We just spent the day driving around Kwale looking for snakes, and/or people who had been bitten by snakes. As the last post showed, snakebites are a persistent problem along the Kenyan Coast, with more then 5% of the households we survey indicating that at least one person in the household had been bitten in the past two years.
It wasn’t difficult to find them.
Snakes are universally feared all over Africa and the associations with witchcraft make it a common topic of discussion. Everyone knows someone who has been bitten. They often know all the details, including where it happened and what occurred following the bite. It’s never a happy story.
We went deep into Kinango, an extremely rural area west of Kwale Town and found a friendly lady who seemed to know everything about everyone. She was incredibly jolly, pulled out some plastic chairs for us to sit under and cracked jokes the whole time. I even got to copy her collection of Sangeya music which she had recorded on her phone (another post but you can hear some of it here) at some local music festivals. In total I got more than five hours of live Sengeya and Chilewa music. In the music world, these would be called “field recordings.” Here, this is just music she cooks and cleans to.
Switching back and forth between snakes and Sengenya (in Africa it seems to be possible to have multiple conversations at once), she told us about a kid who had been bitten two days previous. She even told us where to find her, so off we went.
The child was collecting firewood around a mango tree near her home, when she was suddenly bitten by a large green snake, not once but three times on the foot. The snake bit once skated away, decided it wasn’t enough and came back and bit her twice more.
Ants had moved into the dead tree and hollowed out the area underneath. Presumably, the snake moved in previously and came out to warm up during the day.
The mother thankfully took the child immediately to Kinango Hospital and treated was administered. The child was given a three day course of antivenom injections and charcoal was wrapped around the wounds to absorb any venomous discharge. Though the child complains of some numbness in the area, it looks as if there won’t be any permanent damage. Thankfully.
We were also told of an old woman who had been bitten more than 20 years ago, and was badly scarred, figured out where she was and off we went again.
As we pulled up a friendly young lady came out to greet us, and showed us the way to the house out back. In the distance, we could see an old lady walking with a limp. Otherwise, she was completely fit and seemed to be cutting her own firewood with a panga.
She brought us out some chairs and sat down to chat. In 1992, she had been out back collecting firewood (a pattern) and was bitten on the foot by puff adder, one of the deadliest snakes in the world. She was bitten on the foot, and became immobile for nearly a week. A series of witch doctors were brought in, who administered charcoal rubbed into small cuts in the skin.
Necrosis set in, and watery blood erupted out of the wound site. A large number of maggots appeared. Finally, someone had the good sense to take her to the hospital, where she spent an entire year.
The details were unclear, but it appeared that the gangrene was so severe that multiple infections were presents. They likely had her on intravenous antibiotics for an extended amount of time. Despite this, the foot did not heal. Some Christian missionaries came, and convinced her to convert to Christianity, which, she claimed, improved her condition. This is likely coincidental.
The doctors suggested a skin graft to improve the foot, but she refused. Necrosis was so deep that it permeated the bone and the foot is permanently curved as a result. The leg still shows sign of swelling even more than 24 years after the bite. In most cases, they probably would have simply amputated.
The lady was born in 1948, bore ten children, one of which was born just as she was bitten. She was unable to breast feed or care for the child. Regardless, the daughter has two children of her own now.
Snakebites are bad news. In this woman’s case, the disregard for proper medical care simply made a bad situation worse. She is truly lucky to be alive. If she had died, it is doubtful that the Mgangas would have admitted any responsibility.
I sent our DSS out looking for snake bites, and they found them! We simply asked households if anyone in the household had been bitten by a snake in the past five years. More then 5% of them said “yes” and since we know the locations of the households, we were able to make this cool map. Note that the snake bites tend to cluster around two large areas and are noticeably absent from others.
Kenya hosts many varieties of extremely poisonous snakes included the Puff Adder, the Black and Green Mamba and the spitting Cobra. Snakes are universally feared here and often killed on sight by the locals.
Because we shouldn’t deceive ourselves. The digital age has provided too many opportunities for people who shouldn’t necessarily be putting out records and flooded whatever market may exist, reducing opportunities for everyone.
It’s like the famous tragedy of the commons, “an economic theory of a situation within a shared-resource system where individual users acting independently and rationally according to their own self-interest behave contrary to the common good of all users by depleting that resource.” So, I just quoted Wikipedia. Strike two, maybe.
So here I am, acting in my own self-interest and behaving contrary to the common good, through my second collection of songs for Mark Maynard’s Saturday Six Pack Radio show. For those who don’t know, I wake up every Saturday, improvise a song and send it to him for airplay later than evening. It requires little work from me, no financial investment, and gives me something to do besides mope in my Nairobi apartment about what my life has become.
Enjoy (if you can). You can find it here on Bandcamp and even purchase it if you are feeling particularly sorry for me.
Here’s the video for the lead track.
I traveled out to Kwale on the Kenyan Coast and celebrated Eid (the end of Ramadan) with my friend Juma and his family in Mwachinga. It was a great time for everyone (except the goat). It rained on and off, but the ladies made up some great Pilau and the men had some conversations about Islam and witch doctor Senators. Juma even gave us a detailed family history. Finally, everyone had a serious discussion on the impacts of social media on family relations.
