New chapter from myself in a Springer volume: “Access to Health Care in Sub-Saharan Africa: Challenges in a Changing Health Landscape in a Context of Development”
I wrote a chapter for “Health in Ecological Perspectives in the Anthropocene” edited by Watanabe Toru and Watanabe Chiho. I have no idea if they are related. Either way, my chapter “Access to Health Care in Sub-Saharan Africa: Challenges in a Changing Health Landscape in a Context of Development” occupies pages 95-106 in the volume.
Check it out, you can buy the book through Amazon for a cool $109, or just my chapter through the Springer site for $29 or you can simply write me and I’ll give you a synopsis.
Here’s the abstract for the book:
This book focuses on the emerging health issues due to climate change, particularly emphasizing the situation in developing countries. Thanks to recent development in the areas of remote sensing, GIS technology, and downscale modeling of climate, it has now become possible to depict and predict the relationship between environmental factors and health-related event data with a meaningful spatial and temporal scale. The chapters address new aspects of environment-health relationship relevant to this smaller scale analyses, including how considering people’s mobility changes the exposure profile to certain environmental factors, how considering behavioral characteristics is important in predicting diarrhea risks after urban flood, and how small-scale land use patterns will affect the risk of infection by certain parasites, and subtle topography of the land profile. Through the combination of reviews and case studies, the reader would be able to learn how the issues of health and climate/social changes can be addressed using available technology and datasets.
The post-2015 UN agenda has just put forward, and tremendous efforts have been started to develop and establish appropriate indicators to achieve the SDG goals. This book will also serve as a useful guide for creating such an indicator associated with health and planning, in line with the Ecohealth concept, the major tone of this book. With the increasing and pressing needs for adaptation to climate change, as well as societal change, this would be a very timely publication in this trans-disciplinary field.
Humans have had to deal with the threat of snakebites as long as humans have existed. While deaths from snakebites are rare, the outcomes are so severe and the nature of the animal so mysterious, that humans have developed all sorts of ways of dealing with them.
Witchdoctors, or Mganga as they are known in East Africa, are the first line for snakebite treatment here. The Waganga are fairly useless for treating many serious health issues, but they have carved out a niche for themselves for a few public health problems.
Our survey in Western Kenya confirms that nearly 100% of people who have been bitten by a snake visit the Mganga, regardless of whether they visit a formal health facility or not.
I went and sat down with an established Mganga here in Kwale and he was gracious enough to answer all of my questions openly and (mostly) honestly.
Hello, thank you for taking the time to speak with me today. Is English OK?
No, my English is not very good. Can we do this through a translator?
Of course. So, what happens when a patient comes in for treatment for a snakebite?
When the patient comes in, I first apply the “njiwe na njoka” (lit: snake stone). The stone sucks all the poison out of the wound. When you put it on the bite, it will stick. When the stone has absorbed all the poison, it will fall off.
What do you mean? Like it just sticks to the flesh without tying it?
Yes, if there is poison, the stone will stick to the body. When all the poison is gone, the stone will fall off. After it is done, I take the stone and wash it with milk several times and then use it again for the next patient.
What is the snake stone? Is it like a rock? I’ve seen people use charcoal in the villages. They tie it to the wound, it doesn’t appear to stick on its own.
No, this is different. This is a stone from the snake. The stone is in the skull of the snake, like that of a fish.
(Note: I did not know this, but some species of snakes have otoliths, like most fish. Snakes (and fish) are deaf in the traditional sense. The otolith is a piece of calcium which grows as the animal ages and sit on top of a bed of nerves. When there are vibrations, the otolith vibrates, stimulating the nerve bed so that the animal can “hear” motion around it. Not all snakes have otoliths but some species of burrowing snakes do.)
Where do you get the stone? Can you just buy it in the market?
The snake stones come from the Maasai, from big snakes in Maasai land. My teacher travels to Maasai land to get them and brings them back.
