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Snake Bites in Kwale, Kenya: Into the Field

snakebitesWe 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.

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Snake bite (species unknown). Note the charcoal. Victim is a 10 year old girl.

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.

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Puff Adder wound. Note the permanent curvature of the foot. She continues to have to wrap it and use topical medication, 24 years following the bite.

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.

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Puff Adder victim, born in 1948. Ten kids. Still going strong.

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Links I liked January 23, 2015

Measles cases by yearSome public/global health things that caught my eye today:

1. A visit to the most sickest town in America, a coal mining town in Virginia. Dear Republicans, pay for health care now and abandon “clean coal” or pay more later. It’s up to you. (The Atlantic)

2. How paid sick leave could boost American productivity. (CEPR)

3. Dealing with antibiotic resistance is going to take more than just technology. We can’t sit by and watch everything burn around us while we wait for new drugs to come down the pipe…. because they aren’t coming. (Project Syndicate)

4. I want to deny vaccine deniers. Generally speaking, I don’t like people who are willing to sacrifice kids for politics. Vaccine deniers stick together and increase risks for everyone. (WP) and this one, which puts it all into a nice picture for you. (WP)

5. Diseases without borders: ignoring the problem of piss poor health care in developing countries won’t help us from Jim Kim of the World Bank. (Project Syndicate)

Does the environment cause poverty?

SESKwaleAfrican countries are blessed with ample cropland and resources, but suffer from crippling and unforgivable levels of poverty, have some of the shortest lifespans on the planet and the highest rates of infant mortality in the world. Meanwhile, Japan, Korea, Sweden, Switzerland and Singapore are wholly the opposite, yet mostly lacking in everything that Africa has. Clearly, the picture is more complicated than merely having access to a natural resources.

However, within countries, the picture might be different. African countries are complex and diverse places. Poverty is often confined to the most unproductive regions, areas with poor soils, poor rainfalls or dangerous terrains.

I was just working with some socio-economic data from one of our field sites, and noticed some interesting patterns (note the map up top). In Kwale, a small area along the Coast, socio-economic levels vary widely, but neighbors tend to be like neighbors and patterns of socio-economic clustering emerge.

Note that the poorest of the poor are concentrated to an area in the middle, which I know to be extremely dry, difficult to get to, difficult to farm and generally tough to live in.

I tried to see if socio-economic status (as measured through a composite material wealth index a la Filmer and Pritchett but using multiple correspondence analysis rather than PCA) was related to any environmental variables that I might have data for.

I fit a generalized additive model using the continuous measure of of wealth from the MCA as an outcome. Knowing that very few things in nature or human societies are linear, I also applied smoothing to the predictors to relax these assumptions. The results can be seen in the plot at the bottom.

A few interesting things came out. While it is hard to tell much about the poorest of the poor, we can tell something about the most wealthy. The richest in this poor area, tend to live in areas with the richest vegetation (possibly representing water), a high altitude (low temperature), high relief (no standing water) and in locations distant from a wildlife reserve (far from annoying and dangerous wildlife).

I’m not sure the wildlife reserve is meaningful (unless the reserve was an area undesirable for human habitation to begin with), but the others might be and represent a trend seen in other Sub-Saharan contexts. Areas without malarious swamps and ample farm land tend to do the best. Central Province, one of the most developed areas of Kenya, would be an example.

But the question has to be, does a harsh environment doom people to poverty, or do people self shuffle into and compete for access to more favorable areas? Is environmentally determined poverty (or wealth) an accident of birth, or the result of competitive selection?

Alright, back to work. Oh wait, this is my work. Well….

Results of GAM model of SES in Kwale. Y axis is the continuous measure of socio-economic status.

Results of GAM model of SES in Kwale. Y axis is the continuous measure of socio-economic status.

Today is Jonas Salk’s 100th birthday

100 years ago today, Jonas Salk was born. As the creator of the inactivated polio vaccine, he not only changed the course of human history, he also ushered changed the field of public health forever. We can count the polio vaccines and the elimination of smallpox as probably the two great success of public health.

