance. A public health system only designed to look for and treat a limited window of diseases misses the opportunity to disrupt what is probably a vast ecological complex.

First, we have a problem of poor diagnostics. Facilities traditionally treat most fevers presumptively as malaria, dispensing drugs appropriate to that condition. However, conditions like dengue fever exhibit similar symptoms. While is it extremely likely that dengue is all over the African continent, particularly in urban areas, there is little ability to identify true dengue cases in the public health sector, and thus, in addition to mistreating patients, the extent of the disease burden is unknown. We cannot tackle large public health issues without proper data.

Second, we have the problem of all of the “known unknowns,” that is, we know for a fact that there’s more out there than we have data for but we also know (or at least I do) that there is a greater disease ecology out there. We know that many pathogens interact with one another for their mutual advantage or to haplessly effect significantly worse outcomes. The awful synergy of HIV and TB is just one example.

OK, I’m going to go and deal with my own pathogenic tenant which I think I’ve identified as an enteric pathogen of the genus Pseudomonas, which might have taken hold opportunistically through an influenza infection. This is complete speculation, however. Data quality issues prevent a reliable diagnosis!

Terror in Kenya and pathological domestic politics: a recipe for disaster

From the Guardian

From the Guardian

I’ve fucking had it. I recommend that all Americans live in a country where terror attacks are a common occurrence. 9/11 was a huge wake-up call for the States, but the daily threat of terror, with all of its unpredictability impacts every aspect of life, even in ways which may not be immediately obvious.

I’m not stupid. I know that I’m much more likely to be hit by a car in Nairobi than to be killed in a terror attack, but I can at least minimize the risks of being hit by an automobile. Terror attacks, on the other hand, come from nowhere.

The Kenyatta administration has proven itself completely incapable of dealing with issues of security. It’s pathetic appropriation of the Mpeketoni attacks for petty domestic squabbles is at least as embarrassing as it is dangerous.

From Think Africa Press:

Initially, al-Shabaab claimed responsibility for Mpeketoni killings through a spokesperson, declaring that Kenya was now “officially a war zone.” However, in a speech to the nation the next day, Kenya’s President Uhuru Kenyatta dismissed the notion that the Islamist militants were behind the attack, maintaining instead that it was “politically motivated ethnic violence.”

Though he did not explicitly mention names, local media outlets interpreted Kenyatta’s allegations as being aimed at the leader of the opposition, Raila Odinga. In response to these apparent accusations, Odinga in turn blamed the Kenyatta administration for failing to address the security situation since Westgate and called for the resignation of Joseph ole Lenku, Kenya’s Cabinet Secretary for the Ministry of Interior and Coordination of National Government.

Opposition leader Raila Odinga, a seasoned Luo politician affiliated with the Orange Democratic Party, has been rattling the cage for the past few months, demanding a “dialogue” with the Presidential office. Kenyatta, who ran on a platform of unity, appears uninterested in engaging the Luo stalwart.

If he doesn’t engage Raila, we’re guaranteed a day of demonstrations and inevitable rioting on July 7th, the day celebrating the birth (return to?) multipartyism in Kenya during Moi’s disastrous Presidency. It’s going to be a bloodbath, and Kenyatta will be watching in the safety of the State House. Most likely, though, he’ll be quietly watching football. Regular folks will be blaming this or that tribe for the fallout and we’ll slowly return to the bad old days of tribal violence.

Most troubling is Kenyatta’s refusal to engage the West, instead trying to curry short-term favors from China. A new road to allow Kenyan elites to move around the outskirts of Nairobi is worth more than solid security assistance from the West. Even more troubling is the seeming lack of interest from the Obama admin to a spreading terror threat in East Africa. Recruitment among Kenyans has become even easier given Kenya’s growing political divide, providing a ripe breeding ground for violence which could spread far beyond Kenya’s borders and potentially destabilize the most important economy in East Africa.

From Think Africa Press:

A domestic threat
So far this year, there have been 14 attacks in Nairobi, Mombasa and the nearby coastal tourist area, according to data from Terrorism Tracker. By contrast, there were just eight such incidents in these areas in the whole of 2013. This also marks a geographical shift in the threat, with attacks now being more common in Nairobi, Mombasa and the coast than in the northeastern region bordering Somalia. Although al-Shabaab continues to mount infrequent mass casualty operations inside Kenya, it seems to be Kenyan militant groups operating from Nairobi and Mombasa that now pose the greatest threat.

So the line between Al Shabab and local “militant groups,” the nature of which is mostly unknown, the credit for which goes to a policy of non-communication from the Kenyan Government itself. The Americans are quite good at identifying the nature of the threats, though also quite adept at defining it thereby giving militant groups an opportunity to mold their images in the shape of how the West perceives it. Here, that opportunity doesn’t exist. On the surface, this seems like a destabilizing strategy for militant groups, but in reality, it merely exacerbates the threat by giving it no ideological boundaries to operate in. The violence becomes random, and hobbles the ability to politically engage these groups.

Thoughts on an ISIS propaganda video “The End of Sykes-Picot”

These days, I’m pretty sensitive to the idea of Islamic militants, given that Al-Shabab seems to be successfully killing people not a stones throw from where I live and work. Honestly, as much as it pains me to say, I’d be more than happy to see some American humvees rolling into Kenya’s coast right now since the Kenyan government seems pretty useless when it comes to issues of security.

ISIS’s crusade, however, lies far from here, though ISIS’s successes could embolden Islamist groups elsewhere, though it’s difficult for me to gauge how deep the connections are between Islamist groups.

The video, however, was quite interesting. The first thing that strikes me is that the presenter is Chilean, speaking American English, representing the international nature of ISIS itself. It is not a home grown ethnic Islamist movement, struggling for historical territory and self-determination. Like it’s arch enemy Israel, it is an international movement of foreigners seeking to establish and ideological state in a foreign, based upon a self-created narrative of religious entitlement.

There are various scenes which show the host talking with other members of the group, who are clearly a hodge-podge of ethnicities and nationalities. The common language appears to be, in many cases, English, though at times it’s hard to tell.

The production values, outside of the sound, are excellent. Most striking is the use of symbols. Throughout the video, the host walks through a number of symbolic points, starting at the border of Iraq and Syria itself, to symbols of border checkpoints, military patches and signs. The message is that ISIS is exposing these symbols as empty illusions, positioning itself as the harbingers of Islam in a corrupt and empty landscape.

What’s interesting is that a young Chilean, likely raised in the US or Canada, is seen mocking much older and obviously local prisoners. He calls the Kurds Satan worshipers and mocks the Iraqi soldiers as cowards and fools.

So, how is ISIS, as an international terror group with roots in the West, any different from the corrupting Westerners they so hate? The video repeatedly appeals to Western sentiments that Sykes-Picot was the great destabilizing factor in the middle east, but it’s unclear as to how ISIS provides an avenue of self-determination to the ethnic groups who were broken up or forced to tolerate one another. Does taking the borders away liberate Sunnis and Shiites? Does ISIS respect the right of self-determination for Kurds? Clearly not.

Check out the video. It’s pretty surreal.

On the way back from Kwale

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Sick animals in Gembe East

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

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

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

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

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

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