New publication: An urban-to-rural continuum of malaria risk: new analytic approaches characterize patterns in Malawi
12 years in the making! Our new paper from partners at the University of Michigan and the #Malawi College of Medicine on new approaches to defining urban and rural environments in the context of malaria risk is now out in #Malaria Journal.
It was the last chapter in my dissertation to be published (all the rest were published when I was still in grad school.)Short version: malaria is complicated and really local. Malaria transmits poorly in urban and environments and well in rural environments. There’s urban like spaces in “rural” areas and rural-like spaces in “urban” areas, demanding a more nuanced view of what those terms really mean.
We know that malaria is a “rural” problem, but not all “rural” spaces are the same. Even in the country, there are “urban like” spaces and in “rural like” spaces even in the largest cities in Sub-Saharan Africa. Could those spaces impact malaria risk? If so, shouldn’t we redefine what we mean by urban vs. rural to inform intervention strategies to better target resources?
Here, we combine GIS and statistical methods with a house to house malaria survey in Malawi to create and test a new composite index of urbanicity and apply that to create a more nuanced risk map.
The urban–rural designation has been an important risk factor in infectious disease epidemiology. Many studies rely on a politically determined dichotomization of rural versus urban spaces, which fails to capture the complex mosaic of infrastructural, social and environmental factors driving risk. Such evaluation is especially important for Plasmodium transmission and malaria disease. To improve targeting of anti-malarial interventions, a continuous composite measure of urbanicity using spatially-referenced data was developed to evaluate household-level malaria risk from a house-to-house survey of children in Malawi.
Children from 7564 households from 8 districts in Malawi were tested for presence of Plasmodium parasites through finger-prick blood sampling and slide microscopy. A survey questionnaire was administered and latitude and longitude coordinates were recorded for each household. Distances from households to features associated with high and low levels of development (health facilities, roads, rivers, lakes) and population density were used to produce a principal component analysis (PCA)-based composite measure for all centroid locations of a fine geo-spatial grid covering Malawi. Regression methods were used to test associations of the urbanicity measure against Plasmodium infection status and to predict parasitaemia risk for all locations in Malawi.
Infection probability declined with increasing urbanicity. The new urbanicity metric was more predictive than either a governmentally defined rural/urban dichotomous variable or a population density variable. One reason for this was that 23% of cells within politically defined rural areas exhibited lower risk, more like those normally associated with “urban” locations.
In 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.
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.
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.
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).
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.
The UN keeps data on migrations patterns around the world, tracking origin and destination countries and number of migrants (Trends in International Migrant Stock: Migrants by Destination and Origin). I took some time out and created this network visualization of origin and destination countries from 2010. Other years were available, but this is all I had time for.
The size of each node represents the number of countries from which migrants arrive. By far, the most connected country is the United States, accepting more people from more countries than any other place on the planet. Most areas of the network represent geographic regions. Note that Africa is clustered at the top, and pacific island countries are clustered at the bottom.
An interesting result is that countries tend to send migrants to other countries which are only slightly better off than they are. For example, Malawi sends most of its migrants to Zambia and Mozambique, and Zambians go to South Africa, whereas those countries do not reciprocate to countries poorer than them. Wealthy countries tend to be more cosmopolitan in their acceptance of migrants.
Click on the picture to explore a larger version of the graphic.
It has been announced that Bangui mayor Catherine Samba-Panza has been appointed the Interim President of the near anarchic Central African Republic.
Her ascension couldn’t come at a better time. The Central African Republic, fragile even in the best of times, has been slowly sinking into chaos. No one really knows how many people have been killed in the fighting between Christian and Muslim militias (though this shouldn’t be read as a religious conflict), but reports last year pegged more than 1000 civilian deaths within a two day span. Experts have started using the g-word.