In its mildest form, polio causes a mild bout of diarrhea. In its worst form, the virus migrates to the spine, impedes development and causes debilitating long term paralysis. My grandfather was struck with the disease and had one of his legs stunted and weakened (though he managed to serve in WWII anyway as a Marine). A carpenter who worked for me a while back died due to long term respiratory complications from a childhood polio infection.

Polio is mostly foreign to anyone born in my generation. We were nearly all vaccinated, and the high levels of vaccination have destroyed opportunities for the virus to persist in the environment, protecting everyone, even those who don’t get the vaccine.

Unfortunately, though Salk’s achievements were great, medical care and attention to polio was hardly equitable and tainted by the racism of the time.

During the 1930s the systematic neglect of Black polio victims had become publicly visible and politically embarrassing. Most conspicuously, the polio rehabilitation center in Warm Springs, Ga, which Roosevelt, himself a polio survivor, had founded, accepted only White patients. This policy, reflecting the ubiquitous norm of race-segregated health facilities, was sustained by a persuasive scientific argument about polio itself. Blacks, medical experts insisted, were not susceptible to this disease, and therefore research and treatment efforts that focused on Black patients were neither medically necessary nor fiscally justified.[1]

It is likely true that African Americans experienced a lower burden of disease than white children. We now know that polio’s worst effect arise from the lack of acquired immunity to the disease. Repeated infections from infancy, most importantly during the first six months, when babies still have maternal antibodies to fight for them. Improvements to sanitation delayed exposure to the virus, so that children were not immune and thus more susceptible to the disease’s worst effects.

In short, polio is a disease of development, not underdevelopment. The horrible racism of the pre-civil rights medical system can’t be denied, but the observed disparities in disease incidence might have not been imagined given the disparities in sanitation and access to clean water.

Presently, we are fighting a battle to insure that all kids in Sub-Saharan Africa are vaccinated. However, there still exist pockets where the medical system so dysfunctional and the politics so chaotic, that vaccination rates are low and disease continues to flourish. In places like Afghanistan and Northern Nigeria, the hope of polio elimination is almost non-existent

 

1.    Rogers N: Race and the Politics of Polio: Warm Springs, Tuskegee, and the March of Dimes. American Journal of Public Health 2007, 97(5):784.

 

Ebola: we don’t have time to waste

Ebola is a cool disease. It transmits among fruit bats in the area in and around the Central African Republic. Apes live in and under the trees the bats live in and ingest their feces. Humans who ingest the apes pick up the virus when slaughtering the animal, or so some think. The truth is that no one really knows for sure.

Contacts between humans is increasing as settlements expand and a demand for meat increases. Lacking access to formal methods of employment, individual sellers happily take advantage of market demand and a thinly profitable trade in bushmeat profulgates. Meat equals success and in the place of professionally or pastorally raised beef, which is mostly unavailable to poor people in countries like Liberia and Sierre Leone, people eat the monkeys, chimps and many other of our cousins which are able to harbor the many of the same pathogens we do.

One person gets sick. He or she has no access to formal care because his or her government can’t or won’t provide it so he remains at home. The family consults the local herbalist who provides some medications which offer temporary psychological relief but nothing more. As time ticks on, the victim becomes even sicker until the situation becomes so serious that the family has no choice but to carry their dying loved one to a health clinic 20 km away from their house. Along the way, everyone carrying him or her touches infected feces and vomit and three weeks later the process is repeated.

This could have all been avoided if rural economies were developed enough so that a mass migration to urban areas wasn’t necessary, had there been safer sources of meat available for an affordable price, were there sufficient jobs which wouldn’t necessitate the bushmeat trade, were the governments of Liberia and Sierre Leone effective enough to place a proper health facility close by to patient 0’s house and if health care was dependable enough to be able to spot and deal with an Ebola case.

