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A visit to the local witchdoctor: treating snakebites in Kwale, Kenya

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Wound from a puff adder bite

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.

 (Silence)

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.

 

 

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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.

Does sampling design impact socio-economic classification?

DSC_2057Doing research in developing countries is not easy. However, with a bit of care and planning, one can do quality work which can have an impact on how much we know about the public health in poor countries and provide quality data where data is sadly scarce.

The root of a survey, however, is sampling. A good sample does its best to successfully represent a population of interest and can at least qualify all of the ways in which it does not. A bad sample either 1) does not represent the population (bias) and no way to account for it or 2) has no idea what it represents.

Without being a hater, my least favorite study design is the “school based survey.” Researchers like this design for a number of reasons.

First, it is logistically simple to conduct. If one is interested in kids, it helps to have a large number of them in one place. Visiting households individually is time consuming, expensive and one only has a small window of opportunity to catch kids at home since they are probably at school!

Second, since the time required to conduct a school based survey is short, researchers aren’t required to make extensive time commitments in developing countries. They can simply helicopter in for a couple of days and run away to the safety of wherever. Also, there is no need to manage large teams of survey workers over the long term. Data can be collected within a few days under the supervision of foreign researchers.

Third, school based surveys don’t require teams to lug around large diagnostic or sampling supplies (e.g. coolers for serum samples).

However, from a sampling perspective, assuming that one wishes to say something about the greater community, the “school based survey” is a TERRIBLE design.

The biases should be obvious. Schools tend to concentrate students which are similar to one another. Students are of similar socio-economic backgrounds, ethnicity or religion. Given the fee based structure of most schools in most African countries, sampling from schools will necessarily exclude the absolute poorest of the poor. Moreover, if one does not go out of the way to select more privileged private schools, one will exclude the wealthy, an important control if one wants to draw conclusions about socio-economic status and health.

Further, schools based surveys are terrible for studies of health since the sickest kids won’t attend school. School based surveys are biased in favor of healthy children.

So, after this long intro (assuming anyone has read this far) how does this work in practice?

I have a full dataset of socio-econonomic indicators for approximately 17,000 households in an area of western Kenya. We collect information on basic household assets such as possession of TVs, cars, radios and type of house construction (a la DHS). I boiled these down into a single continuous measure, where each households gets a wealth “score” so that we can compare one or more households to others in the community ( a la Filmer & Pritchett).

Distributions We also have a data set of school based samples from a malaria survey which comprises ~800 primary school kids. I compared the SES scores for the school based survey to the entire data set to see if the distribution of wealth for the school based sample compared with the distribution of wealth for the entire community. If they are the same, we have no problems of socio-economic bias.

We can see, however, from the above plot that the distributions differ. The distribution of SES scores for the school based survey is far more bottom heavy than that of the great community; the school based survey excludes wealthier households. The mean wealth score for the school based survey is well under that of the community as a whole (-.025 vs. -.004, t=-19.32, p<.0001).

Just from this, we can see that the school based survey is likely NOT representative of the community and that the school based sample is far more homogeneous than the community from which the kids are drawn.

Researchers find working with continuous measure of SES unwieldy and difficult to present. To solve this problem, they will often place households into socio-economic "classes" by dividing the data set up into . quantiles. These will represent households which range from "ultra poor" to "wealthy." A problem with samples is that these classifications may not be the same over the range of samples, and only some of them will accurately reflect the true population level classification.

In this case, when looking at a table of how these classes correspond to one another, we find the following:

Misclassification of households in school based sample

Assuming that these SES “classes” are at all meaningful (another discussion) We can see that for all but the wealthiest households more than 80% of households have been misclassified! Further, due to the sensitivity of the method (multiple correspondence analysis) used to create the composite, 17 of households classified as “ultra poor” in the full survey have suddenly become “wealthy.”

Now, whether these misclassifications impact the results of the study remains to be seen. It may be that they do not. It also may be the case that investigators may not be interested in drawing conclusions about the community and may only want to say something about children who attend particular types of schools (though this distinction is often vague in practice). Regardless, sampling matters. A properly designed survey can improve data quality vastly.

Links I liked: November 26, 2014

Can African Countries Learn from North Korea’s Handling of the International Media? – An interesting perspective. He argues that African leaderships, rather than seizing crises as opportunities to draw attention and approval for their countries from Western donors, might actually benefit from clamping down on international media coverage, which often exploits and distorts the story. I’m thinking that the Ebola panic might have been averted if the media hadn’t picked up on the most freakish elements of the story, and focused rather on the mundane issues of poor public health care delivery.

Colonialism and development in Africa – “Most of Africa spent two generations under colonial rule. This column argues that, contrary to some recent commentaries highlighting the benefits of colonialism, it is this intense experience that has significantly retarded economic development across the continent. Relative to any plausible counterfactual, Africa is poorer today than it would have been had colonialism not occurred.” The authors, however, note the different contexts of colonialization and remark that results are mixed, but in general, the countries that have done the best (i.e. those which didn’t experience slavery) would be doing significantly better.

Stop Making Intellectually Disingenuous Market Arguments – “Shall we blame Twitter, trolls or bloggers? I am unsure of the underlying reason. But as we have seen far too, financial discussions seem to entail people arguing at cross-purposes. Bull-bear debates devolve into winning the argument at any cost. Previously, we had a true competition of ideas in the marketplace. Now, we have discussions that range between disingenuous and useless. The hunt for the truth has been replaced by the search for bragging rights.” Well, Barry, I don’t think you should limit your observations to only those talking about markets. It’s endemic now.

