Once again, I tagged along on a trip to Detroit with the D-CREW, a community based participatory research project aimed at developing strategies to improve housing and thereby reduce wasteful water and energy use in Detroit communities.
This weeks data collection efforts focused on the Jefferson-Chalmers area of Detroit, just adjacent to Gross Pointe.
Data collection went as smoothly as before, but with a more affluent and sophisticated group of people the vast majority of whom own their own homes.
The informational session became quickly energized, with participants asking pointed questions like “how is this research going to benefit us?” “are you going to sell our data?” “is my cousin going to be able to see my data?”
Doing research in the communities of Detroit is every bit as exciting and engaging as doing work in Kenya, where researchers are rightly met with skepticism, the goals of the research are obscure, and the direct benefits likely non-existent.
I’m getting used to the new version of ArcGIS (which is a vast improvement!) and gave it a test run on some data from the ACLED (Armed Conflict Location & Event Data Project) database, specifically on this years round of violence surrounding the Kenyan election. ACLED keeps real time data on violence and conflict around the globe, the latest entry in 2017 is Nov 24, just five days ago.
The first election occurred on August 8th, 2017. The opposition contested the results of the election, claiming problems in vote tallying by the IEBC, resulting in a nullification by the Supreme Court. A new election was called and was to be conducted within 60 days of the nullification. Raila Odinga, the opposition leader, claimed that the election again would not be fair, dropped out of the race and called for a national boycott. The election went ahead as place on October 26, 2017 and Uhuru Kenyatta was declared the winner.
There was violence at every stage of the process, both by rioters in support of the opposition and by the police and military who were known to fire live rounds into groups of demonstrators. Opposition supporters were known to set fire to Kikuyu businesses. Local Kikuyu gangs were reported to be going house to house rooting out people from tribal groups from the West and beating them in the street. Tribal groups in rural areas were reported to be fighting amongst one another. The police response has been heavy handed and disproportionate leading to a national crisis.
As of now, though not nearly as violent as the post election violence of 2007-08, the violence has not yet abated.
In the database, there were 420 events logged, including rioting, protests and violence against civilians by the state, police and local tribal militias. There are 306 recorded fatalities in the data base, but this number should be approached with some caution. There were likely more. The database is compiled from newspaper reports, which don’t count fatalities and don’t cover all events.
I made two maps (above), one for Nairobi, and the other for Kenya. They include all non Al-Shabaab events (a Somali Islamist group the Kenya Defense Force has been fighting for several years.) I also included a time series of both events and fatalities.
Some excerpts from the notes:
“Police raided houses of civilians in Kisumu, beating civilians and injuring dozens. Live bullets were used on some civilians, including a 14 year old boy. Of the 29 people injured, 26 had suffered gun shots.”
“One man was found dead in a sugar cane plantation one day after ethnic tensions between the Luo and Kalenjin communities got into an ethnic clash. The body had been hacked with a panga.”
“Rioters started throwing stones at the police in the morning, protesting against the elections to be held the next day. The police responded with teargas and water canons. The rioters were mostly from the Luo ethnic group and they took the opportunity to loot several stores, attack residents and to burn a store owned by an ethnic Kikuyu. One woman was raped.” *This was in Kawangware, not far from my apartment. I was eating at a local bbq place when this happened.
“Police forces attacked supporters of the opposition that went to the Lucky Summer neighbourhood to check on a ritual of beheading of a sheep that was taking place (suspectedly by the Mungiki sect). The police shot at the civilians. The police confirmed that it shot a man and that the group performing the ritual had sought protection.”
“As a revenge to the previous event, the Kikuyu joined forces and attacked the Luo. The ethnic tensions and violence led to one severely injured person. Residents claims three were killed and dozens, including three school children, were injured.”
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.
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.
Unfortunately, the Twa are long gone from the island, which is now occupied by Suba and Luo people, though the Suba are quickly being assimilated into the Luo through marriage.
It’s an odd place. They’ve got a small tourism industry, are currently installing new power lines and have recently gotten true ferry service from the mainland, but the roads are still terrible.
We ran into a group of missionaries on the way back. I always feel somewhat violated after talking with missionaries in Africa. What are they doing here? This looked like some polygamous group of Mormons but it turned out they were from Alberta and Kansas.
One of them asked us what we were “lonesome for.” I didn’t know how to respond so we asked them what they were lonesome for, to which they said “Wal Mart.”
While I hate to judge, it was telling that they all introduced themselves to us, but not Victor, an employee of the Kenyan Medical Research Institute who was standing right next to us. I’m convinced that they don’t see the locals as people.