Ebola is a conflation of ecology, economics, sociology, culture and politics, all mixed together to create conditions for one of the worst health crises the African continent has seen since HIV. It’s going to erase any of the gains of the past decade and collapse the already struggling health systems of some of the poorest places on the planet.

Meanwhile, the United States is having another 9/11 moment and this is where I’m starting to get quite concerned. Panic is about to become policy. Fears of global terrorism prompted our entry into Afghanistan, which might have been justified. But it also paved the way for the invasion of Iraq, which, from the beginning, was a disaster waiting to happen. Out of 9/11, we got the Patriot Act, a massive expansion in government powers to search, seize and detain and America stood by and allowed it to happen with little debate.

I am not a Libertarian, though keep getting accused of being one. I believe in public schools, public health care and government oversight of dangerous industries. So there. John Galt wouldn’t be much into me (but I guess from the far, far left anyone looks like a Libertarian).

I am, however, despite my leftist pedigree, quite concerned with the rights of individuals and the potential for panic and ignorance to lead to a rhetoric that can quickly spiral out of control and veer seemingly caring people away from the direction that the moral compass would normally point us in. I am remembering how many Americans supported torture during Bush II and wondered how many of them would support torture were it to be practiced on their own children. Though seemingly alarmist, I think that we need to be extremely careful.

Enough about me. The reality of Ebola is that it is a man-made crisis. Forest dwelling locals have eaten bushmeat for as long as humans have lived there but there is little evidence that there has ever been a large scale outbreak like the one we are currently experiencing (though history in Africa is often obscure). As I noted earlier, many forces are at play, all of which are associated with the rapid social change that Sub-Saharan African states are currently experiencing.

Some of these forces are inevitable. Population growth, as it did in Europe and Asia before, has led to the creation of mega-cities. The connections, however, between the rural and the urban, however have not been severed. People are going to do what they do, regardless of risk, particularly if they can make a buck meeting some market demand.

Some forces, though, are avoidable. While health care did not initiate the crisis, it helped drag it along. Liberia and Sierre Leone can boast to have two of the worst health systems in the world, but their poor capabilities are hardly unique in Sub-Saharan Africa. NGOs and missionary groups work to plug some of the gaps, but the reality is that without a concerted and proactive effort from the governments of those countries, the system will never improve. International funding is too poor and weak national economies and top heavy tax structures can’t adequately fund these systems domestically. Poor funding leaves many clinics, particularly those in rural areas where these outbreaks begin, without supplies, trained staff and diagnostic equipment. In Kenya, Malawi and Tanzania, I’ve seen more than one rural clinic without power or clean water. Worse yet, Ebola outbreaks, though devastating, are infrequent so that more pressing needs like malaria, diarrheal disease and HIV eat up the brunt of the already scarce funds clinics receive. Pathogens not only compete in the wild, but also for funding and support. This leaves many rural health workers without the protective gear they need, so that they work are the highest risk for death from diseases like Ebola.

What can we do? First, we can calm down. In the United States, the reality is that one of far more likely to be killed by an oncoming car than from Ebola and the probability of sustained transmission extremely low. Though people like to view domestic transmission events such as the one in Texas as failure, the reality is that public health and medical resources move much more quickly and effectively in Texas than in troubled Liberia. Much is made over Ebola’s lethality, but a patient who is found to be infected in the United States has a vastly higher likelihood of surviving than one in Liberia.

Second, leaders can stop spreading and capitalizing on misinformation. While attractive, promoting hysteria only leads to bad policy. The tendency in America is to view as some kind of apocalyptic movie scenario. While fun (not to me), the reality is that there are people in the world who are dying who shouldn’t be. Moreover, closing schools because someone knows someone who knows a Liberian is just simply unwise and counterproductive in the long term.

Third, the international community needs to engage the governments of Liberia and Sierre Leone to improve their public health infrastructure. This is not an easy task. The histories of working relationships of international health bodies and developing countries governments are fraught with failure. Mutual distrust, corruption and indifference of political leaders to the plight of their constituencies has created a mostly untenable system. However, providing supplies and training come at little cost is a mostly uncontroversial affair.