An autopsy review of sudden unexpected natural deaths in a suburban Nigerian population – “Sudden unexpected natural deaths accounted for 13.4% of all medico-legal autopsies. The male to female ratio was 2.1:1, and the mean age was 43.1 years ± 19.5 SD. Cardiovascular (28.3%), respiratory (18.2%), and central nervous system (12.6%) disorders were the major groups of causes. About 64.4% of cardiovascular deaths were due to hypertensive heart disease. Bacterial pneumonia, intracerebral haemorrhage, and breast carcinoma accounted for 34.4%, 60.0%, and 52.6% of respiratory, central nervous system, and cancer-related deaths respectively. Only 16.9% of cases occurred while the patient was admitted to the hospital.” Twice as many men are dying as women, they are dying of heart disease and the average age of death is 43, give or take 20 years. Time to move our focus over to chronic outcomes in developing countries. They are staring into a tidal wave of disease that’s going to break their health systems.

Economics Is a Dismal Science for Women – Wow. Just wow.

Links I liked, November 18, 2014

I liked so many things I read today that, rather than clutter social media, I’ll make note of them right here:

“Falling” by William McPherson – By far, the most depressing thing I have read in a while. McPherson is a Pulitzer winning writer and former editor at the Washington Post who chose a life of curiosity and is now paying the ultimate price. It’s awful that the brightest people have to be punished for thoroughly embracing life. So many people I know are going to go this way, it is possible that I might, too.

In India, Growth Breeds Waste NYT – Documenting India’s mounting problem of what to do with its waste. Europe went through their urbanization pains centuries ago. Unfortunately, developing countries are rising to the challenge fast enough. The problem, of course, is that elites are sheltered from the problems of waste and weak and corrupt government structures disallow people from demanding that their countries clean up. International environmentalists need to focus less on screaming about corporate polluting (though it is important) and need to start making demands for more boring things, like managing waste on a local level.

Stop calling me ‘the Ebola nurse’ – Kaci Hickox – This lady was a hero. She never had ebola, but was still illegally interned for having it because a few Americans don’t understand science. Anybody who supported her detainment should just stop speaking to me now. It was shocking how readily Americans were willing to lock people up simply because they were scared and even more shocking where the calls for her “arrest” came from. I give up. People like Hickox put their money where their mouths are. She did what most humans wouldn’t do and she was vilified for it. Unforgivable.

Ten Things that Anthropologists Can Do to Fight the West African Ebola Epidemic I think it should be required that every field research project include an anthropologist.

Q Fever Is Underestimated in the United States: A Comparison of Fatal Q Fever Cases from Two National Reporting Systems People are dying of Q, but much of it isn’t recorded.

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.

Can the use of technology in surveys change the nature of responses?

In the past, surveys were done on paper, either through a designed questionnaire or by someone frantically writing down interview responses. When computers came around, people would be hired to type in responses for later analysis.

Nowadays, with the advent of cheap and portable computing, research projects are rapidly moving toward fully digital methods of data collection. Tablet computers are easy to operate, can be cheaply replaced, and now can access the internet for easy uploading of data from the field.

Surveyors like them because large teams can be spread out over a wide space, data can be completely standardized and the tedious process of data entry can be avoided.

Of interest to me, however, is whether the technology is influencing the nature of the responses given. That is, will someone provide that same set of responses in a survey using digital data collection methods as in a paper survey?

Recently, we attempted using a tablet based software for a small project on livestock possession and management on Mbita Point in Western Kenya. I intended it as a test to see if a particular software package might be a good fit for another project I`m working on (the one that`s paying the bills).

We had only limited success. The survey workers found the tablets clunky and a number of problems with the Android operating system made it more trouble than the survey was actually worth. Of interest, though, was how the technology distracted the enumerators from their principle task, which was to collect data.

Enumerators would become so wrapped up in trying to navigate the various buttons and options of the software that they couldn`t effectively concentrate on performing the survey. Often they appeared to skip questions out of frustration or would just frantically select one of the many options in the hope of moving on to the next one.

In a survey of more than 100 questions, the process started taking far more time than households were willing to give. We eventually had to abandon the software and revert to a paper based method.

Surveys went from lasting more than one hour, to taking under 30 minutes. Workers were more confident and had more time to interact with the respondents. Respondents had more of an opportunity to ask questions and consider the meaning of what they were being asked. They offered far more information than we expected and felt that they were participating in the survey as a partner and not just as a passive victim.

One of our enumerators noted that people react differently to a surveyor collecting data on the tablets than with paper. She described collecting data with technology as being “self absorbed” and alienating to the respondents. Collecting data on paper, however, was seen as a plus. “They can see me writing down what they say and feel like their words are important.”

I`m thinking that the nature of the responses themselves might be different as well. Particularly with complex questions of health and disease, often the surveyors will have to explain the question and give a respondent a chance to ask for further clarification. Technology appears to inhibit this process, perhaps compromising the chance for a truly reasoned response.

While I am absolutely not opposed to the use of technology in surveys, I think that the survey strategy has to be properly thought through and the challenges considered. At the same time, however, data collection is a team effort and requires a proper rapport between community members and surveyors who often know each other.

Is technology restricting our ability to gather good data? Could the use of technology even impact the nature of the response by pushing them in ways which really only tell us what we want to believe rather than what actually exists?

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