What developmental role do missionaries play? They make no demands on politicians to solve pressing problems of political dysfunction, infrastructural weakness, employment, a lack of access to capital, crippling bureaucracy, corruption, graft, nepotism and terrorism. None of these problems can be solved through missionary activities which emphasize odd moral codes more fitting to white, rural Kansas than complicated and chaotic Kenya.
It’s been an extremely long day.
Nearly 80% of people in this area of Kenya practice open defecation. They don’t use toilets. Of course, fecal matter washes into the lake, which happens to be where they all get their drinking water from. Diarrheal disease is, of course, out of control.
As a public health professional, I’m justifiably annoyed that there are people out there who can’t handle even the simplest sanitation solution: shitting in a single hole. However, it is what it is.
JICA has sponsored the construction of put latrines and the installation of water tanks at several schools in the area. These interventions are dirt cheap, but are way beyond the financial reach of impoverished communities along Lake Victoria. While we would assume that the Kenyan government would be expected to contribute money to help protect their children, the reality is that this area has been politically marginalized since independence. Schools can’t depend on the government to provide even sufficient wages for teachers, let alone sanitation infrastructure. Given the political problems between the current Kikuyu government and the Luo, it’s unlikely that the funds would be provided, even if they were available.
One of the schools we visited is 100% community funded. While it was a rudimentary facility, the locals have to be commended for taking matters into their own hands. I just wish they’d take sanitation more seriously.
Talked to a great bunch of people, listened to some great stories and drank 7 bottles of Coca-Cola. Off to bed.
The thinking, however, isn’t entirely illogical and can, of course, even be traced back to Malthus himself. Malthus believed that helping the poor would only increase their misery through worsening conditions of crowding and starvation. If Malthus had lived in 2013 and were concerned with welfare policy, he’d probably be a card carrying member of the Republican Party.
For the record, I despise Malthus (and his spawn, Paul Ehrlich). I can’t think of a more cynical and heartless thinker. It’s disturbing to me that his ideas continue to permeate today, despite being wrong at best and simply hateful, at worst. More disturbing is how eagerly his ideas are absorbed by even otherwise well meaning people.
“It’s obvious,” I’ve heard people say while implicitly suggesting the some lives (ours) are worth more than others (theirs). As cliched as it may sound, I think that every human has both a right to live and the right to a life that is healthy and meaningful. Not saving kids from malaria compromises the ability to do either.
So far, though, no one really knows whether life saving interventions in developing countries fuel population growth. Does saving a child’s life simply increase the number of mouths to feed, thereby straining resources and insuring misery for everyone? David Roodman, a public policy consultant working on behalf of GiveWell, a group which does analyses on the effectiveness of charity programs, has searched the published literature to find the answer.
I think the best interpretation of the available evidence is that the impact of life-saving interventions on fertility and population growth varies by context, above all with total fertility, and is rarely greater than 1:1. In places where lifetime births/woman has been converging to 2 or lower, family size is largely a conscious choice, made with an ideal family size in mind, and achieved in part by access to modern contraception. In those contexts, saving one child’s life should lead parents to avert a birth they would otherwise have. The impact of mortality drops on fertility will be nearly 1:1, so population growth will hardly change.
He goes through the available data and finds evidence to suggest that averted child deaths are associated with a decrease in the number of births over the lifetime of a woman. This is somewhat non-controversial. It has long been noticed that economic development and increased access to medical care is associated with decreased lifetime fertility.
Where things become controversial is in the case of developing countries, where saving a child’s life might not have the same effect on reducing births overall. This might be true in the short term, and Roodman finds evidence to suggest this. A short term reduction in child mortality might not yield immediate results.
The issue might be more nuanced, however. Merely providing malaria interventions such as insecticide treated nets to prevent disease without increasing access to quality health services might lead to a situation where population increases quite rapidly. I would think that this might explain why some of the most malarious countries in the world are experience the most rapid population growth. Malawi would be an example.
The strategy, then, is incomplete and Roodman’s analysis might suggest that we need to take a holistic approach to include both malaria prevention and reproductive health services.
I would, however, suggest that the problem is more complicated, particularly when reflecting on Kenya, where the most effective method of reducing fertility has probably been the imposition of school fees. The issue then isn’t merely a matter of saving kids and Depo shots, it’s also a matter of finances. If people can’t afford kids, they won’t have them, but the only way to arrive at economic barriers to reproduction is to have an economy, which is exactly what a country like Malawi doesn’t have.