From the NYT:
The interim president selected on Monday at a raucous, five-hour session of a “national transition council” of rebels, rivals and politicians was Catherine Samba-Panza, a French-educated lawyer with a reputation for integrity and no ties either to the Muslim rebels or the Christian militia. Her selection was greeted with cheers in the assembly hall and dancing outside. That she is a woman — the third female head of state in post-colonial Africa — was especially welcomed by many people who felt that men had done nothing but lead the country on its vicious downward spiral.
Though encouraging, it’s too early to tell if Ms. Samba-Panza will be able to contain the bloodshed in the CAR. Certainly, Liberia gained much under the leadership of Ellen Johnson Sirleaf, but it’s hard to say whether there’s been a great transformation in Malawi under Joyce Banda. Rwanda’s female majority Parliament is vastly preferable to Kenya’s (or the United States’) overpaid and corrupt boy’s club, however.
The conflagration in the CAR has been troubling for a number of reasons. First, it represents a general pattern of instability just below the Sahara. Neighboring South Sudan, which just recently obtained independence, is now facing a conflict ridden humanitarian crisis.
Second, the conflicts in South Sudan, the CAR, Northern Nigeria, Mali and Somalia rage on compromise the positive narrative of a newly prosperous and economically viable Africa. The 80’s and 90’s were a stain on the continent. Though I don’t foresee a return to the extended civil wars of Angola and Mozambique (for example), general regional instability compromises the ability to sustain development over the entire continent.
Third, even if the CAR manages to suppress the violence, there are few viable options for the long term economic future of this landlocked and historically marginalized country. Without a long term economic plan chances are high that tensions will flare up once more, setting the country back again.
Third day in TZ. Now that I don’t feel like n octogenarian, I might be able to put together a few comprehensible sentences.
Flew into Dar on Saturday after a grueling flight. Had the pleasure though of sitting next to a group of jolly Hungarian engineers. They were being chaperoned by two Catholic priests who proceeded to repeatedly order whiskey shots for everyone in the vicinity. Catholicism has its finer points.
Dar is bustling. A port town, it is the main point of entry and exit for all goofs bought and sold in TZ. Not nearly as walkable as Blantyre, and not neatly as dangerous as Nairobi. It’s q good mix, plus there’s great Indian food for cheap. TZ has some great seafood.
Left Sunday to make the 20 plus hour trip to Rukwa. Odd seeing zebras and elephants from the highway, but frightening to see the remains of multiple highway accidents. Still, the roads here are far superior to that of Malawi, and the vehicles acceptable.
Road construction is happening at a breakneck pace here , even in the far reaches of nowhere. Trucks line the highways bumper to bumper signaling a rapidly growing economy. Almost everything is available everywhere and it’s only getting better.
Western TZ is gorgeous. Just saw a sign for Malawi. Only a few hours apart but worlds apart economically.
That’s all for now…
Malawi’s President Bingu, or as he was officially known “His Excellency the President Ngwazi Professor Bingu wa Mutharika” died last Thursday.
His death has left a power vacuum in Malawi. Joyce Banda, the current Vice President constitutionally is expected to take power, but members of Bingu’s Democratic Progressive Party are seeking to block her appointment. Banda, though chosen as a running mate by Bingu himself, increasingly found herself at odds with Bingu’s increasingly autocratic Presidency and ultimately left the DPP to form her own political party. Bingu sought to cancel her vice presidential seat unsuccessfully. The Malawian Supreme Court ruled that she was still entitled to the seat.
Both groups within and outside of Malawi are calling for a swift transfer of power to Banda, including the United States.
Malawi could do worse than Banda. A former educator, Banda has sponsored numerous initiatives to expand educational opportunities for children and to increase female empowerment within Malawi. Since 1990, Banda’s National Association of Business Women has provided support and training for female entrepreneurs, reaching a wide network of approximately 30,000 people. She has sponsored health initiatives in Malawi and won numerous international awards. Most impressive, she quietly sponsored a task force to determine the extent of HIV in MSM populations, a dangerous undertaking in conservative Malawi. Forbes magazine listed Banda as the third most powerful woman in Africa. In short, Banda could be the breath of fresh air that Malawi requires.