How long will this last? No one knows but it is inevitable that, even if this epidemic is brought under control, it certainly won’t be the last of its kind. We don’t have time to waste.

The Jigger flea: a neglected scourge

Jigger infestation of the hands. I picked the least awful picture I could find. Note the deformity of the hands. This person has likely been suffering from infections since childhood.

Jigger infestation of the hands. I picked the least awful picture I could find. Note the deformity of the hands. This person has likely been suffering from infections since childhood.

I just learned about probably one of the most horrible dieases I’ve ever seen: the jigger. Tunga penetrans is one of the smallest fleas around, less than 1 mm in length. The gravid female attaches itself to a mammalian host, burrows into the skin head first leaving its read end exposed for breathing and defecation. It feeds on blood from the subcutaneous capillaries and proceeds to produce anywhere from 20-200 eggs. Under the skin it can grow to nearly 1 cm in width.

Tunga penetrans is native to South America, was brought to West Africa through the slave trade. In the mid 19th century it was brought on an English shipping vessel and made its way through trade routes and is now found everywhere throughout the continent.

Bacteria opportunistically invades the site and super-infections (multiple pathogens) are common. Victims suffer from itching and pain and multiple fleas are common. Due to the location of the bite, people often have trouble walking and due to the disgusting nature of the infection, victims are stigmatized and marginalized. Worse yet, the site can becomes gangrenous and auto-amputations of digits and feet and eventually death are not uncommon.

The Parliaments of both Kenya and Uganda have introduced bills in the past calling for the arrest of people suffering from jiggers. Of course, these ridiculous bills don’t come with public health actions to control the disease.

Jiggers are entirely preventable, treatable through either surgical excision or through various medications but risk factors for it are mostly unknown and the data contradictory and mostly inconclusive.

It sometimes occurs in travelers and is easily treated in a clinic on an outpatient basis but is a debilitating infection for poor communities. Thus, it is not taken seriously by international public health groups who choose to focus on big issues like HIV and malaria.

Jiggers are a classic example of the neglected tropical disease: it devastates the poorest of the poor but gets almost no attention from donors or the international press.

We gathered some data on jiggers back in 2011 along the coast of Kenya. Without presenting these results as official, I was drawn to the attached map.

Animals of various species have been implicated as reservoirs for the disease, most notably pigs and dogs. Less understood is the role of wildlife in maintaining transmission. On the map below, the large yellow dots represent cases. Note that they are nearly all located along the Shimba Hills Wildlife Reserve. I calculated the distance of each household to the park’s border (see the funny graph at the bottom), and found a graded relationship between distance and jiggers infections. Past 5km away from the park, the risk of jiggers is nearly zero.

What does this mean? I have ruled out domesticated animals, at least as a primary reservoir. People in this area tend to all own the same types and numbers of animals. Being Islamic, there are no pigs here, but dogs are found everywhere. Despite this, there are distinct spatial patterns which are associated with the park. Note that all of the cases are found between the parks border and a set of lakes, perhaps implying that certain wild animals are traveling there for water and food.

The ecology of jiggers is very poorly understood and, like many pathogens (like Ebola, for example), wildlife probably play an important role.

It’s worth paying me a lot of money to study it.

Locations of jiggers cases. note the proximity to the park.

Locations of jiggers cases. note the proximity to the park.

Distance to wildlife reserve and jiggers risk. Note that risk drops until 5km, then becomes nearly zero.

Distance to wildlife reserve and jiggers risk. Note that risk drops until 5km, then becomes nearly zero.

What if Godzilla came to Kenya?

OLYMPUS DIGITAL CAMERAThis question has been bothering me for a while. While it’s obvious that Godzilla would only visit Japan and the US given that the US and Japan are the only countries which make Godzilla movies, I’ve long been puzzled as to why Godzilla would visit those two exclusively. Specifically, why doesn’t Godzilla visit poor countries? (Note: I realize that Godzilla is a good guy, but ask readers to remember that he didn’t start out that way)

Certainly, the environmental devastation in poor countries is as extensive as in wealthy countries (and perhaps moreso, given the lack of financial and political resources to measure it, let alone do anything about it), making Tanzania, for example, just as much a candidate for kaiju destruction as any other.