If the wound is fresh, I apply the stone. However, if it has been two or three days since the bite, I can’t use the stone anymore. Then I have to use a special medicine made from herbs and crushed snake heads. I mix it all together, then crush it into a powder and keep in a gourd.
When the patient comes in, I use a new razor blade to make small scratches on the wound. Then I rub the powder in it and bandage the wound. The wound will try to heal over time, so you have to make the scratches to be able to apply the powder.
Do you use the razor blade again?
No, I always use a new blade. (He was emphatic on this point.)
What is the powder made from?
Snakeheads. When we kill a snake, we keep the heads to make the powder. We mix it with roots, bark and leaves from special plants from deep in the forest. My teacher is a security guard in one of the forests and can get them when he can find them.
Wait, so your teacher is a forest ranger? Can’t he get by being an Mganga?
Yes. He is a forest ranger.
So he took the job so that he can get the plants from the forest whenever he needs them.
OK, so how many bites do you see per month?
It depends, some months I get more than others but mostly one every three months or so.
Do you refer them to the health facility for formal treatment?
Yes, I do. I treat them, then they go to the facility, then they come back to me. (I’m suspicious on this point, though the Mganga in question appears more together than most.)
Is there a religious component to this?
Well, there are two kinds of bites, those where the snake just bites and there is no witchcraft and those where someone has used magic to send the snake to bite you.
How do you know the difference?
If the bite heals quickly, there is no witchcraft. But if the bite is treated and does not improve then there is definitely witchcraft involved. At that time, I have to use powerful magic to get rid of the curse.
What do you do?
I send the snake back to the person who applied the curse. When we hear that someone nearby has been bitten, we know who applied the curse.
(Note: this is not uncommon. Witchcraft is often associated with hatred and revenge but the person applying the curse risks becoming cursed themselves. It is possible that snakebites are seen as a never ending battle of malevolent spiritual forces. What this does is sow distrust among people, even families and the Mganga is seen as the only cure. The result is that the Mganga are never without work.)
How did you learn this craft?
I was sick for a long time with stomach and head problems. I went to the hospital and it never got better so then I went to an Mganga. I improved. The Mganga suggested that I become on and I started training under him.
Thank you very much for your time.
I made this trip out to the coast, first to do some damn work and second because I can get out of Nairobi and be spared spending Nairobi money for a while. A week’s worth of not-Nairobi-money is money in the bank. In Nairobi, you simply walk outside and 1000 schilling notes start flying away.
Some things I noticed (I’ll get to the snakes in a minute):
- It’s damn hot out here. Nairobi is cold. Here, it’s like being immersed in a sauna continuously, except for the hours of 3 to 5 am, which become cold for some reason.
- Fish from the sea is good. There are ample stocks of mackerel out here. I always want to make 塩サバ and have a side of okra. Or ゴーヤ. Or 山芋. Or something.
- Somalis are cool dudes. As in, they want to do business, they want to make sure you are happy and that you come back again. Kenyan business people are really just interested in getting your money right then probably because they might be out of business tomorrow. They don’t care if you come back. But then, if you don’t keep customers, you will go out of business. Welcome to the world of business in Kenya.
- Somalis make somali coffee, as in, not Nescafe. They put coffee grounds in hot water and steam the shit out of it. It’s refreshing. Though I noticed that they were pulling water from a plastic jerry can on the floor. One has to wonder where the water comes from.
- As much as possible, avoid the tomatoes and onions they put on the pilau (a dish like 混ぜご飯.) Yesterday, as I was eating my pilau, I ate the tomatoes and onions. I knew that things would turn out badly. Imodium is my friend right now.
- Mombasa is a weird place. I always expect to see people with dancing monkeys or snake charmers on the street, but then you look closer and it really is Kenya. They really tried to make a nice city at one point, but the city services never caught up. Trash is a constant problem. But there’s this weird mix of Arab, Brit and Indian architecture. It truly is an international city. They also like perfume. And they love ice cream. I think because they don’t drink and smoke, they can actually smell and taste things.
- Tarbousch: I always used to get the Biryani there, but the waiter convinced me to try the chicken schwarma. Perhaps the best shwarma I’ve ever had. I ordered two in the end.