Mutharika’s Presidency, though initially lauded due to his successful seed voucher program, which he boldly implemented against the advice of the World Bank and the IMF, fell into disgrace due to widespread fuel shortages and a dearth of foreign exchange. The increasingly dire situation led to mass protests all over Malawi, a state crackdown, and the deaths of 19 people. It is questionable though, as to whether Banda can solve these problems, much of which is due to international market forces out of the control of the domestic Presidency.
Of interest to me were the circumstances of Bingu’s death. Bingu collapsed on Thursday night and was rushed immediately to Kamuzu Central Hospital, a public facility. Upon presentation at the Kamuzu, workers realized that they were lacking epinephrine and had to run to a facility run by University of North Carolina to procure it. Bingu likely died because of problems of drug stocking in Malawian facilities and substandard levels of health delivery. Bingu died due to a problem endemic to all of Malawi. Ironically, the opulent President of Malawi died needlessly like that of even the poorest of Malawians.
What were originally intended as peaceful demonstrations, however, have quickly turned to violent riots. Bingu’s Democratic Progressive Party have dispatched trucks filled with machete waving thugs. Police and military, at the behest of the current government, have been reported to have been witnessed beating protesters.
A reporter for Capital Radio Malawi has been beaten by police in Zomba. Deaths and injuries are already being reported.
Worse yet, the chaos has allowed looters to break into store fronts, including the Bata Shoe Store in downtown Blantyre, which now sits empty. Women have ben spotted carting off groceries and household items from local stores.
Protesters have set fire to DPP vehicles, and a police station in Chirimba sits in flames, even as I write this.
The situation is quickly spiralling out of control, though news and pictures are proving difficult to come by. I can imagine that as night falls (very soon) things will only get worse.
DPP thugs are out in full force. The Nyasatimes reports:
The gang of machete-wielding youths took to the streets in DPP branded vehicles and stopped at several points, got out their vehicles and sharpened their pangas.
“It’s scary. They have literally blocked the main road and are sharpening their knives right on the tarmac and threatening
everyone,” a bank executive, who did not want to be named, told Reuters.
Bingu’s Young cadets wileding machetes
Eye witness report said they chanted the now familiar DPP war-cry in Malawi’s lingua franca, Chichewa: “Onyoza boma sagona, timpweteka! (“Those opposing government will not sleep, we will deal with them!”)
They also savagely attacked a Mandasi seller who appeared to have made“rude” remarks against the threats.
Update: Capital Radio reports: “The world is on Malawi, CNN, BBC, Aljazera, CCTV and more. Riots in Ndirande, Chitawira, Zingwangwa. Ndirande is a WAR ZONE.”
Update: 12:07 pm EST RT @ianchakhaza: The volatile township of Ndirande in Blantyre is erupting with reports of police using live ammunition there #July20 #Malawi 20 are reported dead.
(These photos came from Capital Radio Malawi)
Update: 12:21 pm Chirimba, across from teh Queens Hospital is in flames and people are still stoning the police
I first met Harold on my last trip to Malawi. I was shooting footage for a documentary project of mine on atheism in Malawi, as was referred to him as a member of the Malawi Association of Secular Humanists. In fact, he was the vice president of this very small but vocal group. I went to meet him at the Blantyre Sun Bird Hotel on a Monday afternoon. Not knowing what he looked like, I entered the courtyard looking for a Malawian. Instead, a middle aged white man called me over and introduced himself as Harold Williams.
Harold first went to Malawi in the 1950’s to work as a policeman for the Colonial government in Zomba. He instantly fell in love with the country (as everyone does). He met and married a Malawian woman, and signed on to stay after Malawi attained independence in 1963. I asked him why he stayed where many went back to England. He wished to help Malawi create a viable, independent government and help create a brighter future for this struggling country.