But what would happen? First, were Godzilla appear on the shores of the coast of Kenya, he’d (is it male?) have to plow through the port of Mombasa. Godzilla may be destructive, but he’s known to follow standard immigration procedures. He’d meet little resistance, given Kenya’s lax border protection. At the worst, he’d be asked to pay $50 to stay for three months.

Mombasa isn’t a big town, so he’d be over the island and into the country in a matter a seconds, though he might consider a pleasant break on the beach. After finally eradicating Kenya’s terror problem and quashing any ideas of Mombasan separatism, he’d stroll to the Mombasa highway and lumber up to Nairobi, where the real action could start.

In contrast to Japan and the US, Godzilla would find the response by the local military to be tepid at best. A few planes might buzz around aimlessly and a couple of tanks might lob some rounds at his legs, but the military, lacking any incentive to loot cell phones or liquor would probably simply slink away in short order. Response from the African Union or the UN would be slow coming, as they’d have to wait to see if the media reacted with sufficient outrage to warrant action. The US would most certainly refuse to be involved in anything other than a support role.

Godzilla would plod through Nairobi and lay waste to the City Centre in a matter of seconds. It would be like a child stepping through a grandmothers flower garden. He’d probably quickly become bored, lacking much to topple over outside of a few unfinished apartment buildings and maybe a mall here and there. If he were after human destruction, he might take a few steps through Kibera, where he’d certainly kill a half a million people in the space of a single Godzilla breath.

After an anti-climactic fight in Nairobi, he’d have to take a break in Karen to consider what to do next. Maybe he’d move on to Kampala? Or regret his decision and move back to India? It’s hard to say.

The human costs would be incredible. A couple of million people would likely die immediately, the majority of which would be poor given the incredible density in slums like Kibera and their inability to properly evacuate from the city. The sleep inducing traffic jams are unavoidable even under normal circumstances. A manic run for the countryside by all of Nairobi would only make things worse but squatter settlements and slums would reappear within days.

In the long term, however, Godzilla’s destruction of Kenya might pay off. Massive amounts of funding would appear from a number of international sources to rebuild Nairobi’s devastated infrastructure. The Chinese would appear and immediately start rebuilding the highway system from scratch using cheap imported labor. The Americans would set about reconstructing Kenya’s likely devastated military and ports. The British would dump money into overhauling Nairobi’s failing sanitation system, long due for replacement. Kenya would get an infrastructural reboot.

On the other hand, real estate speculators would flow in like flies on roadkill, hoping for a payoff once Kenya’s economy got back on track. Where real estate prices would have crashed immediately following the destruction of Nairobi, leading to a cheap scramble for land, the current real estate boom soon again be underway. Domestic investors would now have even less incentive to develop Kenya’s manufacturing sector and the economy would hobble along as it did before.

Given the political chaos following Godzilla’s destruction of the central government, Chinese investors would grab as much agricultural land as possible, citing “gifts” of highways and football stadiums further entrenching China’s increasingly overbearing presence in the country.

In essence, Kenya, as independent state, would cease to exist.

It might be the case, however, that the destruction of Kenya’s cities might finally sway the Kenyan citizenry away from tribal politics and toward a truly democratic state. People can, and do, often surprise us, but this would be a hard, hard road given that most of the reconstruction would not be democratically determined, but rather orchestrated by World Bank and UN technocrats and Chinese land grabs. It’s clear that Kenya’s self interested leaders would do nothing to stop it.

So, conclusion? Kenya would win big in improved infrastructure, but lose big given the resultant political weakness. In the long term, Kenya might regain some of it’s political footing given improvements in the domestic economy, but it would take decades and a lot of political will to make this happen.

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