- Police: Are stupid. Like really dumb. My tuk tuk driver failed to stop for the police, likely because he couldn’t here them over the cacophony of tuktuk motors everywhere. I apologized to the policemen to be friendly. He tried to arrest me for the tuk tuk driver’s failure to stop. The policeman was obviously a complete moron. I had to start fake calling the Kenyan Ministry of Health to “report him.” Eventually he let me go. I hate those guys. Likely, he wanted money.
- Mombasa is remarkably music free. Given Somalia’s rich musical history and the ubiquity of Taraab music in Zanzibar, you would assume the Mombasa might have some kind of musical culture, but it does not. Plenty of people seem to buy stereos and the matatus blast out Bongo (TZ) music, but there’s a stunning lack of performance culture of any kind here. Again, I blame Moi.
- Living in Nairobi will make you really mean. You just stop being nice to people you don’t know. It’s a cancer really.
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.
Looking at some data on socio-economic status (SES) from two regions of Kenya, I was able to compare current levels of household wealth with those of 2007 in the same households.
We measured SES using a method common to studies of developing countries. An accounting of specific material goods including ownership of radios, TVs and bikes along with type of water source, toilet is performed. We then use multiple correspondence analysis to assign weights to each item as they appear in the data set and a total score is calculated for each household (Filmer and Pritchett, 2001 though they use PCA). Each score (ideally) represents the relative level of wealth of each household.
Kenya’s GDP has been increasing rapidly since 2001. During my five years of travelling to this country, I’ve seen the place transform itself. There are more goods on the shelves, people look better, kids die less and women have fewer children. HIV and malaria are down and people are busier. It’s worth noting that Kenya has no real natural resources; its economy is mostly based on a well developed domestic market economy and agricultural exports.
The question, however, is whether these economic gains are being felt by everyone equally. To test this, I compared data from 2007 and 2015 to see if all households experienced an increase in wealth during this period.
I made the graph above. Assuming I’m interpreting the graph correctly, this would suggest that while wealthier households in 2007 consistently continue to be wealthy in 2015, the relationship for poor households is scattered. Some households are doing better, while other may have experience no change, while others may be poorer in 2015.
Clearly, no matter how one interprets these results, we should be explore what types of households might be falling behind, or experience no gains at all.
I’m only a middle author, but I have a new publication out. After being involved in this, I will never eat mukimo (Kenyan mashed potato dish) ever again. Ever again.
First Report of a Foodborne Providencia alcalifaciens Outbreak in Kenya.
Shah MM, Odoyo E, Larson PS, Apondi E, Kathiiko C, Miringu G, Nakashima M, Ichinose Y.
Am J Trop Med Hyg. 2015 Jun 29. pii: 15-0126.
Providencia alcalifaciens is an emerging bacterial pathogen known to cause acute gastroenteritis in children and travelers. In July 2013, P. alcalifaciens was isolated from four children appearing for diarrhea at Kiambu District Hospital (KDH) in Kenya. This study describes the outbreak investigation, which aimed to identify the source and mechanisms of infection. We identified seven primary and four secondary cases. Among primary cases were four mothers who had children and experienced mild diarrhea after eating mashed potatoes. The mothers reported feeding children after visiting the toilet and washing their hands without soap. P. alcalifaciens was detected from all secondary cases, and the isolates were found to be clonal by random amplified polymorphic DNA (RAPD) fingerprinting. Our study suggests that the outbreak was caused by P. alcalifaciens, although no fluid accumulation was observed in rabbit ileal loops. The vehicle of the outbreak was believed to be the mashed potato dish, but the source of P. alcalifaciens could not be confirmed. We found that lack of hygiene, inadequate food storage, and improper hand washing before food preparation was the likely cause of the current outbreak. This is the first report of a foodborne infection caused by P. alcalifaciens in Kenya.
© The American Society of Tropical Medicine and Hygiene.
PMID: 26123962 [PubMed – as supplied by publisher]
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.