Harold eventually attained Malawian citizenship, raised children in Malawi, and created a life for himself in Malawi. He led a life very integrated with the people around him, spoke the language(s) fluently, and became one of Malawi’s most active and vocal advocates. Harold’s citizenship and dedication to Malawi called the very idea of what it is to be a “Malawian” into question, and larger ideas of “citizenship” that all states in the 21st century must face. Harold would enthusiastically discuss these broad but important questions in a manner usually reserved for sequestered academics.
Harold was deeply involved in the political life of Malawi. He participated actively in demonstrations, once even leading a protest against President Muluzi’s efforts to remain in office beyond the number of terms allotted to him in the Constitution, and found himself strong-armed by members of the Malawian military. Harold worked tirelessly for the right of free speech and protest in Malawi, which faces the same sorts of questions of protest and democracy that have recently been the focus of news reports on Egypt, Iran and Libya. Malawi’s small size and lack of resources keep it out of the world news, but its political concerns are really no different nor any less important than that of other, larger states.Harold ran the Malawi Concern Blog, which publicly addressed the problems of the present administration under Bingu, found himself on a watch list of potential political enemies, and even had his blog blocked and suppressed recently. Harold was a vocal critic of Bingu’s Presidency, and regularly called him out on his habit of playing ethnic politics with Malawi, wide human rights abuses and his unapologetic flouting of Malawi’s secular Constitution.
Of course, Harold’s role as an advocate of secular humanism and secular government cannot be forgotten. Harold was an avowed secularist, and perceived fanatical religious belief to be a threat to the peace and welfare of Malawi. Particularly, he fought alongside other Malawi secular humanists to provide advocacy for persons accused of witchcraft related crimes and the economy surrounding it, battled the inclusion of Christianity into government policy, and publicly resisted the widespread and dangerous phenomena of religious opportunists in Malawi. Among other activities, Harold ran the official blog for the group.
Harold was a great guy. If I end up being half the person that Harold was by the time I am his age, I will consider this a life worth having lived. In writing this short, pseudo-obit, I feel as though I am leaving much out, but I think this speaks loads to what kind of person Harold was as a political activist, a human rights advocate and as a human being.
I miss Harold and am so very sorry that I will never have the opportunity to meet him again.
For those not in the know, George is the head of the Malawi Association of Secular Humanists. He works tirelessly as an advocate for people who have been accused (some are even jailed) of withcraft related crimes and as a spokesman for human rights, rationality, atheism and secular government in Malawi.
George’s story is almost unbelievable, but disturbingly real. Please consider donating to help George’s cause. Even the smallest amount of money goes a long way to help pay for legal fees and to provide support for those imprisoned under some of the most horrific conditions imaginable. There is a donation button on the right corner of this page.
WITCH HUNT IN CHINOKO VILLAGE, LILONGWE –STOPPED, CHIEFS ARRESTED. CHIEFS DETAIN AND CHARGE THINDWA, PAYS THE MK 5000 FINE AND RELEASED
On 1st June, I went to deliver N. Kamphata, the oldest elderly woman prisoner at her village at T/A Chumutu, Dowa who was released on witchcraft offence.
On my way back, I was informed that there was a witch hunt at Chinoko village, T/A Chimutu about 15 kms from Kanengo on Lilongwe- Salima road. I decided to investigate. Indeed, the witch hunt was in full swing with the witch finder named Boston (25- 30 yrs old) doing searches of witchcraft charms. By the time I arrived at the village, the witch finder was at the grave yard. It is alleged that a “witch” by the name of Frazer Kaphanga had hidden his charms at the grave. There were many people at the grave site with drumming and singing.