After a grueling 12 hour bus ride from Nairobi to Mombasa, the highlight of the trip was a two hour tuk tuk ride across the ferry and all the way out to Kwale Town. I’m still not sure how it made it up all the hills.
Infectious disease transmission dynamics and the ethics of intervention based public health research
I think a lot about ethics and ethical issues. Research in Sub-Saharan Africa presents unique risks for ethical breaches. Given income and power disparities between individuals and foreign researchers and even between individuals and local political leaders the possibility of coercive research is ever present. Pressure to produce can lead to unrealistic assumptions of risks and benefits to very poor individuals. Inadequate knowledge or willful ignorance of local political issues can compromise future research activities, both by international and domestic groups.
Recently, though, an interesting situation came across my desk that included an intersection of ethics and the dynamics of infectious disease transmission.
As everyone knows, not all infectious diseases are the same. Some, like measles, impart full immunity upon exposure, whereas diseases such as malaria impart only partial immunity, requiring repeated exposures to acquire full or adequate immunity to prevent death or serious injury. Moreover, as immunity and immune reactions change over the life course, the time (age) of exposure are sometimes crucial to prevent serious disease. Polio is a great example. Exposure in infancy leads merely to diarrhea, where exposure at older ages can lead to debilitating paralysis.
I was thinking of an population based intervention study which provides some sort of malaria medication to a small population in a holo-endemic area. Given the year round nature of malaria transmission in this area, we would expect that even with a depression in symptomatic and asymptomatic cases, active transmission in the surrounding areas would lead to recrudescence within a very short time. Given the short time frame, we would assume very little interruption in the development of immunity in small children and might even see a short term reduction of childhood mortality. Assuming that this medication presented little or no risk of serious side effects, I believe that there is little reason to assume an ethical breach. A short term reduction in malaria would suggest that the benefits far outweigh the risks.
However, conducting the same study on a very large population in the same area might have very different outcomes. Delivering a malaria medication to, say, an entire county surrounded by other areas of extremely high transmission would indicate that recrudescence is also inevitable but that the time required to return to pre-intervention levels is extended. Infectious disease transmission requires a chain of hosts. The longer that chain, the longer it will take for new hosts to become newly infected.
Theoretically, this could delay infections in small children and it is theoretically possible that we might see a spike in childhood mortality, since the timing of initial malaria infection and frequency of infections are crucial to preventing the worst outcomes.
Of course, I’m not suggesting that people should just get infected to induce immunity, but I am suggesting that a study which seeks to reduce transmission through pharmaceuticals given only intermittently (as opposed to prophylactically) consider all possible implications. Insecticide treated nets (ITNs) provide protection over time and are a form of vector control. A medication given at a single time point merely clears the parasite, but does nothing to prevent bites or kill mosquitoes.
Though I could be overthinking the issue, my worry is that ethical approvals approach the issue of mass distributions of pharmaceuticals as a one size fits all issue without taking other factors such as population size and acquired immunity into account. Malaria, as a complex vector borne disease introduces complexities that, say, measles does not. Researchers, IRBs and ethics board would do well to consider this complexity.
Since I’ve arrived here in the Gambia, I’ve been searching for music. Unfortunately, I’ve come up dry every night. Last Thursday, I heard music from behind the research compound, but was too tired to pursue it and, really, you can never be sure. Sometimes things sound cool through the echoes, but you might follow the sounds only to find Kenny Rogers being played for tourists.
Last night, I heard it again, and decided to chance it. It was so loud and chaotic, it sound like it might be a live band. I leave tomorrow, so this is my only chance.
I followed the sounds out to the back of the compound and found a group of old ladies gathered on plastic chairs around a giant stack of speakers, blaring out some kind of ultra hard beats. A kid with a laptop was DJing but it looked like people were just arriving. The scene was bizarre. Old ladies and grandkids politely chilling out to heavy beats through a wall of speakers.
I decided to go back later. I was wary. It could be some religious thing. It’s Islam here, but still…
When I went back, it was total chaos. This is definitely NOT a religious event (in the Abrahamic sense) and most certainly NOT a tourist event.
More people had arrived and were standing in a circle watching young dude do impossibly athletic dances while an old man MC egged them on and called other people to join. I had heard stories of dancing in West Africa and I have to say the stories are absolutely true. The young guys were the craziest, but kids, old ladies, women in fancy dresses and old men all got in the circle and showed their moves off and every time, people would go nuts with approval.
All to an energetic soundtrack that would get the cops out in a second in the US. I had never seen anything like it.
At one point, a blindfolded guy dressed as a woman comes out hold a dead chicken in one hand and money in the other. He does his chicken dance over a money pot and starts handing out notes to whomever is brave enough to get close to him. After the money runs out, he starts doing this thing where he leans over just barely touching the ground, seemingly suspended in air. Eventually, he disappears and returns out with a giant cinder block balanced on his back and does the same thing again. I have no idea what it was about but it’s clear that there’s order to this chaos.
After people start showing their moves again, a guy tries to get me to go into the circle. I’m like “no way.” I’m not going to be that bad dancing white guy. Some kids are egging me on trying to show me moves and cheering and laughing when ever I try. I should have tried harder. Music is a wonderfully great thing.
Unfortunately, I didn’t have a camera on me, but I did get an audio recording and a couple of pictures with my cell phone. I’m am most certainly coming back to West Africa.