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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.

Sunburn…. and thoughts on the dynamic nature of genetics, disease and politics

Not a tree to stand under.

Not a tree to stand under.

I just got back from meeting with our field teams on Lake Victoria in Mbita Point in western Kenya. Normally, I wear up to three layers of clothing, but for some reason, I only wore a single shirt so that an 3cm square area of skin, which would have normally been covered, was exposed to the sun.

Over the course of the day it went from white to brown to red to black. I’m thanking Columbia clothing that the rest of my isn’t black as well.

It sounds really trivial; I got a sunburn. But I’m a really pale guy, and there’s a reason for that. The bulk of my genetics come from northern Europe, an area which is mostly dark, and even when it’s not dark, the sun is filtered through a thick wall of air and moisture.

My skin is not suited to Kenya’s blistering sunlight. My Japanese colleagues inexplicably do their best to keep themselves from tanning. Honestly, I’m jealous of their ability to brown in the sun and don’t really understand why they don’t take full advantage of their innate ability to protect themselves.

In short, I was born pale white, but wish I were black or at least able to brown. It would make field work easier.

Which brings me to this. I often hear people engaging in common conversations about what humans “were meant to do,” as if we were created as complete biological entities designed to perfectly perform specific assigned tasks within the narrow confines of specific environments.

This is a creationist view, but it’s interesting that even non-Christians in the West readily use the same assumptions and terms that are common to religious fundamentalists. The idea is that everything that came after we were kicked out of Eden, in this case East Africa, the birthplace of humanity, is an abomination. Whatever health or social problems we suffer is payback for violating the terms of our initially assigned roles as living beings.

For example, arguments (incorrect ones, by the way) are often made that humans are “meant to be” vegetarians since we don’t have developed canines, an argument of course made preposterous when one runs through the list of mammalian omnivores which also do not have canines. Worse yet, the argument fails to recognize one of humanities greatest adaptations, which is that we can eat just about anything and survive on little for extended periods of time, a skill that allowed us to rapidly move out of East Africa into every corner of the globe.

More salient, however, is that humans were not “meant to be” anything. Like all living beings, we move in response to environment pressures and then adapt while suffering the devastating loss of infants who will not live to pass on traits unsuited to the current environment. Those babies better suited to make it to reproductive age pass on whatever it is that got them there to their children, who then pass it on to their own and mix with others in a sort of genetic democracy.

Babies of my ancestors in northern Europe were more likely to survive with lighter skin, while light skinned babies in Kenya were more likely to not. Neither is “better” than another, but both are suited to their respective environments as they are at that time and neither represent a terminus of genetics.

I take issue with a static view of the world, be it from fundamentalist Christians, who claim that humanity was created fully whole in God’s image or from well meaning secularists, who claim that the world was a biologically static place before the Egyptians, the Romans, the Europeans, the Capitalists and whoever else came in and fucked it all up. Really, it’s interesting how the Biblical creation story persists, even in secular debates.

In my own field, a great failing of research has been to ignore the dynamic nature or disease and human health, assuming that each cross sectionally measured point in time represents a final culmination of set of repeatable events akin to billiard balls on a table. Diseases aren’t that simple. They change in response to the challenges we present to them, which in turn feed back into our own behaviors.

I certainly don’t defend environmental degradation or would I ever minimize calls for developing more sustainable energy and food production systems. However, I would offer that the world, like human genetics is not static, but rather, incredibly dynamic and that a static (and somewhat falsely nostalgic) view of the world is destructive in itself because it keeps us from recognizing the challenges of the present day. Only by thoughtfully examining current conditions and recognizing that things can change can we develop solutions to present and potential future problems.

Alright, I’m done.

Brucellosis creates political uproar over Yellowstone bison herd

Bison population by year. Bars represent culls.

Bison population by year. Bars represent culls. From Dobson, et al. (1996)

Well, at least that’s my take. Most people would probably point to humans when talking about political problems. Here, though, I’m going to blame the bacteria.

Bison were once found across most of the middle and western United States and Canada, but were nearly hunted to extinction in the 19th century. Expansionists sought to cut off Native American food supplies and the Industrial revolution created an intense demand for buffalo hides, which were used for belts to run large machinery.

Fortunately, a few conservationists saved the fewer than 25 animals who remained in the wild in Yellowstone Park. In 1902, captive bison were introduced into the park to increase the genetic viability of the herd. Populations were managed and regulated until 1966 after which the herd was allowed to expand naturally.

However, climate change and food scarcity has caused some of the expanding population to move out of the park in search of grazing lands.

This is a real problem for cattle herders. Bison are thought to be the largest reservoir of Brucellosis in the United States, despite decades of effort to eliminate the disease. When bison roll into cattle ranches, bacteria can spread from bison to cattle.

Bison appear to suffer little from the disease, but in cattle, spontaneous abortions are likely, resulting in major economic losses to livestock producers. When cattle test positive for the disease, they are culled immediately. The US government compensates the farmer for the loss.

Bison who leave the park and wander into neighboring Montana threaten the state’s Brucella free status. If Montana were to lose that status, all cattle exported from Montana would have to be tested and certified Brucella free, which would increase costs to livestock producers.

Park managers have considered culling the herd, and reducing its size to a more manageable 3000 animals. They propose killing several hundred of the animals which are in the vicinity of Montana’s border as both a precaution and a way to scale back the bison population. The carcasses will be sold as meat.

And this is where environmentalists come it. Several organizations have sprung up around the issue. Most notably, a man chained himself to a 55 gallon drum filled with concrete to prevent more bison from being killed and shipped off the slaughter. Hoping to avoid an escalating political confrontation, the authorities called off the cull.

Opponents of the cull claim that Yellowstone can support more than 6000 bison, far over the target population size of 3000. Proponents argue that the park may theoretically support more than 3000, but a larger herd means that it is more likely that bison will wander into Montana in search of food. The risk there, of course, is that Brucella will be brought into Montana. It is conceivable (to me) that this whole row wouldn’t exist without Brucellosis.

I’m especially interested in the issue because it parallels similar problems in Laikipia, Kenya. Livestock producers and conservationists are constantly in conflict over issues of land rights, economic impacts of disease threats, the rights of wildlife and strategies to protect it in increasingly crowded and rapidly changing areas of the world.

Given the very different perspectives of conservationists and ranchers, no solution has been found in Kenya yet. I’m doubting that one will be found in Yellowstone. Environmentalists are taking this as a moral issue (save the bison!), conservationists are approaching this as a practical issue (manage the herds properly and stay out of the political debate) and herders speak to economic issues (Brucella threatens my business).

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