I managed to join the crowd and took pictures. I went into the graveyard where some people had gone to watch the witch finder digging the charm of Mr. Frazer. At the grave, I found the witch finder busy with his act and within a short time; he managed to bring out the charm. He showed it to the crowd claiming that it was a rat that Frazer uses to steal money from other people. Then, Mr. Frazer was detained at the camp smeared with flour all over his face as witch. Next, the witch finder went to the house of an old lady by the name of Kwajere, Ms Mukhalepo Chinsapo (80). I followed and took pixies. At the house the old lady was very disturbed and confused. She was smeared with flour on her face and asked to stand in the middle of a circle so that the witch finder could search her house for charms. The old lady noticed that my mission was different. She faced in desperation clearly asking me in her heart so that I should her help. I went closer and took her hand and whispered to her that I will indeed rescue her at the appropriate time. I assured her that my mission there was to help such vulnerable people and her request would be answered.
I left and went aside to call the police to come and stop this illegal practice. The police headquarters told me to contact the Kanengo police. The community security men were alerted by the witch finder that my presence there was suspect. He briefly suspended his work and told them to bring me to him. The security men wanted to harass me. I resisted and told them that I had no time to go to the witch finder but to the Group Village man. At this time, I alerted my relations and humanists friends about this unfolding drama.
We went to the camp where the Group Village headman –Chinoko Kawenga was supposed to be. He was not there. But all the chiefs were there. At the camp, there were 10 “witches” by that time, surrounded by people. Kwajere, Ms Chinsapo was dragged to the camp while I was there. One could not help to shed a tear to see live how the people labeled as witches are victimized and mistreated. Mostly it is the elderly and women. Here are their names:
1. Mr. Kaphanga Frazer- is said to have a charm in the form of a rat for enrichment.
2. Mr. Boswell Kamuseza-the witch doctor was yet to visit his house to find the charms
3. Mr. Nasoni Kacholora-is said to have a charm to steal manhood from others.
4. Ms Naphiri Nabanda-is said to have a charm for tying pregnancies leading to still births.
5. Ms Moneyi Makata-her charm moved and was found to be at someone`s house.
6. Ms Mukhalepo Chinsapo-Kwajere- very old woman and her charm was found in the roof of the house. This is a very old woman possibly 80 see her photo.
7. Mr. Herbert Kupenga
8. Ms Nankhoma Genitla
9. Ms Anasani Jojo- her charm was said to cause measles to others
10. Ms Angela Mawumusamathe
11. Mr. Kumbali Kamuseza
I was told that once the witch finder had finished his searches of charms, he would come to the camp to deliver his final verdict on the “witches” in terms of punishment!
The chiefs told me that I was being charged with 3 offences: of taking pictures, of entering the grave yard without permission and attending the witch hunt without permission. I was fined to pay MK 13000 ($85). I negotiated this down to MK 5000($32) and paid.
I was destined to stop the witch hunt and to have those in captive released. I went to the captives when I was discharged on my own greeted them one by one and assured them that their freedom was at hand. I went to Mchezi roadblock at Kanengo and told the police about the witch hunt and they quickly phoned their superior to dispatch the 997 immediately. By 8 pm, the police arrived in full gear and we went to the village. At the village when police presence was noticed, people run in all the directions. All the chiefs, two lieutenants of the witch finder were taken for police questioning at Kanengo police. The witch finder disappeared and he was nowhere to be seen. Up to now he is nowhere.
As at 2nd June, 4 chiefs have been arrested and detained at Kanengo police; four lieutenants of the witch doctor are detained. The arrested chiefs are Kalumbu Byton, Chinoko 2, Nachimbo Chapotela and Kachiundu. The police went back on 2nd June to look for the witch finder and brought back two lieutenants of the witch finder. They did not find the witch finder.
The so called witches came to the police to give statement on 2nd June. I was with them. Some due to old age could not make it. I managed to deliver them back to their village especially the very old. At the village the situation is calm now. Some villagers did thank me for helping them and stopping the witch hunt.
George Thindwa 2/6/2011